Family and Community Medicine - CM442- Handout sheet (2023) by Dr.

Rehab Aljerbi

STIs & HIV

Introduction

> 30 different bacteria, viruses and parasites are known to be transmitted through sexual contact.
Some STIs can also be spread through blood or blood products. Many STIs can also be
transmitted from mother to child during pregnancy and childbirth.

Eight of these pathogens are linked to the greatest incidence of sexually transmitted disease
(STD). 4 are currently curable: Syphilis, Gonorrhea, Chlamydia and Trichomoniasis. The other 4
are viral infections which are incurable: Hepatitis B, Herpes simplex virus (HSV or herpes),
HIV, and human papillomavirus (HPV).

Symptoms or disease due to the incurable viral infections can be reduced or modified through
treatment. Both HPV and hepatitis B infections are preventable with vaccination.

STIs can have serious reproductive health consequences beyond the immediate impact of the
infection itself, Examples:

• Herpes and syphilis can increase the risk of HIV acquisition three-fold or more.
• HPV infection causes 570 000 cases of cervical cancer and over 300 000 cervical cancer
deaths each year.
• Gonorrhea and chlamydia are major causes of pelvic inflammatory disease (PID) and
infertility in women.
• Mother-to-child transmission of STIs can result in stillbirth, neonatal death, low-birth-
weight and prematurity, sepsis, pneumonia, neonatal conjunctivitis, and congenital
deformities.

Prevention and control of STIs

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 Family and Community Medicine - CM442- Handout sheet (2023) by Dr. Rehab Aljerbi

1. Primary prevention of STIs:

• Counselling and behavioural approaches
• Use barrier methods
• Vaccines
• Other biomedical interventions

STIs Vaccines
Safe and highly effective vaccines are available for 2 STIs: hepatitis B and HPV. Research to
develop vaccines against herpes and HIV is in advanced stages. Research into vaccines for
chlamydia, gonorrhea, syphilis and trichomoniasis is in earlier stages of development.

Other biomedical interventions

Other biomedical interventions to prevent some STIs include: Male circumcision and
microbicides.

Microbicides: a substance to be applied inside the vagina or rectum to substantially reduce the
transmission of sexually transmitted infections (STIs)

2. Secondary prevention of STIs:

• Screening strategies
• Early diagnosis
• Effective Treatment
• Control infection spread by treating sexual partners

Diagnosis of STIs

Accurate diagnostic tests for STIs are widely used in high-income countries. In low- and middle-
income countries, diagnostic tests are largely unavailable. Where testing is available, it is often
expensive and geographically inaccessible; and patients often need to wait a long time (or need
to return) to receive results. As a result, follow up can be impeded and care or treatment can be
incomplete.

The only inexpensive, rapid tests currently available for STIs are for syphilis and HIV. Several
rapid tests for other STIs are under development.

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 Family and Community Medicine - CM442- Handout sheet (2023) by Dr. Rehab Aljerbi

Treatment of STIs

Effective treatment is currently available for several STIs. 3 bacterial STIs (chlamydia,
gonorrhoea and syphilis) and one parasitic STI (trichomoniasis) are generally curable with
existing, effective single-dose regimens of antibiotics.

For herpes and HIV, the most effective medications available are antivirals that can modulate the
course of the disease, though they cannot cure the disease. For hepatitis B, antiviral medications
can help to fight the virus and slow damage to the liver.

Antimicrobial resistance (AMR) of STIs—in particular gonorrhea—to antibiotics has

increased rapidly in recent years and has reduced treatment options. Current Gonococcal AMR
Surveillance Programme (GASP) have shown: High rates of quinolone resistance, increasing
azithromycin resistance, and emerging resistance of extended-spectrum cephalosporins, last-line
treatment. That make gonorrhea a multidrug-resistant organism.

STI case management

The majority of STIs have no symptoms or only mild symptoms (e.g., vaginal discharge, urethral
discharge, genital ulcers, abdominal pain).

To interrupt transmission of infection and prevent re-infection, treating sexual partners is an

important component of STI case management.

Low- and middle-income countries rely on identifying consistent, easily recognizable signs and
symptoms to guide treatment, without the use of laboratory tests. This is called syndromic
management.

Syndromic management (management depend on clinical diagnosis only)

• Allows health workers to diagnose a specific infection on the basis of observed

syndromes (common presented signs and symptoms).
• Is simple, assures rapid, same-day treatment, and avoids expensive or unavailable
diagnostic tests for patients that present with symptoms.
• Results to overtreatment and missed treatment as majority of STIs are asymptomatic.

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 Family and Community Medicine - CM442- Handout sheet (2023) by Dr. Rehab Aljerbi

Health services for screening and treatment of STIs

People seeking screening and treatment for STIs face numerous problems. These include:

• Limited resources: In many countries, STI services are provided separately and not
available in primary health care.
• Poor quality of services: services are often unable to provide screening for asymptomatic
infections, lacking trained personnel, laboratory capacity and adequate supplies of
appropriate medicines.
• Stigmatization,
• Little or no follow-up of sexual partners.

HIV

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 Family and Community Medicine - CM442- Handout sheet (2023) by Dr. Rehab Aljerbi

Agent

HIV outside the human body does not survive long outside the human body (such as on
surfaces), and it cannot reproduce outside a human host. (so a matter of minutes or hours
depending on conditions).

Host: high risk groups for HIV

• Drug abusers
• Recipients of blood transfusions and dialysis patients
• Homosexuals and prostitutes
• People in prisons
• Health care workers
• Infants of infected mothers
• Household and sexual contacts of people with HIV infection

HIV transmission:

HIV can be transmitted via the exchange of a variety of body fluids from infected individuals,
such as blood, breast milk, semen and vaginal secretions. It spread by needle stick injury,
tattooing, piercing as well as from mother to child at birth (perinatal transmission).

HIV cannot spread by:

• Food
• Mosquitoes, ticks, or other insects.
• Saliva, tears, or sweat that is not mixed with the blood of an HIV-positive person.
• Hugging, shaking hands, sharing toilets, sharing dishes/ food/water, or “social” kissing
with someone who is HIV-positive.

Cleaning Surfaces contaminated with blood

Contaminated surfaces must be wiped down using an appropriate disinfectant such as an EPA-
approved disinfectant. Disinfectants that kill the bacteria that cause tuberculosis can also kill
HIV, hepatitis B and hepatitis C viruses (e.g. Clorox bleach, Opti-phene, Spoicidin, ……)

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 Family and Community Medicine - CM442- Handout sheet (2023) by Dr. Rehab Aljerbi

List of EPA-registered tuberculocidal disinfectants

https://www.epa.gov/sites/production/files/201612/documents/list_b_tuberculocide.pdf

* EPA= Environmental Protection Agency

HIV & AIDS

The HIV targets the immune system and weakens people's defense systems against infections
and some types of cancer. The first few weeks after initial infection, individuals may experience
no symptoms or an influenza-like illness including fever, headache, rash, or sore throat. Immune
function is typically measured by CD4 cell count. As the infection progressively weakens the
immune system, an individual can develop other signs and symptoms, such as swollen lymph
nodes, weight loss, fever, diarrhea and cough. Without treatment, they could also develop severe
illnesses such as tuberculosis, cryptococcal meningitis, severe bacterial infections (opportunistic
infections) and cancers such as lymphomas and Kaposi's sarcoma, among others.

The most advanced stage of HIV infection is Acquired Immunodeficiency Syndrome (AIDS),
which can take from 2 to 15 years to develop depending on the individual. AIDS is defined by
the development of certain cancers, infections, or other severe clinical manifestations.

Prevention of HIV

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 Family and Community Medicine - CM442- Handout sheet (2023) by Dr. Rehab Aljerbi

1. Primary prevention:
• Raising awareness of population, help in reduction of transmission in the community.
• Education to general population about the rout of transmission & health hazards of HIV.
• HCWs should be alerted to the importance of adequate sterilization of all instruments and
to the practice of hygienic measures.
• Cases and carriers should be told not to share razors or tooth brushes and should not
donate blood.
• Implementation of blood safety strategies:
➢ All blood donors should be screened for blood born viruses.
➢ All pregnant ladies should be screened.
• Safe and effective vaccine use (Research is ongoing to develop HIV vaccines)
• Infection control precautions in health care and community settings (e.g., safe injection
practices, safe medical waste disposal)
• Safer sex practice
• Harm reduction practices for injecting drug users
• Occupational safety measures to health care workers
• Pre and Postexposure Management

Elements of Postexposure Management:

I. Wound management
II. Exposure reporting
III. Assessment of infection risk (type and severity of exposure & blood borne infection
status of source person)
IV. Appropriate treatment (PEP, EMTCT, Breastfeeding)
V. Follow-up, and counseling

I. Wound Care
• Clean wounds with soap and water
• Flush mucous membranes with water
• No evidence of benefit for application of antiseptics or disinfectants

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 Family and Community Medicine - CM442- Handout sheet (2023) by Dr. Rehab Aljerbi

• No evidence of benefit for squeezing (“milking”) puncture sites

• Avoid use of bleach and other agents

II. The Exposure Report

• Date and time of exposure
• Procedure details…what, where, how, with what device
• Exposure details...route, body substance involved, volume/duration of contact
• Information about source person and exposed person

III. Assessment of Infection Risk

Source person secreening for presence of HBsAg, presence of HCV antibody and presence of
HIV antibody.

IV. Appropriate treatment for HIV

A. Post-exposure prophylaxis for HIV (PEP)
B. Elimination of mother-to-child transmission of HIV (EMTCT)
C. HIV & breastfeeding

A. Post-exposure prophylaxis for HIV (PEP) in case of needle stick injury:

PEP is the use of ARV drugs within 72 hours of exposure to HIV in order to prevent infection.

PEP includes counseling, first aid care, HIV testing, and administration of a 28-day course of
ARV drugs with follow-up care.

WHO recommends PEP use for both occupational and non-occupational exposures and for adults
and children.

B. Elimination of mother-to-child transmission of HIV (EMTCT)

The transmission from an HIV-positive mother to her child during pregnancy, delivery or
breastfeeding is called vertical or mother-to-child transmission (MTCT). In the absence of any
interventions during these stages, MTCT rates can be 15–45%. MTCT can be nearly fully

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 Family and Community Medicine - CM442- Handout sheet (2023) by Dr. Rehab Aljerbi

prevented if both the mother and the baby are provided with ARV drugs as early as possible in
pregnancy and during the period of breastfeeding.

Delivery method for HIV-positive mother:

The safest way for women with HIV to deliver a baby depends upon her HIV viral load during
pregnancy. In general, a vaginal delivery is preferred for the safety of both mother and infant if
the risk of transmission of HIV is low (when the HIV viral load is low).

For women with high levels of virus in their blood or who are very concerned about infant
exposure to infected blood or vaginal fluids, a cesarean section is recommended.

C. HIV & breastfeeding (Is it safe for a mother infected with HIV to breastfeed her infant?)

No. The best way to prevent transmission of HIV to an infant through breast milk is to not
breastfeed. In countries, where mothers have access to clean water and affordable replacement
feeding (infant formula), recommend to completely avoid breastfeeding, regardless of ART and
maternal viral load.

In resource-limited settings, such as some parts of Africa, the WHO recommends that HIV-
infected mothers breastfeed exclusively for the first 6 months of life and continue breastfeeding
for at least 12 months, with the addition of complementary foods. These mothers should be given
ART to reduce the risk of transmission through breastfeeding.

V. Follow-up

For retesting and counseling. PEP treatment with ART can be stopped once results are negative.

2. Secondary prevention:

HIV: Testing (viral screening) & Diagnostic tests

Antibody/Antigen Combination Tests (check for HIV antigen, a protein called p24): Serological
tests, such as RDTs (Rapid diagnostic tests) or enzyme immunoassays (EIAs), detect the
presence or absence of antibodies to HIV and/or HIV p24 antigen. Most often these tests provide
same-day test results, which are essential for same day diagnosis and early treatment and care.

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 Family and Community Medicine - CM442- Handout sheet (2023) by Dr. Rehab Aljerbi

Most individuals develop antibodies to HIV within 28 days of infection and therefore antibodies
may not be detectable early, during the so-called window period. HIV rapid test result reveals
only HIV status.

RNA Test or PCR are confirmatory tests for HIV.

Treatment of HIV

There is no cure for HIV infection. However, effective antiretroviral (ARV) drugs can control
the virus and help prevent transmission so that people with HIV, and those at substantial risk, can
enjoy healthy, long and productive lives. HIV can be suppressed by combination ART consisting
of 3 or more ARV drugs. ART suppresses viral replication and allows immune system to
strengthen and regain the capacity to fight off infections.

WHO guidelines recommend to provide lifelong ART to all people living with HIV, including
children, adolescents and adults, pregnant and breastfeeding women, regardless of clinical status
or CD4 cell count.

Good luck

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