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  • HIV and conventional sexually transmitted infections (STIs) share common behavioural determinants. However, the association between conventional STIs and HIV is much more complicated, since conventional STIs (in particular those which cause genital ulceration) are known to increase HIV transmission by opening a portal of entry for the virus in the HIV-seronegative. They also provide a readily-available source of virus in those infected with HIV. <br /> In addition HIV can alter the clinical presentation of STIs, their natural history, their relative prevalence and, in some cases, their susceptibility to infection. <br /> Of all the STIs, genital herpes appears to have the most intimate interactions with HIV, having a unique bi-directional relationship with HIV. HIV, as a result of even mild immunosuppression, may alter the relative frequency and clinical presentation of genital herpes. Genital herpes appears to increase shedding of HIV in those who are co-infected and also increases the risk of acquisition of HIV in HIV-seronegative people. <br />

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  • Sexually transmitted Infections Dr. Negussie Tegegne, MD,DDVDr. Negussie Tegegne, MD,DDV DermatovenereologistDermatovenereologist Department of dermatovenereologyDepartment of dermatovenereology FOM, Addis Ababa UniversityFOM, Addis Ababa University Addis AbabaAddis Ababa EthiopiaEthiopia
  • Definition:Definition:  STDs are those diseases that are transmissible through sexual contact
  • BACKGROUND Sexually transmitted infections (STIs) o Why bother with (worry about) STIs? There are a number of reasons to be concerned about STIs: 1. STIs are a very common health problem.(are among the most common causes of illness in the world) - WHO: world wide, - ~ 340,000,000 new cases of curable STIs every year - i.e. about 1,000,000 new STIs every day! -10% adults are newly infected with curable STIs 12 million new cases of syphilis 60 million new cases of gonorrhea 90 million of new cases of chlamydia 176 million new cases of trichomoniasis View slide
  • 85% of new infections have been estimated to occur in developing countries. In developing countries, STIs and their complications are among the top five disease categories for which adults seek health care. Even without considering HIV, STIs cause the second highest burden of disease in women aged 15 to 44 years, after maternal mortality and morbidity. View slide
  • 75-85% cases occur in developing countries
  • 2. STI interaction with HIV/AIDS The relationship between STIs and HIV/transmission has been described as an epidemiological synergy. In addition, HIV and STIs share the same risk factors. a. STDs enhance the sexual transmission of HIV through: a) STDs that cause ulcers When a genital ulcer is present, there is a break in the skin or mucous membrane which provides an easy entry or exit point for the virus. Thus, for ulcerative STIs, the risk of HIV transmission is particularly high. The presence of genital ulcers is known to increase the risk of HIV transmission from 0.1% - 10% to nearly 100% b) When an STI ( non-ulcerative:gonorrhea trichomoniasis, and chlamydial infections ) is present in the partner who has HIV, the number of viruses in the genital secretions is greatly increased. ,
  • STI interaction with HIV/AIDS cont,d c) In both a and b above, infected lymphocytes among HIV infected individuals are attracted to the lesions and hence increase likelihood of infection to the partner -When an STI is present in the partner who does not have HIV, the STI increases the number of target cells (includingCD4 cells) for HIV in the genital tract, thusi ncreasing susceptibility. d) STIs : Increase viral shedding (reported in genital fluids of patients with STIs) and STIs increase susceptibility to HIV.( STI treatment has been demonstrated to significantly reduce viral shedding).
  • INTERACTION BETWEEN HIV AND OTHER STDs cont’d b. HIV infection affects STIs through: a) Altering susceptibility of STD pathogens to antibiotics → decreasing effectiveness of treatment. (This has been reported for chancroid and syphilis) b) Clinical appearance and natural history of STDs may be grossly altered → increasing severity (as in genital herpes and syphilis). c) Increased susceptibility to STDs among immunosuppressed individuals
  • Interactions between conventional STIs and HIV HIVSTI High-risk sexual behaviour Increased transmission Increased progression to clinical disease Impaired immunity Altered frequency, natural history and susceptibility
  • 3. STIs can have serious social economic consequences. Relationship problems, violence, rejection, stigma of infertility 4. STIs can have serious medical consequences. (High rate of complications) - Failure to diagnose and treat STIs at an early stage may result in serious long term complications and sequelae Complications: a. in women include: • Cervical cancer, • Pelvic inflammatory disease with resulting - infertility, - chronic abdominal pain, - ectopic pregnancy and - related maternal mortality • Cardiovascular problems and neurological problems associated with syphilis
  • Complications cont’d b. in newborns include • congenital syphilis, • gonococcal infection of the conjunctiva - a potentially blinding condition, • chlamydial pneumonia and • perinatal hepatitis B infection. c. in males • Urethral stricture • Infertility • Phimosis and Paraphimosis • Meningovascular/cardiovascular complications (syphilis) • Epididymo-orchitis
  • Modes of STI transmission STIs are Transmitted ● Unprotected penetrative sexual intercourse (horizontal transmission) vaginal rectal oral ● Mother-to-child (vertical transmission) either: ° during pregnancy, or ° at delivery, or ° after birth (HIV only), or ° through breast-milk (HIV only) ● Transfusions or other contact with blood or blood-products (syphilis, HIV, Hepatitis B & C)
  • STD risk indicators (risk depends on specific STI) (1) Adolescents, especially if residence in high prevalence area. (2) Increasing number of lifetime sex partners. (a) More than one recent sex partner (past 1-4 months) (b) New partner in the last 2 or 3 months. (c) High risk partner(s) (i) Commercial sex or exchange of sex for drugs. (ii) A sex partner with a known STI diagnosis. (iii) Sex partner with other recent sex partners (past 1-4 months). (iv) Current use or a history of injection drug use or substance abuse by patient or sex partners. (v) A history of prior STI diagnosis and treatment.
  • Classification of STIs 1. According to causative organisms 2. According to mode of transmission 3. According to most common presenting symptoms
  • Classifying STI/RTI By causative Organisms • BACTERIAL: Gonorrhea, Chlamydia, Chancroid, Syphilis Granuloma Inguinale, Mycoplasma genitalium, Ureaplasma Urealyticum, Gardnerella Vaginalis, Gay bowel syndrome • VIRAL: HSV, HPV, HIV, HBV • PROTOZOAL: trichomoniasis, Amebiasis, Giardiasis • FUNGAL: Candidiasis • ECTO-PARASITES: Scabies, Pubic Lice • MIXED: PID, Epididymitis There are more than 20 STIs
  • CLASSIFYING STIs /RTIs BY MODE OF TRANSMISSION • ENDOGENOUS INFECTIONS: eg: yeast infection , bacterial vaginosis • SEXUALLY TRANSMMITTED INFECTIONS: eg: gonorrhea, chlamydia, syphilis • IATROGENIC INFECTIONS: eg: PID following abortion or transcervical procedures
  • CLASSIFYING STIs /RTIs BY MOST COMMON PRESENTING SYMPTOMS and SIGNS • Urethral Discharge • Genital Ulcer • Vaginal Discharge • Lower abdominal Pain • Scrotal Swelling • Inguinal Bubo • Ophthalmia Neonatorum
  • Steps in Syndromic STI case management ● History taking, ● Examination, ● Treatment ● Counseling/Education on risk reduction ● Partner notification ● Condom promotion
  • History:History: 1) Discharge (urinary, vaginal) 2) Urinary symptoms (dysuria, frequency, urgency, haematuria) 3) Genital lesions (sore, spot, blister, growth)
  • History cont. 4) Sexual history:  Sexual exposure: how frequent, last, where, whom  Sexual behaviour: homosexual, bisexual, heterosexual  Protective measures, e.g. condom 5) Past history (of STD), family history.
  • History The following are the basic questions to be asked: • What are your symptoms? • When did they start? • When and with whom did you last have sex? • Number of different sexual contacts in last 3 months • Did you use a condom in last sexual act? • Are you married? When did you last have sex with your wife/husband? • Have you taken any medicine to treat the symptoms you are complaining of?
  • Hx cont’d • When was your last menstrual period? • Obstetric history in women • Does your partner have or does s/he recently had any STI symptoms? • Has your partner had any other partner in the last one- month? • Do you use a condom consistently?
  • Physical Examination: NB. Consent of the patient is essential 1. Male Patient • Request the patient to take his trousers and underwear down • Look at the penis with the foreskin forward and pulled back • Ask the patient to show any discharge by ‘milking’ the penis • Examine the groin, genitalia, perineum, the perianal region, oral cavity and body including palms and soles • Palpate the groins and elbows (for enlarged lymph nodes in suspected syphilis), the testicles for swelling and tenderness Look for : 􀂃 Genital and body rashes, sores/ulcers, warts 􀂃 Swollen glands in the groins 􀂃 Discharge from the urethra
  • Physical Examination cont’d 2. Female Patient • Request the patient to remove her underwear (undergarment) • Examine the patient on a couch or table on her back with the knees flexed and the legs apart  Pt should lie on lithotomy position with labia majora, labia minora, introitus, perineum and perianal area fully exposed and examined.  With a gloved hand separate the outer labia, look at the inner labia, separate them and look at the introitus • Palpate the groin and elbows (for enlarged lymph nodes in suspected syphilis cases) for swelling and tenderness • Speculum examination: Bivalve speculum should be inserted to examine vagina and cervix. • Bimanual examination • oral cavity and body including palms and soles Look for: 􀂃 Genital and body rashes, sores/ulcers, 􀂃 Warts 􀂃 Swollen glands in the groins 􀂃 Vaginal / cervical discharge 􀂃 Adenexal tenderness or mass 􀂃 Redness or itching
  • Laboratory Investigations:Laboratory Investigations: In MaleIn Male •• VDRL , FTA, TPHA, HIV-Ab • Urethral smear • microscopy - Gram stain for pus cell & organism - wet film x trichomonas • Culture for gonococci • Direct IMF, ELISA,PCR, culture for chlamydia (Chlamydiazyme Test)
  • Laboratory investigation cont, •• Dark ground examination for spirochaete • Swab and culture from vesicle/sore for Herpes culture • Smear and culture from sore for Haemophilus ducreyi
  • Laboratoy investigations cont. For homosexual and bisexual - Pharyngeal smear & culture for gonococci - Rectal smear & culture for gonococci - Hepatitis virology
  • Laboratory Investigations:Laboratory Investigations: In FeMaleIn FeMale • VDRL , FTA, TPHA, HIV-Ab • Urethral , vaginal & cervical smear - microscopy (Gram stain for pus cell, organism epithelial cell, candida, trichomonas) • Culture for gonococci • Direct IMF, ELISA, PCR, culture for chlamydia • High vaginal smear for candida spp, TV, Bacterial vaginosis
  • Laboratory investigation cont, - Dark ground examination for spirochaete - Papanicolaou smear - Endocervical/sore swab & culture for herpes - Pharyngeal smear & culture for gonococci - Rectal smear & culture for gonococci