Dr. Anupong Chitwarakorn Consultant: Bureau of AIDS and STI (Thai MOPH) Physician, Site investigator: Silom Community Clinic@Tropmed (Thai MOPH and US CDC Cooperation) President, Thai Medical Society for the Study of STI

1. Approach to STI Management in HIV
Dr. Anupong Chitwarakorn
Consultant: Bureau of AIDS and STI (Thai MOPH)
Physician, Site investigator: Silom Community Clinic@Tropmed (Thai
MOPH and US CDC Cooperation)
President, Thai Medical Society for the Study of STI

2. Current issues on STI and HIV
• Biological interactions between HIV infection
and other STIs.
• STI intervention in limiting HIV spread?
• What role STI control should play in HIV
prevention?
• STI case management in HIV infected person

3. Increased risk of HIV transmission
associated with STI: viral shedding
• Johnson and Lewis (2008): 39
studies evaluating the impact of STI
on genital tract HIV-1 in coinfected
individuals
- 2-3 folds increase with
urethritis(OR 3.1, 95%CI: 1.1-8.6)
cervicitis(OR 2.7, 95%CI: 1.4-5.2)
gonorrhoea(OR 1.8, 95%CI: 1.2-2.7)
Chlamydia(OR 1.8, 95%CI: 1.1-3.1)
HSV
Quinn et al (2000)
- HSV 2 infection significantly
increase HIV plasma viral
load
• Barnabas et al (2009)
-HSV 2 coinfection increased
PVL by a quarter log
(difference in mean PVL
0.22 log10 copies/ml.
95%CI: 0.04-0.40)

4. STI treatment can reduce HIV
infectiousness?
• Studies in Malawi and Kenya: substantial declines in genital viral
load (GVL) both men and women within two weeks of treatment
of gonorrhoea, chlamydia and trichomoniasis
(Cohen et al 1997, Price et al 2003, McClelland et al 2001, Wang et al
2001)
0
5
10
15
NoUrethritis Urethritis 1week 2weeks
t
treatment

5. STI treatment can reduce HIV infectiousness?
• Studies in Malawi and
Kenya: substantial
declines in genital viral
load (GVL) both men and
women within two
weeks of treatment of
gonorrhoea, chlamydia
and trichomoniasis
(Cohen et al 1997, Price et al
2003, McClelland et al
2001, Wang et al 2001)
• Treatment of genital herpes
to reduce HIV transmission
- Valacyclovir 500 mg bid or acyclovir
800 mg bid for 3 months, reduced
genital HIV RNA of 0.2-0.5 log10
copies/ml and PVL of 0.25-0.5 log10
copies/ml (Nagot et al 2007, Dunne
et al 2009 Zuckermann et al 2009,
Maeten et al 2008)
- Acyclovir 400 mg bid showed weaker
or no effects on HIV GVL (Cowen et
al 2008, Delany et al 2009, Tanton et
al)

6. Case 1: genital ulcer
Male, age 19 years
CC: slightly painful genital ulcer
for 10 days
Last sexual intercourse: 20+
days ago, no condom with boy
friend, as insertive anal
intercourse
PE: two ulcer 0.5 and 1 cm in
dia. at prepuce, clean base
ulcer with serum oozing,
slightly indurated, slightly
tender. Both inguinal lymph
nodes enlarged, not inflamed
nor tender, discrete.
Three small wart at frenulum

7. Clinical diagnosis: wart and ?
• A. Herpes genitalis
• B. Chancroid
• C. Primary syphilis
• D. non specific ulcer, may be traumatic?

8. Laboratory
• RPR negative
• HIV rapid test: Positive
• A. Herpes genitalis
• B. Chancroid
• C. Primary syphilis
• D. non specific ulcer, may be traumatic?

9. Dark field examination

10. Serological tests for syphilis by stage of infection
What test is more helpful to confirm diagnosis of primary syphilis?

11. Case 2
A student, age 18 yrs,
known case of HIV, 3
months ago, already on
ARV at private hos.
LSI: N/A, but having
unprotected receptive
anal intercourse and oral
sex with boyfriends
CC: anal pain for 2 weeks
PE: two perianal papules,
not tender. Multiple
greyish white patch at
tongue.

12. Clinical diagnosis: HIV and ?
• A. Condyloma accuminata (perianal wart) and
Apthus ulcer
• B. Perianal Wart and Mucous patch likely from
syphilis
• C. Secondary syphilis
• D. Perianal Wart and fungal infection of
tongue

13. Laboratory
• RPR 1:512
• HIV rapid test: postive
• A. Condyloma accuminata (perianal wart)
and Apthus ulcer
• B. Perianal Wart and Mucous patch likely
from syphilis
• C. Secondary syphilis
• D. Perianal Wart and fungal infection of
tongue

14. Secondary syphilis:
Specific clinical manifestation
1. Skin rash: macular, maculopapular, papular,
papulosquamous, pustualar, (non-itching,
symmetrical)
2. Condyloma lata: papular lesions in intertrigineous
area which erode
3. Mucous patch at genital or oral cavity
4. Moth eaten alopecia

17. Mucous patch

18. Condyloma lata

19. Moth eaten alopecia

20. HIV and Syphilis infection among
MSM

21. MSM: HIV prevalence and incidence by age group and
calendar year: SCC@TropMed
22.5
27.9 28.1 28.5
24.1
26.1 25.6 26.3
31.1
25.9
24.5
27.2
29.8
9.7
6
3.4
0
3.9
2.7
4.1
5.8 5.9 5.6 5.9 5.5 6.5
0
10
20
30
40
<=21 22-29 >=30 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Prevalence(%)
Incidenceper100person-years
prevalence incidence
Age Group Calendar Year

22. 10.1
10.7
12.9
6
3.2
6.2
4.4
8
11.7
10.7
12.7
15.4
16.3
3.9 4
3
0 0
1
0.3
4 3.9 4.2 3.7 4.1 4.4
0
5
10
15
20
<=21 22-29 >=30 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Prevalence(%)
Incidenceper100person-years
prevalence incidence
Age Group Calendar Year
MSM: Syphilis prevalence and incidence by age group and calendar year, SCC@TropMed

23. 4.8
7.2
8.2
5.3
1.6
3.1
2.5
4.5
8.3
6.7
7.5
10.4 10.1
0
5
10
15
20
<=21 22-29 >=30 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Prevalence(%)
Incidenceper100person-years
prevalence
Age Group Calendar Year
HIV-Syphilis Co-infection: prevalence by age group and calendar year, SCC@TropMed

24. Syphilis: treatment
• Early syphilis: primary, secondary and early
latent syphilis (within 1 year duration)
• Benzathine penicillin 2.4 M unit IM, single
dose
• Alternative: doxycycline 100mg. bid. 14 days
or erythromycin 500mg. qid. 14 days

25. Syphilis: treatment
• Late syphilis: latent syphilis (except neurosyphilis)
• Benzathine penicillin 2.4 M unit IM, weekly for 3
consecutive weeks
• Alternative: doxycycline 100mg. bid. 30 days or
erythromycin 500mg. qid. 30 days

28. Case 3: genital ulcer
Known case of HIV infected,
not start ARV yet,
35 years old, LSI: none for 1 yr.
CC: painful genital ulcer for 2
weeks
PE: extensive ulcer at genitalia
and scrotal sac with necrotic
tissue
Additional history: recurrent
genital ulcer since teenage.

29. Extensive genital Herpes in HIV
Rare in immunocompetent
patients
Treatment: Acyclovir 200 mg q 4
hrs for 2 weeks or 400 mg tid for
2 weeks, plus local irrigation
with normal saline
Start ARV

30. Roles of genital Herpes in HIV
• Suppressive Treatment of genital herpes to reduce HIV
transmission
- Valacyclovir 500 mg bid or acyclovir 800 mg bid for 3
months, reduced genital HIV RNA of 0.2-0.5 log10 copies/ml
and PVL of 0.25-0.5 log10 copies/ml (Nagot et al 2007, Dunne
et al 2009 Zuckermann et al 2009, Maeten et al 2008)
- Acyclovir 400 mg bid showed weaker or no effects on HIV
GVL (Cowen et al 2008, Delany et al 2009, Tanton et al)

31. Extensive Molluscum contagiosum
Rare in immunocompetent host
Treatment: removal: cryosurgery
Start ARV

32. Giant wart
Treatment
Cryotherapy with liquid
nitrogen or cryoprobe.
Repeat applications
every 1–2 weeks.
Surgical removal either
by tangential scissor
excision, tangential
shave excision,
curettage, or
electrosurgery

33. 80.8%
4.6%
11.6%
2.9%
No infection
NG
CT
NG and CT
N=1743 MSM
SCC@tropmed
Asymptomatic infection
95.3% in CT
83.2% in NG

34. Recommendation for NG and CT
Ceftraixone 250 mg IM
Plus
Azithromycin 1 gm orally
Or
Doxycycline 100 mg bid for 7 days
Cefixime susceptibility defined as minimum
inhibitory concentrations of 0.25 µg/mL or
greater. Reduced ceftriaxone susceptibility
defined as minimum inhibitory concentrations
of 0.125 µg/mL or greater.
There was a trend in elevated cefixime minimum
inhibitory concentrations from 2006-2011 (P < .001),
2011-2013 (P < .001), and 2013-2014 (P = .02;
using the χ2 test).
There was a trend in elevated ceftriaxone minimum
inhibitory concentrations from 2006-2011 (P < .001),
2011-2013 (P < .001), and 2013-2014 (P = .13;
using the χ2 test). Error bars indicate 95%
confidence intervals.
aCefixime susceptibility was not tested in 2007 and
2008.

35. Conclusion
• Improve access to STI clinical services for HIV
infected patients, including better quality.
• Promoting early and effective STI health care
related behaviors
• Establish surveillance system to monitor STI in
HIV infected population