1. Management of sexually transmitted infections Dr. Anupong Chitwarakorn Department of Disease Control Module 3 Sub module

2. Review of evidence of STD as co-factors in HIV transmission Intervention studies : STD control reduce HIV incidence Principles and strategies of STD control program in developing countries Content

3. presence of STD : increase viral load in genital secretion presence of STD : increase HIV susceptibility, disrupture of epithelium cell Review of evidence of STD as cofactors in HIV transmission Biological evidence

4. ( % ) of pt. with HIV shedding Association of STD and cervico – vaginal HIV shedding

5. Relationship between genital HIV shedding, presence of infections and clinical signs. no pus pus

6. Median concentration of HIV – 1 RNA in semen among 104 men with and without urethritis (Malawi) X 10 4 copies / ml

7. STD increase HIV genital shedding Review of evidence of STD as cofactors in HIV transmission. * Biological evidence Cervico-vaginal secretion muco – purulent cervicitis cervical ulcer vaginal ulcer increased leucocytes N.gonorrhoeae Chlamydia Semen Urethritis genital ulcer - increased leucocytes N.gonorrhoea -

8. Hypothetical model of impact of STD on HIV genital shedding in men 2 4 6 8 10 Log 10 copies STD Antibiotic therapy Seroconversio n AsymptomaticHIV progressionAIDS From ISSTDR, Seville 1997; M. Cohen, plenary presentation HIV RNA in blood plasma HIV RNA in semen

9. Study population STD RR Heterosexual men, Kenya genital ulcer 4.7 Heterosexual men, U.S.A. syphilis 1.5 - 2.2 Heterosexual men, U.S.A. herpes 4.4 Heterosexual women, Zaire gonorrhoea 3.5 chlamydia 3.2 trichomonas2.7 Heterosexual men, U.S.A. herpes 3.3 - 8.5 syphilis 8.4 - 8.5 Relative risk : STD as risk factors for HIV transmission

10. HIV incidence/100 py Before intervention 16.5 Basic strategy : monthly case finding 7.9 Intensive strategy : monthly case 5.5 finding using pelvic exam, and lab Intervention studies : STD case finding strategies among CSW in Abidjan

11. HIV incidence over 2 years in intervention and control communities in the Mwanza trial Establishment of STD reference centre in Mwanza town Training of HCW in syndromic approach, health education and condom promotion Regular supply of effective STD drugs through a separate disbribution system Regular supervisory visits to health centres Periodic visits to the villages by health educators to promote prompt attendance to health centres for symptomatic STD

12. HIV incidence over 2 years in intervention and control communities in the Mwanza trial 0 1 2 3 4 HIV incidence: 123456 intervention control Overall reduction of HIV: 42 % From Grosskurth et al., Lancet, 1995

13. STD group (7,871) Control clusters (7,256) Azithromycin 1 gm Mebendazole 100 mg Ciprofloxacin 250 mg Iron – foliate tablet Metronidazole 2 gm Low dose MTV Both groups were screened and treated for syphilis Result:STD prevalence was significantly reduce in intervention group No impact on HIV incidence Intervention studies : Mass treatment, Rakai, Uganda Mass treatment in 10 monthly intervals (15-59 yrs)

14. STD Control : Objectives To interrupt the transmission of STD (acquired infection) To prevent complication and sequelae To reduce HIV infection risk

15. Incidence of STDs in Thailand (1982-2001) First case of AIDS in 1984 100% condom initiated in 1989 100% condom completed in 1992

16. STD prevention and control: before 1989 Case finding Case treatment Case follow up Contact tracing Health education Control of CSW

17. 1.Health promotion : safer sex practice, condom use 2.Interventions among high risk behavioral groups 3.Adequate, effective STD case management 4.Integration between STD services and other programs : MCH, RH, ANC, etc 5.Increase awareness and improve health care seeking behavior 6.Case screening and specific prophylaxis programs Effective STD control program :Principle

18. Number of STD cases and condom use rate among male & CSW (1984-1998) male prostitute percent thousands Condom use rate - 100 - 75 - 50 - 25 - 0

19. No. of Gonorrheae in two private clinic in Bangkok 1989 - 1998 Clinic A Clinic B

20. Adequate, effective STD case management STD care services: accessible, acceptable and effective - Potential sources: public, private, informal sector - Quality improvement : national guideline, syndromic approach; drugs/condom supplies training Effective STD Control program

21. Integration/collaboration between STD control program and other programs : ANC, MCH, FP, RH, dermatology and other existing programs To enable early detection of STD and to provide more coverage STD service Effective STD Control program

22. National / local media campaigns Education for youth in / out of school Community initiatives (e.g. peer education/ clubs) Education in health facility waiting area Education as part of STD service Work place education programs Effective STD Control program Increase awareness and improve health care seeking behavior

23. Effective STD Control program Case screening and specific prophylaxis programs syphilis screening in pregnancy prophylaxis of opthalmia neonatorum

24. Supporting components STD surveillance system Training of health staffs Monitoring, evaluation and supervision Effective STD Control program

25. 1.Health promotion : safer sex practice, condom use 2. Interventions among high risk behavioral groups 3. Adequate, effective STD case management 4. Integration between STD services and other programs : MCH, RH, ANC, etc 5. Increase awareness and improve health care seeking behavior 6. Case screening and specific prophylaxis programs Effective STD control program :Principle

26. Operational model of the role of health services in STD case management Population with STD Aware and worried Seeking care Correct diagnosis Correct treatment Cure Treatment completed

27. Operational model of the role of health services in STD case management Population with STD 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

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

29. Clinical Diagnosis Approach Identify the STD causing symptoms based on clinical experience even experienced STD providers often misdiagnose STDs miss mixed infections difficult for surveillance

30. Etiologic Diagnosis Approach Identify the organism causing the symptoms with laboratory tests and microscopy tests can be time consuming and expensive e.g. cultures cost $12 - $40 & take up to six days even rapid tests (RPR) require equipment to obtain and separate venous blood dependent technician & lab accuracy

31. Action action Symptom Decision Syndromic Diagnosis Approach Identify all possible STDs that could cause syndrome and give recommended treatment based on epidemiologic and laboratory data Immediate treatment decrease transmission decrease complications Can do syndrome surveillance Need to weigh the ability to treat as many infected as possible (sensitivity) with the risks of overtreatment (specificity) resistance & stigma

32. Oops! I was supposed to... THE SUPPOSED TO … APPROACH RPR

33. Patient complains of urethral discharge or dysuria Take history and Examine. Milk urethra if necessary Discharge confirmed ? Ulcer(s) present? No Yes Use appropriate flow chart No Yes Urethral discharge Educate and counsel Promote and provide condoms Depending on counselling capabilities offer HIV testing Treat for gonorrhoea and chlamydia Educate Counsel if needed Promote and provide condoms Depending on counselling capabilities offer HIV testing Partner management Advise to return in 7 days if symptoms persist Figure 1

34. Patient complains of genital sore or ulcer Take history and examine Sore/Ulcer/Vesi cle present? Educate and counsel Promote and provide condoms Depending on counselling capabilities offer HIV testing Treat for syphilis and chancroid Educate Counsel on risk reduction Promote and /provide condoms Depending on counselling capabilities offer HIV testing Partner management Advise to return in 7 days Yes No Genital ulcers Vesicles or small ulcers with history of recurrent vesicles? No Yes Clinical deterioration, or no improvement after one week? Management of herpes Educate Counsel on risk reduction Promote and provide condoms Depending on counselling capabilities offer HIV testing : Needs adaptation to local epidemiological situation Figure 3

35. What proportion of STD is asymptomatic? Incidence studies l 2% of incident infections with gonorrhoea remained asymptomatic for at least 2 weeks (Harrison et al., New England Journal of Medicine, 1979) Prevalence studies l Screening pregnant women (GC/CT)40% l Screening FP clinic attenders (GC)80% l Male contact of clinical cases (GC)29% l Male contacts of cases detected 76% through screening (GC)

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

37. Where STD control is likely to have a maximum impact In settings with high prevalence of “ relevant ” STD (GUD, urethritis and cervicitis) l Low quality of STD services l At the earlier stages of the HIV epidemic It is NOT A MAGIC BULLET, but an essential component of a package of multiple HIV prevention strategies

38. STI.PAC Advocate for STD inclusion in the health care agenda Assess The epidemic and the response Strengthen STD activities Integrate STD prevention and care Evaluate interventions The 5 elements

39. Thank you See you in Bangkok Word AIDS Conference 11-16 July,2004