Management of Sexually Transmitted

Infections in PLHIV
 Session Objectives
By the end of the session, the participants will be able to:
• Understand the Indian scenario on Sexually Transmitted Infections (STI) &
Reproductive Tract Infections (RTI)
• Understand interactions between STI/RTI and HIV
• Understand Symptoms and Signs of STI/RTI
• Enumerate Syndromic Management of STI/RTI
• Understand STI/RTI preventive measures
 STI data from India
• Sexually Transmitted Infections/Reproductive Tract Infections (STI/RTI) are important public
health problems in India.
• WHO tracks four curable STI- Syphilis, Gonorrhea, Chlamydia and Trichomoniasis
• A community based STI/RTI prevalence study of 2002-03 conducted by ICMR for NACO
suggests :
• 5- 6% of the adults in India have one or more STI/RTI
• Which results into 30-35 million episodes of STI/RTI yearly among adults
• Data from the STI/RTI Control & Prevention Program suggests:
• significant decline of bacterial STI (syphilis, gonorrhea, chancroid)
• Increasing Viral STI (herpes, genital warts, hepatitis B)
• Significant burden of lower RTI (bacterial vaginosis and candidiasis)
• Some of the STI/RTI increase the risk of acquiring/transmitting HIV infection by 3 folds
Prevalence of STI: challenges in reporting of STI

Source: Program data collected from Designated STI/RTI clinics 2010 - 2016
 Relationship Between STI/RTI And HIV

• HIV infection is predominantly sexually transmitted in India (94%)

• Presence of STI/RTI increases risk of HIV acquisition/transmission due to:
• Loss of epithelial integrity
• Recruitment & activation of inflammatory cells
• Immune deregulation
• STI/RTI in HIV-positive people can increase viral load
• A higher viral load increases HIV transmission risk to others
Interactions between STI and HIV

STIs
Impact of STI on HIV Viral Load
STD Infection Status HIV Genital Viral Load
No Gonorrhea 19%
Gonorrhea
Pre-treatment 44%

Post-treatment 21%

Urethral HIV DNA more than doubled when there

was also the presence of an STI (gonorrhea)

However, treatment cut the urethral HIV DNA in

half – almost the same as those without STI

Cohen & Pilcher (2005) JID, 191, p 1392

Moss, GB et al (1995) JID, 172
 Common Symptoms of STI/RTI in Women

• Excessive/abnormal yellowish/greenish/foul-smelling vaginal discharge

• Itching / rash/sores/blisters/ulcers in genital area

• Swellings in the groin and vaginal area

• Lower abdominal pain

• Frequent urination

• Pain/burning while passing urine

• Pain while having sex ( dyspareunia)

• Sore throat
Common Symptoms of STI/RTI in Women
Common Symptoms of STI/RTI in Women
 STI/RTI Syndromes in Women
Symptoms Syndrome Common STIs/RTIs

Vaginal discharge Vaginal discharge Trichomoniasis, Candidiasis, Bacterial Vaginosis.

Vaginal discharge Cervical discharge Gonorrhea, Chlamydia, Trichomoniasis, Herpes simplex.

Gonorrhea, Chlamydia, Mycoplasma, Gardnerella,

Lower abdominal pain Lower abdominal pain
anaerobic bacteria

Genital Ulcers Genital ulcer syndrome Syphilis, Chancroid, Genital herpes

Ano-rectal discharge Ano-rectal discharge Gonorrhoea, Chlamydia

Throat irritation Gonococcal pharyngitis Gonorrhoea, Chlamydia

Genital warts, Molluscum contagiosum, Pediculosis pubis,

Genital skin conditions Genital skin conditions
Scabies - Norwegian Scabies
 Common Symptoms of STI/RTI in Male

• Sores/ ulcers/ blisters in genital area esp. Penis

• Swellings in groin and genital area

• Rashes around genital area/ anal opening / mouth

• Frequency of urination

• Burning/ pain while passing urine/ motion

• Discharge from Penis

• Inflammation or infection around anus/ in rectum

• Sore throat
Common Symptoms of STI in Men
 STI/RTI Syndromes in Men
Symptoms Syndrome Common STIs/RTIs

Urethral discharge Urethral discharge Gonorrhoea, chlamydia, trichomoniasis

Genital ulcers Genital ulcer Chancroid, syphilis, genital herpes

Inguinal bubos Inguinal bubo syndrome Lymphogranuloma venerium, chancroid

Scrotal swelling Painful scrotal swelling Gonorrhoea, chlamydia

Ano-rectal discharge ARD (Ano-rectal discharge) Gonorrhoea, chlamydia

Throat irritation Gonococcal pharyngitis Gonorrhoea, chlamydia

Genital warts, Molluscum contagiosum, Pediculosis

Genital skin conditions Genital skin conditions
pubis, genital scabies - Norwegian Scabies
 Transmission of STI/RTI
A person gets infection from an STI infected partner:
• through sores/ discharge from penis, vagina, anus, rectum, mouth and lips.
• during unprotected sex (Vaginal, Anal, Oral sex)

• Due to poor genital hygiene during menses

• Abortions without precautions

• Physician interventions eg. IUD insertion without proper infection control

• Illegal Abortions

• Asymptomatic clients can have STI/RTI and can transmit the same to their partners

• STI are transferred more from men to women as women are receptive and have a larger
surface area and longer contact period exposure
Transmission of STI/RTI: Women
 Complication of STI/RTI
Untreated or partially treated STI/RTI can cause-
In Women
• Miscarriage
• Ectopic pregnancy
• Neonatal Syphilis
• Increased Risk of cervical cancer
In both Men and Women
• Infertility
• Increased risk of HIV transmission( 5-10 times)
• Late stages of Syphilis can effect heart and brain and sometimes cause death
In Men
• Epididymitis and Rectal Fistulas
 Treating Sexually Transmitted Infections (STIs)
• 1160 Designated STI Clinic for general Population and for High Risk Group through TI
by 3400 Preferred Providers; “Suraksha Clinic”
• Provide quality standardised STI/RTI services at all levels; Colour coded kits (kit 1 to
kit 7) for Syndromic Management
• 8.64 million episodes treated in 2016-17
STI/RTI Episodes Management

89.2 90 86.4
79.6 80
70

2014-15 2015-16 2016-17

Target (In lakhs) Acheivement (In lakhs)

Counselling Flip Book at Suraksha Clinics
 Syndromic Approach to treat STI/RTI
Syndromic approach uses flow charts to identify causes of 7 common syndromes
associated with STI/RTI:
• Urethral discharge / Burning micturition
• Genital ulcer
• Vaginal discharge
• Scrotal swelling
• Lower abdominal pain
• Inguinal bubo
• Oral and Anal STIs
 Syndromic case management: Advantages

This method of management is:

1. Fast, the patient is diagnosed and treated in one visit
2. Relatively inexpensive
3. No need for patient to wait for lab results
4. All possible STIs causing common symptoms and signs are treated
5. Scientifically proven strategy in many parts of the world
6. Easy to learn and practice by health care workers
7. Can be implemented by HCP at all levels of Health Care
8. Facilitates standardization of treatment regimens
 Syndromic management: Limitations
Limitations:

• Not useful in asymptomatic individuals

• Over-treatment

• Cost of over-treatment & side-effects

• Potential for antibiotic resistance development

• Poor sensitivity /specificity

KIT-1
 Urethral Discharge

Urethral Discharge in PLHIV is a surrogate marker for incidence of

STI and denotes:
• Changing sexual behavior ,
• Presence of a infectious case in community
• Non use of condom –client start believing that ART is taking
care & no need to continue safer sexual practices.
Complications
• Epididymitis
• Periurethral abscess
• Urethral stricture
• Prostatitis
• Gonococcal arthritis
Treatment: KIT 1
• Tab. Azithromycin 1gm , single dose
+
• Tab. Cefixime 400 mg , single dose
 Cervical Discharge Syndrome (Cervicitis)
• Nature and type of discharge:
quantity, colour, odor:
• Yellowish discharge with bad
odour
• Burning while passing urine,
increased frequency
• Risk factors include:
• Younger than 21 years
Treatment: KIT 1 • Not married
Tab. Azithromycin 1gm • Multiple (more than one) sex
single dose partners in the last three months
+ • A new partner in the last three
Tab. Cefixime 400 mg months
• Current sex partner has a STI
single dose
• Recent use of condoms by the
partner
 Painful Scrotal Swelling
• Swelling and pain in the
scrotal swelling
• Pain or burning while
passing urine
• Systemic symptoms like
malaise, fever
• History of urethral
discharge

Treatment: KIT 1
• Tab. Azithromycin 1gm , single dose
+
• Tab. Cefixime 400 mg , single dose
 Vaginal Discharge Syndrome
• Vaginal discharge-cheesy white
• Assess :
• - quantity,
• - colour,
• - odor of discharge
• Itching around genitalia

Treatment: KIT 2
Tab. Secnidazole 1G , two tablets stat
+
Tab. Fluconazole 150 mg, single dose
Genital ulcer: Non Herpetic
Genital Ulcer; single or multiple;
painful or painless
Burning sensation in the genital area
Burning sensation in the genital area
Enlarged inguinal lymph nodes

Treatment: KIT 3
Inj. Benzathine Penicillin 2.4 MU given IM after sensitivity test
+
Tab. Azithromycin 1gm, single dose
 Genital ulcer: Non Herpetic

If Patient allergic to Penicillin:

Use KIT 4
Doxycycline 100 mg bid X 15
days
+
Tab. Azithromycin 1gm , single
dose
 Genital ulcer: Herpetic

Eruption of vesicles, painful, multiple genital ulcer

Burning sensation in the genital area
Recurrence is common

Treatment: KIT 5
Tab. Acyclovir 400 mg tds X 7 days
 Lower Abdominal Pain
Common symptoms/signs of Lower Abdominal Pain
• Fever
• Vaginal discharge
• Menstrual irregularities like heavy, irregular vaginal
bleeding
• Dysmenorrhoea, dyspareunia, dysuria, tenesmus
• Low backache
• Cervical motion tenderness
Treatment: KIT 6
Tab. Cefixime 400 mg single dose
+
Tab. Metronidazole 400 mg bid X 14 days
+
Tab. Doxycycline 100 mg bid X 14 days
 Inguinal Bubo
Treatment: KIT-7
Tab Doxycycline 100 mg
bid X 21 days
+
Tab. Azithromycin 1gm
single dose

Swelling in inguinal region, which may be painful

Preceding history of genital ulcer or discharge
Systemic symptoms like malaise, fever
 Syndromic Case Management
• Medical treatment
• Follow-up: Return in 7 days, if symptoms persist
• Partner treatment-STIs need partner/s treatment (even if partner is asymptomatic)
while RTI doesn’t require partner treatment unless partner is symptomatic
• Rule out other STIs
• Voluntary HIV test and counselling
• Counselling & education
• Safe sex
• Risk reduction
• Behavior modification
• Condom promotion and provision
• Proper documentation of STIs
• Regular screening for Hepatitis B and Hepatitis C
 Syphilis in PLHIV
• Although Syphilis is uncommon in PLHIV, unusual serologic responses have been
observed among PLHIV, who have syphilis
• Neuro-syphilis should be considered in the differential diagnosis of PLHIV with
neurological manifestations
• PLHIV should be evaluated clinically and serologically for treatment failure at 6, 9, 12
& 24 months after therapy
• CSF examination and retreatment also should be considered for persons whose non-
treponemal test titres do not decrease four fold within 6-12 months of therapy
 Anogenital warts
Causative Organism: Human Papilloma Virus (HPV)
Clinical features: Single or multiple soft, painless, pink in colour, “cauliflower” like
growths which appear around the anus, vulvo-vaginal area, penis, urethra, and
perineum.
• Warts could appear in other forms such as papules which may be keratinized.
• Most of the small warts disappear after initiation of ART, as the immunity improves
Differential diagnosis
• Condyloma lata of syphilis
• Molluscum contagiosum
Diagnosis: Based on clinical assessment.
 Anogenital warts

Anti-retroviral Therapy- most small warts disappear spontaneously as the immunity improves
Treatment of Large Warts:
• Chemical cauterization- 20% Podophyllin in compound tincture of benzoin
• Cryotherapy with liquid nitrogen, solid carbon dioxide or cryoprobe.
• Electrocautery
• Surgical excision
NACO Guidelines on Prevention, Management and Control of Reproductive Tract Infections and Sexually Transmitted Infections, July 2014
Key counselling messages to patients with HPV infection
• Genital HPV infection is very common.
• Many types of HPV are spread through genital contact, during vaginal and anal sexual
contact. HPV can also be spread by oral sexual contact.
• Usually HPV infection clears spontaneously, some infections do progress to genital warts,
pre-cancers, and cancers.
• The types of HPV that cause genital warts are different from the types that can cause
anogenital cancers.
• HPV vaccines are available, which offer protection against the HPV types that cause
cervical cancer and genital warts.
• Persons with genital warts should refrain from sexual activity until the warts are gone or
removed.
 Molluscum contagiosum

Causative Organism: Pox virus. Facial molluscum lesions are one of the HIV defining
criteria.
Clinical features: Multiple, smooth, glistening, globular papules of varying size from a
pinhead to a split pea can appear anywhere on the body.
• Sexually transmitted lesions on or around genitals can be seen.
• Lesions are not painful except when secondary infection sets in.
• When the lesions are squeezed, a cheesy material comes out.
Diagnosis: Diagnosis is based on the above clinical features.
Treatment
• Individual lesions usually regress without treatment in 9-12 months.
• Needling followed by Chemical Cautery with 25% phenol solution or 30% trichloro-
aceticacid.
 Ectoparasitic infections : Pediculosis pubis
Causative Organism: Lice - Phthirus pubis
Clinical features: There may be small red papules with a tiny central clot caused by lice
irritation.
• General or local urticaria with skin thickening may or may not be present.
• Eczema and impetigo may be present.
Treatment: Recommended regimen:
• Permethrin 1% crème rinse applied to affected areas and washed off after 10 minutes.
Special instructions:
• Retreatment is indicated after 7 days if lice are found or eggs observed at the hair-skin
junction.
• Clothing or bed linen that may have been contaminated by the client should be washed
and sun dried or dry cleaned.
 Ectoparasitic infections : Scabies
Causative Organism: Mite - Sarcoptes scabiei.
Clinical features:
• Severe pruritis (itching) is experienced by the client, which becomes worse at night.

• Other members of family also affected

• Sexual transmission to the partner, other members may get infected through contact
with infected clothes, linen or towels).
Complications
• Eczematisation with or without secondary infection

• Urticaria
REF: NACO Guidelines on Prevention, Management and Control of Reproductive Tract Infections and Sexually
Transmitted Infections, July 2014
 Scabies
Treatment
• Permethrin cream (5%) applied to all areas of the body from the neck down and washed
off after 8 - 14 hours.
• Benzyl benzoate 25% lotion, to be applied all over the body, below the neck, after a bath,
for two consecutive nights. Patient should bathe in the morning, and have a change of
clothing.

Special instructions
• Clothing or bed linen that have been used by the patient should be thoroughly washed
and dried well in the sun.
• Family members and Sexual partner must also be treated along the same lines at the
same time.
 Norwegian scabies
• Crusted scabies, also called Norwegian scabies is an infestation characterized by thick
crusts of skin that contain large numbers of scabies mites and eggs.
• It is a severe form of scabies occurs in people who have a weakened immune system

• Treatment of crusted scabies can require oral medications along with multiple
applications of a scabicide cream
• Norwegian scabies is treated with topical permethrin cream and the
oral medication ivermectin
• Safety of Ivermectin in children weighing less than 15 kg and pregnant women not
established.
• Dose of Ivermectin: Oral drug 200 ug/kg single dose and repeat dose after 2 weeks
 STI Control Objectives
• Interrupt the transmission of STIs

• Prevent complication and sequelae of STIs

• Reduce HIV infection risk

• Proven in the Mwanza trial

Source: Grosskurth H, Mosha F, Todd J, et al. Impact of improved

treatment of sexually transmitted diseases on HIV infection in rural
Tanzania: randomised controlled trial. Lancet 1995;346:530–536.
 Components of STI Control and Prevention

1. Cure with treatment

2. Compliance to treatment

3. Contact tracing for partner management

4. Counseling for behavior change & education on safer sexual practices

5. Condom promotion & provision

6. Clinical follow-up
Prevention of STI/RTIs
 Condom promotion program
Condom promotion is one of key prevention strategies of NACP IV
• Increase condom use as a barrier protection

• Increase the number of condoms distributed by social marketing programmes

• Increase the number of free condoms distributed through STI and STD clinics

• Increase access to condoms, especially to MSM

• Increase the number of commercial condoms sold

• Increase the number of outlets in strategically located hotspots of solicitation

For further information on NACO’s condom promotion program, visit http://naco.gov.in/condom-
promotion-programme
Role of male circumcision in preventing HIV transmission*

• Male circumcision provides an important way of reducing the spread of HIV

infection in sub-Saharan Africa.

• According to an important study, Male circumcision provides up to 60% protection

against acquiring HIV infection (95% CI: 32%-76%).

*Bertran et al 2005
Why the foreskin is more prone for HIV infection?
• Contains more accessible HIV-1 target cells (CD4+ T cells, macrophages and Langerhans
cells)
• The Langerhans cells in the foreskin are closer to the epithelial surface, and are the first
to be infected by HIV
• Inner mucosal surface of the foreskin shows greater infectivity than that of cervical
tissue, which is a known primary site of HIV-1 acquisition in women
• increased risk of genital ulcer diseases

Patterson et al, Am J Pathol. 2002 September; 161: 867–873

 Key Messages
• Every symptom of private parts is not a STI/RTI

• STI/RTI increases risk of HIV transmission

• Chronic, severe, resistant and atypical lesions are common presentations in HIV

• STI/RTI if untreated or partially treated can cause many complications

• The Syndromic Case Management approach provides a great advantage in the

management of STI/RTI, as it benefits both the individual & the community
• Condom promotion is one of key prevention strategies of NACP IV

• These conditions warrant that the ART Medical Officers, should examine Genital &
Ano-rectal areas especially in key populations
Thank You