2. LEARNING OUTCOMES
1. Define various types of STIs
2. List the various forms of STIs
3. Describe various types of STIs
3. Scenario 1:
• A 31 years old male reports to you with 2 weeks h/o sore on the tip of
the penis. The sore is not painful. He also reports thick mucoid
urethral discharge. He is a tax driver, married to three women.
O/E, FGC, afebrile, BP=128/74mmHg, PR=92bpm.
Locally: Not circumcised. There is a dry cold small wound at the glans
penis.
a. Which other subjective and objective data will you need to explore?
b. Which investigations will you request and why?
c. If results return positive, what will be your care plan?
4. STI/D
• A group of diseases in which sexual contact is the most common form
of transmission. This includes anal and oral sex
• Other forms of transmission can be: skin to skin contact, mother to
child, blood transfusion
• Common types of STIs are caused by bacteria, viruses, fungi,
protozoa, and parasites
6. 1: SYPHILIS
• Caused by spirochaete: Treponema pallidum
• The treponemes are motile by three flagella (axial filaments) that
wrap around the surface of the organism and are covered by the
outer membrane which contains lipopolysaccharide.
• Disease has three stages: Primary, Secondary and Tertiary
• Infectious during primary and secondary stages which last 2- years
• Transmitted through exudates of the skin and mucus membrane
• Congenital syphilis: Transmitted between 4th month of pregnancy
until delivery, before, TP cannot pass through placenta
11. Tertiary syphilis
• Neurological syphilis
-Meningovascular disease
-Meningomyelitis
-General paresis
-Tabes dorsalis: a slow degeneration of the nerve cells and nerve
fibers that carry sensory information to the brain.
• Gummatous disease: a mass of inflamed tissue
• Otosyphilis
• Optic syphilis
13. Otosyphilis and optic/ocular syphilis
• Is caused by an infection of the cochleovestibular system with T. pallidum
and typically presents with sensorineural hearing loss, tinnitus, or vertigo.
• Hearing loss can be unilateral or bilateral, have a sudden onset, and
progress rapidly.
• Otosyphilis can result in permanent hearing loss.
• Ocular syphilis can involve almost any eye structure, but posterior uveitis
and panuveitis are the most common.
• Additional manifestations may include anterior uveitis, optic neuropathy,
retinal vasculitis and interstitial keratitis.
• Ocular syphilis may lead to decreased visual acuity including permanent
blindness. loss.
14. Treatment of syphilis
• 1. Long acting IM penicillin
- I.M benzathine 2.4mu stat or weekly x 3 weeks
- If allergic to penicillin, can use azithromycin 500mg daily x 3-6 days or
erythromycin 500mg quid for 10-14 days or tabs doxycycline 100mg
bid x 14 days
- Treat partner as well
• Can use other recommended more effective medicines on the market
at that time
15. Prevention of Syphilis
• Safer sex practices
• Abstinence
• Health education of the adolescents about STIs
• Effective treatment
• Prophylaxis: IM BZ stat dose
16. Complications of Syphilis
• Increases risk for MTCT of HIV during pregnancy
• Increases risk of transmission of HIV
• Can cause infertility in both male and female
• Can cause miscarriage, still birth or early newborn death
• Babies born with congenital syphilis can have bone damage, severe
anemia, enlarged liver and spleen, jaundice, nerve problems causing
blindness or deafness, meningitis, or skin rashes
17. 2. HIV AIDS
• Acquired Immunodeficiency Syndrome (AIDS) is a condition of
reduced immunity as a result of infection with the Human
Immunodeficiency Virus (HIV). HIV should be confirmed with an HIV
test
• Causes: Human Immunodeficiency Virus
18. Modes of transmission of HIV AIDS
• Sexual intercourse with an HIV-infected person,
• Transfusion with HIV-infected blood
• Mother-To-Child Transmission during pregnancy, delivery, or through
breastfeeding
• HIV-contaminated sharp instruments, e.g. dental and surgical
equipment, needles, scalpels, razors, hair shaving equipment, nail
cutters, and other sharp objects
• Exposure to HIV-infected materials through an open wound or cut
19. Epidemiological risk factors for HIV
• Present or past high-risk behaviour (multiple sexual partners)
• Loss of a spouse or partner from HIV disease
• Having sexually transmitted infections, especially Herpes simplex
virus type 2
• Being an uncircumcised man
• Being in an HIV-discordant sexual relationship or marriage
• History of blood transfusion between 1975 and 1986
24. Diagnosis and investigations of HIV
• Provider initiated HIV tests
• Routine HIV tests
- Pregnant women
- Sexual offenders and survivors
- Blood, tissue or organ donors
• If client tests positive, he/she should immediately be connected to
chronic HIV care and treatment
• Below 18months of age, use DBS-DNA PCR test, above 18 months,
use serological test
26. Testing a child less than 18 months
• If the mother is HIV negative, then the baby is negative
If the mother if positive:
• Do DNA PCR at 6 weeks of age or at an earlier opportunity thereafter –
Start cotrimoxazole prophylaxis till HIV status is confirmed
• If PCR is positive, enroll child for ART
• If PCR is negative and child never breastfed: then child is negative: – Stop
cotrimoxazole – Follow up every 3 months and do HIV rapid test
(serological) at 18 months.
• If PCR is negative BUT child is breastfeeding/has breastfed in the last 6
weeks, re-check PCR 6 weeks after cessation of breastfeeding.
• If mother’s status is unknown: Test the mother and continue management
according to the result
• If mother unavailable, test the baby and follow algorithm above
28. HIV care approaches
• Prophylaxis
• Management of OIs
• Nutrition
• Psychosocial support
• ART
• Behavioral change
• Disease monitoring
• Adherence, zero stigma
• Good governance and positive support systems
29. Positive living
Encouraging patient/family to help themselves by:
– Eating a balanced diet
– Engaging in regular exercise
– Keeping active and resting well
– Spending quality time with family and friends
– Obtaining support from a counsellor
– Abstaining from sex or being faithful to one partner
– Using a condom to help ensure safe sex
NB: Uganda adopted the “Test and Treat Policy”, which involves
providing lifelong antiretroviral therapy (ART) to ALL people living with
HIV irrespective of CD4 count or clinical staging
30. Preparing to start client on ART
Take focused history
- Understanding of HIV infection
- Disclosure plan
- Sexual risk factors
- Previous treatment including possibility of exposure to ART such as
nevirapine
- Current medication
- Pregnancy risk
31. Preparing to start client on ART
• Perform physical examination
-Weight y Nutritional status
- Functional capacity and level of disability
-Vital signs, skin, eyes, oropharynx (presence of thrush), lymph nodes,
lungs, heart, abdomen, genital tract (STIs), extremities, nervous system
Baseline lab investigations
-Confirming HIV sero-status CD4 testing
-Pregnancy test
-Full blood count
32. Preparing client to start ART
• Basic lab investigations
• Sputum smear for AFB for patients who have coughed for > 2-3 weeks
and a chest X-ray for patients who have unproductive cough or whose
AFB smears are negative
• Urine analysis for proteinuria, particularly for patients starting on
TDF-containing regimen
• Syphilis screening
• Hepatitis B screening
• Liver and renal function tests
• Cryptococcal antigen screening (Crag) for patients whose CD4 count
is < 100 cells/ml
• Symptom-directed lab tests to diagnose pre-existing illnesses
33. Goal of treatment with ART
• Inhibit viral replication for as long as possible. This promotes
restoration of the immune system.
• Preserve or enhance the immune function (CD4 restoration), which
prevents/delays the clinical progression of HIV disease
• Minimise toxicities and side effects associated with the medicines
• Improve quality of life and reduce HIV-related morbidity and
mortality, improve productivity and contribution to the economy
• Promote growth and neurological development in children
• Minimize risk of HIV transmission
34. Actions to achieve ART goals
• Maximisation of adherence to ART: adequate support to patient to
adhere to treatment
• Disclosure of HIV sero-status
• Rational sequencing of medicines to preserve future treatment
options
• Use of ARV medicine resistance testing when appropriate and
available
• Use of viral load estimates for monitoring response to ART
35. Principles of ART
• Efficacy and durability of the chosen medicine regimens (usually three
or more drugs from at least two ART classes)
• Freedom from serious adverse effects; low toxicity
• Ease of administration including no food restrictions, better
palatability, and lower pill burden
• Affordability and availability of medicines and medicine combinations
• Organized sequencing – spares other available formulations for use in
second line while allowing for harmonisation of regimens across age
and population
• Ongoing support of the patient to maintain adherence
36. Limitations of ART
• ART medicines are not a cure for HIV but greatly improve quality of
life when used appropriately
• ARVs are relatively expensive, require an adequate infrastructure,
and knowledgeable healthcare workers
• Medicine interactions and resistance may decrease the potency of
ARVs
• Patients may develop adverse medicine reactions
• Patients have to take at least 95% of their pills in order to respond
well (adherence is key to successful therapy)
• The medications have to be taken for life
• Some patients may not respond (benefit) to treatment and continue
to regress in spite of high adherence
• Children are dependent on adults for adherence to ART
39. ART treatment – in pregnancy (2023)
• All pregnant women, adults, adolescents and children weighing
30kg or more and tested +ve for HIV should be started on once-
daily FDC of:
-TDF+3TC+DTG or TDF+ 3TC+EFV400 or TAF+FTC+DTG
• If between 20-30kg:
- ABC+3TC+DTG or ABC+3TC+LPV/r or ABC+3TC+EFV
• If less than 20kg:
- ABC+3TC+DTG or ABC+3TC+LPV/r or ABC+3TC+EFV or AZT+3TC+DTG
OR LPV/r.
40. ART treatment (2023): Summary
• First line: All eligible HIV-infected adults and adolescents weighing ≥
30kg should be initiated on
Tenofovir, Lamivudine and Dolutegravir (TDF+3TC+DTG) as a once-
daily fixed dose combination
• Alternative first line: TDF+3TC+EFV400 (if has DM, and dose does
allow use of DTG…….)
• Recommended first line regimen: ABC+3TC+DTG
All HIV-infected children weighing between 20kg to less than 30kg
should be initiated on Abacavir + Lamivudine+ Dolutegravir
(ABC+3TC+DTG)
• NB: Read about pharmacology of ART. Details will be covered in
midwifery & medical nursing
41. Important points about some ARTs
• TDF/3TC/EFV has low toxicity, once daily administration, and is effective
against hepatitis B. It is a relatively inexpensive regimen and does not
cause anaemia as AZT.
• EFV has less risk of treatment failure than NVP.
• Contraindications for EFV: – Severe clinical depression or psychosis –
Patient receiving Benzodiazepines or Carbamazepine – Ongoing
complications of neurological disease that block ability to assess side
effects of EFV – Age < 3 yrs or weight < 15 kg.
• Contraindications for TDF – Renal disease and/or GFR < 60 – Adolescents
below 35 kg.
• Children unable to swallow pellets can start on nevirapine and then be
switched to LPV/r when able to swallow.
42. Common drug interactions to note
• Oral contraceptives: EFV/NVP increase their metabolism causing
possible increased risk of contraceptive failure. Use additional barrier
method
• Injectable progesteron-only contraceptives and IUDs: there is no
significant interaction with ARVs and can be used effectively
• Levonorgestrel implants: effect reduced by EFV and NVP, use
additional barrier method
• For emergency contraception: double the dose
• Rifampicin: increase metabolism of PI/nevirapine.
43. Monitoring patient on ART
• Clinical monitoring
• Laboratory monitoring
- Viral load
- CD4 cell count
44. Prevention of HIV/AIDS
• ABC strategy
• PEP
• PrEP
• STI screening and treatment
• eMTCT
• ART for prevention
• Accelerate HIV testing and treatment
