Management of Sexually Transmitted Infections

Treatment of STDs / STIs

For all these conditions (except vaginitis) the sexual partner(s) of patients should also be examined for STI and promptly treated for the same condition(s) as the index patient.

Successful management of STI requires that staff are respectful of patients and are not judgmental. Examination is done in appropriate surroundings where privacy can be ensured and confidentiality guaranteed.

Urethral discharge

The major pathogens causing urethral discharge are N. gonorrhoeae and Chlamydia trachomatis (C. trachomatis). In the syndromic management, treatment of a patient with urethral discharge should adequately cover these two organisms. Where reliable laboratory facilities are available, a distinction may be made between the two organisms and specific treatment instituted.

Persistent or recurrent urethral discharge

There is new evidence suggesting high prevalence of TV in men with urethral discharge in some geographical settings. Where symptoms persist or recur after adequate treatment for gonorrhoea and chlamydia in index patient and partner(s), the patient should be treated for TV, if the local epidemiological pattern so indicates. If the symptoms still persist at follow up the patient must be referred.

Genital ulcer

After examination to confirm the presence of genital ulceration, treatment appropriate to local aetiologies and antibiotic sensitivity patterns should be given. For example, in areas where both syphilis and chancroid are prevalent, patients with genital ulcers should be treated for both conditions at the time of their initial presentation to ensure adequate therapy in case of loss to follow-up. In areas where granuloma inguinale is also prevalent, treatment for this condition should be included. In areas where granuloma inguinale or lymphogranuloma venereum (LGV) is prevalent, treatment for these conditions should be included. In many parts of the world, genital herpes is the most frequent cause of genital ulcer disease. Where HIV infection is prevalent, an increasing portion of cases of genital ulcer disease is likely to harbour herpes simplex virus. Herpetic ulcers may be atypical and persist for long periods in HIV-infected patients.

Laboratory-assisted differential diagnosis is rarely helpful at the initial visit, as mixed infections are common. In addition, in areas of high syphilis prevalence, a reactive serological test may reflect a previous infection and give a misleading picture of the patient’s present condition.

Genital ulcer and HIV infection

In chancroid atypical lesions have been reported in HIV-infected individuals. The lesions tend to be more extensive, producing multiple lesions that may be accompanied by systemic manifestations such as fever and chills. Reports of rapidly aggressive lesions have been noted by some clinicians. This emphasizes the need for early treatment, especially in HIV-infected individuals.

There is evidence to suggest that HIV infection may increase rates of treatment failure in chancroid, especially when single-dose therapies are given. More research is needed to confirm these observations.

Herpes simplex lesions may present as persistent multiple ulcers that require medical attention, as opposed to self-limiting vesicles and ulcers which occur in immunocompetent individuals. Thus, antiviral treatment may have to be considered therapeutically or prophylactically to offer comfort to the patient. Adequate education needs to be given to the patient to explain the nature and purpose of treatment in order to avoid false expectations of cure.

Genital Ulcer Disease Management

• Treat for syphilis, and, depending upon local epidemiology, either chancroid, granuloma inguinale or lymphogranuloma venereum

• Aspirate any fluctuant glands (surgical incision should be avoided)

• Educate and counsel on risk reduction

• Offer syphilis serologic testing and HIV serologic testing where appropriate facilities and counselling are available

• Review if lesion not fully healed

Herpes Simplex Management

• Advise on basic care of the lesion (keep clean and dry)

• Educate and counsel on compliance and risk reduction

• Offer syphilis and HIV serologic testing where appropriate facilities and counselling are available

• Promote and provide condoms

• Advise to return in 7 days if lesion is not fully healed, and sooner if there is clinical deterioration; if so, treat for other causes of GUD as per guidelines

Vaginal discharge

Among women presenting with discharge, one can attempt to identify those with an increased likelihood of being infected with N. gonorrhoeae and/or C. trachomatis. Microscopy adds little to the diagnosis of cervical infection and is not recommended. To identify women at greater risk of cervical infection, an assessment of a woman’s risk status is useful, especially when risk factors are adapted to the local situation.

Knowledge of the prevalence of gonococcal and/or chlamydia in women presenting with vaginal discharge is important for the decision to treat for cervical infection. The higher the prevalence, the stronger the justification for treatment. Risk assessment positive women have a higher likelihood of cervical infection than those who are risk negative. Women with vaginal discharge and a positive risk assessment could therefore, be offered treatment for gonococcal and chlamydia cervicitis.

Where resources permit, one could consider the use of laboratory tests to screen women with vaginal discharge. Such screening could be applied to all women with discharge or selectively to those with discharge and a positive risk assessment.

In some countries, syndromic management algorithms have been used as a screening tool to detect cervical infection among women not presenting with a genital complaint (e.g. in family planning settings). While this may assist in detecting some women with cervical infections, it is likely that there will be substantial over-diagnosis.

PRACTICAL CONSIDERATIONS IN STI CASE MANAGEMENT

Effective prevention and care of STI can be achieved using a combination of responses:

• promotion of safer sex behaviour

• condom programming – encompassing a full range of activities from condom promotion to the planning and management of supplies and distribution

• promotion of health-care-seeking behaviour

• integration of STI prevention and care into primary health care, reproductive health care facilities, private clinics and others

• specific services for populations at risk – such as female and male sex workers, adolescents, long-distance truck drivers, military personnel, and prisoners

• comprehensive case management of STI

• prevention and care of congenital syphilis and neonatal conjunctivitis

• early detection of symptomatic and asymptomatic infections.

COMPREHENSIVE CASE MANAGEMENT OF STIOne of the essential components of the public health package is comprehensive case management of STI, which comprises:

Identification of the syndrome: This can be done through syndromic diagnosis or laboratory tests.

Educating the patient: Patients should be informed about the nature of the infection, the importance of taking the full course of medication, among other things.

Antibiotic treatment for the syndrome: Whichever means is used for diagnosis – flow charts or laboratory tests – the availability and use of effective antibiotics is an absolute requirement. The drugs must be available at the first point of contact with a patient with an STI. Effective treatment must also be available and used in the private sector.

Condom supply: With people being encouraged to use condoms, health authorities should ensure that there is an adequate supply of good-quality, affordable condoms at health facilities and at various other distribution points in the community. Social marketing of condoms is another way of increasing access to condoms.

Counselling: Counselling should be made available for cases where it is needed – for example, in chronic cases of genital herpes or warts – either for individuals or for couples in a sexual relationship.

Information on partner notification and treatment: Contacting sex partners of clients with STI, persuading them to present themselves to a site offering STI services, and treating them – promptly and effectively – are essential elements of any STI control programme. These actions, however, should be carried out with sensitivity, with social and cultural factors taken into account. This will avoid ethical problems, as well as practical problems such as rejection and violence, particularly against women.