Sexual Transmitted Diseases and STI infection

MBBS.USMLE, DPH, Dip-Card, M.Phil, FCPS.PhD
Assct: Professor Community Medicine
Services Institute Of Medical Sciences Lahore.
Ex- Professor Community Medicine
UmulQurrah University Makka Saudi Arabia & King Khalid
University Abha Aseer.

10/14/2020 Dr Muhammad Tauseef Jawaid 2

What are Sexually Transmitted
Diseases
• STD’s are infections that are spread from
person to person through intimate sexual
contact.
• STD’s are dangerous because they are
easily spread and it is hard to tell just by
looking who has an STD.
• 1 in 4 teenagers has an STD.(Western
Statistics)

4
STDs
• STDs are diseases and infections which
are capable of being spread from
person to person through:
– sexual intercourse
–oral-genital contact or in non-sexual ways.
–IV drug
–Congenitally transmitted

Groupof communicablediseasesin whichsexual contact
isthemostimportantmodeoftransmission.
1.Increasingincidenceworldwide.
2. Thecostanddifficultiesinthetreatmentof the diseases
andtheircomplications.
3.Itisasocioeconomicproblemaswellasbehavioral onesince
it islinkedtoaddiction, lowlevelof religious
values,increaseageof marriage,etc.
I M P O R T A N CE

Viral
AIDS
Genital
herpes
simplex
Genitalwarts
Bacterial
Syphilis
Gonorrhea
Non-
gonorrheal
urethritis
Chancroid
Non-specific
vaginitis
Granuloma
inguinale
Parasitic
Trichomonus
vaginitisand
urethritis.
Scabies
Pediculosis
pubis.
Fungal
Vaginalthrush
Valvovaginitis.
Balanitis

7
Common
STI’s• Chlamydia
• Gonorrhea
• Genital Herpes
(HSV-2)
• Genital Warts
(HPV)
• Hepatitis B
• HIV and AIDS
• Pubic Lice
• Syphilis
• Trichomoniasis

6
Do Patients Want to Know?
About STD’s
• 92.4% wanted to know if they were
infected
• 90.8% wanted to know if their
partners were infected
• 65% expected the test as part of STD
screening
Dr.T.V.RaoMD10/14/2020 Dr Muhammad Tauseef Jawaid 8

It isaworldwidediseaseaffecting mainly
theagegroupfrom15-39
Recentlyit wasfoundto beincreasing.

Spirochaete,treponemapallidum.
Itisdelicateandisrapidlykilled bydrying,high
temperature,disinfectants,andsoap&water.
Causativeorganism

Reservoir:Man:untreatedcaseisinfectiousduringthe1ry & 2ry
stagesofdisease,usuallyfor2-4years.
Exit:
exudatesofskin& mucousmembranes.
blood& bodyfluids(semen,saliva,vaginal& cervical
discharge).
IP: About3weeks

Transmission
1.Contactwithopenlesion:
Sexualcontact(mostimportantmode).
Kissing.
Contactwithbabyhavingcongenitalsyphilis.
Contactwithcontaminated articles.
2.Congenitalinfection:transplacentalfromthe4thmonthtill delivery
(notbeforebecausetreponemacannotpassthe
placentalbarrier).
3.Inoculationinfection:contaminatedblood& bodyfluids
(contaminatedsyringes& needles& bloodtransfusion).

Primarysyphilis:
Chancreattheportalof entry:firm, indurate,painless&highly
infectiousulcer.
Enlargedlymphnodes.
Spontaneouslydisappearswithouttreatmentafter4-6weeks.

Secondary:
Generalizedskinrash“Patchylesionsof mucousmembranes especially
themouth”.
Involvementof theotherpartsof thebody.
Spontaneouslydisappearswithin weeksormonthsfollowed aftera
latentperiod(years)bythe3rdstage.

Latesymptomaticsyphilis:
Reappearanceofsymptoms.
Characterized by the occurrence of neuro &
cardiovascular syphilis and of the characteristic
lesionsinvolvingdifferentpartsof thebody.

Diagnosis
1.History&clinicalpicture.
2. Labinvestigations:
A. Demonstrationof organismin exudatesof lesionsbydarkfield
microscopicexam.

B.Serologictesting:
- Non-treponemaltest(non-specific):usedforscreening
e.g. Wassermann Reaction (WR) &Venereal Disease Research
Laboratory test (VDRL) {high false +ve; so,
+vesshouldbeconfirmedbyspecifictests}.
- Treponemal tests (specific test): Use treponema antigens e.g.
fluorescenttreponemaantibodyabsorption test.

Prevention
A.Generalmeasures:
1.Avoidanceof sexualpromiscuity.
2. Healtheducationto increaseawareness.
3. Religiousandsocialguidanceespeciallyofyouth.
4. Convenientfamilylife andsupervisionofyouth.
5.Suitableplacesforleisuretimeanddevelopmentof hobbies andtalents.
6. Socioeconomicdevelopmentandprovidefacilityformarriage.
B.Specific:Chemoprophylaxis:onedoseof 2.4million unitsof longacting
penicillin I.M.soonafterexposure.

A.Cases:
1.Earlycasefinding:duringsurvey&on healthappraisal:
• Premarital&prenatalexamination.
• Exam of food handlers, blood donors, army recruits, child
nurses.
• Suspectedattendantsof medicalservices.
• Diagnosisof congenitalsyphiliswhenthemotherissyphilitic.
2.Measuresforcases:
• Notificationconfidentially tolocalhealthauthority.
• Isolation: not neededbutavoidsexualcontacttill elimination of infectivity.
• Disinfection:non butprecautionswithbloodandbodyfluids.

Specifictreatment:
Longactingpenicillin 2.4million units in asingledoseI.M.
Penicillinsensitivepatients:doxycycline100mgtwicedailyfor14
days.
Re-examinationaftertreatment.

B.Contacts:
Tracingand enlistment.
Examination.
Health education.
Surveillance.
Chemoprophylaxis:onedoseof 2.4million units oflong
actingpenicillinI.M.
C.Congenitalsyphilis:
Serologictestingandtreatment.
Properhandlingof babywithcongenitalsyphiliswithcautionto
avoidinfection.

Gonorrhea

AcuteinfectiousSTDwhichcanbecome
chronicif neglected.

Neisseriagonorrhea(Gonococcus)
DelicateGram-ve,intracellulardiplococcusthatperishes
rapidlyoutsidethebody.

Reservoir: Man: casewho is infectious for months or yearsif not
treated,whiletreatmenteliminatesthe infection withindays.
Exit:Dischargesof infectedmucousmembranes.
Transmission:Directsexualcontactonly.
IP.:3-4days

Clinicalpicture
It startsasanacuteinfection andif not properlytreatedit becomes
chronic.
In males:urethritiswithpurulentdischarges.
Infemales:urethritisand/orcervicitiswithdischarges.
Arthritis, pharyngitis, rectal infection, septicaemia,
endocarditis or meningitis may occur in both sexes.

Diagnosis
1. Historyandclinicalpicture.
2. Labinvestigations:
Acutecase:demonstrationof causativeorganismfrom filmof
pustakenfromcervixorurethra.
Chroniccase:serologictestsuchascomplementfixation
test.

Prevention
Oralpenicillin 400,000I.U.justbeforeoraftersexualexposure.

Treatment
Cases:
Amoxicillin 3gmorallyasasingledose.
Penicillinresistantstrains:ceftrioxone250mgasasingle
dose.
Re-examinationaftertreatment.
Contacts:
Oralpenicillin 400,000I.U.

AIDS
(AcquiredImmune-
DeficiencySyndrome)

It isalife threateningclinicalconditionthat represent
thelateclinicalstageof infection withHIV which
resultsin progressivedamage totheimmune&other
organsystems speciallyCNS.

Humanimmunedeficiencyvirus(HIV) whichisRNA
retrovirus.
2serologically&geographicallydistincttypeswith similar
epidemiologicalcharacteristics:
HIV-1isfoundinAmerica,EuropeandSubsaharanAfrica.
HIV-2 isfoundmainlyin WestAfrica.
Causativeagent:

HasspecificaffinitytoT-helperlymphocytecellscausing their
depletion.

Reservoir:man
Exit:in bloodandbodyfluids e.g.semen,vaginal
secretion,salivaandtears.
Periodofcommunicability:solongtheinfectedpersonisalive.
IP.:variable,but50%of thoseinfecteddevelopAIDSabout10
yearsafterinfection.

Modesofinfection:
1Sexual contact: most important mode especially homosexual and
bisexual.
2 Parenteralinfection:
Contaminatedsyringes& needlesespeciallybyi.v.drug abusers.
Contaminatedblood transfusion.
3Perinataltransmission:25-35%ofinfantsbornto infectedmothersare
infectedbefore,duringorshortlyafter birth.

Non-specific
manifestations:

Specificindicatordiseases:
(a)Opportunisticinfections:pneumocystitiscarenii pneumonia,
chroniccryptosporidiosis,CNStoxoplasmosis.
(b) Neurologicdiseases:dementiaorsensoryneuropathy.
(c) Cancers:KaposisarcomaandHodgkin'slymphoma.
(d) Otherse.g.pulmonaryorextra-pulmonaryT.B.

Diagnosis:
1- Clinicalpicture.
2- Laboratorydiagnosis:
- SerologictestsforHIVantibodiese.g.ELISA, Western
blot, IndirectImmunofluorescenceAssay.
- PCRtesttodetectHIV antigen.

Control:
A.Preventivemeasures:
1Healtheducationof youthaboutthedisease&itsmodesof transmission.
2Increasereligionrootstoavoidillegalsexualintercourse. 3-Use
disposablesyringes&needles.
4 Controlof drugabuse.
5Testingblood donorsforAIDS&only screenedblood &blood derivatives
shouldbeused.
6 Propersterilizationof instruments&sharpobjects.
7 Carein handling,using&disposingneedles&othersharp
objects.
8 Notattooingoracupuncture.
N.B.:Novaccinationorchemoprophylaxisisavailableyet.

B.Measuresforcases:
1Case finding: screening of high risk groups e.g. male
homosexuals, i.v. drug abusers, sexual partners of infected
persons, patients taking repeated blood transfusion as
haemophilics.
2Notification: isobligatorytolocalhealthauthority&WHO.
3Isolation: Isolation of HIV+ive person is unnecessary, ineffective
andunjustified.
4Concurrent disinfection: of equipment contaminated with blood
or body fluids and with excretions & secretions visibly
contaminatedwithblood&body fluids.

5-Treatment:
-ttt of opportunistic diseases that complicated HIV
infection.
- Antiretroviral ttt: it is complex, involving a combination
of drugs asresistance will rapidly appear if asingle drug
is used. The drugs are toxic & ttt must be lifelong. A
successful ttt is not a cure, although it results in
suppressionof viralreplication.

N.B.:
Patients& theirsexualpartnersshould not
donateblood,plasma,organsfor
transplantation,tissues,cells,semenfor
artificialinseminationorbreastmilkfor human
milkbanks.

C.Measuresforcontacts:
1Notification of contacts and source of infection: The
infected patient should ensure notification of sexual and
needlesharing partnerswheneverpossible.
2Screening of contacts for HIV infection. 3-
Healtheducation.
4- Novaccinationorchemoprophylaxis.

N.B.:
WHO recommendsimmunizationof asymptomaticHIV
infectedchildrenwiththeEPI (Expandedprogram
Immunization) vaccines; thosewhoaresymptomatic
shouldnotreceive BCGvaccine.
LiveMeasles-Mumps-Rubella(MMR)andpolio
vaccinesarerecommendedforallHIV- infected

2
Human Immunodeficiency Virus
Acquired Immune Deficiency Syndrome

Everybody is at risk
of getting HIV.
However certain
Persons have high
risk.

HIV- Agent
 It is a RNAvirus
 Which replicates in actively dividing T4lymphocytes.
 Uniqueability todestroyT4 Helpercells
 Reservoir- Once a person gets infected virus remains
in his body lifelong. And the person is a symptomless
carrier foryears before the symptomsactuallyappear.

•More than 7000
new infections &
6000 deathsoccur
each day

Epidemiology
 Males>females
 Occurs in all ages and ethnic groups
 All areas of the country are affected
 AIDS is now the second leading cause of death for all men
aged 25-44 years
 (Unintended injuries is #1 and heart disease is #3 for this
age group)

Human Immunodeficiency Virus
• Acquired Immunodeficiency syndrome first
described in 1981
• HIV-1 isolated in 1984, and HIV-2 in 1986
• Belong to the lentivirus subfamily of the
retroviridae
• Enveloped RNA virus, 120nm in diameter

HIV in Body Fluids
Semen
11,000 Vaginal
Fluid
7,000
Blood
18,000
Amniotic
Fluid
4,000 Saliva
1
Average number of HIV particles in 1 ml of these body fluids

Hos
t Age- Mostcasesareamong sexuallyactivepeopleaged
between age 20- 49years.
 High riskgroups-
Male homosexuals, hetero sexual partners, i.v. drug
abusers, blood transfusion recipients, haemophiliacs
and patients having STDs.

HIV Transmission
 HIV enters the bloodstreamthrough:
Open Cuts
Breaks in theskin
Mucous membranes
Direct injection

Routes of Transmission of HIV
Sexual Contact: Male-to-male
Male-to-female orvice versa
Female-to-female
Blood Exposure: Injecting drug use/needlesharing
Occupational exposure
Transfusion of blood products
Perinatal: Transmission from mother tobaby
Breastfeeding

Routes of Transmission of HIV
Occupational Transmission
Health care worker/ hospitalstaff
Laboratory workers
Otherroutes
Organ transplantation
Artificial insemination
Needle-prick

Incubation Period
 The incubation period is from HIV infectiontill
development of AIDS.
 It is from a few months to 10 yearsoreven more.
 However it is estimated that 75% of people infected
with HIV will developAIDS at theend of 10 years.

HIV-Infected T-Cell
HIV
Virus
T-Cell
HIV Infected
T-Cell
New HIV
Virus

Clinical
Manifestations
I] Initial Infection
II] Asymptomatic CarrierState
III] AIDS-related Complex(ARC)
IV] AIDS

HIV Infection And Antibody Response
6 month ~ Years ~ Years ~ Years ~ Ye
Virus
Antibody
Infection
Occurs
AIDS Symptoms
Initial Stage---------------- --------Intermediate or Latent Stage-----------------Illness Stage
Flu-like Symptoms
Or
No Symptoms Symptom-free
<
----
----

The Acute HIV
Syndro
me
Follows 3-6 wks following primary
infection

Asymptomatic Carrier State
 Infected peoplewith antibodies butwithoutanyovert
signs of the disease, except persistent generalized
lymphadenopathy.
 It is howevernot firmlyclearabout how long does the
asymptomatic stagelasts.

AIDS-Related Complex
 Has illnesses caused by damage to immune system,
butwithout theopportunistic infectionsand cancers
associated withAIDS.
 They mayexhibit-
Unexplained diarrhea(lasting more than a month),
fatigue, malaise, loss of body weight(>10%), fever,
night sweats.
Signs of Mild infections like oral thrush, generalized
lymphadenopathy, enlarged spleen.

Common manifestation of AIDS
Lung infection:
P.Cariniipneumonia
Gastrointestinal infection:
candidiasis of mouth
or oesophagus
Skin infection: Kaposi’s
sarcoma - red or violet
macules or papules
Central nervous
System Infection:
Toxoplasmosis
Dementia
Meningitis
Primary CNS Lymphomas.
Progressive Multifocal
Leucoencephalopathy.

27
Kaposi sarcoma
Candidiasis Of Mouth

Swollen parts of the body

Primar
y
• Primary HIV prevention refers to activity focused on
preventing uninfected people becoming infected.
Secondary
• Secondary HIV prevention aimed at enabling people
with HIV to stay well (e.g. testing to allow people to
know their status; welfare rights advice; lifestyle
behaviour ; anti–discriminatory lobbying).
Tertiary
• Tertiary HIV prevention aims to minimise the effects
of ill–health experienced by someone who is
symptomatic with HIV disease (e.g. the prophylactic
use of drugs and complementary therapies )

Diagnosis of
HIV• HIV antibody test – using different antigen &/ orwith
different principle of thetest
• Viral antigen test - used forscreening blood donors in
USA
• Detection of viral nucleic acid inblood.
• Determining the CD4 counts toassess thedisease
progression.

ANTIRETROVIRAL DRUGS
NRTI NNRTI PI
Zidovudine (AZT)* Nevirapine(NVP)* Indinavir(IDV)*
Lamivudine (3TC)* Efavirenz(EFV)* Nelfinavir(NFV)*
Stavudine (d4T)* Delavirdine(DLV) Saquinavir(SQV)*
Didanosine (ddl)*
INTEGRASE
INHIBITORS Ritonavir(RTV)*
Zalcitabine(ddC)* Raltegravir Amprenavir(APV)
Abacavir(ABC)* CCR5 antagonists Lopinavir(LPV)*
Tenofovir(TFV)* Maraviroc Atazanavir(ATV)*
Emtricitabine(FTC) Foseamprenavir
MAMC- Feb2009
FusionInhibitor:Enfuvirtide(T-20)
* Available in India , available under national programme
Cost of Therapy reduced from Rs.30,000 in 1998 to Rs1000 per month in 2006, no. of pills from 32 to 1 or 2 per day,10/14/2020 Dr Muhammad Tauseef Jawaid 82

PREVENTION
 Avoid multiple partners – useCondoms.
 Use sterile needles each time for injection
 Never share needles
 Avoid unnecessary blood transfusions
 All pregnant women should be testedfor
HIV

Preventi
on Use standard work precautions – handhygiene,
personal protectivegear.
 Proper disposal of biomedicalwaste.
 Immunization againstHBV
 Education
10/14/2020 Dr Muhammad Tauseef Jawaid

Occupational Exposure
HCW comes in contactwith potentially infectious body
fluids due to–
 A percutaneous injury ( needlestick, cutwith sharp
object)
 Contact with mucousmembrane
 Contactwith non intactskin (abraded, chapped,
dermatitis )

Management of Exposure site
 Do notpanic
 Skin
 Wash wound & surrounding withsoap/water
 Rinsewell
 Do notscrub
 Do not use Antisepticor Skin washes

Management of Exposure site
 Splash of Blood/OPIM
 Eye
 Eye irrigation with wateror Saline
 If using contact lens leave them in place while irrigating
.Removeonceeye is cleaned remove them & clean
 Mouth
 Spit fluid immediately
 Rinse mouth thoroughlywith water / saline repeatedly
 Do not use soap ordisinfectant

PEP Prescription
 Contact ARTspecialist
 Decision of starting PEP based on Exposure type&
HIV status of source
 Decide PEP regimens
 Basic regimen
 Expanded regimen
2 drugcombination
3 drug combination
 If source person is on ART drugs expert should be
consulted after starting 2drugs

Post Exposure Prophylaxis
 In India recommended for occupational
exposure
 It should be started asearly as
possible(within 72 hours)
 ARV is given for 4 weeks
 HIV testing should be done at baseline, 6wks,
3mths & 6mths

Life at Risk with Sexually Transmitted
Infections Best Choice Play
safe
9010/14/2020 Dr Muhammad Tauseef Jawaid

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