Communicable Diseases Module: 31. Prevention and Control of Sexually Transmitted Infections

Study Session 31  Prevention and Control of Sexually Transmitted Infections

Introduction

In this study session you will be learning about prevention and control of sexually transmitted infections (STIs) or in other words, infectious diseases that are transmitted primarily (although in some cases not exclusively) by the sexual route. You will also be studying about the relationship between HIV and other STIs. This session also describes syndromic management of STIs, that is a diagnosis based on the identification of the symptoms the patient reports and the signs the health care provider observes. Syndromic management of STIs is the standard approach for diagnosis and management of these communicable diseases recommended by the WHO and adapted by the FMOH for use at both health centre and hospital level. After studying this study session you should be able recognise patients who have STIs in the community. This will help you to refer patients with STIs to the nearest health facility. Treatment and care for STIs includes HIV testing and counselling, prevention and treatment of other STIs, and couple counselling and treatment. Note that at the moment you are not expected to treat or manage patients with STIs at the health post or in the community. You are expected to recognise cases of STIs in your community or at the health post and refer them to the health centre for further care.

Learning Outcomes for Study Session 31

When you have studied this session, you should be able to:

31.1  Define and use correctly all of the key words printed in bold. (SAQ 31.1)

31.2  Explain the routes of transmission and risk factors for the common sexually transmitted infections (STIs). (SAQ 31.1)

31.3  Describe the signs and symptoms of common STIs. (SAQ 31.2)

31.4  Briefly describe the importance of syndromic management of STIs. (SAQs 31.3 and 31.2)

31.5  Explain the importance of STIs in the prevention of HIV transmission. (SAQ 31.4)

31.6  Describe how you would identify and offer provider-initiated testing and counselling for people with STIs and refer them to the nearest health centre for treatment. (SAQ 31.2)

31.1  Introduction to sexually transmitted infections (STIs)

Sexually transmitted infections (STIs) is a term used to describe more than 20 different infections that are transmitted mainly through sexual contact via the exchange of semen, vaginal fluid, blood and other fluids; or by direct contact with the affected body areas of people with STIs. Sexually transmitted infections are also called sexually transmitted diseases (STDs) or venereal diseases. In this study session, we will be talking about STIs in general, with particular emphasis on their impact on individual health. You will also appreciate the implications of preventing STIs in reducing HIV transmission, and the complications resulting from untreated STIs.

STIs are very common. The most widely known are gonorrhoea, chlamydia, syphilis and HIV. STIs can cause serious and permanent complications in infected people who are not treated in a timely and effective way. In people with untreated STIs, the complications and long-term consequences can be devastating. The social and economic burden of STIs can be enormous. Untreated STIs can lead to loss of employment and broken marriages. STIs can place a heavy financial burden on families, communities and health services.

Prevention campaigns in order to reduce the incidence of STIs have a marked impact on the general health of the population. Effective prevention of STIs reduces complications that are life threatening for the infected individual, and decreases economic and psychosocial problems associated with the complications arising from STIs.

Fewer STIs means fewer complications like pelvic inflammatory disease (PID), inflammation of the uterus and fallopian tubes due to bacterial infection or other pathogens), infertility, ectopic pregnancy (pregnancy outside of the uterus), etc. as well as decreased rate of HIV transmission during unprotected sexual contacts.

For patients who are HIV-negative, or who have not been tested, the presence of an STI is an important indication to trigger testing (or repeat testing). Because STIs and HIV infection frequently co-exist and are transmitted together, anyone seen for an STI should be offered HIV testing and counselling. So you should refer any patient presenting with STIs for HIV counselling and testing services.

31.2  Transmission and risk factors for STIs

31.2.1  Transmission of STIs

Now you are going to learn about how STIs are transmitted from one person to another person. As the name implies, by far the most common mode of transmission of STIs is sexual transmission. The modes of transmission could be vaginal or anal sex. In Ethiopia, most STIs in relation to sexual transmission are through the vaginal route (though cases of anal transmission are also common). Heterosexual (sexual intercourse with an individual of the opposite sex) transmission is the most common mode of transmission of STIs. Another mode of transmission is mother-to-child during pregnancy (e.g. HIV and syphilis), at delivery (e.g. gonorrhoea and chlamydia), and during breastfeeding (e.g. HIV). Rarely STIs can also be transmitted through unsafe use of unsterile needles or injections, or coming in contact with contaminated blood or blood products (e.g. syphilis, HIV and hepatitis).

31.2.2  Risk factors for STIs

There are a number of factors that increase the risk of transmission of STIs, including biological, behavioural and socio-cultural factors. In this section we will be discussing the major risk factors that are associated with the transmission of STIs. Understanding these factors will help you in identifying the factors that promote STIs and their relation to the most ‘at risk’ groups of the population affected by STIs. In your daily assessment you will utilise this knowledge to assess patients and give them health education and counselling support in order to prevent STIs.

31.2.3  Epidemiology of STIs in Ethiopia

There is little information on the incidence and prevalence of STIs in Ethiopia. The prevalence of HIV has been mentioned in Study Session 20 and that of syphilis is thought to be about 2.7% (FMOH, 2006). There is no actual information or estimate on other STIs in Ethiopia. This is because reports often under-represent the true number of people infected with STIs. As you can imagine the reasons are many, but a major contributing factor is that people with STIs who have minor or no symptoms do not seek treatment at public health facilities. They usually tend to take self-prescribed drugs or go to private pharmacies to buy treatment without consulting trained health workers.

Another contributing factor to the lack of information on STIs is also irregular access to treatment; that is health facilities offering treatment for STIs may be too far away from clients who present with STIs. Stigma associated with attending public STI clinics is also a factor in that clients tend to shy away from being seen at STI clinics. As noted above, many patients may then choose to go to alternative providers like pharmacies and traditional healers that do not report formally to the Federal Ministry of Health.

The formal public health facilities also do not report all STI cases properly and comprehensively for data to be compiled nationally. Last but not least some patients also do not attend formal STI clinics due to economic factors and they would rather go to traditional healers that provide services for free or with cheap costs.

31.3  Presentation of common STIs

In this section you will study the clinical presentations of common STIs caused by bacteria, viruses or protozoa. The clinical signs and symptoms of common STIs described below will help you to reasonably identify STIs. Now let us describe them.

31.3.1  STIs caused by bacteria

Gonorhoea

Figure 31.1  Gonorhoeal urethral discharge.

Gonorhoea is one of the most common STIs and is caused by bacteria called Neisseria gonorrhoeae. Men with gonorrhoea may present with a burning sensation while urinating and a discharge from the urethra (Figure 31.1), whereas women may present with vaginal discharge and lower abdominal pain. A discharge is a yellowish or whitish substance released from the opening of the reproductive tract in both men and women. Most men infected with gonorrhoea have symptoms, but in women gonorrhoea is commonly asymptomatic (i.e. they do not have any symptoms). Women who have gonorrhoea (with or without symptoms) can transmit the bacteria to infants during birth. In newborn babies, gonorrhoea usually presents with eye disease (termed neonatal conjunctivitis) and can lead to blindness.

• What can you see in Figure 31.1? What could be the possible cause?

• A whitish discharge from the opening of the penis can be seen; the likely clinical diagnosis is gonorrhoea.

Syphilis

Syphilis is caused by bacteria called Treponema pallidum. Syphilis has four stages: primary, secondary, latent and tertiary syphilis, with different signs and presentations according to the time passed from the initial infection. The different stages can be described as follows:

• Primary syphilis is characterised by a painless ulcer (known as chancre) in the genital or anal area resulting from direct sexual contact with a person with syphilis. The chancre has obvious edges, and the lymph nodes in the groin may also appear swollen. Primary syphilis takes 10 to 90 days to develop from initial exposure to the bacterium.

Figure 3.2  Primary syphilitic chancre.

• Describe what you see in Figure 31.2. What could be the most likely diagnosis?

• A solitary ulcer with clear edges on the penis. The possible diagnosis is primary syphilis.

• Secondary syphilis is characterised by a non-itchy rash over the trunk and the extremities, arising 1 to 6 months after primary syphilis.
• Latent syphilis is the stage between secondary and tertiary syphilis in which an infected patient shows few or no symptoms.
• Tertiary syphilis is a rare phenomenon characterised mainly by soft tumour-like balls of inflammation under the skin, or on bones, that may appear anywhere in the body. Some individuals with tertiary syphilis may show serious neurological (nervous system) or cardiovascular problems (heart and blood vessels). Tertiary syphilis takes 1 to 10 years to develop, but it can take up to 50 years.

Granuloma inguinale

Figure 31.3  Raised solid bumps on both sides of the groin caused by granuloma inguinale.

Granuloma inguinale is caused by an infection with bacteria called Calymmatobacterium granulomatis. It presents initially with small lesions in areas surrounding the anus and/or genitals, which are difficult to differentiate from chancroid, but then turn into ulcerative lesions and lead to painless raised solid bumps in both sides of the groin area (Figure 31.3).

31.3.2  STIs caused by viruses

HIV, the virus that causes AIDS, has been dealt with extensively in previous study sessions. Here we will focus on other STIs caused by viruses.

Herpes genitalis

Figure 31.4  Extensive ulcers and sores caused by Herpes genitalis.

Herpes genitalis is the most common STI caused by a viral infection. The pathogen responsible for genital herpes is Herpes simplex virus type 2 (HSV-2). Genital herpes usually presents with blisters that, when they break, lead to painful sores and ulcers in the outer surface of the genitals and in areas surrounding the anus. Following initial infection, it may take around 2–4 weeks for the lesions to heal, but symptoms usually recur weeks or months after the first outbreak. Although geneital herpes may affect anyone, if it involves an extensive area of the genitals and persists for longer than a month as seen in Figure 31.4, you should suspect an HIV-related opportunistic infection. Hence you should offer or refer these patients for provider-initiated HIV testing and counselling if their HIV status is unknown.

Genital warts

Genital warts is a viral STI caused by human papilloma virus (HPV) and commonly presents with small fleshy growths of skin on the genital area or around the anus (Figure 31.5). HPV has also been shown to be the causative agent of cervical cancer in women. However, the types of HPV that cause genital warts are not the same as the types that can cause cancer, which is usually asymptomatic for years.

Cancers (including cervical cancer) are covered in Study Session 3 of the Non-Communicable Diseases, Emergency Care and Mental Health Module.

Figure 31.5  Small fleshy growths on the penis caused by HPV.

31.3.3  STI caused by a protozoan

Trichomoniasis is a STI caused by a protozoan that is usually found in vaginal and urethral tissues. It presents in women with profuse and frothy vaginal discharge. Although this condition is most often treated in women, men can also be infected but often show no symptoms.

31.3.4  STI caused by a fungus

Vaginal candidiasis is a vaginal infection caused by a fungus termed Candida albicans. The main symptoms of candidiasis in women are a curd-like vaginal discharge, vaginal itching and sometimes a burning sensation.

31.4  Syndromic management of STIs

A syndrome is a group of symptoms that patients describe, combined with classic signs that health workers observe during clinical assessment. A number of different organisms that cause STIs give rise to a limited number of syndromes.

Now that you have studied about how common STIs present, in this section you will learn about how to group similar STI together and manage them. You should identify and classify patients into syndromes for effective management of their condition.

31.4.1  Classification of patients into syndromes

Using the syndromic approach, health workers at health centres and hospitals can identify one of these syndromes and treat accordingly. The objective of introducing you to syndromic management of STIs is to help you identify and refer cases to the nearest health centre. At this moment you are not expected to treat STI cases either at the health post or in the community. In the health centre the patient will receive all necessary services including testing for HIV. Table 31.1 shows a modified summary version of syndromic management of the common STIs described in Section 31.3 and others. For detailed reading you can refer to the Ethiopian National Syndromic Management of STIs Guideline.

31.4.2  Treatment and management of STI syndromes

The aim of syndromic management is to identify the seven syndromes listed in Table 31.1 and manage them accordingly. While clinical diagnosis is based on identifying just one specific causative agent, syndromic diagnosis leads to immediate treatment for all of the most important possible causative agents. This is important because mixed infections occur frequently in STIs. Besides, syndromic management of STIs can effectively treat cases in settings with limited laboratory capacity like health posts and health centres. This means that, if necessary drugs are available and affordable, syndromic treatment can quickly render the patient non-infectious.

Therefore the key features of syndromic case management of STIs are first that it is problem-oriented, i.e. it responds to the patient’s symptoms; second, it is efficient in identifying the causes of STIs; and third, it does not miss multiple infections caused by different pathogens.

Syndromic management also makes treatment and control services for STIs more accessible to patients as it can be implemented at health centre level. For example, syndromic management offers a good opportunity to provide health education and HIV testing and counselling during any encounter with STI cases.

In managing STI cases using syndromic management, the health worker is guided through logical steps of clinical decision-making. The following four steps are to be followed:

1. Assessing patients for symptoms, signs and risk factors.
2. Syndromic diagnosis and treatment.
3. Education and counselling on HIV testing and safer sex, including condom use, promotion and provision.
4. Management of sexual partners, in your case tracing sexual partners.

31.5  Common complications of STIs

In this section we will just briefly describe the common complications of STIs. You have to note that complications of STIs have huge health, social and economic implications. Therefore your active identification and referral of STIs cases in the community greatly reduces the burden associated with them. Table 31.2 summarises the common complications of STIs with their respective causes.

31.6   STIs and HIV

Remember that you have learned that HIV is sexually transmitted in Study Session 20. HIV infection is therefore a STI but due to its high priority as a general health concern it has been dealt with separately in this module. In this section you will learn about the relationship between HIV and other STIs. It is important that you remember that HIV is transmitted in the same ways as any other STIs. There are strong links between having an STI and becoming HIV-positive. STIs increase the risk of HIV transmission and HIV infection may make people more susceptible to other STIs and even make other STIs more difficult to treat. These observations make it even more urgent to prevent and control STIs.

31.6.1  The link between STIs and HIV/AIDS

Certain STIs facilitate the spread of HIV. The following three points generally describe the relationship between HIV and other STIs:

• Certain STIs facilitate the transmission of HIV through the small cuts and inflammations they cause around the genitalia.
• The presence of HIV can make people more susceptible to the transmission of STIs. This is because HIV weakens the immunity that can protect us from other infections like STIs.
• The presence of HIV increases the severity of some STIs and makes them more difficult to treat than in HIV-negative individuals. This is also related to the poor immunity of PLHIV.

31.6.2  Which STIs facilitate the transmission of HIV?

A person with open sores in the genital area is much more likely both to contract and to transmit HIV. Chancroid and syphilis are the main bacterial causes of sores: if they are correctly diagnosed and treated, these routes of HIV transmission can be reduced. Genital herpes also facilitates HIV transmission. Genital herpes causes recurrent genital ulcers. An ulcer in the genital area provides an open door, through which HIV can easily pass. Chlamydia, gonorrhoea and trichomoniasis can also facilitate the transmission of HIV although they do not cause sores. This may be due to the fact that genital inflammation associated with these STIs can cause microscopic cuts in genital tissues, creating potential sites where HIV can enter the body.

31.6.3  HIV increases the risk of infection with other STIs

It is also true that people infected with HIV are more vulnerable to getting multiple infections. This is because changes in their body’s immunity make them more vulnerable to infection by pathogens in general.

31.6.4  Key issues regarding STIs and HIV infection

You need to keep in mind the following essential points about the relationship between HIV and STIs. Firstly, an obvious point in common between STIs and HIV is behavioural. For example, unprotected sexual behaviour exposes people to both HIV and other STIs as you learned in Section 31.2.1 and elsewhere in this Module. Equally, the consistent use of condoms can prevent both kinds of infection. So, you need to educate and counsel your clients about the proper and consistent use of condoms to reduce the risk of transmission of both HIV and other STIs.

Secondly, STI control is also important for preventing the spread of HIV from PLHIV, which you learned in Study Session 29 on positive living. PLHIV are more likely to transmit HIV to others if they also have another STI. PLHIV should thus be taught how to recognise STI symptoms and be encouraged to seek care promptly if they think they may have an infection.

Note that all STI cases that you identify at your health post and in your community have to be referred to the nearest health centre for treatment. In the health centre, STI treatment should be provided along with the following key interventions:

• Educating clients about the transmission, treatment and control of STIs and HIV
• Providing risk reduction counselling by focusing on the prevention of STIs and HIV
• Condom promotion and provision for all clients
• Consideration of HIV-related illness and offering provider-initiated counselling and testing
• Partner counselling and treatment: management of partners for STIs is an essential component of STIs to stop further recurrent infection among partners
• Encouragement for HIV testing through provider-initiated counselling
• Referral of patients and their partners to counselling units and laboratories for HIV and syphilis testing, or to higher health care if they do not respond to syndromic treatment of STIs.

Summary of Study Session 31

In Study Session 31, you have learned that:

1. STIs are very common communicable diseases in the community.
2. The transmission of STIs is greatly affected by demographic, social, biological, economic and behavioural factors.
3. Syndromic management of STIs is an important tool to simplify the diagnosis and treatment of STIs. It involves treating all possible causes, even though the specific infectious agents have not been identified.
4. HIV testing and counselling is an essential component of STI management.
5. The risk of HIV transmission increases when an individual has concurrent and untreated STIs. The presence of HIV increases the severity of some STIs and makes them more difficult to treat.

Self-Assessment Questions (SAQs) for Study Session 31

Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering the following questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.