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

2. Public Health Importance of RTIs/STIs

3. 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.

4. 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

5. Situation in world 340 million new cases of curative STIs every year
% 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

6. 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: %
Gonorrhoea: 8.5 – 23.9%
Overall prevalence of STIs among adults: 6 %

7. 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

8. 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

9. 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

10. 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

11. STI – HIV Link

12. 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

13. 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

14. 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

15. Problems in management of RTIs/STIs Piot – Fransen model

16. 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

17. 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

18. 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

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

20. Common sites for RTIs/STIs

21. 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

22. 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.

23. 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.

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

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

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

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

28. 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

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

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

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

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

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

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

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

36. 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.

37. 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.

38. 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.

39. 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.

40. 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.

41. 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

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

43. 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.

44. Syndromic Management Flowcharts
Module 4
Syndromic Management Flowcharts

45. 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

46. 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

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

48. 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

49. 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

50. History Taking and Risk Assessment
Module 6
History Taking and Risk Assessment

51. 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

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

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

54. 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)

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

56. 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

57. 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

58. Male Syndromes Scrotal Swelling Inguinal Bubo Genital Ulcer

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

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

61. 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

62. 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

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

64. 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

65. 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.

66. Client Education and Counseling
Module 9
Client Education and Counseling

67. 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

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

69. 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

70. 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

71. 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

72. Module 10
Partner Management

73. 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

74. 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

75. 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

76. 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