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Lunch Hour Session

3 April 2008
Dr. Arvin C. Chaudhary
MBBS (Fiji) MSc in STI/HIV Medicine (UK)

Coordinator for Sexual Health, STI & HIV Medicine Western Health Service

Presentation Outline
• • • • Sexuality Overview STI Guidelines [interactive session] HIV [overview] Questions/Answer



STI Issues
• • • • • • • Early Age of first sex Too many sexual partners Wrong Knowledge and attitude Lack of employment, recreation Poverty Decline in morality, family values Opportunity

Problems associated with SEX
• Unwanted pregnancy • Sexually Transmitted Infections [STI] • HIV/AIDS • …and many more

Risky Behaviours Personal sexual behaviour
• • • • • • • • Personal sexual behaviour Changing sexual partner frequently Having sex with casual partners, sex workers or their clients Previous STI infection(s) in the past year Exchanging sex for money, goods or favours Exchanging sex for drugs, or drugs for sex Using vaginal drying agents Penile artifacts Other personal behaviours associated with risk • Skin-piercing • ° Alcohol or other drugs before or during sex • ° Blood transfusion Partner(s) behaviour • ° has sex with others • ° has STI • ° is HIV-positive • ° injects drugs • ° has sex with other men (male partner)

Protective Behaviours — Behaviours That Reduce Risk
• Limit number of sexual partners • Using condoms • Low-risk sexual activities for example, mutual masturbation

• • • •

Chronic abdominal pain Pelvic inflammatory disease (PID) Infertility Death due to sepsis, ectopic pregnancy or cervical cancer • Spontaneous abortion, stillbirth or perinatal death • Potentially blinding eye infections or pneumonia in infants • Increase risk of HIV

Principal Complications of STI Infections in Women and Children

Principal Consequences of STI Infections in Men
• Urethral stricture • Infertility • Increase risk of HIV

The syndromic approach to STI management
WHO Recommendations Background and introduction

Syndromic vs Clinical vs Etiological

Interactive Cases

What is it? How will you treat?

What is it? How will you treat?

Uncomplicated Anogenital Gonococcal Infection
• Recommended regime
– Amoxil 2.5g, Augmentin .625g Probenicid 1g or – Ciprofloxacin, 500mg orally, as a single dose or – Cefixime,400mg orally, as a single dose or – Ceftriaxone, 125 mg by intramuscular Injection, as a single dose

What is it? How will you treat?

Neonatal Gonococcal Conjunctivitis
• Recommended regimen
– Ceftriaxone, 50mg/kg I.M. injection, as a single dose, to a maximum of 75 mg or – Spectinomycin, 25mg/kg I.M. imjection, as a single dose, to a maximum of 75 mg (single dose of ceftraixone and kanamycin are of proven efficacy.The addition of tetracycline eye ointment to these regimen is of no documented benefit) Follow up- Patients should be reviewed after 48 hours

What is it? How will you treat?

Gonococcal Ophthalmia (adult)
• Recommended regimen:
– Ceftriaxone,125mg Intramuscular (I.M.) injection as a single dose or or – Ciprofloxacin, 500mg orally, as a single dose (this regimen is likely to be effective although there is no published data on its use in gonococcal ophthalmia)

What is it? How will you treat?

What is it? How will you treat?

Chlamydia Trachomatis Infection Uncomplicated Anogenital infection • Recommended regimen:
– Doxycycline, 100mg orally,twice daily for 7 days or – Azithromycin, 1g orally,in a single dose

• Alternative regimen:
– Erythromycin, 500mg orally, 4 times a day for 7 days

Chlamydia Trachomatis Infections
• Single dose Azithromycin 1g–as effective in achieving microbiological cure as a 7 day course of doxycycline. • Ciprofloxacin unlikely to be beneficial.

Chlamydial Infection During Pregnancy
• Recommended regimen;
– Erythromycin, 500mg orally, 4 times a day for 7 days or – Amoxycillin,500mg orally, three times a day for 7 days

Vaginal Discharge


Frothy, foul smelling copious discharge

Trichomonas Vaginalis
• Almost exclusively STI • May be asymptomatic • Presents with offensive vaginal discharge and vulval itching in women and uretheritis in men. • Sexual partners should be notified and treated. Advise against sexual intercourse until both treated.

Trichomonas Vaginalis
 Recommended regimen for vaginal infection:
–Metronidazole,2g orally, in a single dose or –Note: reported cure rate in women : 82-88% but may be increased to 95% if partners are treated simultaneously.  Alternative regimen: -metronidazole, 400mg or 500mg orally, twice daily for 7 days

Trichomonas Vaginalis
• Recommended regimen for uretheral Infections:
– Metronidazole, 400mg or 500mg orally, twice daily for 7 days

• Recommended regimen for neonatal Infections
– Metronidazole, 5mg/kg orally, 3 times daily for 5 days. Infants with symptomatic trichomoniasis or with urogenital colonisation persisting past 4 months of life should be treated with metronidazole.

Thick flowing discharge

Bacterial Vaginosis
• Clinical syndrome resulting from replacement of normal hydrogen peroxide-producing Lactobacillus sp. In the vagina by high concentrations of anaerobic bacteria, such as Gardnerella vaginalis & Mycoplasma hominis. • Cause of microbial alteration is not fully understood. • Endogenous reproductive tract infection/treatment of sexual partners has not been of demonstrated benefit.

Bacterial Vaginosis & surgical procedures
• Women with BV scheduled to undergo reproductive tract surgery or a therapeutic abortion should receive treatment with metronidazole. • Recommended regimen:
– Metronidazole,400 or 500mg orally, twice daily for 7 days (avoid taking alcohol 24 hours after the last dose)

Thick Curd like discharge

Vulvo-Vaginal Candidiasis
• Therapy- topical imidazoles (miconazole, clotrimazole, econazole,butaconazole,terconazole) or nystatin.Imidazoles more effective than nystatin and require shorter courses of treatment.

What is it? How will you treat?

Treatment Regimen for Syphilis
• Early Syphilis (primary) • Recommended regimen
– Benzathine benzyl penicillin, 2.4 million units by I.M. injection, at a single session. Because of
volume involved this dose is given as two injections at separate sites

• Alternative regimen
– Procaine benzylpenicillin, 1.2 million units by I.M. inj. For 10 consecutive days

Syphilis in Pregnancy
• Require close surveillance- detect possible re-infection after treatment has been given • Important to treat sexual partners • Pregnant (all stages) patients not allergic to penicillin should be treated with penicillin according to dosage schedules recommended for treatment of nonpregnant patients at similar stage of the disease

Treatment Regimen for Syphilis
Early Syphilis (primary ,secondary ,or latent of not more than 2 years duration)

• Alternative regimen for penicillin-allergic non-pregnant patients
– Doxycycline 100mg orally, twice daily for 14 days or

• Alternative regimen for penicillin-allergic pregnant patients
– Erythromycin,500mg orally, 4 times daily for 14 days

What is it? How will you treat?

Latent Syphilis VDRL/TPHA
• • • • • • • • • Reactive 1:1 1:2 1:4 1:8 1:16 1:32 1:64 1:128

Treatment Regimen for Secondary Syphilis Late Latent Syphilis
• Infection of more than 2 years duration without evidence of treponemal infection • Recommended regimen:
– Benzathine benzylpenicillin, 2.4 million units IU by I.M. injection, once weekly for 3 consecutive weeks.

• Alternative regimen:
– Procaine benzylpenicillin, 1.2 million IU by I.M. injection,once daily for 20 consecutive days

VDRL Follow-ups
• 3 Months after treatment • 6 Months • 1 Year

• Recommended regimen:
– Aqueous benzylpenicillin, 12-24 million IU by I.V. injection administered daily in doses of 2-4 million IU every 4 hours for 14 days

• Alternative regimen:
– Procaine benzyl penicillin, 1.2 million IU by I.M. Injection, once daily,& probenecid,500mg orally, 4 times daily, both for 10-14 days

• Alternative regimen for penicillin-allergic non-pregnant patients:
– Doxycycline, 200mg orally, twice daily for 30 days

• Note:
– Above treatment have not been evaluated. Although efficacy is not yet well documented, third generation cephalosporins may be useful in the treatment of neurosyhilis. – Exam. Of CSF is also highly desirable in all patients with syphilis of more than 2 years duration. Consult a neurologist.

Congenital Syphilis
Early congenital syphilis (up to 2 years age) & infants with abnormal CSF • Recommended regimen:
– Aqueous benzylpenicillin 100,000-150 000 IU/kg/day administered as 50,000 IU/kg/dose every 12 hours, during 7 days of life and every 8 hours thereafter for a total of 10 days. Or – Procaine benzylpenicillin, 50,000 IU/kg by IM injection, as a single daily dose for 10 days Note: Some experts treat all congenital syphilis as CSF findings were abnormal. Erythromycin is only recommended in cases of allergy to penicillin.

Congenital Syphilis of 2 or more years
• Recommended regimen:
– Aqueous benzylpenicillin, 200 000 – 300 000 IU/kg/day by I.V. or I.M. injection, administered as 50 000 IU/kg/dose every 4-6 hours for 10-14 days

• Alternative regimen for penicillin –allergic patient, after the first month of life:
– Erythromycin, 7.5-12.5 mg/kg orally, 4 times daily for 30 days.

Painful ulcers

• Recommended regimen:
– Ciprofloxacin, 500mg orally, twice daily for 3 days or – Azithromycin, 1g orally, as a single dose or – Erythromycin base, 500mg orally 4 times daily for 7 days [ some cases may require longer treatment than 14 days] (cpirofloxacin – contraindicated in pregnancy & breastfeeding) (erythromycin estolate- contraindicated in pregancy because of drug related hepatotoxicity ..only erythromycin base and erythromycin ethylsuccinate should be used)

What is it? How will you treat?

Treatment Options for Genital Herpes – recommended regimen
• For first clinical episode:
– Acyclovir , 200mg orally, 5 times daily for 7 days or – Acyclovir, 400mg orally 3 times daily for 7 days – The topical application does not do much

Genital Herpes Infection - recurrent infections
• Recommended regimen:
– Acyclovir, 200mg orally, 5 times daily for 5 days or – Acyclovir, 400mg orally, 3 times a day for 5 days or – Acyclovir, 800mg orally, twice daily for 5 days

Herpes in Pregnancy
• During the first clinical episode of genital herpes, treat with oral acyclovir • Vaginal delivery in woman who develop primary genital herpes shortly before delivery puts babies at risk for neonatal herpes. Careful history and exam serve as guide to need for caesarean section in mothers with genital herpes lesions • Recommended regimen for neonates: – Acyclovir, 10mg/kg I.V., 3 times a day for 10-21 days

Herpes and HIV Co-infection
• Deficient immunity-persistent &/or sever mucocutaneous ulcerations may occur, often involving large areas of perianal, scrotal or penile skin. Lesions-painful & atypical. • Natural History of herpes may be altered • Respond to acyclovir but dose may have to be increased and treatment given for longer than standard recommended period. • Patients may benefit from chronic suppresive therapy

Herpes and HIV Co-infection
• Recommended regimen for severe disease: acyclovir, 5-10 mg/kg IV, every 8 hours for 5-7 days until clinical resolution is attained • Recommended regimen for severe herpes lesions with co-infection with HIV
– Acyclovir, 400mg orally, 3-5 times daily until clinical resolution is attained

Suppressive Therapy
• Reduces the frequency of genital herpes recurrences by more than 75% among patients who have frequent recurrences(6 or more recurrences per year). Safety demonstrated for daily acyclovir therapy for 6 years • Suppressive therapy with acyclovir reduces, but does not eliminate asymptomatic viral shedding.

Suppressive Therapy
• Recommended regimen for suppressive therapy:
– Acyclovir, 400mg orally, twice daily continuously

What is it? How will you treat?

What is it? How will you treat?

What is it? How will you treat?

Genital Warts – recommended regimen- chemical
• Self applied by patient:
– Podophyllin 0.5% solution or gel, twice daily for 3 days, followed by 4 days of no treatment, cycle repeated up to 4 times (total volume of podophyllin should not exceed 0.5 ml per day) or – Imiquimod 5 % cream [NOT available in FIJI] applied with a finger at bedtime, left overnight, 3 times a week as long as 16 weeks. The treatment area should be washed with soap and water 6-10 hours after application. Hands washed with soap & water immediately after application – * safety of both not established in pregnancy

Genital Warts – recommended regimen- chemical
• Provider administered:
– Podophyllin 10-25% in compound tincture benzoin, applied carefully to warts, avoiding normal tissue. External genital and perianal warts must be washed thoroughly after 1-4 hours after application of podophyllin. Should be allowed to dry before speculum removed. Repeated at weekly interval. – Use of podophyllin in pregnancy & lactation is contraindicated or – Trichloroacetic acid(TCA), applied carefully to warts followed by powdering of treated area with talc or sodium bicarbonate to remove acid. Repeat weekly.

Genital Warts - Physical
• Cryotherapy with liquid nitrogen, solid carbondioxide or a cryoprobe. Repeat applications every 1-2 weeks or • Electrosurgery or • Surgical removal

What is it? How will you treat?

What is it?

Pubic Lice (Phthirus pubis)
• Recommended regimen:
– Lindane 1% lotion or cream-rubbed gently but thoroughly into infested area and adjacent hairy areas & washed off after 8 hours. or – Pyrethrins– applied to infested area and adjacent hairy areas& washed off after 10 minutes; retreatment indicated after 7 days if lice are found or eggs are observed at hair-skin junction. – Clothing & bed linen that may have been contaminated by patient in two days prior to start of treatment should be washed and dried well , or dry cleaned

What is it?



Scabies causing eczema-like hand condition

Treatment of Scabies in Adults, Adolescents and older children
• Lindane 1% lotion or cream- apply thinly to all areas of the body from neck down and washed off thoroughly after 8 hours or • Permethrin cream 5 % or • Benzyl benzoate 255 lotion, applied to entire body from neck down,nightly for two nights; patients may bath before reapplying the drug and should bathe 24 hours after the final application or NB : Lindane is not recommended for pregnant and lactating women Resistance to lindane has been reported in some areas.

Treatment of Scabies:
in infants, children <10 years, pregnant and lactating women

• Recommended regimen:
– Permethrin 5% cream, applied in the same way as sulphur regimen described above

Uretheral Discharge SYNDROME

Uretheral Discharge
• Pathogens
– Neisseria Gonorrhoea (gonococci) – Chlamydia trachomatis (chlamydia)

• Syndromic treatment
– therapy for uncomplicated gonorrhoea plus – Therapy for chlamydia

Persistent or Recurrent Uretheral Discharge
• May result from :
– Poor compliance to treatment – Drug resistance – Re-infection – Other co-infection – (Trichomonas Vaginalis)

Vaginal Discharge SYNDROME

Vaginal Discharge
• Symptom of abnormal vaginal discharge is highly indicative of vaginal infection but poorly predictive of cervical infection • All women presenting with vaginal discharge should receive treatment for trichomonas and Bacterial Vaginosis • Among women presenting with vaginal discharge, one can attempt to identify those with increased likelihood of being infected with Neisseria gonorrhoea &/or Chlamydia trachomatis

Vaginal Discharge
• Assessment of woman’s risk status may be useful to determine cervicitis – (gram stain in referral clinic – GC & T. vaginalis) – Local prevalence of GC & CT in women presenting with vaginal discharge is important when making the decision to treat for cervical infection. Higher the prevalence the stronger the justification for treatment – Woman with vaginal discharge and positive risk assessment should therefore be offered treatment for gonococcal and Chlamydial infection

Vaginal Discharge Summary
• Vaginal Discharge VAGINITIS • Trichomonas • Bacterial vaginosis • Candidiasis • Cervical Discharge CERVICITIS • Gonococcal • Chlamydial

Lower Abdominal Pain SYNDROME

Lower Abdominal Pain (LAP)
• All sexually active women presenting with LAP should be carefully evaluated for the presence of salpingitis &/or endometritis – elements of pelvic inflammatory disease (PID) • All women with presumptive STI should have routine bimanual & abdominal examination since some women with PID will be asymptomatic • Endometritis- vaginal discharge +/-bleeding &/or uterine tenderness on pelvic examination • PID – abdominal pain, dyspareunia,vaginal discharge, menometorrhagia, dysuria, fever, and sometimes nausea and vomiting

Pelvic inflammatory Disease (PID) • PID is inflammation and infection of the upper genital tract in women, typically involving fallopian tubes, ovaries, and surrounding structures • Difficult to diagnose because of varied clinical manifestations

• PID becomes highly probable when one or more of symptoms described earlier are seen in woman with adnexal tenderness, evidence of lower genital tract infection and cervical motion tenderness. Enlargement or induration of one or both fallopian tubes , a tender pelvic mass, and direct or rebound tenderness may also be present. Patients temperature may be elevated but is normal in many cases. • Clinicians should err on overdiagnosing and treating suspected cases

PID – etiological agents
• Neisseria Gonorrhoea • Chlamydia trachomatis • Anaerobes ( bacteroides spp., gram positive cocci) • Facultative gram negative rods • Mycoplasma hominis * Impossible to differentiate clinically & precise microbiological diagnosis is difficult, the treatment regimen must be effective against this broad range of pathogens

Pelvic Inflammatory disease (PID) hospitalisation considered:
• Diagnosis uncertain • Surgical emergencies (appendicitis, ectopic pregnancy) cannot be excluded; • A pelvic abscess suspected • Severe illness precludes management on an outpatient basis • The patient is pregnant • Patient is unable to follow or tolerate the outpatient regimen or • The patient failed to respond to outpatient therapy

Outpatient Therapy - LAP
• Recommended regimen: – Single dose therapy for uncomplicated gonorrhoeaceftriaxone (other single dose regimen have not been formally evaluated) plus – Doxycycline 100mg twice daily or tetracycline 500mg orally, 4 times daily for 14 days plus – Metronidazole, 400-500mg, twice daily for 14 days
NB. Patients taking metronidazole should be cautioned from taking alcohol Tetracyclines are contraindicated in pregnancy

Outpatient Therapy - LAP
• Adjuncts to therapy : removal of intrauterine device (IUD)
– If PID should occur with an IUD in place, treat the PID using appropriate antibiotics – There is no evidence that removal of the IUD provides any additional benefit – Thus, if the individual should wish to continue its use ,it need not be removed. – If she does not want to keep the IUD, removal is recommended after antimicrobial therapy has been commenced. – When IUD is removed contraceptive counselling is necessary Follow-up : Outpatients with PID should be followed up after 72 hours and admitted if their condition has not improved

Acquired Immune Deficiency Syndrome

What happened on Sept 11 in 2001?…

Consider this, which also happened on that day:
• 16000 people were diagnosed with HIV • 8600 people died of AIDS

How many pictures and front covers of magazines did you see that were devoted to the 9/11 tragedy?
How many have you seen that were dedicated to the people who make up the statistics you just saw?

The SARS virus claimed 500 lives in six months; HIV/AIDS kills 8600 people every single day.

AIDS definition

HIV in Fiji
• 259 • 59% males • 84% Fijians 41% females 12% Indians 4% Others

• 89% in income generating age
• 90% Sexual, 7% Peri-natal, 1% each BTF/IVDU/Unknown

• 94% Heterosexual 6% Homosexuals

• Indicators
– STIs – Age of First Sexual Intercourse – Total number of Sexual Partners – KAP

• Legislation • Lab Facility

HIV Transmission
• • • • • • • • • • Blood Tears X Saliva X Breast Milk Sweat X Semen Vaginal Fluid Urine X Mucus X CSF

Routes of Exposure and HIV Risk
• • • • • • Female to male Male to female Male to male Needle Stick Needle Sharing Mother to child (without AZT)
(with AZT)

• Blood Transfusion
SOURCE: The New England Journal of Medicine

1:700-1:3000 1:200-1:2000 1:10- 1:1600 1:200 1:150 1:4 <1:10 95:100


What does HIV do inside the body?

Normal response during infections

Infection by HIV

When HIV destroys most of the defenses…

CD4 and HIV Viral Load

Signs of HIV Infection

Ervin “Magic” Johnson - 1991

Greg Louganis - 1995

Tommy Morrison - 1996

Asymptomatic HIV
• No sign or symptoms for many years

Symptomatic Phase
• After 7-10 years later when ample damage is done to the CD4 cells, simple opportunistic infection begin to happen on and off for couple of months

First signs of HIV disease Fever

First signs of HIV Disease Headaches-forgetfulness

First signs of HIV disease Painless Lymph node swelling

Tinea infections


Seborrhic Dermatitis

Molluscum Contagiosum

Herpes Zoster

Pulmonary TB


Signs of Advanced HIV disease Weight loss > 10%

Other Symptomatic HIV Complexes (ARC)
• Unexplained diarrhea >1/12 • Night sweats • HIV Dementia

When the majority of the immune cells are destroyed, many other infections and cancer begin to invade the body and cause illness

AIDS Defining Illnesses
• Opportunistic Infections:
– – – – – – – – – – – – – – Cryptococcosis Toxoplasmosis HIV encaphalopathy Cytomegalovirus disease Esophageal Candidiasis PCP Extrapulmonary TB Invasive Cervical Cancer Herpes simplex ulcerations > 1/12 Kaposi sarcoma Lymphoma Non-typhoid salmonella septicemia Cryptosporidiosis diarrhea >1/12 MAC

Without proper management… AIDS is almost always… FATAL!

Dr. Arvin C. Chaudhary
MBBS (Fiji), MSc in STI/HIV Medicine (London)

Coordinator for Sexual Health, STI & HIV Medicine Western Health Service

– Anti-retroviral – Palliative – Multi-discipline approach

– According to guidelines

Anti-Retro Viral Therapy ARV
• HIV infected person may have millions of HIV particles in every ml of their blood. • The aim of treatment is to reduce the viral load to below 50 copies/ml (undetectable)

ARV- Mode of Action

CD4 and Viral load with ARV

Palliative Care
• Pain Management with effective analgesic • Provide emotional support- counseling • Provide spiritual support • Counsel family and corers • Prevent dehydration • Meet nutritional support

Answer is to:
• • • • • … don’t get it at the first place (ABCD) … Know your P.E.P … get tested to detect it in early stages … commence management early … stick to management

Thank You

• • • • • • • • •

WHO STI Treatment Guidelines British HIV Association (BHIVA) Guidelines for treatment of HIV infected adults with antiretroviral therapy. Dr. A. Poznial et al. London. United Kingdom. July 2003 Smith D. et al, ARV for HIV infection: Principles of use (Standard of Care Guidelines) HIV/AIDS Clinical Trials and Treatment Advisory Committee Booklet, Sydney, Australia, Oct 1997 Carpenter CCJ et al. ARV in Adults. Updated recommendations of the International AIDS Society-USA panel. JAMA 2000; 283:381-390 CDC Guidelines for the use of ARV in HIV infected Adults and Adolescents ( The Living Document) HIV/AIDS Treatment Information Service (ATIS) Apr 2001, Atlanta, GA. Prof. Michael Adler. ABC of AIDS, Fifth Edition. 2004. University College London. BMJ Books HIV/AIDS Care and Treatment: Guide for implementation, WHO December 2004
Nam booklet, Information series for HIV positive people

• • • •

Anti-HIV Drugs HIV Drugs HIV Therapy Adherence

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