RTI/STI MANAGEMENT AND PREVENTION Dr RTI/STI MANAGEMENT AND PREVENTION Dr. Dilip Kumar Das Community Medicine

Public Health Importance of RTIs/STIs

What is RTI/STI ? Reproductive Tract Infections (RTIs): Any infection of reproductive tract in male and female Sexually Transmitted Infections (STIs): STIs are infections caused by germs such as bacteria, viruses, or protozoa that are passed from one person to another through sexual contact.

RTIs RTIs in both men and women include: RTIs in women also include: - STIs RTIs in women also include: - Disruption of normal vaginal flora (Candida and bacterial vaginosis) - Postpartum and post abortion infections - Infections following procedures (e.g. IUD insertion) RTIs in men also include: - Prostatitis and epididymitis

Situation in world 340 million new cases of curative STIs every year - 75-85% in developing countries - 10 % adults newly infected with curable STIs 12 million new cases of syphilis 62 million new cases of gonorrhoea 90 million new cases of chlamydia 176 million new cases of trichomonas

Situation in India Prevalence of suggestive symptoms of STIs Women: 23-43% Men: 4-9% STI clinic data for men indicates: Syphilis: 12.6 – 57% Chlamydia: 20-30% Chancroid: 9.9 -34.7% Gonorrhoea: 8.5 – 23.9% Overall prevalence of STIs among adults: 6 %

Factor contributing to RTI/STI spread Human behaviour Lack of access to healthcare Lack of awareness about STIs Migrating population Healthcare providers not adequately trained Poor medical services Hygiene and environmental factors Hormonal and other factors

High risk groups Adolescent boys and girls Women who have multiple partners Sex workers and their clients Men and women who has to stay away from families for long Men having sex with men Partners of various high risk groups Street children

Factors increasing risk of transmission Biological - Age - Sex - Immune status Behavioural - Personal sexual behaviour - Other non-sexual personal behaviour - Even without any risk behaviour Social - Status of women in society - Sexual violence - Child marriages

Why women are at a higher risk? Biological differences -Thin lining of vaginal mucosa - Larger exposed area - Genital fluids stay in contact for longer time - Young women- Immature genital tract - Symptoms less reliable indicator Use of vaginal douches Different socio-cultural norms for men and women

STI – HIV Link

RTIs/STIs – A Public Health Problem Major cause of ill health in country Cause serious complications in men and women Increases risk of HIV transmission Responsible for reproductive loss Increases cost to health system

Barriers – system and providers side Failure to recognize magnitude Not all seek treatment form trained providers Overemphasis on lab based diagnosis Irrational use of drugs No standardized treatment regimen by all providers Less emphasis on patient education and counseling Specialized clinics carry stigma

Barriers – Client side Lack of knowledge Misconceptions Asymptomatic infections Reluctance to discuss sexual matters Stigma Fear of judgmental attitude of providers Reluctance for physical examination

Problems in management of RTIs/STIs Piot – Fransen model

Operational model of the role of health services in STI case management Population with STI Aware and worried Seeking care Correct diagnosis Correct treatment Cure Treatment completed Promotion of health care seeking behaviour Improve quality of care Attitudes of personnel

Operational model of the role of health services in STI case management Population with STI Aware and worried Seeking care Correct diagnosis Correct treatment Cure Treatment completed Syndromic approach Include STI drugs in essential list Prescribe single dose Counsel about compliance

Operational model of the role of health services in STI case management Population with STI Aware and worried asymptomatic STI Seeking care Correct diagnosis Partner notification Case finding Screening Selective mass treatment Correct treatment Treatment completed Cure

Common RTIs/STIs and their Complications Module 3 Common RTIs/STIs and their Complications

Common sites for RTIs/STIs

Common RTIs/STIs Male and female - Scabies - Gonorrhoea - Pubic lice - Chlamydia - Molluscum contagiosum - Syphilis - Chancroid Only in females - Genital herpes - PID - Lymphogranuloma venerium - Bacterial vaginosis - Trichomonas - Genital warts Only in males - Candidiasis - Epidydimitis/Orchitis - HIV - HBV

Symptoms and signs of RTIs/STIs in Men Urethral discharge Burning or pain during micturition or urination. Genital itching Inguinal swelling/Scrotal swelling /swollen and painful testes Blisters or ulcers on the genitals, anus, mouth, lips Itching or tingling in genital area. Warts on genitals, anus or surrounding area. Fever, body ache, muscle ache, jaundice.

Symptoms and signs of RTIs/STIs in Women Unusual vaginal discharge Genital itching Abnormal and/or heavy vaginal bleeding Dyspareunia Lower abdominal pain Blisters/ulcers on the genitals, anus, mouth, lips Burning micturition Itching or tingling in genital area. Warts on genitals, anus or surrounding area. Fever, body ache, muscle ache, jaundice.

Ways of classifying RTIs/STIs According to causative organisms According to modes of transmission According to most common presenting symptoms

According to causative organisms Bacterial: - Gonorrhoea, Chlamydia, syphilis Viral: - Herpes, HPV, HIV Protozoal: - Trichomonas Fungal: - Candidiasis Mixed: - PID, epididymitis

According to modes of transmission Endogenous infection: - yeast infection, vaginosis Sexually Transmitted Infections: - Gonorrhoea, chlamydia, syphilis Iatrogenic Infections: - PID following abortion or transcervical procedure

Complications in Men Urethral stricture Phimosis/paraphimosis Disfigurement of genitals Infertility Cardiovascular complications (syphilis) Neurosyphilis

Complications in Women Pelvic Inflammatory Disease (PID) Infertility Ectopic pregnancy Spontaneous abortions Stillbirths Low birth weight babies Increased susceptibility to opportunistic infections Cervical cancer Chronic pelvic pain

Complications in neonates Congenital eye infections – Syphilis, chlamydia, gonorrhoea Sepsis Arthritis Meningitis Infant pnumonias Mental retardation

Systemic infections Gastrointestinal: Proctitis, proctocolitis Renal: Acute membranous granulonephritis Neurological: GPI, Tabes dorsalis Cardiovascular: Myocarditis, aortitis Ophthalmic: Iritis, coroidoretinitis Musculoskeletal: Osteomyelitis, arthritis Septicemia

Approaches for RTI/STI Management Module 4 Approaches for RTI/STI Management

RTI/STI Case Management Correctly diagnosing and treating symptomatic patients. Providing patient education and partner management. Preventing re-infection

Steps in Clinical Case Management History taking Clinical examination Laboratory tests Diagnosis Treatment Advice and counseling Follow up

Approaches to RTI/STI Case Management Traditional clinical approach Laboratory assisted approach Syndromic approach

Traditional Clinical Approaches: Advantages Simple Inexpensive Can be used in any settings Immediate diagnosis. Immediate treatment. No lab expense.

Traditional Clinical Approach : Limitations Diagnosis is often incorrect or incomplete (especially in mixed infections). More than one STI is often present at the same time- focus is on diagnosing a single cause. Asymptomatic infections could not be diagnosed.

Lab-Assisted Approach Advantages Exact diagnosis using laboratory tests. Avoids over-treatment. Avoids wrong treatment. May avoid antibiotic resistance. Avoids the negative consequences Asymptomatic infections can also be detected.

Lab-Assisted Approach Limitations Expensive. Trained laboratory technicians are needed. Infrastructure and supplies are needed. Patient must return for test results. Patient must wait for treatment.

Syndromic Approach Diagnosis is based on the identification of syndromes, which are combinations of the symptoms the client reports and the signs the health care provider observes. The provision of the most effective therapy at patient’s first contact with a health or medical facility. The recommended treatments are effective for all the diseases that could cause the identified syndrome. Provides single dose treatment as far as possible Comprehensive to include patient education on risk reduction, counseling, condom promotion and provision, partner notification, follow up.

Syndromic Management- Advantages Fast—the patient is diagnosed and treated in one visit. Highly effective for most of the syndromes. Relatively inexpensive since it avoids use of laboratory. No need for patient to return for lab results. All possible STIs are treated at once. Scientifically tested in many part of the world. Easy for health workers to learn and practice for patients. Integrated into primary health care services more easily. Can be used by providers at all levels.

Syndromic Management- Limitations Not useful in asymptomatic individuals. Over-treatment in patient with one STI that causes a syndrome. Financial cost of over-treatment, side- effects. Increases potential for antibiotic resistance especially if full course not completed. Not effective in some cases such as vaginal discharge

The Syndromes Urethral discharge Vaginal discharge Genital ulcer non-herpetic Genital ulcer herpetic Lower abdominal pain Inguinal bubo Scrotal swelling

To sum up ……… Syndromic management is a scientific and proven approach. Syndromic approach does not deny use of lab tests, it can supplement the approach (Enhanced syndromic approach). This approach ensures correct and complete treatment of all most common organisms responsible for a particular syndrome. Syndromic management goes beyond pharmaceutical treatment to include client education and counseling. The clinical skills of a doctor are well utilized in syndromic approach.

Syndromic Management Flowcharts Module 4 Syndromic Management Flowcharts

Using Flow Charts Determine the clinical problem Pick up appropriate flow chart by looking at the clinical problem box at the top Take history Perform clinical examination Make decisions based on history and clinical examination – choosing “yes” or “no” Followed by more boxes to consider and make choices Follow the arrows No skipping of steps One step at a time until you reach the end of the branch Each exit path leads to action box - how to manage the case

Painful scrotal swelling confirmed Man complains of scrotal swelling and pain Painful scrotal swelling confirmed Treatment for Gonorrhoea and Chlamydia. Patient Education, counselling Provide and promote condom Partner management Testes rotated/ elevated or history of trauma Refer immediately for a surgical opinion Take history & examine Testes normal. No history of trauma Cured Return in 7 days if symptoms persist No improvement Refer to higher care center

Why Syndromic Management? Simple Treatment at first visit Treatment for all common causative organisms Standardized at all sites Patient education, an integral part

Criteria for Selection of Drugs High efficacy (at least 95%) Low cost Acceptable toxicity and tolerance Organism resistance unlikely to develop or likely to be delayed Single dose Oral administration Not contraindicated for pregnant or lactating women

To sum up …………….. The drugs use in syndromic management are chosen based on scientific criteria Syndromic management is a comprehensive approach which includes: Treatment of index client Treatment of partners Risk reduction Client education and counseling Referral, as necessary

History Taking and Risk Assessment Module 6 History Taking and Risk Assessment

Goals of history taking for RTIs/STIs Make an accurate and efficient syndromic diagnosis Establish the client’s risk of transmitting and contracting RTIs/STIs Find out about partners who may have been infected

Pre-requisites for good history taking Privacy Confidentiality Good verbal and non-verbal communication skills Unbiased/non-judgmental attitude of provider Patient- friendly atmosphere

Sexual history Currently active sexually Current partners New partners in last 3 months Risky sexual and other behaviour

Risk assessment Why risk assessment? Risk assessment is a process of confidentially asking a patient particular questions to determine his or her chance of contracting or transmitting a RTI/STI (e.g. many women may be at risk due to the behavior of their husbands or partners). Why risk assessment? To determine RTI/STI treatment To tailor patient education messages Determine need for lab test Determine need for specific referrals (ICTC)

Clinical Examination in RTI/STI Clients Module 7 Clinical Examination in RTI/STI Clients

Why clinical examination is important? Confirmation of client’s symptoms Elicit signs to confirm symptoms Find out signs for something the patient is not complaining To arrive at a clinical dignosis

Pre-requisites for clinical examination Visual and auditory privacy Assistant of same sex that of client, if examining opposite sex Explain process to client (with pictorials/diagram) Take permission from client Well lit room Approach in a confident manner

Male Syndromes Scrotal Swelling Inguinal Bubo Genital Ulcer

Vaginal Discharge Syndrome SYNDROME: VAGINAL DISCHARGE VAGINITIS TRICHOMONIASIS CERVICAL HERPES CERVICITIS

Laboratory Tests for RTIs/STIs Module 8 Laboratory Tests for RTIs/STIs

Use of Lab in RTI/STI Control Screening and detection Screening asymptomatic in high risk population To diagnose single and mixed infections Improve diagnostic value of syndromic management Detection of infection in asymptomatic Epidemiological data – prevalence, incidence Testing for antimicrobial resistance Sentinel surveillance Accurate etiological diagnosis

Diagnostic tests for RTIs/STIs Microscopic examination: - Wet mount: Trichomoniasis, candida, bacterial vaginosis - Gram staining: Gonorrhoea, Bacterial vaginosis - Dark field: Syphilis Antigen detection: EIA for gonorrhoea and chlamydia Antibody test: EIA for Syphilis and HIV Vaginal pH : Bacterial vaginosis Culture: Trichomonous, Candida albicans, Chlamydia DNA detection DNA detection by amplified technique

Lab tests for detection of common RTIs/STIs Vaginal pH Wet mount microscopy Whiff test Gram stain microscopy Rapid Plasma Reagine (RPR) for syphilis

Limitations of laboratory tests Costly Time consuming Need trained manpower Need expensive equipment Delay in diagnosis and treatment Not all tests are high sensitivity and/or specificity

We must remember ……. Some simple lab tests can assist us enhancing the effectiveness of syndromic management. The doctors are expected to interpret the results of lab tests. Do not delay the syndromic treatment for the sake of laboratory results. Lab tests can be useful for specific diagnosis of the infections and for collecting epidemiological data.

Client Education and Counseling Module 9 Client Education and Counseling

Importance of Client Education and Counseling Better compliance to treatment if clients know the logic/reasons To reduce chance of re-infection To enable clients change behavior Satisfied clients return for other services too Satisfied clients refer others to health center

Goals of Client Education Help clients resolve current infection Prevent future infections Make sure sex partners are also treated and educated.

What Clients Needs to Know Prevention of RTIs/STIs - Risk reduction - Correctly and consistent use of condoms, availability - Limiting the number of partners - Alternatives to penetrative sex Information about RTIs/STIs - How they are spread between people - Consequences of RTIs/STIs - Links between RTIs/STIs and HIV - RTI/STI symptoms - what to look for

What Clients Needs to Know Cont… RTI/STI Treatment - How to take medications - Signs that call for a return visit to the clinic - Importance of partner referral and treatment - Acknowledge gender inequalities

Creating Opportunities for Client Education Use every place where client is likely to visit Use every interaction as an opportunity Use various media Reinforce consistent messages

Module 10 Partner Management

What is Partner Management ? Partner management is an activity in which the partners of those identified as having RTI/STI are located, informed of their potential risk of infection, and offered treatment and counseling services. Timely management is important because…….. Prevention of re-infection in index client/s Prevention of transmission in partner/s Timely treatment of symptomatic partners Identification of asymptomatic partners and their treatment

Approaches to Partner Management Referral by index clients: - Index clients inform partners - Does not involve extra person hence inexpensive - May include client-initiated therapy Referral by providers: - Providers approach partner/s through referral card - Needs extra staff and hence expensive

General principles of partner treatment Partners to be treated for same infections as index client. Provider should be reasonably sure of presence of STI, especially in vaginal discharge cases. Special care for PID cases due to serious complication. Call for follow up – for compliance/cure and to see test reports, if advised

Syndrome of index patient Treatment for partner/s Partner Treatment Syndrome of index patient Treatment for partner/s Urethral discharge Treat partner/s for gonorrhea and chlamydia Genital ulcer Treat partner/s for syphilis and chancroid Vaginal discharge: Patient treated for vaginitis and cervicitis Patient treated for vaginitis Not necessary for partners to be treated unless there is recurrent discharge Pelvic inflammatory disease Scrotal swelling Inguinal bubo Treat partner lymphogranuloma venereum Neonatal conjunctivitis Treat both parents for gonorrhea and chlamydia