STI

BY : Hamdi

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 Sexually transmitted infections (STIs)
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 Reproductive tract infections (RTIs) are infections of the genital tract of
women and men.
 There are three types of RTIs:
1.Sexual transmitted Infections caused by organisms that are passed through sexual
activity with an infected partner.
More than 40 have been identified including.
 Chlamydia
 Gonorrhea
 Hepatitis B and C
 Herpes and HPV
 Syphilis
 Trichomonas and HIV.
 2.Endogenous infections
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 Infections that result from an overgrowth of organisms normally present in the
vagina.

 These infections are not usually sexually transmitted, and include

 Bacterial vaginosis
 Candidiasis.
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 3.Iatrogenic Infections
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Infections introduced into the reproductive tract by a medical procedure such as
menstrual regulation, induced abortion, IUD insertion, or childbirth.
 This can happen if surgical instruments used in the procedure are not properly
sterilized, or if an infection already present in the lower reproductive tract is
pushed through the cervix into the upper reproductive tract.
 These three types of RTIs overlap and should be considered together. For
example, some STIs, like gonorrhea or Chlamydia, can be spread in the
reproductive tract if not treated prior to a procedure.
 In addition, some non-sexual infections, such as candidiasis, can be passed on
through sexual activity.
 Not all STIs are RTIs; and not all RTIs are sexually transmitted; STI refers to the
way of transmission whereas RTI refers to the site where the infections develop
 Main STI Pathogens
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 More than 30 pathogens are transmissible through sexual intercourse-oral, anal, or vaginal.
The main sexually transmitted bacteria are:
 Neisseria gonorrhoeae (causes gonorrhoea)
 Chlamydia trachomatis (chlamydial infections)
 Treponema pallidum (causes syphilis)
 Haemophilus ducreyi (causes chancroid)
The main sexually transmitted viruses are:
 Human immunodeficiency virus (causes AIDS)
 Herpes simplex virus (causes genital herpes)
 Human papilloma virus (causes genital warts)
 Hepatitis B virus
 Cytomegalovirus
 The main parasitic organisms are: Trichomonas vaginalis (causes vaginal trichomoniasis)
 Public Health Significance of STIs
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 Over 340 million curable, and many more incurable, STIs occur each year.
 Among women, non-sexually transmitted RTIs are usually even more common.
 In developing countries, STIs and their complications rank in the top five disease
categories for which adults seek health care.
 In women (15-49 years), STIs, even excluding HIV, are second only to maternal
factors as causes of disease, death and healthy life lost.
 Self reported prevalence of STIs in Ethiopia is 2 % in women and 1.5 % in men.
 The links between STIs and HIV is one of the reasons that force the world to give
attention to almost neglected sexually transmitted infections,
 Cont.…
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 Untreated STI enhances both acquisition and transmission of HIV. HSV-2 plays an important role in
the transmission of HIV infection.
 STI treatment is an important HIV prevention strategy in a general population
 Clinical services offering STI care are important for providing information and education about STIs
including HIV in order to promote lower risk behavior.
 STIs can lead to the development of serious complications like:
 Women: cervical cancer, pelvic inflammatory disease, chronic pelvic pain, ectopic pregnancy and
infertility.
 Men: sub-fertility
 Newborn: blindness and lung damage
 Syphilis can result in congenital syphilis for the baby and fatal cardiac, neurological and other
complications in adults
 Cont.…
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Genital warts can lead to ano-genital cancers
 Untreated gonococcal and chlamydial infections in women will result in pelvic inflammatory disease
in up to 40% of cases.
 1 in 4 of these will result in infertility.
In pregnancy, untreated early syphilis will result in
 stillbirth rate of 25%
 14% of neonatal deaths
 overall perinatal mortality of about 40%.
 Human papillomavirus (HPV) causes about 500 000 cases of cervical cancer 240,000 deaths, mainly
in resource poor countries.
 Worldwide, up to 4000 newborn babies become blind every year because of eye infections
attributable to untreated maternal gonococcal and chlamydial infections.
 STIs constitute a huge health and economic burden, especially for developing countries, where they
account for 17 % of economic losses due to ill-health.
 Cont.…
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 The socioeconomic costs of STIs and their complications are substantial:

 Ranks among the top 10 reasons for health-care visits in most developing countries, and substantially
drain both national health budgets and household income.
 Care for the sequel of STIs accounts for a large proportion of tertiary health-care costs
 The social costs of STIs include conflict between sexual partners and domestic violence.
 These are the main reasons to consider STIs as public health problems and to design and implement
appropriate intervention both preventive and curative
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Classification of STIs
Diseases characterized by genital ulcer
 Chancroid, Genital herpes simplex virus, Granuloma inguinal (Donovanosis), Lymphogranuloma Venarum,
Syphilis
 Diseases characterized by urethritis and cervicitis
 Chlamydial infection, Gonorrhoea
Diseases characterized by vaginal discharge
 Bacterial vaginosis, trichomoniasis, Vulvovaginal candidiasis
 Pelvic Inflammatory Disease (PID)
 Epididymitis
Human papillomavirus infection (Genital wart)
Vaccine preventable STDs
 Hepatitis A, Hepatitis B
 Proctitis, Proctocolitis and enteritis
 Ectoparasitic Infections
 Pediculosis Pubis, Scabies
 Prognostic
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classification of STDs

Curable (mostly bacterial)

 Gonorrhoea Syphilis
 Chlamydia Trichomoniasis
Incurable (virus)
 HIV/AIDS
 Hepatitis
 Herpes
 Human papilloma virus
 Prognostic
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classification of STDs

Curable (mostly bacterial)

 Gonorrhoea Syphilis
 Chlamydia Trichomoniasis
Incurable (virus)
 HIV/AIDS
 Hepatitis
 Herpes
 Human papilloma virus
 13
Traditional Approaches to STI
 Etiologic diagnosis: using laboratory tests to identify the causative agent
 Clinical diagnosis: using clinical experience to identify the symptoms typical for a specific STI.
Even in a well-structured health system, etiological and clinical diagnoses are problematic because
they are low in sensitivity.
 Etiological diagnosis is expensive and time-consuming; it requires special resources and delays
treatment.
 With clinical diagnosis, it is easy to diagnose some STIs incorrectly and also to miss mixed
infections.
 Many different agents cause STIs, however, some of these agents give rise to similar or overlapping
clinical manifestations
 Aim of Syndromic management of STIs
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 Prompt and effective detection and treatment of STDs
 Decrease STD incidence and prevalence by reducing period of infectiousness
 The main STI syndromes are:
 Urethral discharge
 Genital ulcer
 Inguinal bubo
 Scrotal swelling
 Vaginal discharge
 Lower abdominal pain and Neonatal conjunctivitis
 Main Features of Syndromic Management
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Periodic laboratory-based classification of the main causal pathogens by the clinical syndromes they
produce
 Use of flow charts derived from this classification to manage a particular syndrome
 Treatment for all important causes of the syndrome
 Education and counseling of the patient on how to prevent re-infection
 Notification and treatment of self
 Principles in the Syndromic management

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 Many STIs can be identified and treated on the basis symptoms and signs.
 Treatment covers several possible infections responsible for the syndrome
 Syndromic management will reduce the cost of laboratory work up and extra visits to the clinic and
treatment delay.
 Advantages of Syndromic management:
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 Immediate treatment: Clients receive diagnosis and treatment within a single visit.
 Effectiveness: Clients are treated for a potential mixed infection. The use of flowcharts with
appropriate treatment recommendations reduces the chance of ineffective treatment. This approach
helps to prevent incorrect diagnoses in settings where clinical diagnosis is common.
 Ease of use: It is easy to teach and learn. So, all levels of health care providers and facilities can use it.
It requires good training, but not specialized knowledge about STIs/RTIs.
 Low costs: There are cost savings since expensive lab tests are not used
 Cont.…
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 Potential for over treatment: Clients are treated for multiple infections, although some will have no
infection or only one. This is costly in terms of unnecessary drug use, waste of drugs that could be used
to treat other clients, and the potential for microorganisms to develop resistance to antimicrobial drugs.

 Ineffectiveness against asymptomatic infections: This approach cannot be used with clients who are
infected, but show no signs and symptoms.

 Need for data: Algorithms, risk assessment tools, and treatment protocols should be based on
information that is difficult to collect in many settings, including: disease surveillance data, studies of
risk factors, and microbial resistance tracking in the geographic location where the Syndromic
approach is being used
 Limitations and concerns
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Limitations in diagnosing vaginal discharge:
 Vaginal discharge poses a particular challenge since the syndrome might not be related to an STI.
 Because of the potential for negative reactions from clients and partners when the infection may not
even be caused by an STI, it is important to consider each case on an individual basis.
 Women who do not have STIs, but who have non-sexually transmitted RTIs that cause vaginal
discharge may be told that they should have their partners come for treatment; this can lead to
relationship problems, including violence.
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 Why
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Invest in STI Prevention and Control
 To reduce STI-related morbidity and mortality
 To prevent HIV infection because: Genital ulcer diseases have been estimated to increase the risk of
transmission of HIV 50–300-fold per episode of unprotected sexual intercourse
 Improved syndromic management of STIs reduced HIV incidence by 38% in a community intervention
trial in Mwanza, Tanzania
 Thailand also reduced HIV prevalence by effectively controlling STIs
 To prevent serious complication in women
 STIs are main preventable cause of infertility
 Cont.…
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 PID, ectopic pregnancy and cervical cancer

 To prevent adverse pregnancy outcome
 Perinatal deaths
 Spontaneous abortions
 Preterm deliveries
 Ophthalmic neonatorum
 Universal institution of an effective intervention to prevent congenital syphilis should prevent an
estimated 492 000 stillbirths and perinatal deaths per year in Africa alone.
 STI
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Control Strategies
 Prevention by promoting safer sexual behaviors;
 What is safer sex? It is any sexual activity that reduces the risk of passing STI and HIV from one
person to another.
Some safer sex practices:
 Consistent use of condom every time individual is having sex
 Reducing the number of sex partners-sex with uninfected monogamous is safe
 Massaging, rubbing touching, dry kissing, hugging or masturbation instead of intercourse
 To be away from unsafe sexual practices, like “dry sex”
 Not to have intercourse with partner having genital sore or discharge
 General access to quality condoms at affordable prices;
 Cont.…
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 Promotion of early recourse to health services by people suffering from STIs and by their partners;
 Inclusion of STI treatment in basic health services;
 Specific services for populations with frequent or unplanned high-risk sexual behaviors
 Proper treatment of STIs, i.e. use of correct and effective medicines; treatment of sexual partners
education and advice; reliable supply of condoms
 Screening of clinically asymptomatic patients
 Provision for counseling and voluntary testing for HIV infection
 Prevention and care of congenital syphilis and neonatal conjunctivitis
 Cont.…
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 Involvement of all relevant stakeholders, including the private sector and the community, in prevention
of STIs and prompt contact with health services for those requiring care.
 Many people with an STI/RTI do not seek treatment since they are asymptomatic or have mild
symptoms and do not realize that anything is wrong.
 Others who have symptoms may prefer to treat themselves or seek treatment at pharmacies or from
traditional healers.
 Even those who come to a clinic may not be properly diagnosed and treated.
 In the end, only a small proportion of people with an STI/RTI may be cured and avoid re-infection.
 To25address challenges providers should
 Raise awareness in the community about STIs/RTIs and how they can be prevented
 Promote early use of clinic services.
 Promote safer sexual practices when counseling clients.
 Detect infections that are not obvious.
 Prevent iatrogenic infection
 Manage symptomatic STI/RTI effectively
 Counsel patients on staying uninfected after treatment.
Obstacles
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to STI Services AND Control
 Decline in interest and resources for STIs prevention and control globally in favor of ART and VCT
 Lack of integration of prevention and care activities for STIs (including HIV) into sexual and
reproductive health services
 Problem with Syndromic management of women with vaginal discharge, especially in low prevalence
areas
 Intervention efforts to prevent STIs have failed to take into consideration the full range of the
underlying determinants
 Inability to ensure consistent supplies of STI medicines and condoms
 Counseling on risk reduction is also usually lacking
 Inadequate participation of partners, especially communities
 Diagnostic problem: either asymptomatic or do not seek care