National AIDS and STI Prevention

and Control Program

De Guzman | Montalvo | Tiu Serra | Tobias | Turingan | Valdueza |
Yenson| Yopo | Zulueta
Group 8
Learning Objectives
• General
• At the end of the session, the students should be able to understand the DOH
program for the prevention and control of Reproductive Tract Infections
• Specific
• Discuss the National AIDS and STD Prevention and Control Program (NASPCP)
including the following:
• Epidemiology of HIV positive cases in the Philippines
• National Objectives for Health for AIDS and STD
• Rationale of the Program
• Process of diagnosing a patient with HIV Infection
Learning Objectives
• Specific
• Discuss the National AIDS and STD Prevention and Control Program (NASPCP)
including the following:
• Medical management of HIV positive patients
• Preventive measures against HIV infection and AIDS transmission
• Overview of local and national responses to HIV infection and AIDS
• Methods of STD detection
• Objectives of STD case management
• Syndromic Approach to the diagnosis and management of STD
Human Immunodeficiency
Virus (HIV)
HIV/ AIDS
• Human Immunodeficiency Virus
(HIV) is a disease which renders
people’s defenses vulnerable to
infections and some types of
cancers.
Epidemiology
In Males In Females
83% MSM 92% Male-female sex
34,742 2,843
12% Male-female sex
5,042
In the Philippines
Cumulative number of cases since 1984
New cases in June 2017

1,013 45,023
17% 21,035
841 new cases last June 2016
Cases using Antiretroviral therapy
1,098
Highest number of cases in a
month since 1984(May 2017)
55,000
Projected Filipinos with HIV/AIDS by end of this year
 3,095 41,917

189
Pregnant women with HIV

92% (2,859 cases) 93%

Female aged 15-49 years old

23,100 25-34 years old

82% 12,386 15-24 years old

Median age: 27 years old

 Global statistics shows..
Estimated number of People living with HIV in 2016
New cases in 2016

1.8 million 36.7 million

1.9 million new cases in 2015
5%
500,000
Target case per year by 2020
200,000 28 million
Target case per year by 2030 Projected averted HIV cases by 2030
In the Philippines
Cumulative number of cases since 1984
New cases in June 2017

1,013 45,023
17% 21,035
841 new cases last June 2016 Cases using Antiretroviral therapy

1,098 2,185
Highest number of cases in a
month since 1984(May 2017)
Deaths due to AIDS-related illness
55,000
Projected Filipinos with HIV/AIDS by end of this year
In Males In Females
83% MSM 92% Male-female sex
34,742 2,843
12% Male-female sex
5,042
 National AIDS and STD
Prevention and Control Program
(NASPCP)
 DOH-National Philippine AIDS
Manila Rapid
AIDS/STI Prevention and
Treatment
Prevention and Control Act of
Center
Control Program 1998

50 years
1986 1988 1994 1998 Aquino
ago

National AIDS STI Aquino Health

National Agenda: Achieving
Prevention and
HIV/AIDS Universal Health
Control Program
Registry Care for All
(NASPCP)
Filipinos
Gaps and Challenges
• Emerging at risk populations (prisoners, transgender) needs to be
evaluated
• Waiting period for HIV test results hinders access for timely treatment
and care
• Retention of volunteers is a concern for continuity of services
• Engagement of private sector
• Funding to scale up interventions
• Tolerance/Acceptance of the community to address barriers to service
delivery
VISION

Zero new infections, Zero AIDS-related deaths and Zero

Discrimination.
GOAL
To maintain prevalence of <1% in 2020 by preventing
the further spread of HIV infection and reducing the
impact of the disease in individuals, families, sectors
and communities
General Objectives
• To improve coverage and linkage of services from prevention and
diagnosis among Key populations to treatment and care for PLHIV
through an intensified delivery of quality and evidence based services
• To raise the awareness of key populations and the public on HIV and
STI prevention and care services
General Objectives
• To increase demand and access to available HIV and STI services
• To provide timely evidence-based information for planning,
monitoring, evaluation and quality assurance of HIV and STI program
• To intensify delivery of quality STI and HIV services through a
strengthened support system by addressing barriers, improving
linkages and ensuring availability of critical enablers
Targets to achieve from 2015 to 2020
• Reduction of HIV incidence among MSM to < 50%
• Maintain HIV Prevalence of <1% among young (<20yo) childbearing
women in NCR cities and Cebu city from baseline
• Reduction in percent of KP with STI (syphilis) to <1.5%
• Reduction of HIV-related deaths by 80%
• Reduction of TB-related deaths to <1%
Strategies
 Strategy 2: Health Promotion
Strategy 1. Continuum of
and Communication on HIV and
HIV/STI Prevention, Diagnosis,
STI Prevention and Care Services
Treatment and Care Services to
Key Populations

STRATEGIES

Strategy 4: Strengthened Health

Strategy 3: Enhanced Strategic
System Platform for Broader
Information Systems
Health Outcomes
 Strategy 1
Continuum of HIV/STI Prevention, Diagnosis, Treatment and Care
Services to Key Populations
Strategy 1. Continuum of HIV/STI
Prevention, Diagnosis, Treatment and
Care Services to Key Populations
Objective:
• To improve coverage and linkage of services from
prevention and diagnosis among KP to treatment and
care for PLHIV through an intensified delivery of
quality and evidence based services
Key Populations
1. Female Sex Workers (FSW), categorized into two as follows –
• High risk group or Group 1: Freelance FSW or street-based
• Low risk group or Group 2: FSW in Registered Entertainment Establishments
2. Men having sex with men (MSM)
3. Transgender women
4. Injecting Drug Users (IDU) or People Who Inject Drugs (PWID)
5. Young people (high risk)
Implementation of Cascade for Continuum of Care
Key Interventions
1. Prevention, Treatment and Care
2. HIV Counseling and Testing (HCT)
3. Essential Packages for Specific KP
1. Prevention, Treatment and Care
• HIV-specific interventions needs to be strengthened and expanded.
• Core programs to enhance the quality, effectiveness and coverage of HIV
interventions and approaches, as well as to identify new HIV interventions
on prevention, diagnosis, treatment and care.
• Core programs for preventions are
1) Prevention of sexual transmission of HIV and includes condom availability and
provision
2) Detecting and managing sexually transmitted infections
3) Elimination of congenital syphilis
4) Blood safety
5) Elimination of HIV transmission in health care settings and
6) Eliminating new HIV infections in children.
1. Prevention, Treatment and Care
• Treatment and care program will include prophylaxis, diagnosis and
treatment for common opportunistic infections and co-morbidities.
• TB remains the main cause of mortality in people living with HIV
including those who are on ART,
• HIV-positive TB patients are identified and treated appropriately, and
to prevent TB in HIV-positive patients.
2. HIV Counseling and Testing (HCT)
A. Client-initiated HIV testing and counseling (CITC)
B. Provider-initiated HIV testing and counseling (PITC)
• HIV-negative are taught how to remain negative
• HIV-positive are taught how to prevent transmission to others and
maintain their own good health.
HCT coverage (%) among Key Populations
3. Essential Packages for Specific KP
• Essential health packages aim to concentrate scarce resources on
interventions that provide the best ‘value for money’.
Essential Package Services for SEX WORKERS
Essential Package Services for MSM AND TRANSGENDER
Essential Package Services for PWID
Essential Package Services for YOUNG PEOPLE
Prevention and Diagnosis
Treatment, Care and Support Services
Procurement of Affordable Drugs, Reagents, and Supplies
Procurement of Affordable Drugs, Reagents, and Supplies
Augmentation of Human Resources
 Strategy 2
Health Promotion and Communication
Strategy 2: Health Promotion and
Communication
Objectives
• To raise the awareness of key populations and the public on HIV
and STI prevention and care services.
• To increase demand and access to available HIV and STI services.
Strategy 2: Health Promotion and
Communication
• Demand generation from the community can accelerate the access to
a strengthened and quality prevention, treatment and care packages.
• This can be achieved by creating activities which can scale up demand
through intensified information and education on HIV and STI coupled with
promotion of related services.
• This in turn may increase the coverage of the target population.
• Community-based outreach can be the most effective way in
delivering HIV prevention, treatment and care to key populations
(KP).
Strategy 2: Health Promotion and
Communication
Major Activities
1. Implementation of National Communication Plan that strategizes
demand generation for STI and HIV services, and executes in part the “One
BCC Framework for KP”
2. Assist LGUs and their respective partners in localizing National
Communication Plan that strategizes demand generation for STI and HIV
services
3. Develop standards for peer education, peer counseling, and other
community-led support services
4. Develop and operate ICT-based BCC tools as supplementing channels
for primary approaches of the “One BCC Framework for KP”
Strategy 2: Health Promotion and
Communication
Major Activities
5. Develop and produce BCC materials for primary approaches of, and for
facility-based information services supporting the “One BCC Framework for KP”
6. Launch publicity-generating national advocacy campaigns on ART, HIV
testing and condom use, consistent with “HIV Stigma Management Strategy”
7. Assist LGU and other community leaders in local advocacy campaigns,
consistent with “HIV Stigma Management Strategy”
8. Assist private sector and non-health sector partners for strategic
participation in demand generation for STI and HIV services (including promotion of
Treatment hubs and CBO services, and PMTCT of HIV programs to medical societies
and private testing facility)
9. Number of advocacy events conducted that help generate demand for STI
and HIV services
 Strategy 3
Enhanced Strategic Information System
Strategy 3: Enhanced Strategic Information
System
Objective
• The objective of this strategy is to provide timely evidence-based
information for planning, monitoring, evaluation and quality
assurance of HIV and STI program.
Strategy 3: Enhanced Strategic Information
System
• This strategy aims to install a system that could monitor the
implementation of health policies and programs.
• Information backed-up by evidence can be generated through
surveillance and monitoring.
• To help define and redefine program interventions which are
appropriate to the needs of the target population, researches and
special studies regarding HIV and STIs will be conducted.
Strategy 3: Enhanced Strategic Information
System
• Systematic collection of strategic information on HIV and other STIs
among key populations is essential in establishing health policy,
planning, resource allocation, program management, service delivery
and accountability.
Strategy 3: Enhanced Strategic Information
System
• HIV surveillance generates data that allows understanding of the
magnitude and determinants of the country’s epidemic, assessing the
burden of disease, monitoring trends over time, developing
interventions and evaluating their impact.
• Mapping and developing reliable estimates of the size of populations
at high risk for HIV should also be considered for assessment of needs
and development of appropriate policies and programs.
Strategy 3: Enhanced Strategic Information
System
Major Activities
1. Implement surveillance
a. Integrated HIV Behavioral and Serologic Surveillance (IHBSS)
b. Sentinel STI Etiologic Surveillance System (SSESS)

2. Implement activities related to estimates and projections

a. Rapid Assessment of HIV Vulnerability (RAV) - Micro Mapping

3. Implement HIV Program Monitoring

a. Unique Identifier Code (UIC)
b. Development of tracking system to monitor patient follow-up in treatment hubs
c. Opportunistic Infections and TB-HIV Reporting
Strategy 3: Enhanced Strategic Information
System
Major Activities
4. Implement special studies
a. Bed Assay, STI and HIV Drug Resistance Study (Transmitted Resistance), Transgenders
and/or partners of PLHIV, Opioid substitution therapy for Nalbuphine, HIV Risk and
Vulnerabilities in Closed-settings and among emerging subgroups KP (e.g. deaf mute), HIV-
related stigma, PLHIV mental health, etc.
5. Implement data utilization activities in sites
a. Local Dissemination forums
b. Develop LGU Data Utilization scorecards - Local strategic and operation planning
6. Implement strategic and operation planning in sites
7. Conduct monitoring, evaluation and quality assurance of
Epidemiology Bureau (EB) data systems
Strategy 3: Enhanced Strategic Information
System
Major Activities
8. Conduct quality assurance and evaluation of HIV programs
a. Program Implementation Review (PIR) - Prevention programs and STI services
b. HCT services
c. Treatment and care services
9. Ensure timely release and utilization of data
 Strategy 4
Strengthened Health System Platform for Broader Health Outcomes
STRATEGY 4: Strengthened Health System
Platform for Broader Health Outcomes
• Objective: To intensify delivery of quality STI and HIV services through
a strengthened support system by addressing barriers, improving
linkages and ensuring availability of critical enablers.
STRATEGY 4: Strengthened Health System
Platform for Broader Health Outcomes
• Health System
• Totality of all the organizations, people and actions whose primary intent is to
promote, restore or maintain health
• Includes:
• Influence the determinants of health
• deliver health-improving services
• Roles of a well-functioning health system:
• To ensure that the expanded response to HIV will be effective, efficient and
comprehensive
• Able to respond to current and future emerging and revival HIV / AIDS issues
• Improved to create broad synergies and better health outcomes
• Address barriers and gaps for the efficient delivery of services.
STRATEGY 4: Strengthened Health System
Platform for Broader Health Outcomes
• The DOH National Objectives for Health (2011-2016)
• Improve the health status of the population
• Develop a health system that is more responsive to the health needs of the people
• Ensure equity in financing health care.
• Achieved by strengthening the health system in terms of efficiency and
effectiveness through addressing problems with:
• Infrastructure
• Health workers/ human resource
• Health commodities
• Logistics
• Information technology
STRATEGY 4: Strengthened Health System
Platform for Broader Health Outcomes
• Strengthened Health System platform addresses concerns about:
• Leadership/ Governance
• Health Financing
• Human Resource
• Medical Products and Technologies
• Information Systems
• Service Delivery
Major activities conducted for
Strategy 4
In addressing Leadership/ Governance:
1. Strengthen regulation/guidelines for HIV and AIDS Core Teams in hospitals
2. Establishment of psycho social sup through partnership with professional
organizations like the Psychological Association of the Philippines
3. Establish and maintain public-private partnership in the delivery of STI and
HIV services for key population
4. Strengthen coordination and linkages with TB, MCH program at national
and regional level ensuring guidelines are disseminated and implemented
by local implementers.
5. Strengthening of Procurement Supply Management Chain from National to
Treatment Hub
In addressing Leadership/ Governance:
LGU-related
6. Develop policy to establish sub-national laboratories for HIV diagnosis
7. Organization and conduct of HIV and STI advocacy and stigma reduction
activities
8. Expand sites implementing 100% Condom Use Program (CUP)
9. Organization and Strengthening of Local AIDS Council (LAC) which includes
a local community organization as an active member through an ordinance
10. Establish performance -based financial grant mechanism to LGU and/or
NGO financing HIV and STI services
Concerns in Human Resources/ Manpower:
Capability building among key stakeholders in the LGU on
11. 100% CUP (Condom Use Program)
12. SOGIE (Sexuality, Orientation, Gender Identity and Expression)
13. PWID interventions
14. Capacity building of LAC members to respond to HIV
Diagnosis
Diagnosis
• 5 key populations (WHO 2016)
• Men having sex with men (MSM)
• People who inject drugs
• People in prisons and other closed settings
• Sex workers
• Transgender people
Diagnosis
• •HIV infection established by
• (1) culture or by (2) detecting the ff:
o antibodies to the virus,
o viral antigens,
o viral DNA/RNA
Diagnostic Tests
ELISA Test – (+) -> Western blot to confirm
• (-)/uncertain -> repeat – 1-3 months
• Sensitive in chronic HIV infection
• Antibodies are not produced immediately upon infection
Diagnostic Tests
P24 Antigen Test- EIA based/ uses antibody to capture the disrupted
p24 antigen from the serum.
• Useful for specimens from high risk symptomatic px but HIV EIA-
negative or for specimens that are EIA-positive but Western blot
negative or indeterminate
Diagnostic Tests
Western Blot- highly sensitive
• Used to confirm a positive ELISA test
• Immunoblot that allows characterization of antibodies to each viral
protein.
• Serum is reacted w/ a nitrocellulose strip containing all of the
constitutive HIV virus proteins, arranged by mol. weight after
polyacrylamide gel electrophoresis.
Diagnostic Tests
• Qualitative PCR- amplifies viral nucleic acid to allow for its detection
in specimens.
• Very useful in the diagnosis of HIV infection in babies born to infected
mothers
Management and Prevention
Anti Retroviral
Drugs for HIV
PREVENTION
Oral Pre-Exposure Prophylaxis for
Preventing the Acquisition of HIV

• Tenofovir disoproxil fumarate (TDF)

• Substantial risk for HIV
• HIV incidence of 3 per 100 person-
years
• Local epidemiology and individual
assessment
 Post-Exposure Prophylaxis
• Initiated as early as possible, preferably within 72 hours
• Exposed to body fluids, mucuous membane, and parenteral
exposure
• Not given to those exposed but already HIV positive, source
is negative for HIV, exposure to body fluids that do not pose
a significant risk
Antiretroviral
Therapy
ART
• Patients willingness and readiness to initiate ART
• Drug regimen, dosage and scheduling
• Benefits, possible side effects and the required follow-
up and monitoring visits
• Reduce time between HIV diagnosis and ART initiation
ART: Guiding Principles
• Treatment should be started based on a person’s informed decision to
initiate ART.
• Interventions to remove barriers to ART initiation once an individual is
diagnosed HIV positive should be implemented.
• HIV programmes should promote treatment literacy among all people with
HIV, including information on the benefits of early treatment, the lifelong
commitment required, the risks of delaying treatment and available
adherence support.
• Care providers should be trained to support shared decision-making.
• Although ART initiation is rarely urgent, it may need to be expedited in
certain circumstances, such as serious ill health and for pregnant women in
labour whose HIV test result is positive.
What to Expect in the First Months of ART
• Clinical and immunological improvement and viral
suppression
• Opportunistic infections and immune reconstitution
inflammatory syndrome (IRIS)
• Adverse drug reactions (eg. hypersensitivity)
When to start ART in Adults
(>19 y/o)
• All adults living with HIV regardless of WHO clinical
stage and at any CD4 cell count
• Priority given in adults with severe disease or
advanced HIV clinical disease (WHO clinical stage 3 or
4) and those with CD4 count ≤350 cells/mm3
When to Start ART in
Pregnant and Breastfeeding Woman
•Started regardless of WHO clinical stage and at
any CD4 cell count and must be continued
lifelong
When to Start ART in
Adolescents (10-19 y/o)
• Initiated regardless of clinical stage and at any CD4 cell
count
• Priority must be given to those with severe or
advanced HIV clinical disease
When to Start ART in
Infants and Children < 10 y/o

• Initiated in infants diagnosed in the first year of life and

children living with HIV 1-10 years old regardless of stage or
CD4 cell count
• Priority should be given to all children ≤2 years old or
children younger than 5 years of age with WHO clinical stage
3 or 4 or CD4 count ≤750 cells/mm³ or CD4 percentage
ART for Adults and
Children with TB
• Started in all TB patients regardless of CD4 count.
• TB treatment comes first followed by ART as soon as possible
• Those with profound immunosuppression (CD4 ≤50 cells/mm³)
should receive ART within the first two weeks of TB treatment
• Initiated in any child with active TB disease as soon as possible within
8 weeks following TB treatment regardless of CD4 count or stage
Treatment of Recent HIV Infection
• Period up to 6 months following HIV acquisition
• Specific anti-HIV antibodies become detectable by serological tests
(seroconversion)
• Viral load steady state (set point) and viral reservoirs are usually established
• Clinical studies have indicated that initiation of ART during recent HIV
infection can reduce the size of the latent viral reservoir and delay
viral rebound after ART discontinuation
• WHO has not yet established a diagnostic strategy or any specific
recommendation to identify or treat people during this phase of
infection
First-Line ART
• Fixed-dose
regimens and
once-daily
regimens are
preferred
Second- and Third-Line ART
 Managing
Coinfections and
Comorbidities
Co-trimoxazole Prophylaxis
• Co-trimoxazole prophylaxis for adults
Malaria
Tuberculosis
• TB patients who are HIV positive and TB patients living in HIV
prevalent settings should receive at least six months of a rifampicin-
containing treatment regimen
• Optimal dosing frequency is daily during the intensive and
continuation phases
Cryptococcal Disease
• Prompt lumbar
puncture w/
measurement of CSF
opening pressure and
rapid CSF cryptococcal
antigen- preferred
diagnostic approach
• ART initiation is not
immediate in cases of
HIV-infected patients
with cryptococcal
meningitis
• It should be deferred
until there is evidence
of a sustained clinical
response to anti-
fungal therapy
Chronic Care for People Living with HIV
• Assessment and management
• Of cardiovascular risk should be provided for all individuals living with HIV
according to the standard protocols recommended for the general
population.
• Of depression should be included in the package of HIV care services for all
individuals living with HIV
Combination HIV Prevention
• Biomedical
• ART drugs
• Male and female condoms and condom
compatible lubricant
• Needle and syringe programs
• Opioid substitution therapy
• Voluntary medical male circumcision
• Behavioral
• Targeted information and education
• Structural and supportive interventions
Local and National Responses
Country’s Response
• Philippine AIDS Prevention and Control Act of 1998 (RA 8504)
• Implementation of Principle of Three Ones
• One national coordinating body, one strategic framework, and one national monitoring
and evaluation system
• Philippine National AIDS Council (PNAC)
• acts as the primary policy- making and coordinating body and is committed to
end the spread of HIV and continuously assist in improving the lives of people
living with HIV.
AIDS Medium Term Plan (AMTP)
• Blue print of our national response on HIV and AIDS
• national goal of maintaining a prevalence of less than 66 HIV cases
per 100,000 (or 0.066%) by 2016
5th AMTP Objectives
• To improve the coverage and quality of prevention programs for persons at
most risk, vulnerable and living with HIV;
• To improve the coverage and quality of TCS programs for people living with
HIV (including those who remain at risk and vulnerable) and their families;
• To enhance policies for scaling up implementation, effective management
and coordination of HIV programs at all levels;
• To strengthen capacities of the PNAC and its members to oversee the
implementation of the 5th AMTP; and
• To strengthen partnerships and develop capacities for the 5th AMTP
implementation of LGUs, private sector, civil society, including communities
of at risk, vulnerable, and living with HIV.
The following recommended outcome and impact evaluation
components from midterm review of 5th AMTP were
considered in HSP:
• HIV prevalence trends in key populations (registered and unregistered
female and male sex workers, MSM and PWID, transgender and
transsexual people; STI patients; and tuberculosis patients);
• HIV incidence using newly available assays;
• Mean CD4 count in newly diagnosed PLHIV;
The following recommended outcome and impact evaluation
components from midterm review of 5th AMTP were
considered in HSP:
• Incidence and prevalence of STIs as proxies for assessing changing
preventive and careseeking behaviors.
• Other measures of outcome and impacts should consider behavioral
trends (e.g.; use of condoms and other safe sexual practices; use of
sterile needles and other harm-reduction practices, such as drug
substitution and treatment)
• Trends in the ability of key populations and PLHIV to be freed of
stigma and discrimination, resume productivity, increase their
autonomy and participation in public affairs, and improve their
quality of life.
6th AMTP for 2022
• Increase knowledge of HIV transmission, prevention, and services
among 15-24 years old to 90%
• prevent new HIV infections among 15-24 years old
• test and treat 90% of people living with HIV
• eliminate mother-to-child transmission of HIV.
HEALTH SECTOR’S RESPONSE
• Disease Prevention and Control Bureau (DPCB)
• providing technical guidance
• resource mobilization
• monitoring
• capability-building
DPCB
• DPCB directs the implementation of strategic objectives and activities
that will greatly contribute in the attainment of national goals
towards halting and reversing the HIV epidemic
• Regional counterparts
• Developmental organizations
• LGUs
• NGOs
Sexually Transmitted Infections
(STIs)
Epidemiology
 Worldwide
• More than 30 different bacteria, viruses and parasites are known to
be transmitted through sexual contact
• 8 of which are the most common
• Curable infections: Syphilis, gonorrhea, chlamydia and trichomoniasis
• Incurable: Hepatitis B, herpes simplex virus (HSV or herpes), HIV, and human
papillomavirus (HPV).
• STIs are spread predominantly by sexual contact, including vaginal,
anal and oral sex
• Some STIs can also be spread through non-sexual means - blood or blood
products and from mother to child during pregnancy and childbirth

http://apps.who.int/iris/bitstream/10665/112323/1/WHO_RHR_14.10_eng.pdf
Estimated new cases of curable STI

http://apps.who.int/iris/bitstream/10665/112323/1/WHO_RHR_14.10_eng.pdf
• >500 million people are estimated to have genital infection with HSV
• >290 million women have HPV infection
• An estimated 257 million people are living with hepatitis B virus
infection
• Each year, there is an estimated 357 million new infections with 1 of 4
curable STIs
• Over 900,000 pregnant women were infected with syphilis resulting in
approximately 350,000 adverse birth outcomes including stillbirth in 2012

http://apps.who.int/iris/bitstream/10665/112323/1/WHO_RHR_14.10_eng.pdf
Global and regional estimates of the number of prevalent cases
of curable STIs for men and women aged 15-49 years
 Philippines
Positivity Rate by Type of STI and Sex

SSESS-DOH, 2013
Prevalence (%) of syphilis by key populations
Syphilis among pregnant women in NCR

DOH-NCRO, 2014
STD Detection
 History and Physical Examination

• The diagnosis of STIs relies on proper history taking and physical

examination
• History of unprotected sex, STI in the partner, multiple sexual partners, and
change in sexual partners
• Discharge, pain, ulceration,
• Physical examination in men
• Skin, oral cavity, penis, scrotum and testes, lymph nodes
• Physical examination in women
• Skin, oral cavity, vulva, speculum exam, digital bimanual exam
 Laboratory tests
• Gram-stain
• Culture
• Microscopy
• ELISA
• PCR
 Laboratory tests
Laboratory tests for the identification of STI pathogens that cause genital ulcers
Laboratory tests for the identification of human papilloma virus
Laboratory tests for the identification of STI pathogens that cause
genital discharge
Tests for Syphilis in pregnancy
Syndromic Approach
Guidelines in the Management
• DOH adopted WHO guidelines through Administrative Order No. 5 s.
2003
Guidelines in the Management
• Case Management
• care of a person with an STI-related syndrome or with a positive test for one
or more STIs
• Syndromic Management
• based on the identification of consistent groups of symptoms and easily
recognized signs, and the provision of treatment that will deal with the
majority of, or the most serious, organisms responsible for producing a
syndrome.
Syndromic Approach in STI Management
• Urethral Discharge
• Genital Ulcers
• Scrotal Swelling
• Vaginal Discharge
• Lower Abdominal Pain
• Neonatal Conjunctivitis
Syndromic Approach in STI Management
• Urethral Discharge
• Genital Ulcers
• Scrotal Swelling
• Vaginal Discharge
• Lower Abdominal Pain
• Neonatal Conjunctivitis
Urethral Discharge
• Presence of abnormal secretions from the distal part of the urethra
• Characteristic manifestation of urethritis
• Associated symptoms:
• Increased frequency and urgency of urination
• Itching sensation of the urethra
• Discharge can be purulent or mucoid, clear, white, or yellowish-green
Urethral Discharge
• Microscopy (Urethral smear)
• Increased PMNs (>5 per OIF in males)
• Gram stain may demonstrate the presence of gonococci
• Pathogens causing urethral discharge:
• Neisseria gonorrhoeae
• Chlamydia trachomatis
• Mycoplasma genitalium
• Trichomonas vaginalis
• Ureaplasma urealyticum
• Acute complications : disseminated gonococcal syndrome, perihepatitis,
acute epididymo-orchitis
• Chronic complications : urethral stricture, infertility, Reiter’s syndrome.
Urethral Discharge
• The recommended syndromic treatment by the WHO
• therapy for uncomplicated gonorrhea
PLUS
• therapy for chlamydia
Persistent Urethral Discharge
• May be due to
• drug resistance
• poor compliance
• reinfection
• In some cases there may be infection with Trichomonas vaginalis.
Syndromic Approach in STI Management
• Urethral Discharge
• Genital Ulcers
• Scrotal Swelling
• Vaginal Discharge
• Lower Abdominal Pain
• Neonatal Conjunctivitis
Genital Ulcers
• Open sores or breaks in the continuity of the skin or mucous
membrane of the genitalia
• Clinical differential diagnosis of genital ulcers is inaccurate,
particularly in settings where several etiologies are common
• After examination to confirm the presence of genital ulceration,
treatment appropriate to local etiologies and antimicrobial sensitivity
patterns should be given.
Genital Ulcers
• Recommended syndromic treatment include therapy for syphilis PLUS
EITHER therapy for chancroid where it is prevalent OR therapy for
granuloma inguinale where it is prevalent OR therapy for LGV where it
is prevalent OR therapy for HSV2 infection where indicated.
Inguinal Bubo
• Localised enlargements of the lymph nodes in the groin area
• Painful and may be fluctuant
• Frequently associated with LGV and chancroid
• Non-sexually transmitted local and systemic infections (e.g. infections
of the lower limb or tuberculous lymphadenopathy) can also cause
swelling of inguinal lymph nodes
• Recommended syndromic treatment includes ciprofloxacin, 500 mg
orally, twice daily for 3 days AND doxycycline, 100 mg orally, twice
daily for 14 days OR erythromycin, 500 mg orally, four times daily for
14 days.
Syndromic Approach in STI Management
• Urethral Discharge
• Genital Ulcers
• Scrotal Swelling
• Vaginal Discharge
• Lower Abdominal Pain
• Neonatal Conjunctivitis
Scrotal Swelling
• Epididymitis
• acute onset of unilateral testicular pain and swelling
• Men under 35 years
• sexually transmitted
• Older men
• Escherichia coli
• Klebsiella spp.
• Pseudomonas aeruginosa
• Tuberculous orchitis
• Mumps epididymo-orchitis
• Testicular torsion
• Sudden onset of scrotal pain
• If not effectively treated, STI-related epididymitis may lead to infertility.
Scrotal Swelling
• Recommended syndromic treatment:
• therapy for uncomplicated gonorrhoea
PLUS
• therapy for chlamydia.
Syndromic Approach in STI Management
• Urethral Discharge
• Genital Ulcers
• Scrotal Swelling
• Vaginal Discharge
• Lower Abdominal Pain
• Neonatal Conjunctivitis
Vaginal Discharge
• A spontaneous complaint of abnormal vaginal discharge (in terms of
quantity, color or odor) is most commonly a result of a vaginal infection
• It may in rare cases be caused by mucopurulent STI-related cervicitis
• T. vaginalis, C. albicans and bacterial vaginosis are the most common
causes of vaginal infection
• N. gonorrhoea and C. trachomatis cause cervical infection
• The clinical detection of cervical infection is difficult, because a large proportion of
women with gonococcal or chlamydial cervical infection are asymptomatic
• The symptom of abnormal vaginal discharge is highly indicative of vaginal
infection, but poorly predictive for cervical infection
• Thus, all women presenting with vaginal discharge should receive treatment for
trichomoniasis and bacterial vaginosis
Vaginal Discharge
The discharge can be characterized as:
• Thin, homogenous whitish discharge with fishy odor
• Thick, profuse, malodorous, yellow-green, frothy itchy
• Purulent exudate from the cervical os
• White, thick and curd like discharge coating the walls of the vagina
CERVICAL INFECTION

GONORRHEA CHLAMYDIA
• Ciprofloxacin • Doxycycline
• Ceftriaxone • Azithromycin
• Cefixime
• Spectinomycin
VAGINAL INFECTION
RECOMMENDED SYNDROMIC TREATMENT
Therapy for T. vaginalis
PLUS
Therapy for BACTERIAL VAGINOSIS
PLUS (if indicated)
therapy for C. albicans

Metronidazole is indicated in bacterial vaginosis, as well as in T. vaginalis infection

Aside from Metronidazole gel, Clindamycin may be an alternative treatment for bacterial vaginosis.

For C. albicans infection, Miconazole, Clotrimazole, and Fluconazole may be used.

Nystatin is an alternative medication for candida infection.
Syndromic Approach in STI Management
• Urethral Discharge
• Genital Ulcers
• Scrotal Swelling
• Vaginal Discharge
• Lower Abdominal Pain
• Neonatal Conjunctivitis
Lower Abdominal Pain
• All sexually active women presenting with lower abdominal pain
should be carefully evaluated for the presence of salpingitis and/or
endometritis — elements of pelvic inflammatory disease (PID)
Etiologic agents
• N. gonorrhea
• C. trachomatis
• anaerobic bacteria (Bacteroides spp. and Gram-positive cocci)
• facultative Gram-negative rods
• Mycoplasma hominis
Lower Abdominal Pain
• As it is impossible to differentiate between these clinically, and a
precise microbiological diagnosis is difficult, the treatment regimen
must be effective against this broad range of pathogens.
• Early identification and treatment should be implemented to reduce
occurrence of complications, with treatment regimens covering all
possible causative agents.
• It is important to rule out surgical emergencies, as these can be
indications for immediate hospitalization and urgent surgical
intervention.
OUTPATIENT THERAPY
RECOMMENDED SYNDROMIC TREATMENT

Single-dose therapy for uncomplicated gonorrhea

PLUS
DOXYCYCLINE, 100 mg orally twice daily
OR
TETRACYCLINE, 500 mg orally 4 times daily for 14 days
PLUS
METRONIDAZOLE, 400–500 mg orally twice daily for 14 days

Outpatients with PID should be followed up after 72 hours and admitted if their
condition has not improved.
INPATIENT THERAPY
RECOMMENDED SYNDROMIC TREATMENT

CEFTRIAXONE, 250 mg IM once daily

PLUS
DOXYCYCLINE, 100 mg orally or IV inj twice daily
OR
TETRACYCLINE, 500 mg orally 4 times daily
PLUS
METRONIDAZOLE, 400–500 mg orally or IV inj twice daily
OR
CHLORAMPHENICOL, 500 mg orally or IV inj 4 times daily
 CIPROFLOXACIN, 500 mg orally, twice daily
OR
SPECTINOMYCIN 1 g IV inj 4 times daily
PLUS
DOXYCYCLINE, 100 mg orally or IV inj twice daily
OR
TETRACYCLINE, 500 mg orally 4 times daily
PLUS
METRONIDAZOLE, 400–500 mg orally or IV inj twice daily
OR
CHLORAMPHENICOL, 500 mg orally or IV inj 4 times daily
RECOMMENDED SYNDROMIC TREATMENT

CLINDAMYCIN, 900 mg IV inj every 8 hours

PLUS
GENTAMICIN, 1.5 mg/kg IV inj every 8 hours
Syndromic Approach in STI Management
• Urethral Discharge
• Genital Ulcers
• Scrotal Swelling
• Vaginal Discharge
• Lower Abdominal Pain
• Neonatal Conjunctivitis
Neonatal Conjunctivitis
• can lead to blindness when caused by N. gonorrhoea and when
treatment is delayed
• The most important sexually transmitted etiologic agents are
N. gonorrhoeae and C. trachomatis
• In developing countries, N. gonorrhoea accounts for 20–75% and C.
trachomatis for 15–35% of cases brought to medical attention.
• Other common causes
• Staphylococcus aureus
• Streptococcus pneumoniae
• Haemophilus spp.
• Pseudomonas spp
Neonatal Conjunctivitis
• As the clinical manifestations and possible complications of
gonococcal and chlamydial infections are similar, in settings where it
is impossible to differentiate between the two infections, treatment
should be provided to cover both
• This would include single-dose therapy for gonorrhea and multiple
dose therapy for chlamydia
• All newborn infants with conjunctivitis should be treated for both N.
gonorrhoea and C. trachomatis because of the possibility of mixed
infection.
Recommended Treatment
NEONATAL CHLAMYDIAL CONJUNCTIVITIS

ERYTHROMYCIN SYRUP
(50 mg/kg per day orally, in 4 divided doses for 14 days)
OR
TRIMETHOPRIM (40 mg)
with
SULFAMETHOXAZOLE (200 mg orally, twice daily for 14 days)
Recommended Treatment
NEONATAL GONOCOCCAL CONJUNCTIVITIS

CEFTRIAXONE
(50 mg/kg by IM injection, as a single dose, to a maximum of 125 mg)
OR
KANAMYCIN
(25 mg/kg by IM inj, as a single dose, to a maximum of 75 mg)
OR
SPECTINOMYCIN
(25 mg/kg by IM inj, as a single dose, to a maximum of 75 mg)
THANK YOW!