This document discusses STI, HIV, and eMTCT (elimination of mother-to-child transmission of HIV). It defines key terms and outlines the prevalence of HIV and STIs in Uganda. It describes how STIs are transmitted and managed, including syndromic case management. It discusses complications of STIs and the burden of mother-to-child transmission of HIV. It provides a history of efforts to eliminate mother-to-child transmission of HIV, including Option B+ which initiates all HIV-infected pregnant women on antiretroviral therapy.

1. STI, HIV & EMTCT

2. Outline
• Definitions
• Prevalence of HIV & STI
• Transmission of STIs
• Management of STIs
• Complications of STIs
• EMTCT of HIV
• Burden of MTCT
• History of EMTCT of HIV
• Option B+
• EMTCT

3. Definitions
 HIV infection - presence of HIV virus in blood without necessarily
having symptoms or signs of disease
 HIV disease - presence of signs and symptoms due to infection with
HIV
 AIDS – clinical syndrome suggestive of advanced HIV infection
 MTCT – when the HIV virus is passed from the mother to her child
during pregnancy, birth or breastfeeding
 PMTCT – the package of services given to women to prevent
acquisition of HIV and/or reduce risk of MTCT
 PMTCT Plus – provision of ART and support to HIV infected mothers,
their
babies and family members to ensure proper nurturing, care
and protection of the child
 eMTCT – Uganda’s strategy for virtual elimination of MTCT using
option B+

4. PREVALENCE OF HIV
• The prevalence of HIV among adults aged 15 to 64 in Uganda is 6.2%:
7.6% among females and 4.7% among males.
• This corresponds to approximately 1.2 million people aged 15 to 64
living with HIV in Uganda.
• HIV prevalence is higher among women living in urban areas (9.8%)
than those in rural areas (6.7%).

5. PREVALENCE OF STIs
• In Uganda, the prevalence of self-reported STIs has remained
persistently high 27% , with an increase from 22% in 2006 to 26.0%
• 2011 [10], while up to 1.5 million cases of STIs have reported
between 2015 and 2017
• Prevalence according to individual disease; Chlamydia trachomanitis
(CT) 4.5%, Neisseria gonorrhoea (NG) 9.0%, and Trichomonas
vaginalis (TV) 8.0%, and syphilis 4.0%.

6. Causes of STIs

7. Transmission of STIs
• A person with an STI can pass it to others through contact with skin,
genitals, mouth, rectum, or body fluids.
• This includes contact through vaginal sex, anal sex, or oral sex.
• Even if there are no symptoms, your health can be affected.

8. GENERAL SIGNS AND SYMPTOMS OF HIV
• Possible signs and symptoms include:
• Fever
• Headache
• Muscle aches and joint pain
• Rash
• Sore throat and painful mouth sores
• Swollen lymph glands, mainly on the neck
• Diarrhea
• Weight loss
• Cough
• Night sweats

9. GENERAL SIGNS AND SYMPTOMS OF STIs
The symptoms of an STI can include:
• an unusual discharge from the vagina, penis or anus
• pain when peeing
• lumps or skin growths around the genitals or bottom (anus)
• a rash
• unusual vaginal bleeding
• itchy genitals or anus
• blisters and sores around your genitals or anus
• warts around your genitals or anus
• warts in your mouth or throat, but this is very rare

10. Syndromic Management of
Sexually Transmitted Infections

11. What is Syndromic Management?
1
1
Syndromic management refers to the approach of treating STI/RTI
symptoms
responsible
and signs based on
for each syndrome.
the organisms most
A more definite or
commonly
etiological
diagnosis may be possible in some settings with sophisticated
laboratory facilities, but this is often problematic.

12. STI – Syndromic Case Management
REQUIREMENTS:
• Adequate medical history
• Good sexual history
• Complete STI clinical examination
• Management guidelines
• Good supply of effective drugs
1
2

13. Essential Steps In STI Care
Management*
Syndrome
Assessment
Risk
Assessment
Diagnosis Treatment 5Cs
Contact tracing
Compliance
Confidentiality
Condom use
Counseling
(screening tests)
(diagnostic tools)
* Adapted from Holmes & Ryan
1
3

14. Syndromic Flow Charts for SCM
1
4
1. Urethral discharge
2. Vaginal discharge
3. Ophthalmia neonatorum
4. Pelvic Inflammatory Disease (PID)
5. Genital ulcer disease (M & F)
6. Scrotal swelling
7. Inguinal swelling

15. URETHRAL
DISCHARGE
1
5

16. What is Urethral Discharge Syndrome?
• Discharge coming from the
urethral meatus
• May be frank pus,
mucopurulent, or serous
(clear)
• Occasionally discharge will
be white in colour
Gonococcal urethral discharge
Photo: Cincinnati STD/HIV Training Ctr 8

17. VAGINAL
DISCHARGE
17

18. Causes of Abnormal Vaginal Discharge
Trichomoniasis
• Greenish frothy
discharge
• Treatment of sex
partner needed
•Candidiasis
•Curdy white
discharge.
•Common after
antibiotic treatment.
18

19. Cervicitis
• Chlamydia
• Gonorrhoea
• Trichomonas
• HSV
• Limitations of syndromic
management
• Use local prevalence
data, if available
• Risk assessment
• Partner treatment
Bacterial vaginosis
• Overgrowth of
anaerobic/facultative
anaerobic flora
• Associated with
increased risk of PID,
preterm labor, PROM
• May enhance HIV
transmission
• Adherent discharge
12

20. Step 1
Step 2
Step 3
Step 4
Step 5
Take History (esp. sexual). Determine Risk Score
Do Bimanual Pelvic Exam, Pass speculum
Clean and Inspect Cervix
Observe nature of Vaginal Discharge
Give Prevention Messages
20

21. Per speculum examination
21
Vaginits
oTrichomoniasis – Greenish Frothy
oCandidiasis – Curdy White
oBacterial vaginosis - Adherent Discharge
oMixed – Atypical discharge

22. Treatment
Vaginitis Cervicitis
(TV+BV+Candida) ( CT and NG)
Tab. Secnidazole 2gm orally one dose Tab. Cefixime 400mg orally one dose
Tab. Tinidazole 500 mg orally bd for 5 days
Tab. Metochlorpromide to prevent gastric intolerance due Azithromycin 1gm an hour before lunch. If
to secnidazole vomiting occurs give anti emetic and repeat
Candidiasis – Tab Fluconazole 150 mg oral single dose
- vaginal pessary of clotrimazole once 500 mg
19

23. In Pregnancy!
23
T1
 Clotrimazole – vaginal pessary/cream for Candidiasis. Fluconazole is CI in pregnancy.
 Metronidazole pessaries or cream intravaginally if TV or BV is suspected
T2 and T3
 Tab. Secnidazole or tinidazole
 Metachlorpromide 30 mins before Metronidazole

24. LOWER
ABDOMINAL PAIN
24

25. Pelvic Inflammatory Disease
• Minimal criteria for diagnosis
• Simple supporting signs
• Fever >38.3°C
• Abnormal discharge
• In presence of HIV infection, PID may be more common and more severe
Acute Salpingitis
22

26. Take History and Assess Risk. Do Exam:
Abdominal, pelvic, bimanual, speculum
•Bowel or urinary symptoms?
•Missed/overdue period; pregnant?
•Recent childbirth or abortion?
• Rebound tenderness; guarding?
•Vaginal bleeding or pelvic mass?
Immediate
Referral to
Surgical or
OBGYN
no to all
26
yes
to
any

27. Either:
•Temperature > 38oC
•Dyspareunia or previous PID
•Vaginal discharge
• Mucopurulent cervicitis
•Risk assessment positive
With:
•Pain on moving cervix/adnexa
Treat for PID.
If IUD present:
Remove after 2-4 dys.
Examine and treat
partner(s).
[40% may be
asymptomatic].
Counsel re 4 Cs.
27
Re-evaluate 3 days. Improved – complete Tx 10-14 days.
Not improved – refer hospital, (esp. if temperature elevated).

28. Treatment
28
Mild or Moderate PID, OPD treatment can be given. Therapy is required to cover NG, CT, & Anaerobes.
Tab. Cefixime + metronidazole 400mg Orally twice daily for 7 & 14 days respectively.
Tab. Doxycycline 100mg Orally twice a day for two weeks.
Tab. Ibuprofen 400mg Orally thrice a day for 3-5 days.
Tab Ranitidine 150mg Orally to prevent gastritis.
OBSERVE THE PATIENT FOR THREE DAYS!! IFTHERE IS NO IMPROVEMENT, THEN ADMIT
HIM IN HOSPITAL, IN SITUATIONS WHEN,
The diagnosis is uncertain
Surgical emergencies (appendicitis).
Pelvic abscess is suspected.
Pregnancy
Failed OPD therapy

29. GENITAL ULCERS
29

30. Genital Ulcer Disease
Syphilis Chancroid Herpes Simplex
30

31. Genital Ulcer Disease
31
• Other Causes
• Lymphogranuloma venereum
• Granuloma inguinale (Donovanosis)
• Neoplasm
There are many published studies on HIV transmission and GUD including HSV.

32. Treatment
32
• Vesicles or multiple Painful ulcers are present, Treat for HERPES with
Tab. Acyclovir 400mg thrice a day for 7 days
• Only Ulcer is seen treat for syphilis and chancroid
• Syphilis by Inj. Benzathine Penicillin 2.4MU IM + Tab azithromycin 1gm oral
single dose. Treatment should be extended beyond 7 days if ulcers have not
epithelialized. Refer to higher centre if not responding to treatment or has
recurrent lesions or is HIV positive.

33. SCROTAL
SWELLING
33

34. Scrotal Swelling
34
• Common STI causes of scrotal swelling are
• Neisseria gonorrhea
• Chlamydia trachomatis
• Exclude non-STI causes of scrotal swelling:
• TB
• Inguinal hernia
• Testicular torsion, etc

35. Lab Diagnosis:
35
Gram Stain of urethral smear to differentiate from
gonococcal and non gonococcal.

36. If the partner is pregnant, then depending on the
findings, drugs are prescribed. Doxycycline is
contraindicated, where as ERYTHROMYCIN or
AMOXICILLIN can be used.
36
Scrotal Swelling Recommended Therapy
• Ciprofloxacin 500mg PO stat,
or
• Spectinomycin 2gm IM stat
plus
• Doxycycline 100mg PO BID for 7 days, or
• Tetracycline 500mg BID for 7 days

37. INGUINAL BUBO
37

38. Inguinal Bubo
• Swelling of inguinal lymph nodes as a result of STIs (or other causes)
• Common causes:
• Treponema pallidum (syphilis)
• Chlamydia trachomatis (LGV)
• Hemophylus ducreyi (chancroid)
• Calymatobacterium granulomatis (granuloma inguinale)
• DD
• TB, Filiariasis
• Malignancy
38

39. Inguinal Bubo
39
• Recommended treatment:
• Ciprofloxacin 500mg PO BID for 14 days, and
• Erythromycin 500mg PO QID for 14 to 21 days

40. In Pregnancy!!!
40
Quinolones, Sulfonamides, Doxycycline are CI in pregnancy.
Inj. Benzathine Penicillin 2.4MU IM one dose (after a test dose)
Tab. Erythromycin 500mg orally four times a day for 15 days.
All pregnant women must be asked for history of genital herpes.
Women without symptoms of genital herpes can deliver vaginally.
Genital Herpes must be treated with Acyclovir orally.
Metronidazole is generally not recommended in pregnancy. But it can be used
in severly acute PID

41. Complications of STIs
Because many people in the early stages of an STD or
STI experience no symptoms, screening for STIs is important to
prevent complications.
Possible complications include:
•Pelvic pain
•Pregnancy complications
•Eye inflammation
•Arthritis
•Pelvic inflammatory disease
•Infertility
•Heart disease
•Certain cancers, such as HPV-associated cervical and rectal cancers

42. MTCT of HIV
• About 30-35% of HIV-infected mothers with infect their babies if no
intervention.
• Peripartum HIV transmission can be reduced to under 5% in resource
limited settings using a feasible ART regimen
• B/F causes about 1/3 – ½ all infant HIV infections and reducing
postnatal transmission through B/F, whilst maintaining child survival,
is an urgent priority.
• Evidence highlights the impact of breastfeeding duration & pattern,
and hazards associated with the avoidance of breastfeeding in
different settings
• About 90% of HIV-infected children in SSA acquire HIV through MTCT

43. MTCT
MTCT can occur
• during pregnancy
• during delivery or
• through breastfeeding

44. Rates of MTCT….5 December 2018
The Global Strategy for Women’s, Children’s and Adolescents’ Health (2016-2030)
Time of transmission Absolute transmission rate (%)
During pregnancy 5-10
During labour and delivery 10-20
During breast feeding 5-20
Overall without b/feeding 15-30
Overall with b/feeding through 6 months 25-35
Overall with b/feeding through 18 -24 months 30-45

45. Burden of MTCT
• Annually about 25,000 to 40,000 babies get HIV infection in Uganda.
• 0.6% U5s are infected with HIV
• Over 90% of HIV infected children acquire it from MTCT
• In Uganda, 66% of the HIV infected children do not survive to
celebrate their 3rd birthday with no intervention

46. Risk factors for MTCT
Source: WHO, CDC Prevention of Mother to Child Transmissionof HIV Generic Training Package, July 2008
Maternal and neonatal factors that may increase the risk of HIV transmission
Pregnancy Labour and delivery Breastfeeding
 High maternal viral load (new
infection or advanced AIDS)
 Viral, bacterial, or parasitic
placental infections, such as
Malaria
 Sexually transmitted infections
(STIs)
 Low CD4+ count
 Virulent HIV strain
 High maternal viral load
 Prolonged rupture of
membranes for >4 hours
 Prolonged labour
 Vaginal delivery
 Assisted vaginal delivery
 Invasive delivery procedures
(e.g. episiotomy, artificial
rupture of membranes)
 Chorioamnionitis (from
untreated STI or other
infection)
 Preterm delivery
 Low birth weight
 High maternal viral load
 Long duration of breastfeeding
 Mixed feeding (giving water,
other liquids, or solid foods in
addition to breastfeeding)
 Breast abscesses, nipple
fissures, mastitis
 Oral disease in the baby (e.g.
thrush or sores)

47. History of PMTCT
PMTCT is a dynamic and rapidly changing field.
2010 WHO Guidelines
Option A
Treatment or prophylaxis dependent on CD4 count
CD4 ≤350 or WHO stage 3 or 4 regardless of CD4 count:
Life-long ART
 CD4 >350, and WHO stages 1 and 2:
Antenatal and intrapartum prophylaxis (AZT, sdNVP, TDF/FTC)
Extended infant NVP syrup for BF infants

48. Option B
All HIV infected pregnant women initiated on
ART regardless of CD4 count
CD4 ≤350, or WHO stage 3 or 4
life-long ART
CD4 ≤350, or WHO stage 3 or 4
life-long ART
 CD4 >350 and WHO stages 1 and 2, stop
ART after delivery if FF, or after cessation
of BF if BF

49. Advantages of Option B+
 Simplification of PMTCT regimen requirements
 No need for CD4 count to determine eligibility
 Extended protection from MTCT in future pregnancies from
conception
 Strong & continuing prevention benefit against sexual transmission in
serodiscordant couples/partners
 Improved benefit for the woman’s health in between pregnancies
 Simple community message; start ARVs, continue for life

50. Interventions in EMTCT
 HIV testing and counselling during ANC, labour and delivery and
postpartum
 Provision of antiretroviral (ARV) drugs to mother and infant
 Modified safer obstetric practices e.g elective c/section
 Infant feeding information, counselling and support
 Modified infant feeding practices
 Referrals to comprehensive treatment, care and social support for
mothers and families with HIV infection

51. Specific interventions
 WHO Clinical staging of HIV disease.
 Initiate ART treatment as soon as possible during pregnancy labour
/delivery and through BF and for the entire life of the women
 Special ART adherence counseling for treatment as prevention
 Special support and follow up of discordant couples
 Linkage to ART center for lifelong chronic care using referral system
 Infant feeding counseling and support based on knowledge of HIV
status
 Maternal nutrition including assessment, counseling and support

52. Specific interventions
 Co-trimoxazole prophylaxis
 Malaria prevention and treatment
 Additional counseling and provision of family planning services
 TB screening and treatment
 Counsel on other prevention interventions, such as safe drinking water
 Supportive care, including, psycho social support, adherence support, and
palliative care including pain and symptom management
 Provide outreach services for clients and family members unable to come back
for routine follow up.
 De-worming
 Counseling and referral for women with history of harmful alcohol or drug use

53. Effectiveness of EMTCT
 ARV prophylaxis in labour alone reduces MTCT in B/F popn by 41-47%
after SVD
 If ARV prophylaxis is started in the last month of preg, reduction is by
up to 63%
 Current recommendations of ART started early can reduce MTCT to
<2%
 Breastfeeding a major source of MTCT can be addressed by use of
ART during B/F

54. Comprehensive Approach Of EMTCT
1. Primary prevention
• ABC-mutual faithfulness
• access to condoms
• HCT
• Prevention and early treatment of STIs
• Counselling for HIV negative men and women
• Male circumcision
• Prevention of blood-to-blood transmission

55. Comprehensive approach to PMTCT….
2. Prevention of unintended pregnancies among women who are HIV-infected
• Address FP and contraceptive needs of the woman
3. Prevention of HIV transmission from women infected with HIV to their Infants
• HCT
• ART to mother and infant
• Modified obstetric practices
• Modified infant feeding practices
• Infant feeding information, counselling and support
• Referrals to comprehensive treatment, care and social support for mothers and
families affected

56. Comprehensive approach to PMTCT….
4. Provision of treatment, care and support to women infected with HIV,
their infants and their families
To promote long-term care of women who are HIV-infected and their families
 Care and treatment with ARV therapy for the long-term health of women and families.
 Symptom management
 Prevention and treatment of HIV-related conditions
 Reproductive health care, including family planning and contraception counselling
 Nutritional support
 Psychosocial and community support
 Palliative care, if indicate

57. Barriers to universal access to EMTCT
 Weak healthcare systems, including inadequate antenatal care (ANC)
 Limited access to pre-test counselling, either because systems are not
in place or providers are not routinely offering testing
 Lack of effective coordination to oversee implementation
 Inadequate community engagement
 Stigma and discrimination
 Lack of awareness that HIV can be passed from mother-to-child
 Inadequate access to ARV therapy or prophylaxis
“Universal Access” is the idea that everyone has a right to the prevention, care, support and treatment
related to HIV and AIDS.

58. REFERENCES
Prevention of mother-to-child HIV transmission in resource-poor countries: translating research into policy and practice, De Cock et al, JAMA
283(9), March 2000
World Health Organization. Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants: recommendations for a
public health approach, 2010 version
World Health Organization. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection:
recommendations for a public health approach, June 2013.
World Health Organization. Prevention of Mother-to-Child Transmission of HIV: Generic Training Package, January 2008
World Health Organization. Use of antiretroviral drugs for treating pregnant women and preventing HIV infection in infants: Programmatic
update, 2012