Final SYNDROMIC MANAGEMENT OF SEXUALLY TRANSMITABLE INFECTIONS REFERENCE

SYNDROMIC
MANAGEMENT
OF SEXUALLY
TRANSMITABLE
INFECTIONS
PARTICIPANT
MANUAL
July 2015
SYNDROMIC
MANAGEMENT
OF SEXUALLY
TRANSMITABLE
INFECTIONS
PARTICIPANT
MANUAL
Content
PREFACE i
ACKNOWLEDGMENT ii
LIST OF ABBREVIATION iii
INTRODUCTION TO TRAINING MANUAL iv
MODULE 01
INTRODUCTION TO STIs 6
MODULE 02
INTRODUCTION TO SYNDROMIC APPROACH 16
MODULE 03
HISTORY TAKING AND PHYSICAL EXAMINATION 22
MODULE 04
DIAGNOSIS AND MANAGEMENT 29
MODULE 05
STIs IN CHILDREN AND ADOLESCENTS 51

MODULE 06
MANAGEMENT OF STIs NOT PRESENTING WITH TYPICAL SYNDROMES 55
MODULE 07
STIs SCREENING AND STIs IN MARPs 62
Module 08
PRACTICAL CONSIDERATION IN MANAGING STIs 68
MODULE 09
PARTNER/S MANAGEMENT 77
MODULE 10
STIs PROGRAM MANAGEMENT 81
MODULE 11
MONITORING AND EVALUATION OF STIs PROGRAM 87
ANNEXS 94
i
Preface
Sexually Transmitted Infections (STls) constitute a major public health problem in Ethiopia. The health and socioeconomic
impacts are substantial. Likewise, the high prevalence of STls is fuelling up the epidemic of HIV/AIDS.
To make the STls prevention and control efforts effective, standardized case management is crucial. Cognizant of this
fact, the Ministry of Health in collaboration supportive partners developed syndromic management of STls training
materials (participant manual and a trainer’s guide) to enable service providers to diagnose and treat patients with STls
using syndromic approach.
The training materials are grounded in two specific principles. First, the methodologies used are learner centered based
on the principles of adult learning, and second, the use of modular approach which allows trainees and organizers the
flexibility to tailor individual course to the specific needs of different training participants and situations.
This participant manual is designed to serves as the “text” for the participants and the “reference source” for the trainer.
ii
Acknowledgment
The Ministry of Health would like to acknowledge and thanks everyone who provided technical support and guidance
for the review of the Syndromic Management of Sexually Transmitted Infections Training Materials, which includes the
Participant Manual and Trainer’s Guide.
The development and graphics design of training materials has been funded by ICAP Ethiopia through CDC fund and
WHO country office.
The Ministry of Health is grateful for the valuable technical inputs provided by professionals and institutions listed below:
Dr Frehiwot Nigatu FMOH

Dr Mizan Kiros FMOH
Dr Ghion Tirsite WHO
Dr Afeworke Mebratu CDC
Mr Israel Lemma PSI
Mr Fissha Eshete PSI
Dr Mulugeta Workalemaw ICAP
Dr Mulugeta H/Mariam ICAP
Dr Abera Resisa ICAP
Mr Desse Ayalew MSI
Dr Mahbub Ali MSI
Dr Dawit Endale ITECH
Mr Surafel Fantaw EPHI
Mr Ajema Bekele FAMHACA
Dr Abiyou Muhiye EPHA
Mr. Bayisa Bulcha FHAPCO
Mr. Wagari Ayu Volunteer
Dr Tesfahun Nega Volunteer
iii
List of abbreviation
AIDS Acquired Immunodeficiency Syndrome

ART Anti Retroviral Treatment
ANC Antenatal Care
BV Bacterial Vaginosis
CDC Centers for Disease Control and Prevention
DNA Deoxyribonucleic acid
EPHI Ethiopian public health institute
EDHS Ethiopian Demographic Health Survey
FMOH Federal Ministry of Health
FP Family Planning
FSWs Female sex workers
GC Gonococal
HDA Health Development Army
HEWs Health Extension Workers
HMIS Health Management Information System
HSV2 Herpes Simplex Virus Type-2
HTC HIV Testing and Counseling
HPV Human papiloma virus
IM Intramuscular
IV Intravenous
KOH Potassium Hydroxide
LGV Lymphogranuloma Venereum
iv
MARPs Most At Risk Populations

NGO Non governmental organization
PCR Polymerase Chain Reaction
PFSA Pharmaceutical fund supply agency
PID Pelvic Inflammatory Disease
PITC Provider initiated testing and counseling
RHB Regional Health Bureaus
RPR Rapid Plasma Reagin
SCM Supply chain management
SMA Syndromic Management
STDs Sexually Transmitted Diseases
STIs Sexually Transmitted Infections
TPHA Treponema Pallidum Haemagglutination Assay
UDS Urethral Discharge Syndrome
VCT Voluntary Counseling and Testing
VDRL Venereal Disease Research Laboratory
VVC VulvoVaginal Candidiasis
WHO World Health Organization
M&E Monitoring and Evaluation
INTRODUCTION TO
TRAINING MANUAL
1
Introduction
Sexually Transmitted Infections (STls) are among the most common causes of illnesses in the world and have far reaching
health, social and economic consequences. It is estimated that over 499 million new cases of curable STls, i. e. syphilis,
gonorrhoea, chlamydia and trichomoniasis, occur every year throughout the world in men and women aged 15-49
years, with the largest proportion in the region of south and south-East Asia, followed by sub-saharan Africa and Latin
American and the Caribbean (WHO, 2008). STls are important because of their magnitude, potential complications and
their interaction with HIV/AIDs. Disproportionately, they affect the health and social well being of women by producing
significant impact on their reproductive potential.
Because of underreporting, lack of uniformity of reporting and weak surveillance, there is little information on the
incidence and prevalence of STls in Ethiopia. According to 2011EDHS, 1%, of each Ethiopian women and men reported
having had an STIs in the past 12 months before the survey. According to the 2012 ANC sentinel surveillance, the
prevalence of syphilis is 1% which shows a reduction in trend as compared to 2.7% in 2007 and 2.3% in 2009 surveillance
report .The single point adult HIV prevalence estimate for the year 2014 is 1.14%.
More than 30 bacterial, viral and parasitic pathogens are transmissible sexually (Holmes KK). While STls are mostly
transmitted through sexual intercourse, transmission can occur also from mother to child during pregnancy and
childbirth and through blood and blood products, tissue/organ transfer and, occasionally, through other non-sexual
means.
Cognizant of the importance of controlling STls as a major public health intervention and in view of making the
syndromic approach a standard practice in most health institutions of the country, the MOH developed two series of
national guidelines on syndromic management of STls in December 2001 and March 2006. The current guideline was
revised in July 2015 on the basis of the findings of STls gonococcal validation study result and further enriched by recent
recommendations and experts opinions through a consultative process.
The use of updated and standardized STls management guidelines and Training material is strongly recommended
in order to ensure adequate treatment at all levels of the health services. It also simplifies and facilitates training and
supervision of health care providers, delays the development of antimicrobial resistance, improves surveillance, and
assists in more rational drug procurement for treatment of STls.
To this effect, the ministry has developed this updated training material for the proper syndrome management of STI in
the country.
This training package is comprised of 11 modules:
Module I: Introduction to STls Prevention and Control introduces the epidemic of STls, how STls are transmitted,
the burden STls place on individuals, society, health services. national economy and mechanism of prevention.
Module II: STls Syndromic Case Management introduces the syndromic approach to STls case management.
It deals with why syndromic case management is an effective approach in treating and preventing STls.
The module also introduces flow-charts and explains how to use it.
Module III: History-Taking and Physical examination explains step-by-step details of what to ask, how to ask and
how to examine patients.
Module IV: Diagnosis and Treatment covers each syndromic flow-chart in detail, explaining the specific signs and
symptoms to help service providers diagnose and treat STI patient. It also lists the drug options recommended for each
condition identified. It also explain what to do during follow up including treatment failure
Module V: STls in Children and Adolescents covers factors that increase vulnerability of children and adolescents to
STls and issues to consider during management of STls in adolescents and children.
Module VI: Management of STls not presenting with syndromes deals with management of syphilis in pregnancy,
serologic tests for syphilis, management of genital warts, management of genital scabies and management of pediculosis.
Module VII: STI screening and STI in MARPs. Explore the role of STI screening, recommendation and available tool
for STI screening. It also describe special considerations or principles when managing MARPs with STIs.
Module VIII: Patient Education and Counseling explores how to educate and counsel STI patient in line with risk
reduction,consistent and correct use of condom, advantage of HIV testing and partner treatment.
2 Syndromic Management Of Sexually Transmittable Infections-participant manual
Module IX: Partner Management It discusses why partner management is so important and explores how to bring
patient’s partner/s to HFs.
Module X : STI program management explore essential components of STI program
Module XI: Monitoring and Evaluation of STls explores the benefits of gathering and utilization of information about
STls at various levels.
Core Competencies for trainer guide
The core competences that trainees are expected to attain after completed the course are able to:
• Do clinical evaluation of patients (History taking & Physical examination)
• Diagnosis , treat and follow STIs cases using syndromic approach (UD,VD,GU,LAP/PID ,SS , IB and NC)
• Manage children & adolescent infected by STIs
• Counsel on STI risk reduction methods
• Manage STIs not presenting with typical syndrome (Syphilis in pregnancy, gentle warts , scabies , Pediculosis pubis&
neonatal herpes )
• Screen syphilis for eligible client using available tools.
• Provided clinical cervical infection screening for eligible clients
• Provide friendly service for general population and MARPs
• Diagnosis treatment failure and treat/refer for possible culture and sensitivity test.
• Demonstrate condom use for clients
• Treat the patients’ sexual partners
• Record and report STI data using HMIS timely and use data for action
Course Syllabus for four days basic syndromic management of STI
Course Goal
• To equip health care professionals with basic knowledge, attitude, skills needed to practice syndromic management
of sexual transmittable infection )
Course objectives
• After completing the course, participants will be able to:
• Describe global and national burden of STIs
• Identify features of syndromic approach to diagnosis and treat STIs
• Perform skills in interviewing, history-taking and diagnosis of patient with STIs
• Use syndromic flow-charts to diagnose and treat patients with STIs
• Educate and counsel patients about the prevention and successful treatment of STIs
• Linking patients to appropriate facility in case of treatment failure
• List peculiarity of STIs in children and adolescent
• Explain the role of STIs screening and available tools for STIs screening
• Describe special considerations or principles when managing MARPS with STIs
• Treat partners of STIspatients who attend the health facility
• Describe the essential components of STIs program
• Provide integrated quality STIs service
• Explain benefits of recording and reporting
• Describe the role STIs surveillance system for STIs program
3
Training/Learning Methods
Different method will be used to deliver this training
• Presentation and Discussion
• Group discussion
• Home take assignments( Recap)
• Case studies
• Role play
• Modeling
Learning materials
• Participant manual
• Prainer s’ guide
• PPT presentation (LCD, laptop)
• Flipchart/white board
• Markers
• Penile model and condoms
Trainers’ qualification and requirements
Trainers should be a clinician certified with STI TOT( with the current STIs training material )
Target Audience
The trainee should be currently practicing clinician (Physician, HO, Nurses) and HIV,STI,RH program managers
Course evaluation
Evaluation of the training is achieved by collecting feedback from learners and trainers at the end of each day of training
and at the end of the course. When trainers review feedbacks from learners daily, they can often make immediate
changes to improve the course. Daily evaluation and end-of-course evaluation forms are included in this manual. Pre
test questionnaires are included in this guide to assess participants’ knowledge and experience before the training so as
to reorient the course content and approach after reviewing the test results. Moreover, the pre test results will be used
to assess the knowledge and competence gained after the training by comparing against the post test results.
Criteria for certification
• 100% attendance
• post test result >70%
Course schedule
Day 1
TIME ACTIVITY
8:30 - 10:55 • Registration( 60 minutes)
• Official opening (10 minutes)
• Participants introduction (20 minutes)
• Participant expectation(15 minutes)
• Establish ground rules for the course (15 minutes)
• Pretest (25 minutes)
10:55 - 11:15 Break
11:15 - 12:30 • Course overview and introduction (20 minutes)
• Module 1 objectives (5 minutes)
• Transmission of STIs (35 minutes)
• Epidemiology of STIs (15 minutes)
12:30 - 2:00 Lunch
2:00 - 3:30 • Epidemiology of STIs continued (15 minutes)
• Complications and impacts of STIs(25 minutes)
• The link between STIsand HIV/AIDS (10 minutes)
• Strategies for STIs prevention and control (10 minutes)
• Challenges of STIs prevention and control program in Ethiopia (20 minutes)
• Module 2 objectives (5minutes)
• Approaches to STIs diagnosis (5minutes)
3:30 - 3:50 Break
3:50 - 5:30 • Approaches to STIs diagnosis continued(15minutes)
• Syndromic management (25minutes)
• Criticism of the syndromic approach (30 minutes)
• Using flow charts (20 minutes)
• Daily evaluation (10 minutes)
Day 2
TIME ACTIVITY
8:30 - 9:00 • Recap of Day 1 (30 minutes)
9:00 - 10:30 • Module 3 objectives (5minutes)
• Introduction to history taking and examination (15 minutes)
• Communication skills for establishing a good rapport with a patient (15 minutes)
• Gathering information (35 minutes)
• Skills practice (20 minutes)
10:30 - 10:50 Break
10:50 - 12:30 • Skills practice continued (30 minutes)
• Module 4 objectives(5 minutes)
• Genital ulcers (20 minutes)
• Urethral discharge and/or dysuria (45 minutes)
12:30 - 2:00 Lunch
2:00-3:30 • Genital ulcers continued (10 minutes)
• Vaginal discharge (40 minutes)
• Lower abdominal pain (40 minutes)
3:30 -3:50 Break
3:50-5:30 • Scrotal swelling (20 minutes)
• Inguinal bubo (15 minutes)
• Neonatal conjunctivitis (20 minutes)
• Treatment issues (15 minutes)
• Follow up visit for patients with STI (15)
5
Day 3
TIME ACTIVITY
8:30 - 9:00 Recap of Day 2 (30 minutes)
9:00 - 10:30 • exercise 4 (one minutes
• Issues to consider during management of STI in children and adolescents (15 minutes)
• Management of STIs in children and adolescents (10 minutes)
10:30 - 10:50 Break
10:50 - 12:30 • Module 6 objectives (5 minutes)
• Syphilis in pregnancy and congenital syphilis (30 minutes)
• Genital warts(15minutes)
• genital scabies(10minutes)
• pediculosis pubis(10minutes)
• Neonatal herpes (10minutes)
• Importance and type of STI screening( 5minutes)
• Syphilis screening( 10minute)
12:30 - 2:00 Lunch
2:00 - 3:30 • Cervical infections screening( 15minutes)
• STI in MARPs (45minutes)
• STI in MARPs (10minutes)
• Basic principles of health education and counseling (20minutes)
3:30 - 3:50 Break
3:50 - 5:30 • Counseling for STI(25 minutes)
• HIV testing and counseling( 30minutes)
• Educating and providing condom 30 minutes
Day 4
TIME ACTIVITY
8:30 - 9:00 • Recap of Day 3 (30 minutes)
9:00 - 10:30 • Educate and provide condom (30 minutes)
• Case study 8.1 ( 60 minutes)
10:30 - 10:50 Break
10:50 - 12:30 • Module 9 objectives (5 minutes)
• Principles and approaches to partner management (5 minutes)
• Partner notification through patient referral (15minutes)
• Challenges of partner referral and treating partner(s) (20 minutes)
• Module 10 session one objective and Components of STI program (5minutes)
• Clinical care, Leadership and coordination, Procurement and supply management, Advocacy and social
mobilization and Surveillance (60minutes)
12:30 - 2:00 Lunch
2:00- 3:30 • Module 11 objective ( 5 minutes)
• Introduction to monitoring and evaluation of STI program( 5 minutes)
• Tools in M&E( 5 minutes)
• Surveillance and its components(30 minutes)
• Evaluation( 5 minutes)
3:30 - 3:50 Break
3:50 - 5:30 • Group work on the STI HMIS formats(30 minutes)
• Post test (25minutes)
• End of course evaluation (15 minutes)
• The way forward (10 minutes)
• Certificate and Closing (30 minutes)
MODULE 01
INTRODUCTION TO STIs
7
MODULE I: INTRODUCTION TO STI PREVENTION AND CONTROL

Total duration :135 minutes
Module objective
After completing the module, the participants will be able to:
ΞΞ Identify common STIs based on the epidemiology
ΞΞ Describe factors that influence STIs prevention and control
ΞΞ Describe the magnitude of STIs
ΞΞ Discuss about the public health impacts of STIs
ΞΞ Describe the relationship between STIs and HIV
ΞΞ Describe modality of STIs prevention and control
ΞΞ Describe Challenges in the prevention and control of STIss
SESSION ONE: INTRODUCTION TO STIs

Sexually transmitted infections (STIs) are among the most common causes of illness in the world and have far reaching
health, social and economic consequences. STIs are important because of their magnitude, potential complications and
their interaction with HIV/AIDS. Disproportionately, they affect the health and social well being of women by producing
significant impact on their reproductive potential. The main mode of transmission of STI is through unprotected
penetrative sexual intercourse.
STIs are caused by more than 30 different pathogens including bacteria, viruses, protozoa, fungus and ecto-parasites.
These organisms can be transmitted through unprotected sex and they tend to cause similar symptoms and signs.
The common classical STIs are gonorrhea, chlamydia trichmatis ,syphilis, chancroid, lymphogranuloma Venereum,
and trichomoniasis. STIs can be broadly recognized as ulcerative or non-ulcerative and can be classified as curable
or not curable. The common curable STIs are gonorrhea, chlamydial infection, syphilis, chancroid, trichomoniasis and
lymphogranuloma Venereum. The STIs that is preventable but not curable are the viral STIs, which include human
immune deficiency virus, human papilloma virus, hepatitis B virus, and herpes simplex virus.
Transmissions of STIs
By far the most common mode of transmission of STls is by sexual intercourse. Other modes of transmissions include:
• Mother-to-child:
ΞΞ During pregnancy (e. g. HIV and syphilis)
ΞΞ At delivery (e. g. Gonorrhoea, Chlamydia, Genital Herpes and HIV)
ΞΞ Through breast feeding (e. g. HIV)
• Unsafe (un sterile) use of needles or injections or other contact with blood or blood-products (e. g. syphilis, HIV and
Hepatitis).
STIs Transmission dynamics
Improved understanding of the transmission dynamics of STIs has implications for the designing of strategic prevention
and control interventions.
Within a given population the distribution of such infections is not static. Over time, epidemics evolve through different
phases characterized by changing patterns in the distribution and transmission of the sexually transmitted pathogens
within and between subpopulations. Generally, early in an epidemic or in some geographical settings, sexually
transmitted pathogens are likely to be transmitted within and from high-risk persons with high rates of infection and
frequent changes of sexual partner (core groups). As the epidemic progresses, the pathogens spread into lower-risk
populations (bridging populations) who may be an important sexual link between the core groups and the general
population. Social or economic conditions of certain population groups can increase their vulnerabilities for acquiring
or transmitting an infection and bring them into this bridging category. Sexual partners of individuals with high rates
of infection (i.e. bridging populations), in turn, infect other sexual partners, such as their spouses or other regular sexual
partners within the general population. The transmission could also occur from general population to the bridging
population or core groups.
Transmission dynamic of Sexually Transmitted Infection at the Population
General Population
Bridging
Population
Core group
These factors need to be taken into consideration, where possible, when planning an effective program for the
prevention and control of STI infections.
There are a number of factors that increase the risk of transmission of STls, including biological, behavioral and socio-
cultural factors:
BIOLOGICAL FACTORS
Certain biological factors influence the transmission of STls. These include age, sex, immunological status of the host and
virulence of the organism.
1. Age
The vaginal mucosa and cervical tissue in young women is immature and makes them more Vuinerable to STls. Young
women have also cervical ectropion, a normal condition where cervical surface cells more readily allow infections
to occur. Young women are especially at risk in cultures where they marry or become sexually active during early
adolescence. On average, women become infected at a younger age than men.
2. Sex
Infective agents enter the body most easily through a mucosal surface such as the lining of the vagina. Since the mucosal
surface that comes into contact with the infective agent is much greater in women than in men, women can be more
easily infected than men.
3. Immune status
The immune status of the host and virulence of the infective agent affect transmission of STls. As we can see later in this
module, certain STls increase the risk of transmission of HIV and HIV in turn, facilitates the transmission of most STls and
worsens the complications of STls by weakening the immune system.
BEHAVIOURAL FACTORS
Many behavioral factors may affect the chance of getting STls. Such behaviors include:
• Changing sexual partners frequently
• Having more than one sexual partner
• Having sex with ‘casual’ partners, sex-workers or their clients
• Use of alcohol or other drugs before or during sex; alcohol or drug use may negatively affect condom use
SOCIO-CULTURAL FACTORS
A number of social factors link both gender and behavioral issues and may affect a person’s risk of getting STls:
• In most cultures women have very little decision making power over sexual practices and choices, including use of
condoms
• Women tend to be economically dependent on their male partners and are therefore more likely to tolerate men’s
risky behavior
• Sexual violence tends to be directed more towards women by men, making it difficult for women to discuss STls with
their male counterparts
• In some societies the girl-child tends to be married off to an adult male at a very young age, thus exposing the girl
to infections
• In some societies a permissive attitude is taken towards men allowing them to have more than one sexual partner
• Harmful traditional practices that include skin-piercing increases the risk of STls transmission. This refers to a wide
range of practices including the use of un sterile needles to give injections or tattoos, scarification or body piercing
and circumcision using shared knives.
SESSION TWO: EPIDEMIOLOGY OF STIs
Global burden of STIs
According to 2008 WHO estimates, 499 million new cases of curable STIs (syphilis, gonorrhea, chlamydia and
trichomoniasis) occur annually throughout the world in adults aged 15-49 years. This does not include HIV and other
STIs which continue to adversely affect the lives of individuals and communities worldwide. In developing countries, STIs
and their complications rank in the top five disease categories for which adults seek health care.
Geographically, the largest proportion of patients is located in the region of south and south-east Asia followed by sub
Saharan Africa (SSA), Latin American and the Caribbean. Globally, STI constitute a huge health and economic burden,
especially for developing countries where they account for 17% of economic losses. Men and women aged 15–49 years
are most affected segments of the population.
Epidemiology of STIs in Ethiopia
Even though there is little information on the incidence and prevalence of STIs in Ethiopia, the problem of STIs is generally
believed to be similar to that of other developing countries. According to 2011EDHS, 1%, of each Ethiopian women and
men reported having had an STI in the past 12 months before the survey. 3% of women and 2% of men reported having
had an abnormal genital discharge. Also 1% each of women and men reported having had a genital sore or ulcer in the
12 months preceding the survey. These numbers may be underestimates because respondents could be embarrassed
or ashamed to admit having STIs.
In the STI surveillance study which was conducted from January - June 2013 in 8 health facilities located in Amhara,
Oromia and Addis Ababa by EHNRI in collaboration with CDC-E, a total of 636 STI cases were reported from eight
sentinel surveillance sites and the commonest syndrome was vaginal discharge (50%), followed by urethral discharge
(31%), genital ulcerative disease (9%), lower abdominal pain (7.3%) and two syndrome were present in few patients (3%).
About 16% of the STI patients were co-infected with HIV (8.1% male and 21%female) and HIV prevalence is higher on STI
patients with lower abdominal pain (41%) and genital ulcer (24.5%). Young people, in the age group 20-34 yrs were the
highly affected ones (68.2%), with a larger proportion being females (61%).
According to the ANC sentinel surveillance reports, the prevalence of syphilis was 2.7%, 2.3% , 1% for 2007,2009 and
2012 respectively.
The single point adult HIV prevalence estimate for the year 2014 is 1.14%. Taking syphilis and HIV as proxy indicators, the
STI prevalence is in a declining trend.
While effective STI case management represents the cornerstone of STI control, STI control efforts must go beyond
case management, given that only a small proportion of people with STIs actually access health care services. There is
increasing evidence that a large proportion of STIs are asymptomatic and most symptomatic patients seek treatment
from traditional healers, pharmacists, drug vendors shops and marketplaces, where reporting is not the standard practice.
According to 2011 EDHS, 34%percent, of each, women and men sought care for STIs or symptoms of STIs from a clinic,
hospital, or health professional. 1% of women and 6 % of men sought advice or medicine from drug retail outlet. 63%of
women and 56 %of men who had STIs or STI symptoms in the 12 months preceding the survey did not seek any advice
or treatment.
Figure 1. STI epidemiology model and care seeking behavior
Partner
Notification
Cure
Complete tretment
Correct treatment
correct diagnosis
presenting for treatment
population with symptoms
population with STIs
Sexually active population
Total population
Implications of the model for STIs Control:

The scenario presented by the STI operational model mandates various interventions to contain the STI epidemic. They
include:
• Reduce risk through education to communities and specific groups
• Condoms promotion through improving their availability to the sexually active
• Case finding through partners’ notification and screening programs such as routine antenatal syphilis serological
screening.
• Promotion of health seeking behavior through early STI symptom recognition
• Provision of user friendly services and increase accessibility of services particularly for youth and other vulnerable
groups
• Other innovative approaches for STI service delivery e.g. training pharmacists, traditional healers, etc in STI recognition
and referral.
• Improve STI case management in health facilities through training and supporting health workers to make correct
diagnosis and provide correct treatment
• Provision of full package of STI case management including partner notification
SESSION THREE :PUBLIC HEALTH IMPACT OF STIs
Failure to diagnose and treat STIs at an early stage may result in serious complications. The most serious health
consequences of STIs, other than HIV/AIDS, tend to occur in women and newborn children. Complications in women
include cervical cancer, pelvic inflammatory disease with resulting infertility, chronic abdominal pain, ectopic pregnancy,
preterm labor and related maternal mortality. Women may lose their fertility without ever realizing that they had PID. PID
also increases the risk of ectopic pregnancy.
Complications in newborns include congenital syphilis, gonococcal infection of the conjunctiva - a potentially blinding
condition, chlamydial pneumonia and perinatal hepatitis B infection premature deliveries, low birth weight, growth
retardation. Urethral stricture and infertility are complications that could occur in men who are not treated early.
Table 1. Common complications that may result from common STls
Cause Complications
Gonococcal and chlamydial infection Infertility in men and women
Epididymitis
Ectopic pregnancy
Chronic pelvic pain
Urethral stricture
Perihepatitis
Gonorrhoea Blindness in infants
Disseminated gonococcal infection
Chlamydia Chalmydial pneumonia in infants
Gonococcal, chlamydial and anaerobicbacterial infections Pelvic and generalized peritonitis
syphilis in pregnancy Extensive organ and tissue destruction
in children
Still birth
Abortion
Human papilloma virus Cervical cancer.
Majority of the complications of STIs are preventable, if the patient is diagnosed and treated early. STIs have also
enormous social and economic consequences. For instance, marital disharmony may occur when one partner develops
STI or infertility. The costs of STI drugs may place a heavy financial burden on families, communities and the country at
large. This is in part because antimicrobial resistance of several sexually transmitted pathogens has been increasing in
most parts of the world and has rendered some low-cost regimens ineffective.
SESSION FOU:RELATIONSHIP BETWEEN CONVENTIONAL STIs AND HIV
The relationship between STIs and HIV/transmission has been described as an epidemiological synergy. In addition, HIV
and STIs share the same risk factors. Thus, it is very critical to strengthen STI prevention and control program not only
to improve quality of life but also to overcome the complications caused by these infections, but also to prevent the
spread of HIV infection.
2.1. STIs enhance the sexual transmission of HIV through:
a. STIs that primarily cause ulcers disrupt the integrity of the skin barrier and create easy acess for viral transmission.
The presence of genital ulcers is known to increase the risk of HIV transmission by five folds.
b. STIs that primarily cause inflammation such as gonorrhea, trichomoniasis, and chlamydial infections present a weak
barrier to HIV.
c. In both the above scenarios, infected lymphocytes among HIV infected individuals are attracted to the lesions and
hence increase likelihood of infection to the partner.
d. STIs Increase viral shedding (reported in genital fluids of patients with STIs) and increase susceptibility to HIV. (STI
treatment has been demonstrated to significantly reduce viral shedding).
2.2. HIV infection affects STIs through:
a. HIV alters susceptibility of STI pathogens to antibiotics
b. Increased susceptibility to STIs among immune suppressed individuals
c. The clinical features of various types of STIs are influenced when there is co-infection with HIV. This can be demon-
strated well in the following examples:
• Syphilis has atypical presentation with a tendency to rapidly progress to neurosyphilis. The patient could present
with atypical facial plaques, which is different from the typical rash of secondary syphilis. Both the specific and
the non-specific treponemal serologic tests for syphilis may be non-reactive in the presence of infection with T.
Pallidum when there is co-infection HIV.
• Atypical lesion of chancroid are common and tend to be less purulent often with indurations mimicking primary
syphilis. The lesions could as well be extensive and multiple which could be associated with fever and chills.
• Recurrent or persistent genital ulcers caused by Herpes simplex virus are common in patients with HIV and they
are often multiple and extensive. Extra-genital or perianal ulceration could as well occur.
• Human papillomavirus produces epiphytic genital warts that may be large and extensive, with an increased
tendency to produce epithelial dysplasia and cervical cancer.
d. The treatment of conventional STIs is also affected when infection with HIV coexist.
• Risk of treatment failure following single injection of Benzathine penicillinis increased among patients with
primary syphilis.
• Topical anti-fungals are less effective and hence oral antifungals like Fluconazole may be indicated for patients
with candidiasis.
• Severe genital herpes may require treatment of primary episode or suppression of recurrence with acyclovir.
However, resistance to acyclovir may subsequently develop.
Notes:
• Conventional STI and HIV infection share similar risk factors.
• Conventional STI facilitate the acquisition and transmission of HIV infection
• Effective management of STI can reduce HIV infection.
13
SESSION FIVE: SEXUALLY TRANSMITTABLE INFECTIONS PREVENTION AND CONTROL

STRATEGIES
All STls, including HIV, are preventable. Looking into the factors that hinder the control effort will help to decide how we
might overcome them.
The objectives of STI prevention and control program are:
1. To break transmission dynamics
2. To prevent HIV infection
The presence of an untreated inflammatory or ulcerative sexually transmitted disease increases the risk of transmission
of HIV during unprotected sex between an infected and an -uninfected partner. Improved syndromic management of
such infections reduce HIV incidence by 38% in a community intervention trial in Mwanza. Services providing care for
sexually transmitted infections are one of the key entry points for HIV prevention. Patients seeking such care should be
offered HIV testing and counseling and should be counseled on safe sex.
3. To prevent serious complications
Sexually transmitted infections are the main preventable cause of infertility, particularly in women. Between 10% and
40% of women with untreated chlamydial infection develop symptomatic pelvic inflammatory disease. Post-infection
tubal damage is responsible for 30% to 40% of cases of female infertility. Furthermore, women who have had pelvic
inflammatory disease are 6 to 10 times more likely to develop an ectopic (tubal) pregnancy than those who have not,
and 40% to 50% of ectopic pregnancies can be attributed to previous pelvic inflammatory disease. Prevention of human
papillomavirus infection will reduce the number of women who die from cervical cancer.
4. To prevent adverse pregnancy outcome
Untreated sexually transmitted infections are associated with congenital and perinatal infections in neonates, particularly
in the areas where rates of infection remain high.
In pregnant women with untreated early syphilis, 25% of pregnancies result in stillbirth and 14% in neonatal death
an overall perinatal mortality of about 40%. Up to 35% of pregnancies among women with untreated gonococcal
infection result in spontaneous abortions and premature deliveries, and up to 10% in perinatal deaths. In the absence of
prophylaxis, 30% to 50% of infants born to mothers with untreated gonorrhoea and up to 30% of infants born to mothers
with untreated chlamydial infection will develop ophthalmianeonatorum, which can lead to blindness. Worldwide,
between 1000 and 4000 newborn babies become blind every year because of this condition.
Preventive measures
Effective prevention and care can be achieved by use of a combination of responses. Services for prevention and care of
people with sexually transmitted infections should be expanded and embrace a public health package.
Prevention can be primary or secondary:
• Primary prevention aims to prevent people from being infected with STls or HIV
• Secondary prevention is about the provision of treatment and care for infected people in order to avoid complications
and further transmission of infection to others.
Primary Preventive measures:
Some of the measures one can employ to avoid STIs includes:
• Abstinence: This might be total abstinence from sex or for groups such as students and youths not yet married, one
should encourage, delaying sexual activity till one is ready for marriage.
• Mutually faithful sexual relationship or “Mutual monogamy”. This is what is usually termed as “Zero grazing”. It is
useful if both partners are not already infected.
• Correct and consistent use of condoms. This intervention is especially recommended for those who cannot abstain
and yet cannot have mutually faithful relationship.
Secondary prevention includes:
1. Promoting STI care-seeking behavior through:
• Public education campaigns
• Providing non-stigmatizing and non-discriminatory health services
• Providing quality STls care
• Ensuring a continuous supply of highly effective drugs
• Ensuring a continuous supply of condoms and promotion of consistent and correct use
2. Early diagnosis & prompt and correct treatment
• Providing comprehensive syndromic STI case management through:
ΞΞ Making correct diagnosis
ΞΞ Providing correct antimicrobial therapy for the STls syndrome
ΞΞ Educating on the nature of the infection, behavior, safe sex acts and risk reduction in order to prevent or reduce
future risk-taking behavior
ΞΞ Educating on treatment compliance
ΞΞ Demonstrating the correct use of condoms and provision of condoms
ΞΞ Advice on how the patient’s partners may be treated and to issue a partner referral card for the patient to pass on
to his/her partner(s).
ΞΞ Offering voluntary HIV testing and counseling service
• Training of service providers on syndromic management of STls.
• Integration of STI services within primary health care.
STls treatment should be available at all health facilities throughout the country. It should be integrated within
primary health care at - primary care clinics, maternal, child health, family planning clinics and ART clinics - through
the syndromic management of STls.
3. Case finding and screening:
ΞΞ Screening women attending maternal, child health, family planning and ART clinics
ΞΞ Partner notification and treatment
ΞΞ Education, screening and treatment of key population groups who may have placed themselves at risk of infection,
such as sex workers, long distance truck drivers, mobile workers, uniformed services, and young people, both in and
out of school
ΞΞ Testing of blood donors for syphilis, HIV and hepatitis B
15
SESSION SIX: CHALLENGES OF STIs PREVENTION AND CONTROL

The challenges are related to three major factors:
• Health system factors
• Biological factors
• Socio-cultural and behavioral factors.
1. HEALTH SYSTEM FACTORS
Health services may be:
• Unavailable or too far away (geographic inaccessibility)
• Too expensive (not affordable, specially in the private setup)
• Considered to stigmatize those who visit (negative attitude)
• ill equipped in terms of staff , equipment and drugs.
• Not user friendly (particularly for adolescents) (lack of skill, judgmental attitude, opening hour and cost)
• There may be too little emphasis on educational and other efforts to prevent infection
• Skill gap on comprehensive syndromic STls management.
• Difficulty of partner management
2. SOCIO-CULTURAL AND BEHAVIORAL FACTORS
The social factors include:
• Reluctance to seek health care.
• Ignorance or misinformation. These powerful obstacles exist in all age groups and all types of people and tend to be
widespread among adolescents and young people - the very ones likely to be most sexually active
• Preference for alterative health sources, which are not reporting such as traditional healers for the initial visit
• Reluctance to follow safe sex practices for a variety of reasons, including:
ΞΞ lack of knowledge of safe sex
ΞΞ dislike of condoms or negative attitudes towards condom
• The social stigma so often attached to STls. This may mean that people hide what they are experiencing is shameful,
and so avoid seeking treatment
• Failure to take the full, prescribed course of treatment for STls, for a number of reasons:
ΞΞ it can take many days to complete
ΞΞ the patient’s symptoms disappear and or signs subsides so that they believe the infection has cured and they can
‘save’ the medication for another time or share to other people
• The difficulty of notifying and bringing sexual partners through fear, embarrassment or unawareness of consequences.
4. BIOLOGICAL FACTORS
As many as 70%-80% of infected women may be asymptomatic and so will not seek treatment. This also applies to a
significant number of men. Such people will continue to be infected, risking complications and perhaps infecting others.
MODULE 02
INTRODUCTION TO SYNDROMIC
APPROACH
17
MODULE II. INTRODUCTION TO SYNDROMIC APPROACH

Total duration :100 minutes
Module objectives
• List number of problems associated with classic approaches in treating patients with STls
• Identify the main features of syndromic case management
• Describe various advantages that syndromic case management offers
• Explain the limitations of syndromic approach
• List the steps In using flow-charts to treat patients
SESSION ONE: APPROACHES TO STls MANAGEMENT
Classical and syndromic approaches of diagnosis and treatment of STls are widely practiced thought the world. This
session elaborates the basic principles and comparative advantages and disadvantages of the two approaches.
1. CLASSICAL APPROACHES TO STls MANAGEMENT
Health care providers generally use one of the two approaches to classical STls diagnosis:
ΞΞ Etiological diagnosis: using laboratory tests to identify the causative agent.
ΞΞ Clinical diagnosis: using clinical experience to identify the symptoms typical for a specific STls.
Etiological diagnosis is often regarded as the ideal approach in medicine and clinical diagnosis is the choice of resort
when laboratory services are not available. However, in the diagnosis and treatment of STls, both classical approaches
present a number of problems.
1.1. Etiological Approach
Laboratory testing requires skilled personnel and consistent support and supplies, which are often not available. But
even if they are available, etiological diagnosis is not always appropriate because:
• Treatment does not begin until the results are available, which usually requires patients to revisit the health facility.
Infected individuals continue to transmit the infection to others and may be unwilling to return for follow-up.
• Testing facilities are not available at the primary health care centre, where many people with STls first seek care.
• Tests for Chlamydia trachomatis are expensive and the collection of specimens is invasive and unpleasant for both
men and women.
• Some bacteria fastidious &difficult to culture (H.ducrey, C.trachomatis)
• Lab. Results often not reliable.
• The diagnosis of primary syphilis requires a special microscope and training, and even in the best hands the spirochete
may not be visualized.
1.2. Clinical Approach
Using clinical diagnosis, the clinician treats STls based on the clinical symptoms and signs and his/her professional
experience. However, different STls cause similar symptoms, so the clinician may pick the wrong one to treat. Mixed
infections are common and the clinician may diagnose only one of them. A patient with multiple infections needs to be
treated for each of them. Failure to treat one infection may lead to the development of complications and the continued
transmission of that STls.
Notes:
Even in a well-structured health system, etiological and clinical diagnoses are problematic.
Etiological diagnosis is expensive and time-consuming; it requires special resources and delays treatment where
rapid diagnosis and treatment are important. Moreover, with clinical diagnosis, it is easy to diagnose some STls
incorrectly and also to miss mixed infections
2. SYNDROMIC APPROACH TO STls MANAGEMENT

A syndrome is a group of symptoms that patients describe, combined with classic signs that providers observe during
physical examination. A number of different organisms that cause STls give rise to a limited number of syndromes. Using
the syndromic approach providers can identify one of these syndromes and treat accordingly.
Table 3.1. Advantages and disadvantages of STI diagnostic approaches
Diagnostic Approaches Advantages Challenges

Etiologic
This is done by identifying the • Avoids over treatment. • Identifying the 30 or more STI causative agents
causative agent(s) using laboratory • Conforms with traditional training. requires skilled personnel and sophisticated lab equip-
tests and giving treatment targeting • Satisfies patients who feel not ment.
properly attended • Testing facilities usually not available at primary health
to the pathogen identified.
• Can be used to screen asymptom- care level where a large number of patients seek care
atic patients. for STI.
• Lab tests are expensive, time consuming and results
may not be reliable.
• Delay in treatment and reluctance of patients to wait
for lab results.
• Mixed infections often overlooked, thus miss treat-
ment/under treatment can lead to complications and
continued transmission.
Clinical
Uses clinical experience to identify • Saves time for patients • Requires high clinical skill
symptoms which are typical for a • Reduces lab expenses • Mixed infections often overlooked
specific STI, then giving treatment • Doesn’t identify asymptomatic STIs
targeted, to the suspected
pathogen(s)
Syndromic
Identification of clinical syndrome • Complete STI care offered at first • Risk of over-treatment
and giving treatment targeting all visit • Requires prior research to determine the common
the locally known pathogens which • Simple, rapid and inexpensive causes of particular syndromes
• Patients treated for possible • Asymptomatic infections are missed
can cause the syndrome
mixed, infections • Has low specificity and positive predictive value for
• Accessible to a broad range of detecting cervical infections in women presenting
health workers with vaginal discharge
• Curtails unnecessary referral to
hospitals
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Table 3.2. Sign and symptoms of the main STI syndromes and their causes
Syndrome Symptoms Signs Most Common Causes

Vaginal discharge Unusual vaginal discharge, Abnormal vaginal dicharge Vaginitis
vaginal itching, dysuria (pain • Bacterial vaginosis (Gardnerella
on unination), dyspareunia vaginalis)
(pain during sexual • Candidiasis
• Trichmoniasis
intercourse)
Cervicitis
• Gonorrhea
• Chlamydia trachomatis
Urethral discharge • Urethral discharge Uretharal discharge if necessary ask • Gonorrhea
• Dysuria patient to milk his penis • Chlamydia trachomatis
• Frequent urination
Genital ulcer Genital sore Genital ulcer • Syphiis ,chancroid and genital
herpes
Lower abdominal pain Lower abdominal pain • Vaginal discharge • Gonorrhea
Dyspareunia • Lower abdominal tendemess on • Chlamydia trachomatis
palpation • Mixed anaerobes
Vaginal discharge • Temperature 38 degree and above
Scrotal Swelling Scrotal pain and swelling Scrotal swelling • Gonorrhea
• Chlamydia
Inguinal bubo Painful enlarged inguinal • Enlarged inguinal lymph nodes • LGV
lymph nodes • Fluctuation • Chancroid
• Abscesses or fistulae • Gi
Neonatal conjunctvitis • Swollen eyelids • Oedema of the eyelids • Gonorrhea
• Discharge • Purulent discharge • Chlamydia
• Baby can’t open eyes
The aim of syndromic management is to identify one of these seven syndromes and manage it accordingly. While
a clinical or etiological diagnosis tries to identify just one causative agent, syndromic diagnosis leads to immediate
treatment of all possible causative agents. This is important because mixed infections occur frequently. This means that,
if the necessary drugs are available and affordable, syndromic treatment can quickly render the patient non-infectious.
The key features of syndromic case management are:
• Is problem-oriented (it responds to the patient’s symptoms)
• Is highly sensitive and does not miss mixed infections
• Treats the patient at the first visit
• Makes STls care more accessible as it can be implemented at primary health care level
• Uses flow-charts that guide the health worker through logical steps
• Provides opportunity and time for education and counseling.
The five steps in syndromic STls case management
1. History taking and physical examination
2. Syndromic diagnosis and treatment, using flow charts
3. Education and counseling on HIV testing and safer sex, including condom promotion and provision
4. Management of sexual partners
5. Recording and reporting
Syndromic approach is called “comprehensive approach” because in addition to the provision of treatment it includes:
education of the patient, condom supply, counseling, notification and management of sexual partners and HIV testing
and counseling (HTC).
FREQUENTLY RAISED ISSUES ABOUT THE SYNDROMIC APPROACH

A number of issues have been raised around the syndromic approach. This section illustrates such issues:
1. Issues related to scientific ground
Syndromic approach is based on a wide range of epidemiological studies in both the industrialized and developing
world. This case management approach has been used and adapted in several countries throughout the world, such as
Zimbabwe, Botswana, uganda, and Tanzania. Validation studies have compared syndromic and laboratory diagnosis to
assess the accuracy of syndromic diagnosis and found their results to be similar, so syndromic diagnosis is accurate, with
limitations relating to only one of the syndromes, vaginal discharge, which we will discuss later in this module.
Other studies have thrown light on the possible impact of syndromic case management on the incidence of STls and
HIV in a given population. This was a trial in 1995 in the Mwanza region of Tanzania, which aimed to learn what impact
STls case management and treatment-seeking behaviour would have on HIV transmission and STls in a population. After
two years, findings in the trial areas compared with control areas included: (Joint United Nations Programme on HIV/
AIDS 2000).
• A reduction of 50% in the prevalence of symptomatic urethritis in men
• A significant reduction in the prevalence of serological syphilis
• A 38% reduction in HIV incidence.
2. Issues related to simplicity of management
A streamlined diagnosis and treatment process also allows health workers to have more time to offer education for
behavior change.
3. Issues related to service provider’s clinical skills and experience
Many clinicians rely heavily on their own clinical judgment, but a number of studies have shown that clinicians using
their judgment get the diagnosis wrong in up to 50% of cases:
“Studies have shown that even highly experienced STI specialists using this system of clinical diagnosis will fail to make
the correct diagnosis and/or will miss concurrent infections in a significant number of cases.” (WHO/UNAIDS 2000)
4. Issues related to treating a single pathogen causing STI based on prevalence
Many patients are required to return to a health centre for treatment fails. They may even seek treatment elsewhere. If
the first course of treatment is not effective, the patient may continue to transmit the STls at best for a few days but at
worst for years.
5. Issues related to use of multiple
The drug adverse out come is less due to short duration of treatment and combination treatment delays resistance.
Studies have shown that the syndromic approach is less expensive than clinical or etiological diagnosis. This is because,
in weighing the alternatives, we need to include not only the high cost of etiological diagnosis or wrong clinical diagnosis
but also the biological and social costs, including infertility, loss of income, family breakdown and so on.
6. Issues related to the use of simple laboratory tests such as Gram’s stain
The sensitivity of gram’s stain to diagnose N.gonorrhea is very low (30-50%). Laboratory diagnosis must never be at the
expense of delayed treatment or the risk of patient non return.
Remember: Rapid and effective treatment of people with STls is the best way to interrupt the cycle of transmission.
Notes:
• The main reason for the development of STI syndromic approach is not merely lack of skilled health professionals
rather it is inadequate access to sophisticated laboratory for etiological diagnosis.
• Any patient who presents with STI syndrome have to be manage by syndromic approach at all level regardless
of the expert capacity provided that it is a first visit for the current syndrome ( unless you suspect treatment
failure).
In conclusion, for rapid and effective treatment of patients with STls in a resource poor country like Ethiopia, adopting
the syndromic approach is a plus.
21
SESSION TWO: USING THE FLOW-CHARTS

A flow-chart is a diagram or type of map representing steps to be taken through a process of decision-making. The
syndromes are relatively easy to identify and it is possible to devise a flowchart for each one.
A major benefit of the flow-charts is that, once trained, service providers find them easy to use – so health providers at
any health facility are able to manage STls cases.
Each flow-chart is composed of three steps :
• The clinical problem (the patient’s presenting symptom) at the top, this is the starting point.
• A decision to make, usually by answering ‘yes’ or ‘no’ to a question.
• An action to take: what you need to do. Action boxes suggest treatment, education and condom promotion recording
and reporting etc, and patient referral if necessary.
Figure 2. Illustrative example of a flow chart for urethral discharge
This is an action box, here asking

This is Starting point the clinical Problem
you to take a history and examine
Expressed as a symptom
the patient
Decisions like these ask you to

Patient complains of
answer a question. they have two
urethral discharge or dysuria
exit paths the path you choose
depends on whether your answer
to the question is YES or NO
Take history and

examine urethral if necessary
NO NO
Discharge Any other STIs?
confirmed?
YES
Use approprate Educate and Counsel

YES flow -Chart Promote and Provided Condoms
Offer HTC
Treat for gonorrhoes and Chlamydia

Educate and counsel on risk reduction
Promote Use and Provide condoms
Offer HTC
Partner/s managment
Advise patient to return in 7 days if
symptoms persist
Exit boxes like these explain what you need to do ( what action you need to make)
To use a flow chart, simply start at the clinical problem box and work through step-by-step until you arrive at an exit box
MODULE 03
HISTORY TAKING AND PHYSI-
CAL EXAMINATION
23
MODULE III: HISTORY TAKING AND PHYSICAL EXAMINATION

Total duration:120 minutes
Module objectives
By the end of this session, participants will be able to:
• Describe the challenges of interviewing a patient with a suspected STIs and the need to offer confidentiality and
privacy.
• Explain the importance of demonstrating respect for each patient.
• List a range of verbal and non-verbal communication skills to gather information effectively and ensure patient
compliance.
• Practice using verbal and non-verbal skills.
• Identify the informations to cover during the interview to make an accurate syndromic diagnosis.
• Recall the steps to conduct an efficient clinical examination.
SESSION ONE :INTRODUCTION ON HISTORY TAKING AND PHYSICAL EXAMINATION
History taking and physical examination are important part of the syndromic approach that leads to diagnosis and
treatment. In order to use flow charts effectively, the service provider must able to gather sufficient and accurate
information by refining his/her interviewing and physical examination skills. The three aims of history taking and physical
examination are to:
1. Make an accurate and efficient syndromic STls diagnosis.
2. Establish the patient’s risk of transmitting or contracting STls.
3. Find out about partners who may have been infected.
Things to consider during history taking and physical examination:
• The patient may be concerned or embarrassed, so it is important that the service provider and the environment set
him or her at ease.
• Confidentiality and privacy are crucial: somewhere to talk where others cannot see or hear-are a particular need for
patient confidentiality.
• Perhaps most important of all: patients need to feel that the service provider understands and respects them and
wants to listen. To do this, you need to develop a rapport with the patient and be non-judgmental.
COMMUNICATION SKILLS FOR ESTABLISHING RAPORT
Establishing a good rapport with the patient is a crucial step at first contact with the patient. A first step should be to
greet the patient in an appropriately friendly manner and introduce yourself. When the service provider makes interviews
he/she should:
• Smile and use a welcoming tone of voice
• Introduce himself/herself
• Use the patient’s name
• Offer the patient a seat
• Begin the history-taking only when there is privacy
• Make eye contact if culturally appropriate
• Be respectful and understanding - especially when the patient stammers and hesitates.
There are two types of communication skills
• Non verbal skills: how you behave with the patient
• Verbal skills: the way you talk to the patient and ask questions
1. NON VERBAL COMMUNICATION SKILLS
The key to effective non-verbal communication is to treat each patient with respect and give them full attention:
• Maintain appropriate eye contact. Where culturally appropriate, eye contact shows that you are interested in
the patient’s issues. We transmit a considerable amount of information by non-verbal communication, such as facial
expression and eye movements. Watch and listen and pay attention to feelings as well as facts.
• Listen carefully to what the patient says. Active listening is a function of what we pay attention to in the person
we are trying to help. Real communication occurs when we listen with understanding. Listening intelligently,
understandingly and skillfully to another person is not that easy. Listening involves the use of both verbal and non-
verbal gestures and signals.
• Stay as close to the patient as is culturally acceptable. A desk or table forms a barrier between patient and
service provider, so it is better to sit at the corner of the desk or table if you can.
These three points are very simple, but they can mean the difference between gaining and losing the patient’s trust or
confidence.
2. VERBAL COMMUNICATION SKILLS
Verbal skills entail the way you talk to the patient and ask questions. It is one of the skills you require for establishing
rapport with the patient.
General tips for questioning patients with STls
• Always phrase your questions politely and respectfully, however busy or rushed you may be
• Use words that the patient understands. Avoid using medical terms that he/she may not understand
• Make your questions specific, so that the patient knows exactly how to answer you
• Ask one question at a time: double questions confuse.
• Keep your questions free of moral judgments.
• Avoid ‘leading’ questions that ask the patient to agree with you: let people answer in their own words.
• Ask the patient’s permission before asking about his/her STls or sexual behavior.
Open and closed ended questions
When gathering information, we can ask two main sorts of question:
Open and closed ended questions.
Open ended questions enable the patient to give a detailed reply or to keep talking:
• “What is troubling you?”
• “What kind of medicines are you taking at the moment?”
Closed questions ask a patient to answer in one word or short phrase, often with ‘yes’ or ‘no’.
• “Is your period late?”
• “Do you have a regular partner?”
• “What is your age?”
Open-ended questions enable patients to explain something in their own words, and to say everything they think is
important. This means that it is possible to gather much more information from one open question than from several
closed ones. Also, because patients often have trouble talking about their own sexuality, open questions can help them
to feel more in control and comfortable.
Closed questions, on the other hand, ask the patient to answer a precise question based on the service provider’s words.
Closed questions are normally better saved for later in the interview, when you have won the patient’s confidence and
are checking particular details.
SPECIFIC VERBAL SKILLS
Some specific techniques and skills can be extremely useful when interviewing patients with STls. They can help to deal
supportively with the patient’s emotions as well as to gather information effectively.
The commonly used effective verbal specific techniques are:
• Facilitation
• Summarizing and checking
• Empathy
• Reassurance
• Expressing partnership.
25
Facilitation
This is about using words, sounds or gestures to encourage patients to keep on talking. Nodding the head and raising
the eyebrows are two examples of non-verbal facilitation. Its aim is gently to encourage the patient to continue.
Summarizing and checking
Summarizing and checking enable you to check that you have understood the patient correctly. The patient is also
able to correct any misunderstanding. To do this, you paraphrase what the patient has said, then ask if your summary is
correct. Use this skill when the patient has mentioned a number of things that you want to confirm.
Service provider:
(Summarizing) “So you’re worried what to tell to your husband and you feel very embarrassed about this infection. You
want to know whether we can cure it or not”
(Checking) “Am I right?”
Patient: “That’s right.
Empathy
This may be the most important skill of all when dealing with the patient’s feelings. If you notice that a patient is anxious
or tense, for example, you can express your empathy by commenting on what you have noticed. This shows that you
allow the patient to express his or her fears, and establishes more open communication between you. Like facilitation, it
encourages the patient to continue speaking:
Service provider: (Gently) “I can see that this is worrying you a good deal.”
Patient: “Yes, it’s been bothering me for over a week now
I’m worried sick”
Reassurance
Reassurance is a useful way to show that you accept the patient’s feelings and that the problem need not last forever.
You indicate with words or gestures that the patient’s anxiety can be addressed.
Expressing partnership
Expressing partnership confirms a commitment to help the patient.
“I can understand that you feel worried about symptoms like these. As soon as we confirm what’s wrong with you, we
can try to begin treatment that will make you better”
“ So what else do you need to know?”
Expressing partnership confirms a commitment to help the patient. This commitment could be with the service provider
personally or on behalf of the health facility team
Most experienced service providers use some of these interviewing skills some of the time. The key to interviewing
patients who may have STls is to use all above skills most of the time.
SESSION TWO: HISTORY TAKING

Improving ability to gather information about a patient is useful because it will help to make an accurate diagnosis of
STls in the time available. The information collected will be the starting point for understanding the patient’s behavioural
risks of transmitting or contracting STls in the future, as well as for partner referral and treatment.
First, it is worth reminding ourselves of why we are taking the patient’s history. It is to:
1. Make an accurate syndromic STIs diagnosis.
2. Establish the patient’s risk of transmitting or contracting STls.
3. Find out about partners who may have been infected.
This is the information you need to collect, in more or less this order:
1. The patient’s general details.
2. The patient’s present illness.
3. His or her medical history.
4. His or her sexual history.
1. General details
ΞΞ Age
ΞΞ Marital status
ΞΞ Locality or address
ΞΞ Employment
2. Present illness
Presenting complaints and duration.
• Men:
ΞΞ If a urethral discharge - pain while passing urine? Frequency? Color and consistency?
ΞΞ If scrotal swelling - Onset? Presence of pain? History of trauma and concomitant urethral discharge?
• Women:
ΞΞ If a vaginal discharge - Presence of itching? Appearance of discharge? Odor? Pain while having sex? Pain while
passing urine? Frequency? Risk assessment positive?
ΞΞ Lower abdominal pain - vaginal bleeding or discharge? The onset, type of pain radiation, severity, presence of vaginal
discharge, last menstrual period, and systemic symptoms like fever, nausea and vomiting are essential components
of the history.
• Painful or difficult or irregular menstruation?
• Missed or overdue period?
• Pain during sex (Dysparunia)?
• Men and women:
ΞΞ If a genital ulcer - is it painful? Recurrent? Appearance? Single/multiple? Other symptoms, such as itching or
discomfort?
ΞΞ If an inguinal swelling - is it painful? Associated with genital ulcer? Swellings elsewhere in the body?
3. Medical history
ΞΞ Any past STls - type? Dates? Any treatment and response?
ΞΞ Other illness - type? Dates? Any treatment and response? Results of tests? Treatment history of partner?
ΞΞ Medications being taken currently
ΞΞ Drug allergies
ΞΞ Habits: use of illicit drugs, alcohol abuse
27
4. Sexual history
ΞΞ Currently sexually active?
ΞΞ New partner in the last three months?
ΞΞ Consistent and correct use of condom?
ΞΞ Type of sexual practice? Ask this especially if the patient comes with clinical presentations mimicking oral or anal
transmission.
ΞΞ Risk assessment.
SESSION THREE PHYSICAL EXAMINATION

The purpose of a physical examination is to confirm any STls symptoms that patient has described exist by checking
for signs of STls. Physical examination should be systematic and comprehensive, restriction to a single system (genitalia)
could specially miss STls not presenting with syndromes.
Examining the most private parts of a person’s body requires sensitivity from the service provider. Patients may be
embarrassed or uncomfortable.
EXAMINING MALE PATIENTS FOR STls
1. Examination of a male patient can easily be done in a standing position, but the lying position can as well be used. The
patient should be asked to expose the area from the chest to knees for physical examination.
2. Palpate the inguinal region in order to detect the presence or absence of enlarged lymph nodes and buboes.
3. Palpate the scrotum, feeling for individual parts of the anatomy:
ΞΞ Testes
ΞΞ Spermatic cord
ΞΞ Epididymis.
4. Examine the penis, noting any rashes or sores. Then retract the foreskin if present, and look at the:
ΞΞ Glans penis
ΞΞ Urethral meatus.
If you cannot see an obvious urethral discharge, ask the patient to milk the urethra gently in order to express any
discharge. If a discharge is present, wipe it with a swab and dispose of it in a leak-proof container, ready for incineration.
5. Record your findings
EXAMINING FEMALE PATIENTS FOR STls

1. Ask the patient to lie down comfortably on a couch for genital physical examination. Ask patients to expose the area from
the chest to knees for physical examination. The patient should be covered with a sheet to maintain dignity and respect.
2. Palpate the abdomen for pelvic masses and tenderness, taking great care not to hurt the patient.
3. Palpate the inguinal region in order to detect the presence or absence of enlarged lymph nodes and buboes.
4. Ask the patient to bend her knees and separate her legs, then examine the vulva, anus and perineum and note for ulcer,
excoriation, swelling and discharge.
5. The physical examination may include, where possible, an internal pelvic physical examination involving
ΞΞ Bimanual physical examination to check for active PID; cervical motion tenderness, shape, size and position of uterus
for uterine masses, for example, pregnancy.
ΞΞ Speculum physical examination to check for the nature of the vaginal discharge, purulent cervicitis and/or erosions.
6. Record your findings.
For both male and female
General examination: an inspection of the skin is carried out and any rash, sores, warts and discoloration are noted. Then
palpation is carried out to determine the presence of enlargement of lymph nodes in the anterior and posterior cervical
region, submental, suboccipital, axillary and epitrochlear areas.
Note:
Examination of the oral cavity: The oral cavity should be carefully visualized with a torch for ulcers, candidiasis, leukoplakia,
gingivitis
Physical examination of other systems like bucal mucosa and the skin may give a clue to other STls not presenting
with classic signs and symptoms.
Do exercise 3.2 on page 95 to practice techniques of history taking and physical examination
MODULE 04
DIAGNOSIS AND MANAGEMENT
MODULE IV: DIAGNOSIS AND MANAGEMENT

Total Duration: 340 minutes
Module objectives:
After completing this module, participants will be able to:
• Make decisions and take actions on each of the syndromic case management flow-charts
• Use the flow charts and reach at syndromic diagnosis of commonly seen STIs
• Use the correct drugs and dosages for each syndromes
• Offer HIV counseling and testing
• If reactive for HIV link clients to ART care and treatment services
• Educate and counsel on risk reduction
• Promote use and provide condoms
• Undertake partner management
• Proper recording and reporting of cases
• Arrange for a follow-up visit
SESSION ONE: URETHRAL DISCHARGE SYNDROME (UDS)
The causative agents of urethral discharge syndrome are many; but the two most common causative agents of the
syndrome are Neisseria gonorrhea and Chlamydia trachomatis ( 81% and 36.8% respectively according the 2014 EPHI
gonococcal antimicrobial sensitivity validation study ) .Some of the other causative micro-organisms are mycoplasma
genitalum,Trichomonas vaginalis, and Ureaplasma urealiticum,. Most of the time urethral discharge is due to mixed
infection of Neisseria gonorrhea and Chlamydia trachomatis.
Gonococcal Infections:
Neiseria gonorrhea is a gram negative intracellular diplococcus. It is one of the causative agents of urethral discharge
syndrome in males and commonly transmitted during sexual intercourse. Most affected population groups are young
sexually active individuals between ages 15 - 29 years of age. The risk of contracting gonorrhea after a single exposure is
about 20%. The average incubation period in men is 2-5 days and the majority will experience symptoms within 14 days.
Gonococcus affects the epithelial surface of the urethra, conjunctiva, pharynx, rectum and synovium.
Sign and symptoms:
• Purulent/mucopurulent and profuse urethral discharge with or without dysuria (typically thick, yellow urethral
discharge)
• Occasionally urethral discharge is absent, or may be clear and apparently non purulent
• Symptoms usually more prominent than for chlamydial infection
• Symptomatic proctatis causes anal discharge, pruritus, occasionally tenesmus and rectal bleeding
• Occasional sore throat, most pharyngeal infections are asymptomatic
Complications:
• Epididymo-orchitis
• Urethral stricture
• Cowperitis
• Perihepatitis
• Disseminated gonococcal infection
• Perirectal abscess
31
Chlamyial Infections
The other important cause of urethral discharge syndrome in men is Chlamydia trachomatis. Chlamydiae are small,
obligatory gram negative intracellular bacteria that infect eukaryotic cells. A number of serotypes of C. trachomatis have
been identified worldwide and among these serotypes D-K cause sexually transmissible genital tract infections.
The incubation period is often difficult to determine accurately, but usually longer than that of gonorrhea. The range for
most cases is 5-30 days but may be much longer in a few cases. Over 30% of the cases may be asymptomatic. Chlamydia
trachomatis like gonococcus infect columnar and transitional epithelium of the genitalia. Infection is confined to
epithelial surfaces but an immune mediated host response can cause severe inflammation and damage deeper tissues
especially after repeated attack (episode).
Generally clinical manifestation of chlamydial infection is similar to that seen in gonococcal infection. However, it is less
likely to cause severe symptoms but more likely to cause serious sequelae.
Sign and symptoms:
• Urethral discharge typically mucopurulent but occasionally purulent
• Many patients lack demonstrable discharge, depending partly on time since urination
• Occasionally erythema at urethral meatus
Complications:
• Epididimo-orchitis
• Reiters syndrome
• Coeperitis
• Perihepatitis
Note:
Assess for the presence of urethral discharge during physical examination
• As urine could wash the discharge from the urethra, patient should not urinate for at least 2 hours before
examination
• Look for spontaneous discharge and note the color, quality and quantity of the discharge
• Crusting and redness at the urethral meatus due to scanty discharge are suggestive of urethritis
• To bring the discharge forward the urethra should be milked when discharge is not visible.
The above clinical features of urethral discharge described for Neisseria gonorrhea and chlamydia trachomatis are
not specific enough to make a diagnosis that is why it is recommended to treat urethral discharge syndromically
Figure 1. The algorithm of syndromic case management of urethral discharge syndrome
Urethral discharge syndrome flow chart in men
Complains of Urethral discharge or dysuria
Take history and Examine [Milk urethra if necessary]
NO NO Educate on RR
Discharge present? Other STIs? Promote and provide
condoms
YES
YES
Treat for GC and CT

Educate and Counsel on risk Reduction
Offer HTC Use appropriate flow chart
Promote the use and provide condoms
Partner management
Record and reporting
Advise to return in 7 days if
symptoms persist
Management of Urethral Discharge

Treatment of urethral discharge syndrome should cover both gonococcal and chlamydial infections because of the high
probability of mixed infection with both pathogens. Patients may also have another syndrome in addition to urethral
discharge
Recommended Treatment for Urethral Discharge and Dysuria

Ceftriaxone 250mg IM stat/Spectinomycin 2 gm IM stat
Plus
Azithromycin 1gm po stat/Doxycycline 100 mg po bid for 7 days/Tetracycline 500 mg po qid for 7 days/
Erythromycin 500 mg po qid for 7 days in cases of contraindications for Tetracycline (children and pregnancy)
Note: The preferred regimen is Ceftriaxone 250mg IM stat plus Azithromycin 1gm po stat
Persistent/Recurrent Urethral discharge

Some patients may complain of persistent or recurrent burning sensation on urination, with or without discharge, due
to various reasons:
• Inadequate treatment or poor compliance
• Re-infection (partner/s not managed)
• Persistent urethritis after doxycycline based treatment might be caused by doxycycline-resistant M. genitalium
• T. vaginals is also known to cause urethritis in men
• Infection by drug-resistant organisms ( N.gonorrhea)
33
Figure 2. The algorithm of syndromic case management of recurrent or persistent urethral discharge syndrome
Recurrent/Persistent Urethritis in men flow chart
Complains of Recurrent/Persistent Urethritis in men
Take history & Examine [Milk urethra if necessary]
NO NO Educate on RR
Discharge Confirmed? Other STIs? Promote and Provide
Condoms
YES
YES
Use appropriate
Does Hx suggest poor YES flow chart
compliance/ re-infection
NO
Repeat urethral discharge
treatment for gonorrhoea
and Chlamydia
Treat for M.genitalum T.vaginalis
Educate on RR
Offer HTC
Promote and
provide condoms
Educate and counsel on risk reduction
YES
Offer HTC
Promote the use and provide condoms
Partner management Improved
Record and report
NO
Advise to return in 7 days if symptoms persist
Refer
TREATMENT OF PERSISTENT/RECURRENT URETHRITIS SYNDROME

Re-treat with initial regimen
• If non-compliant or re-exposure occurs ,re-treat with the initial regimen with due emphasis on drug compliance and/or partner
management.
Cover M. genitalium and T. vaginalis
• If compliant with the initial regimen and re-exposure can be excluded, the recommended drug for persistent or recurrent urethral
discharge syndrome in Ethiopia is:
• Metronidazole 2 gm po. stat/Tinidazole 1gm po once for 3 days (Avoid Alcohol!)
PLUS
• Azithromycin 1 g orally in a single dose (only if not used during the initial episode to address doxycycline resistant M.genitalium)
Referral
• If men require treatment with a new antibiotic regimen and a sexually transmitted agent is the suspected cause, all partners in the
past 3 months before the initial diagnosis and any interim partners should be referred for evaluation and appropriate treatment of
treatment failure.
SESSION TWO: GENITAL ULCERS SYNDROME

Genital ulcer is an open sore or a break in the continuity of the skin or mucous membrane of the genitalia as a result
of sexually acquired infections. Commonly genital ulcer is caused by bacteria and viruses. Genital ulcer facilitates
transmission of HIV more than other sexually transmitted infections because it disrupts continuity of skins and mucous
membranes significantly. The causes for genital ulcerations include:
• Herpes simplex virus type 2
• Treponema pallidum (Syphilis)
• Haemophilus ducreyi (Chancroid)
• Chlamydia trachomatis serovars L1, L2, L3 (LGV)
• Klebsiella granulomatis (Donovanosis)
1. Syphilis:
Syphilis is a sexually transmitted systemic disease caused by a spirochete Treponema pallidum with variable clinical
manifestations. The average incubation period is 21 days (ranging from 3 to 90 days). Although the major mode of
transmission is through sexual contact, syphilis can be spread by kissing or touching a person who has active lesions on
the lips, oral cavity, breast or genitals. Syphilis can also be transmitted to the fetus in utero. Thus syphilis can be classified
as congenital or acquired. Acquired is divided in to primary, secondary, latent and tertiary syphilis.
Clinical Manifestations:
Primary syphilis presents with an ulcer or chancer at the site of infection. Secondary syphilis may show generalized skin
rash, mucocutaneous lesions, lymphadenopathy, etc. Characteristic presentation of tertiary syphilis may include visceral
organ damage such as cardiac, ophthalmic, auditory abnormalities and gummatous lesions. Latent infections has no
clinical manifestation but are detected by serologic testing. Latent syphilis acquired within the preceding year is referred
to as early latent syphilis (all other cases of latent syphilis are either late latent or latent syphilis of unknown duration).
35
Tabel 1. Clinical Features of Acquired Syphilis by Stage of Infection
Stages of Infection Clinical Manifestations

Primary Syphilis • Chancer presents as single painless or minimally painful round or oval genital ulcer with clean base
and firm indurated borders, little or no purulent exudates
• Most chancer appears on external genitals, but intravaginal, cervical or perianal lesions are also com-
mon, sometimes oral chancers appear
• Regional lymphadenopathy are common , generally bilateral, firm, non-fluctuant, non-tender without
overlying erythema
• Usually no systemic symptoms
• Asymptomatic infections is common, probably due to unrecognized chancer
• Atypical cases are common
Secondary Syphilis • Protean manifestations
• Most common presentations is generalized papulomacular, non-pruritic, skin rash, typically including
palms and soles
• Atypical rashes including pruritic ones may occurs
• Also common are mucous patches (painless mucous membrane lesions), Genital or perianal warty
outgrowths, condylomata lata, partly alopecia of scalp, generalized lymphadenopathy, fever, malaise
and headache
• Focal neurological manifestations, especially cranial nerve abnormalities and signs of meningeal infec-
tion/inflammation occur occasionally
Tertiary Syphilis • Gummatous syphilis
• Most common features are locally destructive granulomatous lesions (gummas) of the skin, liver,
bones, or other organs
• Neurosyphilis
• Tabes dorsalis and dementia often with paranoid features
• Latent meningovascular parenchematous
• Optic atrophy
• General paresis
• Cardiovascular syphilis
• Aoritic aneurysm and aoritic valve insufficiency
• Ngina pectoris
Latent • By definition latent syphilis is asymptomatic infection that follows primary syphilis
• Only detectable serologically
• Subdivided into two stages
• Early latent (infectious, less than one year)
• Late latent (greater than one year, usually noninfectious stages)
2. Genital Herpes:
Herpes virus 1 and 2 primarily affects oral and genital areas. Genital lesions caused by HSV1 and HSV2 are clinically
indistinguishable. In 20-60% of the cases, HSV1 produces genital ulceration while HSV2 disease is almost always results
in genital infections. Genital infection is caused by inoculation of the virus onto a mucosa surface or through cracks in
the skin, usually through close sexual contact.
Latency and frequent recurrence characterize genital herpes, producing a lifelong infection after the primary infection.
The incubation period is usually 2-10 days for symptomatic initial herpes, occasionally up to 3 weeks.
Primary infection, the virus ascends peripheral sensory nerves and established in the root ganglia of the sensory
or autonomic nerves evading immune attack. Primary infection is more severe than recrudescence but may be
asymptomatic.
Recurrent genital disease is due to reactivation of the initial strain of virus from infected latent sacral root ganglia.
First episode primary genital herpes is characterized by fever, headache, malaise, and myalgia and manifested by
severe disease requiring hospitalization. Pain, itching, dysuria, vaginal and urethral discharge and tender inguinal
lymphadenopathy are the predominant local symptoms.
Lesions largely involve the external genitalia, skin, the urethra and cervix. Lesions may present with varying stages,
including multiple vesicles, pustules, or painful erythematous ulcers. The cervix and urethra are involved in more than
80% of women with first episode infections. HSV2 is the leading cause of genital ulcer and enhance the acquisition or
transmission of HIV virus following unprotected sex.
Complications:
• Neuritic shooting pains down to the legs
• Aseptic meningitis
• Extra genital lesions
• Yeast vaginitis
• Disseminated herpes
3. Chancroid:
Chancroid is caused by gram negative facultative anaerobic gram negative bacillus called Haemophilus ducreyi. The
incubation period is 3-7 days progressing from a small papule to pustule and then to ulcer with soft margins described
as soft chancer. Multiple ulcers are commonly present with painful inguinal lymphadenopathy. The ulcer edge is typically
ragged and undermined. Lesions occur on the prepuce and frenulum in men and on the vulva, cervix and perianal area
in women. Extra genital ulcers on the inner thighs, breast and fingers have been reported.
4. Lymphogranuloma venereum (LGV):
LGV is a sexually transmitted diseases caused by L1, L2, L3 strain of Chlamydia trachomatis. Incubation period ranges
from 3-30 days after acquisition of infection. Initial infection can be urethral or cervical producing urethritis or cervicitis.
• Primary lesion is a small papule or herpetiform ulcer that produces few or no symptoms and generally not noticed
and heals without leaving a scar.
• Secondary stage occurs after few days or weeks of the primary lesion. Characterized by inguinal lymphadenopathy
accompanied by systemic symptoms such as fever, headache, myalgia, etc.
• Third stage refers to the complication of LGV and occurs years after the initial infection:
ΞΞ Hypertrophic chronic granulomatous enlargement with ulceration of the external genitalia (vulva, scrotum and
penis), rectal stricture, anogenitorectal syndrome.
ΞΞ Lymphatic obstruction leads to elephantiasis of the male or female genitalia
5. Granuloma inguinale (Donovanosis)
Granuloma inguinale is a chronic progressive ulcerative disease of the genitalia caused by intracellular gram negative
bacterium Klebsiella granulomatis previously known as Calamitobacterium granulomatis. Incubation period ranges
from 1 to 4 weeks and may extend up to a year.
Primary lesion is a small painless indurated papule/nodule which soon ulcerates to form beefy red granulomatous ulcer
with rolled edges and bleeds easily on contact. Multiple lesions may coalesce to form large ulcers. Subcutaneous spread
of the infection is progressive and more destructive. Blockage of lymphatic vessels by scarred tissue will result in lymph
edema and elephantiasis of the external genitalia.
Common sites of infections in men are the prepuce, penile shaft and in female labia and fourchette. Lesions on the
vaginal wall and cervix are rarely seen.
Table 2. Complications of genital Ulcer Syndrome
Disease Etiology Complications

1. Syphilis T. Pallidum • Secondary syphilis
• Latent Syphilis
• Aorititis with vavulitis
• Aoritic aneurysm
• Gumma
• Neurosyphilis
2. Genital Herpes Hepes Simplex Virus • Recurrence
(HSV1, HSV2) • Aseptic meningitis & encephalitis
3. Chancroid H. ducreyi • Penile autoamputation

4. LGV C. trachomatis L1, L2, L3 • Genital oedema
• Salpingitis
• Infertility
• PID
5. Granuloma inguinale C. granulomatis • Genital pseudoelephantiasis
• Adhesions
• Urethral, Vaginal, or rectal stenosis
37
Figure 3. THE ALGORITHM OF SYNDROMIC CASE MANAGEMENT OF GENITAL ULCER SYNDROME
Patient complains of genital sore or ulcer
Take history and examine
NO NO
Vesicular recurrent Solitary non-recurrent Educate on RR
Ulcers or > three ulcers Non - Vesicular ulcer, Promote and provide
condoms
YES
YES
Treat HSV2 Treat syphilis, Chancroid, HSV2
Educate on risk reduction

promote and provide condoms
Offer HIV testing and Partner Managment
Record and report
Ulcers healed?
NO
YES Ulcers improved? Refer
YES
Educate and provide condoms
Offer HIV testing Continue Rx
Recommended treatment for non-vesicular genital ulcer

• Benzathin penicillin 2.4 million units IM stat /Doxycycline(in penicillin allergy) 100mg bid for 14 days
plus
• Ciprofloxacine 500mg bid orally for 3 days /Erythromycin 500mg tab qid for 7 days
Plus
• Acyclovir 400mg tid orally for 10 days (or 200mg five times per day of 10 day)
Recommended treatment for vesicular multiple

first episode genital ulcer
• Acyclovir 400mg tid for 10 days
or
• Acyclovir 200 mg 5 times per day for 10 day
SESSION THREE: VAGINAL DISCHARGE SYNDROME (VDS)

Abnormal vaginal discharge can be caused by a number of endogenous and exogenous microorganisms. when
considering the types of vaginal discharge, it is useful to distinguish between noninfectious/physiological secretions
from STI related discharge. The common causes of vaginal discharge syndrome include:
• Neisseria Gonorrhea
• Chlamydia trachomatis
• Trichomonas vaginalis
• Gardnerella
• Candida albicans
The first three are sexually acquired and the last two are endogenous infections. The first two cause cervicitis while
the last three cause vaginitis. In Ethiopia, Bacterial vaginosis is the commonest cause of vaginal discharge followed by
Candida, Trichomonas, Gonococcal and Chlamydia cervicitis.
Noninfectious vaginitis is usually due to allergic reaction or irritation. Another common cause is atrophic vaginitis due
to estrogen deficiency.
1. Bacterial vaginosis (BV)
Bacterial vaginosis (BV) is a clinical syndrome resulting from replacement of the natural vaginal flora (hydrogen peroxide
producing Lactobacillus) by high concentration of anaerobic bacteria namely gardnerella, mycoplasma hominis,
ureaplasma urealyticum, etc.
Typical symptoms of Bacterial vaginosis include the following:
• Vaginal odor (the most common, and often initial, symptom of BV); often recognized only after sexual intercourse
• Mildly to moderately increased vaginal discharge
• Vulvar irritation (less common)
• Dysuria or dyspareunia (rare)
Physical findings in bacterial vaginosis may include the following:
• Thin, homogeneous, malodorous, and grayish white or yellowish vaginal discharge, which adheres to the vaginal
mucosa
• Increased light reflex of the vaginal walls, but typically with little or no evidence of inflammation
• Normal-appearing labia, introitus, cervix, and cervical discharge
• In some case, evidence of cervicitis
Risk factors that may predispose patients to Bacterial vaginosis:
• Recent use of antiseptic/antibiotic vaginal preparation
• Decreased estrogen production of the host
• Presence of intrauterine device (IUD)
• Frequent douching
Bacterial vaginosis is an endogenous reproductive infection. Treatment of sexual partners has not been demonstrated to
be of benefit. Therefore, it is recommended that predisposing factors mentioned above should be reduced or eliminated.
Complications:
• Bacterial vaginosis is associated with increased incidence of adverse pregnancy outcomes
• Premature rupture of membranes
• Preterm delivery
• Low birth weight
• Postpartum endometritis
• Pelvic inflammatory disease (PID)
2. Vulvovaginal Candidiasis (VVC)
Vulvovaginal candidiasis is caused by Candida albicans and also known as vaginal thrush. It is a common condition
caused by a yeast infection in the vagina and surrounding area. Candida lives harmlessly on the skin, in the mouth, gut
39
and vagina and is normally kept under control by harmless bacteria. But sometimes conditions change and the yeast
increases rapidly, causing symptoms of discharge and irritation.
Vulvovaginal candidiasis is common among women of child bearing age especially in their thirties and forties, and in
those who are pregnant. It is not clear why some women are more prone to thrush than others.
Precipitating factors for the acquisition of Candidiasis:
• Medical conditions that compromise the body’s immune system such as (immunosuppression), diabetes mellitus,
pregnancy, and hormone replacement therapy, etc.
• Taking antibiotics/chemotherapy – about 30 per cent of women will have thrush
• Use of chemical products that irritate the vagina, such as vaginal douches or bubble bath
• Wearing tight clothing – this prevents natural ventilation
Sign and symptoms
Up to 20% of women with candidiasis may be asymptomatic and be completely unaware of their condition. It may only
be picked up by chance when clients go for medical examination. Typical manifestation includes:
• Vulval itching, soreness and irritation
• Redness of the vagina and vulva
• Vaginal discharge, often white (like cottage cheese) and this can be thick or thin but is usually odorless
• Pain or discomfort during sex or when passing urine.
About 75% of all women have at least one episode of candidiasis in their lifetime. Recurrent episodes may indicate
underlying immunodeficiency or diabetes.
Since candidiasis is usually not acquired through sexual intercourse, treatment of sexual partner is not recommended.
3. Trichomonas vaginalis (TV)
Trichomonas vaginitis is a sexually transmitted infection caused by flagellated protozoa known as T. vaginalis
predominantly spread by unprotected intercourse. Incubation period rages from 1-4 weeks. About one fourth of
the cases remain asymptomatic. Some may produce recurrent attacks of cystitis with dysuria and frequency, etc.
Symptoms of trichomoniasis can be quite severe for some women, whereas others may have no symptoms at all.
Symptomatic trichomoniasis presents with an offensive vaginal discharge and Vulval itching in women. Vulva becomes
erythematous and excoriated and vaginal walls are reddened. Frothy, greenish vaginal discharge with a ‘musty’
malodorous smell is characteristic. Rarely the cervix can be involved with a strawberry appearance as a result may bleed
easily when swabbed. Infection during pregnancy has been associated with preterm deliveries and low-birth-weight
infants.
Association with adverse pregnancy outcomes
• Premature rupture of membranes
• Preterm delivery and
• Low birth weight
This association is particularly important in symptomatic women and hence the impact of treating trichomoniasis should
be demonstrated in the prevention of adverse outcomes of pregnancy.
Trichomoniasis is frequently asymptomatic in men but is increasingly recognized as a cause of symptomatic non-
gonococcal, non-chlamydial urethritis.
Some patient may have concomitant gonococcal or chlamydial infection in addition to T. vaginalis which may modify
the clinical manifestations.
Due to the nonspecific clinical features of vaginitis and the presence of mixed infections syndromic diagnosis and
management is recommended. Sexual partners should be notified and treated. Patient should be advised against sexual
intercourse until both the index patient and the partner (s) are treated.
4. Mucopurulent Cervicitis
Mucopurulent cervicitis is mainly caused by sexually transmitted pathogens particularly by N. gonorrhoeae and C.
trachomatis. The presence of purulent exudate from the cervical os frequently indicates gonococcal or chlamydial
infection.
Cervicitis is frequently asymptomatic. Cervicitis may be detected on routine pelvic physical examination or during
evaluation of a patient with vaginal discharge. Accordingly, cervical speculum evaluation should be an essential part
of the physical examination of a patient with vaginal discharge. Redness, contact bleeding, spotting and endocervical
discharge suggest that diagnosis of cervicitis.
Risk assessment - specific for use of vaginal discharge flow-chart
Using vaginal discharge as an entry point to manage cervical infection is far from ideal. While vaginal discharge is highly
indicative of vaginal infection, it is poorly predictive of cervical infection with gonorrhoea and/or chlamydia.
The flowchart may become more predictive of cervical infection if a number of risk factors are included. Number of risk
factors have been shown to be indicative of cervical infection.
• Multiple sexual partners in the last 3 months
• New sexual partner in the last 3 months
• Ever traded sex
• Age below 25 year
The presences of one or more risk factors suggest cervicitis.
Table 3. Differences between vaginitis and cervicitis
Diseases Vaginitis Cervicitis

Causes Trichomonas, Candidiasis, and bacterial vaginosis Gonorrhea and chlamydia
Occurrence Most common cause of vaginal discharge Less common cause of vaginal discharge
Diagnosis Easy to diagnose Difficult to diagnose
Complications No major complication Major complications
Partner Mgt. Unnecessary to treat partners except for TV Need to treat partner
Complications of Cervicitis and vaginitis

• PID
• Premature rupture of membrane
• Pre-term Labor
• Infertility
• Chronic pelvic pain
41
Figure 4. THE ALGORITHM OF SYNDROMIC CASE MANAGEMENT OF VAGINAL DISCHARGE SYNDROME
VD or vulval/Itching /burning
Educate on risk reduction Promote &
provide condoms Recording and reporting
Take Hx, examine patient (external,

speculum & bimanual) & assess risk
Use LAP flowchart
NO
Abnormal discharge present?

Educate on risk reduction
Promote and provide condoms
YES Offer HIV testing
Partner(s) Managment
YES Recording and reporting
Lower abdominal tenderness or Advise to return in
cervical motion tenderness 7 days if symptoms persist
NO
YES
Is Risk assessment +ve Treat GC, CT, TV,BV
NO
Vulvar oedema/curd like Discharge, YES

Treat for BV,TV Treat for VVC
Erythema, Excoriations present?
NO
Educate, Offer HTC, Promote & provide condoms, Recording and reporting
Recommended treatment for Vaginal Discharge

Risk Assessment Positive Risk assessment Negative
Ceftriaxone 250mg IM stat/Spectinomycin 2 gm IM stat Metronidazole 500mg bid for 7 days
plus
Azithromycin 1gm po stat/Doxycycline 100mg po bid for 7 days
Plus If discharge is white or curd-like add
Metronidazole 500mg bid for 7 days Clotrimazole vaginal pessary 200 mg at bed
If discharge is white or curd-like add Clotrimazole vaginal time for 3 days
pessary 200 mg at bed time for 3 days

Note: The preferred regimen is Ceftriaxone 250mg IM stat plus Azithromycin 1gm po
stat plus Metronidazole 500 mg bid for 7 days
Recommended regimens for pregnant women

Although metronidazole is not recommended for use in the first trimester of pregnancy, treatment may be given where
early treatment has the best chance of preventing adverse pregnancy outcomes. In this instance a lower dose should
be used (2gm single dose rather than a long course). Studies have not demonstrated constant association between
metronidazole use during pregnancy and teratogenic or mutagenic effects in newborns.
• Metronidazole 200 or 250mg orally, 3 times per day for 7days , after first trimester
• Metronidazole 2gm orally, as a single dose, if treatment is imperative during the first trimester of pregnancy.
SESSION FOUR: LOWER ABDOMINAL PAIN SYNDROME OR PELVIC INFLAMMATORY

DISEASES (LAPS/PID)
Pelvic inflammatory disease (PID) is a syndrome characterized by lower abdominal pain syndrome. It is an inflammatory
disorder of the upper female genital tract, involving the uterus, fallopian tubes, ovaries and adjacent pelvic structures.
PID includes endometritis, salpingitis, tubo-ovarian abscess, oophoritis and pelvic peritonitis. Infection and inflammation
may spread to the abdomen, including perihepatic structures.
PID is a Polymicrobial inflammation caused by infection that ascends from the vagina and cervix into the upper genital
tract. The predominant sexually transmitted organisms associated with PID include C. Trachomatis and Neisseria
gonorrhoeae. Other organisms implicated in the pathogenesis of PID include Gardnerella vaginalis, Haemophilius
influenzae, Mycoplasma and anaerobes such as Peptococcus and Bacteroides species.
Risk Factor:
The classic high-risk patient is a menstruating woman younger than 25 years who has multiple sex partners, does
not use contraception, and lives in an area with a high prevalence of sexually transmitted disease (STD). Use of an
intrauterine device (IUD) for contraception confers a relative risk of 2.0-3.0 for the first 4 months following insertion, but
risk subsequently decreases to baseline. Follow-up is recommended within the first month after IUD insertion.
Depending on the severity of the infection (manifestation of patients with PID may be mild or severe with toxic Symptoms
like fever, nausea, vomiting, and severe pelvic and abdominal pain may occur.
Women with PID usually present with lower abdominal pain and vaginal discharge. The pain is typically dull, aching
or crampy, bilateral, and constant. It begins a few days after the onset of the last menstrual period and tends to be
accentuated by motion, exercise, or coitus. Abnormal vaginal discharge is present generally in approximately two third
of the cases. Unanticipated vaginal bleeding, often postcoital, is reported in about one third of the cases.
Other suggestive symptoms include: painful urination, pain during menstruation, fever and sometimes nausea and
vomiting.
Alternative causes of lower abdominal pain such as appendicitis, ectopic pregnancy, and cholecystitis, should be ruled
out by proper history and physical examination.
PID become more probable when one or more of the symptoms above combine with physical findings of:
• Lower abdominal tenderness
• Vaginal discharge
• Cervical motion tenderness
Over diagnosis and treatment nay be justified in order to prevent complications.
During history taking the service provider should ask in detail for other symptoms such as erratic bleeding, missed or
overdue period, recent delivery, abortion or miscarriage. Erratic bleeding may be an early symptom of ectopic pregnancy.
You need to ask similar questions such as:
• Are there any problems with your periods?
• Do you have any vaginal bleeding not related to normal menstruation?
• Have you had a miscarriage, abortion or delivery in the last six weeks
When examining the patient:
• Check patient’s temperature. A high temperature indicates infection
• Palpate the abdomen for tenderness, rebound tenderness, guarding and detection of a mass.
• Guarding and rebound tenderness are features of peritonitis or intra-abdominal abscess.
• Check for vaginal bleeding. This could alert you to the possibility of an ectopic pregnancy or abortion.
• Finally, check for abnormal vaginal discharge.
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Complications of PID
• Peritonitis and intra-abdominal abscess
• Adhesion and intestinal obstruction
• Ectopic pregnancy
• Infertility
• Chronic pelvic pain
Seriously consider hospitalizing patients (Indications for Admission of patients) when:
• The diagnosis is uncertain
• Surgical emergencies such as appendicitis and ectopic pregnancy cannot be excluded
• Pelvic abscess is suspected
• Severe illness precludes management on an outpatient basis
• The patient is pregnant
• Patient is unable to follow or tolerate an outpatient regimen
• Patient has failed to respond to outpatient therapy
• PID in HIV patients
Figure 5. THE ALGORITHM OF SYNDROMIC CASE MANAGEMENT OF LOWER ABDOMINAL PAIN SYNDROME
Complains of lower abdominal pain
Take history & examine (abdominal & vaginal)
NO Cervical exitation NO
Missed/overdue period, Any other illness?
tenderness or
Pregnancy
lower abdominal
Recent delivery/abortion YES
tenderness and VD
/Miscarriage
Abdominal guarding/ YES
rebound tenderness Manage appropriately
Vaginal bleeding
Treat for PID
Abdominal mass & review in 3 days
YES
NO Refer patient for
Improved?
admission
Refer patient for surgical or YES
gynaecological assessment
Set up IV line
Resuscitate if required Continue treatment
Educate on RR
Offer HTC
Condom use
Partner(s)treament
Recording and reporting
Recommended treatment for PID

Broad spectrum antibiotics to cover all pathogens are indicated because PID is Polymicrobial infection even with setting
of gonococcal or chlamydial infection. Empirical treatment should be instituted as soon as diagnosis is suspected. The
vast majority of PID with or without pelvic abscess to improve with antibiotics alone and the fever usually subsides in
less than 72 hours.
However, failure to improve within 72 hours after antibiotic treatment indicates failure of medical treatment and the
patient should be referred for surgical or gynecological evaluation and treatment.
Recommended treatment for PID
Out patient Inpatient
Ceftriaxone 250mg IM stat/Spectinomycin 2 gm IM stat Ceftriaxone 250mg IV/IM daily /Spectinomycin 2gm IM
plus bid
Azithromycin 1gm po stat/Doxycycline 100mg po bid for 14 days plus
plus Azithromycin 1gm po daily / Doxycycline tablet 100 mg
Metronidazole 500mg bid for 14 days bid for 14 days
Admit if there is no improvement within 72 hours Plus
Note : The preferred regimen is Ceftriaxone 250mg IM stat plus Metronidazole 500mg bid for 14 days
Azithromycin 1gm po stat plus Metronidazole 500 mg bid for 14 days
Note: For inpatient PID, ceftriaxone, spectinomycin or azithromycin should continue for 24hrs after the patient
remain clinically improved, after which doxycycline and metronidazole should continue for a total of 14 days
SESSION FIVE: SCROTAL SWELLING SYNDROME (SSS)

The cause of scrotal swelling can vary depending on the age of the patient. Among patients who are younger than
35 years, the swelling can be caused by N. gonorrhoea or C. trachomatis. However, scrotal swelling among patients
older than 35 years is commonly can be caused by other microorganisms or possibly tuberculosis if the patient has not
been involved in unsafe sex. Other infectious causes of scrotal swelling could be brucellosis, mumps, onchocerciasis or
infection with W. bancrofti. However, these conditions produce systemic disease and may be associated with additional
findings.
In pre-pubertal children the usual etiology is coliform, pseudomonas or mumps virus.
Mumps epididymo-orchitis is usually noted within a week of parotid gland enlargement.
It is important to exclude other causes of scrotal swelling that require urgent referral for proper surgical evaluation and
treatment such as
• Testicular torsion
• Trauma
• Tumor
• Incarcerated inguinal hernia
Complications of scrotal swelling caused by STIs
• Epididymitis
• Infertility
• Impotence
• Prostatitis
Steps in examining patients with scrotal swelling:
1. Inspect the scrotal sac and compare the two sides for swelling of testis. Palpate and note any tenderness.
2. Determine the position of the testis in the scrotal sac. Is it elevated or rotated? If so , this is characteristic of testicular torsion.
3. Is there bruising of the scrotal skin which could indicate trauma?
45
4. Is there an obvious urethral discharge? If not, ask the patient to gently squeeze the penis and milk the urethra in order to
express any discharge.
5. Is there evidence of any other STIs such as an ulcer?
6. Is there swelling in the inguinal area or does the scrotal swelling increase when the patient raises intra-abdominal pressure
(straining as if passing stool)? This may point to a hernia and may require referral to a surgical facility.
Figure 6. THE ALGORITHM OF SYNDROMIC CASE MANAGEMENT OF SCROTAL SWELLING SYNDROME
Complains of scrotal sewlling/pain
Take history and examine
NO
Swelling/pain confirmed? Reassure patient/ educate
Promote and provide condoms
Analgesics
YES
NO
Testis rotated or elevated, Treat Gc & CT
or history of trauma? Educate on RR
Promotoe and provide condoms
Offer HIV testing
YES Partner/s treatment
Recording and reporting
Review in 7 days or earlier if
Refer immediately for necessary, if worse, refer
surgical opinion
Recommend treatment for Scrotal Swelling

Ceftriaxone 250mg IM stat/ Spectinomycin 2gm IM stat
plus
Azithromycin 1gm po stat/Doxycycline 100mg bid PO for 7 days
Note :The prefered regimen is Ceftriaxone 250mg IM stat plus Azithromycin 1gm po stat
The treatment of STI caused scrotal swelling is similar to that of a urethral discharge and thus the following drugs are
recommended. In addition analgesia and scrotal support may be indicated as required.
SESSION SIX: INGUINAL BUBO SYNDROME (IBS)
Inguinal bubo is painful, often fluctuant, swelling of the lymph nodes in the inguinal region (groin). It should be
remembered that infections in the lower extremities or in the perineum could produce swelling of the inguinal lymph
nodes, but strictly speaking this regional enlargement should not represent inguinal bubo.
The common sexually transmitted pathogens that are associated with inguinal bubo include:
• C. trachomatis (serovar L1; L2; and L3)
• H. ducreyia
• C. granulomatis and
• T. pallidum
T. pallidum can be a cause of inguinal lymphadenopathy. Unlike other causes of inguinal bubo, it doesn’t generally
produce necrosis and abscess collection in the lymph nodes. In conditions where the physical examination doesn’t
reveal a fluctuant bubo, syphilis should be additionally considered and treated accordingly. Surgical incisions are
contraindicated and the pus should be aspirated through healthy skin using a hypodermic needle.
When examining the patient, try and determine whether the swelling is really a bubo or simply enlarged lymph nodes
or any other pathology which has enlarged nodes in other sites. A bubo is usually painful, warm, tender and fluctuant
when palpated. There may be one large mass or a collection of smaller painful swellings. Occasionally the bubo might
have ruptured and a sinus, discharging pus, will be present.
ΞΞ In uncircumcised men, remember to examine the underside of the foreskin and the parts normally covered by the
foreskin. If the patient cannot retract the foreskin because of the swelling assume that there is a genital ulcer and
use the appropriate flow chart.
ΞΞ In women, examine the skin of the external genitalia and then separate the labia and look at the mucous surface for
ulcers.
COMPLICATIONS
• Fistula or sinus formation
• Multiple draining sinus
• Extensive ulceration of genitalia
• Extensive scarring
• Proctocolitis with tenesmus and bloody purulent discharge.
• Retroperitoneal lymphadenopathy
• Chronic untreated LGV may result in lymphatic obstruction, elephantiasis of the genitalia
• Rarely hematogenous dissemination to lung, liver, spleen and bone.
47
Figure 7.THE ALGORITHM OF SYNDROMIC CASE MANAGEMENT OF INGUINAL BUBO SYNDROME
Complains of inguinal swelling
Take history & Examine
Inguinal/femoral NO NO
Other STIs? Educate on RR
bubo(s) present? Condoms use
YES
YES
Use appropriate flowchart
Ulcer(s) present?
YES
NO
Use GU flowchart
Rx LGV,chancroid,GI
Educate on RR
provide condoms
Partner(s) management
Offer HIV testing
Reporting and recording
Advice to return in 7 days
Recommended treatment for Inguinal bubo

Ciprofloxacin 500mg bid for 3 days
plus
Doxycycline 100mg bid orally for 7 days/ Erythromycin 500mg qid orally for 14 days
NB. * surgical incisions are contraindicated, aspirate pus with hypodermic needle through the healthy skin
* If patient have genital ulcer add Acyclovir 400mg tid orally for 10 days (or 200mg five times per day of 10 day)
SESSION SEVEN: NEONATAL CONJUNCTIVITIS SYNDROME (NNCS)

Neonatal conjunctivitis (ophthalmia neonatorum) is a purulent conjunctivitis occurring in a baby less than one moth of
age. It is transmitted by contact during delivery or passage through the birth canal.
The most important causes of this potentially sight threatening condition are gonorrhea and chlamydia. If caused by
gonorrhea blindness often follows. In developing countries gonorrhea often accounts for 20-75% and chlamydia 15-
35% of cases of neonatal conjunctivitis. Newborn babies are generally presented because of redness and swelling of the
eyelids, discharge from the eye or sticky eyes. For babies older than one month, the cause is unlikely to be STIs.
In exceptional situation epidemic of gonococcal conjunctivitis occurred as a result of mechanical transmission by house
flies where environmental sanitation and hygiene is very poor.
CLINICAL MANIFESTATIONS OF NEONATAL CONJUNCTIVITIS
The common clinical presentations of neonatal conjunctivitis (ophthalmia neonatorum) are:
• Red and edematous conjunctiva
• Edematous eye lead
• Discharge which may be purulent
• Orbital cellulitis in more serious cases
COMPLICATIONS OF NEONATAL CONJUNCTIVITIS
Neonatal conjunctivitis can lead to some serious ophthalmic complications if it is not managed promptly. Some of the
complications of neonatal conjunctivitis (ophthalmia neonatorum) are:
• Pseudo membrane formation
• Corneal edema
• Thickened palpebral conjunctiva
• Corneal opacification
• Corneal perforation
• Endophthalmitis
• Blindness
Prevention of Neonatal Conjunctivitis
Prompt eye prophylaxis at delivery should prevent gonococcal conjunctivitis. All newly born babies should have
preventive therapy carried out as follows.
• As soon as the baby is born, carefully wipe both eyes with dry, clean cotton wool
• 1% tetracycline eye ointment into the infant’s eyes
Remember that the baby’s eyes are usually swollen soon after birth and may be difficult to open. Therefore the eyes
should be opened and the eye ointment placed in the lower conjunctivas sacs and not on the eyelids.
49
Figure: 8.The Algorithm of Syndromic Case Management of Neonatal Conjunctivitis
Neonate with eye discharge
Take history & Examine
Bilateral or unilateral NO
Reassure mother
swollen eyelids with Advise to return if
purulent discharge necessary
YES
Rx child for GC & Chlamydia

YES
Rx the mother and partner (s) for
GC & Chlamydia Improved
For the mother and partner (s):
Educate on RR
provide condoms
NO
Offer HIV testing
Refer
Advice to return in 3 days with the neonate
Recommended Treatment for Neonatal Conjunctivitis

• Ceftriaxone 50mg/kg IM stat maximum dose 125/ Spectinomycin 25 mg/kg IM stat maximum dose 75mg
plus
Erythromycin 50mg/kg orally in four divided doses for 14 days
Note: TTC is used as prophylaxis for neonatal conjunctivitis but note for treatment
SESSION EIGHT: FOLLOW UP VISIT FOR PATIENTS WITH STIs

The importance of follow up visit is
• To assess treatment adherence, response and ensure cure,
• To exclude incubating STIs particularly syphilis,
• To offer HIV testing and counseling if not done during the initial visit,
• To assess for safer sexual behavior.
• To further counsel patient to bring partners if not yet treated
Some patients may not respond to the initial syndromic treatment and hence reassessment may be necessary. The
response to treatment might not be as expected when patients with STIs have concomitant HIV infection. Moreover
testing for HIV infection can be offered during a follow up visit, if not provided at the initial visit.
Incubating syphilis is either not affected or will be inadequately treated by the syndromic treatment of syndromes
other than genital ulcer. Thus, RPR is an important test that needs to be done in order to exclude syphilis, particularly in
patients presenting with urethral or vaginal discharge syndromes. HIV counseling and testing and partner treatment can
be offered during a follow up visit, if not provided at the initial visit
If patient didn’t respond to the initial treatment it is good to rule out possible re-infection, treatment incompliance,
treatment failure and misdiagnosis. Once re-infection, treatment incompliance are ruled out, then patient should be
work up in line with treatment failure using etiologic approach especially for Neisseria gonorrhea resistance using
culture and sensitivity.
For other STI causing microorganisms since there is no culture and sensitivity, only etiological identification is enough.
Table 4. Etiological diagnostic modalities
Organism Golden standard Confirmatory

N.gonorheae Culture PCR
C.trachomatis PCR PCR
T.Vaginalis Wet mount PCR
Syphylis TPHA
Culture and sensitivity tests are available only at few sites (Adama, Nekemt, Jimma University Hospital, Hawassa,
Arbaminch, Metu hospital,Mizan tepi hospital,Harar, Bahrdar, Dessie, Mekele, Gondar University hospital, Black lion,
Yekatit 12 Hospital and Ethiopian Public Health Institute (EPHI)). All treatment failure patients of Urethral discharge, and
vaginal discharge should be referred to these laboratories. The advantage of culture technique is to have live organism
and doing antimicrobial susceptibility tests.
Nucleic acid amplification and testing method (Polymerase chain reaction) is done for etiological identification. If the
patient is diagnosed for urethral or vaginal discharge syndromes and become culture negative for Neiserria gonorhe a,
PCR will be done to rule out other etiologies that cannot be identified by culture method. PCR is currently available at
EPHI and some private facilities and in the near future in the above mentioned regional laboratories. The appropriate
sample for such could be urine or discharge. All STI causing etiologies could be diagnosed using this method.
All facilities are expected to refer patients to their nearby facility or regional laboratory where this facilities can be given
for patient suspected with syndromic treatment failure.
Note: Sometimes other gynecological, dermatological, surgical and medical disorder can be misdiagnosed as STI
syndromes and it will be wise to consider if patients fails to syndromic management. Therefore, patient should be
workup/referred for non STI cause in parallel with treatment failure workup
Do exercise 4.1 on page 97 to further understand diagnosis and treatment of STIs using flow chart
MODULE 05
STIs IN CHILDREN AND
ADOLESCENTS
MODULE V STIS IN CHILDREN AND ADOLESCENTS

Total duration 60 minutes
Module Objectives:
After completing this module, participants will be able to list and explain:
• Issues to consider during management of STIs in adolescents and children
• The comprehensive care package for children and adolescents with STIs
• The correct drug therapies and dosages for each diagnosis in children and adolescents
Management of STIs in Children and Adolescents
The presence of STIs in children with the exception of neonatal infections and congenital syphilis invariably indicates
sexual abuse. Health workers therefore should arrange for emotional as well as legal support for the child as part of the
comprehensive management. In rare instances, however chlamydial vaginitis, acquired prenatally could manifest up to
the age of three. Genital warts are not specific indicators of abuse unless supported by other evidence. Bacterial vaginitis
has been diagnosed in children who have been abused, but its presence alone does not prove sexual abuse. Candidiasis
is not a sexually transmitted infection in adults or children.
Factor that increase vulnerability of children and adolescent for STIs
Biological factors:
• Mucosal tear during sexual act
• Underdeveloped vaginal epithelium
• Cervical ectropion
Social factors:
• Multiple sexual partners
• Commercial sex work
• Poor health seeking behavior
• Poor self-esteem
• Lack of youth friendly services
• Substance abuse
• Peer influence
During management of STIs in adolescents the following issues have to be considered:
• Adolescents may have limited accesses to health care and may not seek care adequately. Therefore, arrangements
should be made to ensure compliance and future follow up.
• Partner notification and management is often difficult , thus risk of reinfection exists
• Pregnancy should be considered ad screening is pertinent in adolescent females
Syndromes in children and adolescents are caused by similar pathogens as in adults and thus follow similar management
principles. However, some medications used in adults may not be used for children. The following table shows the
management of STIs in children or adolescents.
53
Syndrome Infectious agent Regimen

Urethral N. gonorrhea Adolescents:
Discharge C. trachomatis • Ceftriaxone 125 mg IM stat
M.genitalium Plus
• Azithromycin 1gm po stat/Doxycycline 100mg bid for 7 days
Children:
• Ceftriaxone 125mg IM stat
Plus
• Erythromycin 10mg/kg qid for 7 days
Note: Use metronidazole 10 mg/kg bid for 7 days for persistent symptoms and
500mg bid for 7days in Adolescents:
Vaginal N. gonorrhoeae Adolescents:
Discharge C. Trachomatis • Ceftriaxone 125 mg IM stat
T. vaginalis Plus
• Azithromycin 1gm po stat/Doxycycline 100mg bid for 7 days
Bacterial vaginosis(BV)
Plus
Vulvovaginal candidiasis (VVC) • metronidazole 500mg bid for 7 days
Children:
Plus
plus
• metronidazole 10 mg/kg bid for 7 days
Genital Ulcer H SV type 2 Adolescents:
T. pallidum • Acyclovir 400mg tid for 10 days
H. ducreyia Plus
• Benzathine penicillin 2.4 million units IM stat
Plus
• Erythromycin 500mg qid for 7 days
Children:
• Acyclovir 10 mg/kg tid for 7 days
Plus
• B. penicillin G 100,000 units/kg IM single dose
Plus
PID N. gonorrhoeae Adolescents:
C. Trachomatis • Ceftriaxone 125mg stat
Anaerobics Plus
• Azithromycin 1gm po stat/Doxycycline 100mg bid for 14 days/Erythromycin
500mg qid for 14 days
Plus
• Metronidazole 500mg bid for 14 days
Note :
• The dose of ceftriaxone for children and adolescent weight less than 45 kg is 125 mg IM stat.
• For those who are greater than 45 kg, use adult dose which is 250mg IM stat
Comprehensive package for children and adolescents with STIs should include:
• Effective medical treatment
• Education on risk reduction
• HIV testing and counseling
• Contact tracing and management
• Promotion and provision of condoms
• Ensure follow up management
• Legal and emotional support
Care for rape victims
• Provide psychological support
• Screen for Syphilis, Hepatitis B virus and HIV
• Screen for pregnancy, if the victim is on the reproductive age group
• Provided emergency contraceptive, if victim present within 5days
• Provide HIV post exposure prophylaxis according to the national PEP protocol, if victim present within 3days .
• Provide prophylactic antibiotics for N. gonorrhea , Chylamdia trachomatis and T.vaginalis
Plus
• Azithromycin 1gm po stat/Doxycycline 100mg po bid for 7days
Plus
• Metronidazole 2gm po stat
• Link to legals support ,gynecological care/ rape centers for additional management
• Arrange follow up visit at 2weeks,12weeks and 6 months
MODULE 06
MANAGEMENT OF STIs NOT
PRESENTING WITH TYPICAL
SYNDROMES
MODULE VI: MANAGEMENT OF STIS NOT PRESENTING WITH TYPICAL SYNDROMES

Learning objectives:
After completing the module, participants will be able to:
• List STIs not presenting with typical syndromes
• Explain the clinical features of STIs not presenting with syndromes
• List the correct drug therapies and dosages for each diagnosis
SESSION ONE: SYPHILIS IN PREGNANCY

In Ethiopia, the estimated syphilis prevalence among ANC attendees in 2012 was 1%, indicating a low prevalence of
syphilis in pregnant women (RPR >5% indicates high prevalence). Adverse pregnancy outcomes such as miscarriage
or stillbirth, congenital syphilis in the new born and progression of latent syphilis in the mother are anticipated
complications if the mother is left untreated. Thus RPR test should be routinely done on pregnant mothers in their first
trimester and treatment should be instituted if the RPR test shows reactivity.
The treatment regimen recommended for syphilis in pregnancy is:
1. If primary syphilis, secondary syphilis or history of non-reactive RPR test within the past 1 year
Benzathin penicillin G 2.4 million units i.m stat
Or
Ceftriaxone 1gm i.m daily for 8-10 days in case of penicillin allergy
2. If infected more than one year ago or no prior history of non-reactive RPR test( unknown duration)
Benzathin penicillin G 2.4 million units i.m weekly for 3 weeks
Or
Erythromycin 500 mg po q.i.d for 30 days
3. Treatment for neurosyphilis
Aqueous bezylpenicillin 10-12 million IU by intravenous injection, administered daily in doses of 2-4 million IU, every 4 hours for 14
days.
Alternative regimen:
Procain benzylpenicillin, 1.2 million IU 1M, once daily, and probenecid, 500 mg orally, 4 times daily, both for 10-14 days.
NB: Partner should be treated.
Lumbar puncture should be done in latent syphilis of more than 1 year duration if:
• There are neurological symptoms
• Treatment fails
• Serological titer is 1 :320 and higher
• Non penicillin therapy is planned
• There is concomitant HIV infection
SESSION TWO: CONGENITAL SYPHILIS
Children contract congenital syphilis from their mothers who are not properly treated for syphilis during pregnancy, i.e.
it is trans-placental infection of the fetus.
In about 70% of women with untreated maternal syphilis there is an occurrence of adverse effects to the fetus. To
minimize these adverse effects pregnant mothers should be screened for syphilis at ANC clinic and if they are serological
reactive they should get treatment immediately.
The outcome of pregnancy in untreated syphilis depends on how recently a woman has been infected. During the early
57
stages of active syphilitic infection there are large numbers of circulating treponemes. Pregnancy in this phase may
result in large numbers of treponemes crossing the placenta and the effect on the fetus may be severe. In pregnancy
occurring at later stage when the infection becomes old the damage to the fetus will be less severe. Thus the possible
outcomes in diminishing order of severity are:
• Abortion
• Delivery of premature stillborn child
• Full term still born child
• Live born child showing signs of congenital syphilis
• Delivery of an apparently healthy infant but developing sign and symptoms and signs of early congenital syphilis in
the first weeks or few months of life
CLINICAL MANIFESTATIONS
Early manifestations of congenital syphilis (less than 2 years)
• Jaundice
• Hepatosplenomegaly
• Pseudo paralysis
• Bullous skin lesions and mucous membrane lesions, such as generalized rash
• lymph node enlargement
• Nasal discharge (serosangenous)
• Hoarse voice
• Chorioretinitis
• Nephrotic syndrome
Late manifestations of congenital syphilis (greater than 2 years)
• The scars of healed early infection which include collapse of the nasal bridge
• Perforated palate
• Sabre tibiae
• Deformity of long bones and nasal bridge
• Hutchinsons triad (deafness ,keratitis, and peg shaped incisor teeth
• Hydrocephalous with evidence of mental retardation
• Interstitial keratitis
• Deafness and abnormalities of the teeth.
• Children may also present with syphilitic gumma affecting mucous membranes skin and viscera
• Central nervous system involvement from syphilis.
• Cardiovascular syphilis rarely occurs as a result of congenital syphilis
TREATMENT OF CONGENITAL SYPHILIS
To avoid complications of congenital syphilis treatment must be instituted as fast as possible after diagnosis of the
disease. The recommended regimen for congenital treatment is:
1. Treatment for early congenital syphilis
Aqueous crystalline penicillin G 50, 000 units/kg IV tid for 10 days
Or
Procaine penicillin G 50,000 units/kg IM daily for 10 days
2. Treatment of late congenital syphilis
Aqueous crystalline penicillin G 50,000 units/kg IV or IM qid for 10 days
Or ( for penicillin allergy)
Erythromycin 7.5 – 12.5 mg/kg orally qid for 30 days
SESSION THREE: GENITAL WARTS

Genital warts affect both men and women and can occur at any age. Most patients with genital warts are between the
ages of 17-33 years. Genital warts are highly contagious. There is around a 60% risk of getting the infection from a single
sexual contact with someone who has genital warts.
In children younger than three years of age, genital warts are thought to be transmitted by nonsexual methods such as
direct manual contact. Nevertheless, the presence of genital warts in children should raise the suspicion for sexual abuse.
The peak time for acquiring infection for both women and men is shortly after becoming sexually active. HPV is sexually
transmitted, but penetrative sex is not required for transmission. Skin-to-skin genital contact is a well-recognized mode
of transmission.
ETIOLOGY
Genital warts are caused by the human papilloma virus (HPV). About 90% of genital warts are caused by two specific
types of the Human Papilloma virus with a low cancer causing potential. The viruses are:
• Human papilloma virus (HPV-6)
• Human papilloma virus ( HPV-11 )
• HPV type 16, 18, 31 and 45 ( high risk of oncogencity)
In men, genital warts can infect the urethra, penis, and scrotum. The warts can appear as soft, raised masses with a
surface that can be smooth (on the penile shaft) or rough with many fingerlike projections. Others may appear pearly,
cauliflower-like, or rough with a slightly dark surface. Most lesions are raised, but some may be flat or papillary with
only slight elevation above the skin surface. Sometimes lesions may be hidden by hair or in the inner aspect of the
uncircumcised foreskin in males. In women the warts usually first appear on the fauchete and extend to the labia, vaginal
wall and perineum. Papapillomatous warts also can be seen on the cervix.
59
COMPLICATIONS
Common complications of genital warts are:
• Extensive anogenital warts
• Laryngeal papilloma in the infant (passage of HPV from the mother to infant at birth)
• Squamous cell carcinoma
• Carcinoma of the cervix
Treatment of external genital warts
The primary goal of treatment of genital wart is to eliminate the symptoms caused by the visible warts. Eradication of
the virus and elimination of infectivity is difficult to achieve.
The recommended treatment regimen for external genital warts in Ethiopia is:
Patient applied:
• 1st line
• Imiquimod 5% cream to be applied directly on the warts 3 times per week for up to 16 weeks if available . The
treatment area should be washed with soap and water 6-10 hours after application.
• Alternative
• Topical application of Podophylotoxin 0.5% bid for 3 days followed by 4 days of no treatment the cycle continued
up to 4 times if available.
• Hands should be washed immediately after application.
• If the above options are not available, 10% KOH can be applied once daily till the lesion gets cleared
Provider administered:
• Trichloroacetic acid (TCA) (30-90%) weekly base, applied carefully to the warts avoiding normal tissue. TCA should be
applied to genital wart after applying vasline to surrounding normal skin.
• Podophylin resin 10-25% to be applied on the warts, avoiding normal tissue. Wash thoroughly 1-4 hours after
application. Treatment should be repeated at weekly intervals until wart resolve.
Cryotherapy : destruction of wart tissue by applying extreme cold
• liquid nitrogen is most commonly used
• Repeated weekly application is required till the lesion cleared
• Wart on the shaft of penis and vulva respond very well to cryotherapy
•Tolerable side effect with trained hand
Surgical removal
Surgical removal should be spared for:
• Lesion that doesn’t respond to medical therapy
• Extensive or giant warts
Note:
• Referral of patients with meatal or cervical warts is necessary for cryotherapy or surgical removal.
• Do not use podophylin toxin and resin during pregnancy.
SESSION FOUR: GENITAL SCABIES

Scabies is a condition of very itchy skin caused by tiny mites Sarcoptis scabiei that burrow into the skin. Sarcoptis scabiei
is transmitted by close skin to skin contact with an infested case. This includes sexual, non-sexual or social transmission
within families, at schools and with workmates. The sites commonly affected are the pubis, lower abdomen, scrotum,
vulva and perianal region. The mites may, however spread to other hairy parts of the body such as chest, armpits,
eyelashes and eye brows, but not to the scalp.
Itching is the main complaint. Erythematous papules and burrows tunneled by the female mite can be seen using a
hand lens. Some patients may be completely unaware and lice are spotted on routine clinical examination; therefore,
careful examination under a good light is necessary.
TREATMENT OF GENITAL SCABIES
Non pharmacologic
• Washing clothes in hot water or ironing clothes after normal washing.
Pharmacologic
First line
Permethrin 5%, Thin films of cream applied to all areas of body from the neck down for 8-14 hrs. then washed
off. Repeat the same dose after a week.
Alternative
Benzyl Benzoate 25%, applied to the entire body, neck to toe for 3 to 5 consecutive
evenings. Bath should be taken before the first and after the last application.
• Give 12.5% for children and 6.25% for younger children(2-8 years old)
• For < 2years old, Crotamiton10% cream bid for 10 days
Sulphur ointment : Children 5%, Adult 10%: thinly applied to the entire body for 3 consecutive nights. The
patient should wash thoroughly before each new application and 24 hours after the last treatment.
Children
• Give Benzyl Benzoate 12.5% for children and 6.25% for younger children(2-8 years old)
• For < 2years old, Crotamiton10% cream bid for 10 days
SESSION FIVE: PEDICULOSIS PUBIS

The pubic louse (Phthirus pubis) is transmitted by sexual contact and can produce itching around the pubic area. The
parasite can spread to the thighs, chest, and axilla and even to the eye lids. The diagnosis is established by clinical
examination, as the parasite is visible by the naked eyes.
TREATMENT OF PEDICULOSIS PUBIS
Treatment
Objectives
• Completely delouse the patient to prevent recurrence and transmission to fellow individuals.
Non pharmacologic
• Launder all clothes, sheets, blankets in hot water
• Iron all clothing
• Shave the pubic area
Pharmacologic
First line
Permethrin, Permethrin, thin films of 1% or 5 % cream, applied for 10 minutes then washed
• Should be applied below the neck
• Vaseline can be applied if it involve the eye brows and eyelash (suffocation method) or 5 % Permethrin cream,
applied for 10 minutes then washed.
Alternatives
Benzyl benzoate, 25% emulsion applied once.
SESSION SIX: NEONATAL HERPES
Neonatal herpes is an infection to neonates by viruses called herpes simplex. Herpes infection can be vertical from
infected mothers or horizontal from infected people after the delivery of the neonates. In vertical transmission it can be
in the womb, during labor or immediately after delivery.
Neonatal herpes can be localized or systemic and can affect different parts of the body like the skin, eye, mouth and it
can also involve central nervous systems. In disseminated infection cases, it can involve more organ systems like liver,
lungs, kidneys and the others. If it is left untreated or the treatment is delayed, it can cause grave consequences and even
death. So to avoid these grave complications, neonatal herpes must be diagnosed and treated promptly without delay.
Prevention interventions also must be applied to avoid both vertical and horizontal infections.
ETIOLOGY OF NEONATAL HERPES
The etiologies of neonatal herpes are Herpes Simplex Virus 1 and 2 (HSV1 and HSV2).
CLINICAL MANIFESTATIONS OF NEONATAL HERPES
The clinical manifestation of neonatal herpes infection varies depending on the extent of the organs involved and time
of infection. The common clinical features observed on neonates infected with herpes simplex viruses are
• Vesicular mucocutaneous skin lesions
• Fever
• Seizures
• Lethargy
• Irritability
• Bulged fontanel
• Growth retardation
• Prematurity
• Microcephalus
• Hydrocephalus
TREATMENT OF NEONATAL HERPES

Grave consequences of herpes infections to neonates must be avoided by early diagnosis and treatment. Through
maternal and neonatal history must be sought with relevant physical examinations.
The recommended drug with doses in Ethiopia to treat neonatal herpes is
For localized mucosal or dermal infections: Acyclovir 10 mg/kg IV TID for 14 days
For disseminated infections: Acyclovir 20 mg/kg IV TID for 21 days
MODULE 07
STIs SCREENING AND STIs
IN MARPs
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SESSION ONE: SCREENING OF STIs
After completing the session participants will be able to:
• Explain the role of STI screening
• List the type STI screening
• Explain the recommendation and available tool for STI screening
Introduction
A significant proportion of women and men with STIs do not have symptoms, or have minimal symptoms and do not
realize that anything is wrong. Silent asymptomatic infections can be more serious than symptomatic ones. Syphilis,
gonorrhoea, human papilloma virus infection, genital herpes and chlamydia have serious consequences, yet are often
asymptomatic .Identifying and treating such patients prevent the development of complications for the individual
patient and help reduce transmission in the community.
Table 7.2 Types of STI screening method
Type Method
Clinical screening Assessing about the presence of any of the STI syndrome
General examination including speculum and bimanual examination to look
for signs of STI not noticed by the client.
Laboratory screening Serological screening for syphilis
Heptatis B&C screening
VIA for early detection of cervical precancerous lesion
Testing and counseling for HIV.
Table 7.2 Sensitivity of STI screening method
In 100 cases,
Number that will be
Infection/condition Screening method detected Remark
Syphilis Non-treponemal serological 80–86 (primary infection) Positive test indicates a high likelihood of
screening tests 100 (secondary) syphilis infection, although not necessarily
current active disease.Patients who test positive
80 (latent infection)
should receive treatment.
71–73 (late stage)
Cervical infection • Clinical examination(Specu- 30-40 Inexpensive; misses many cases
(gonorrhoea and or lum examination) (false negatives).
chlamydia) • Gram stain
Cervical dysplasia VIA 77 Effective for early detection and
prevention of cervical precancerous lesion
a. RPR (rapid plasma reagin)

1. SYPHILIS
Syphilis in both men and women is associated with serious complications. More importantly, syphilis remains a leading
cause of perinatal mortality and morbidity in many parts of the world despite widely available and affordable technology
for diagnosing and treating infection in pregnant women. Among pregnant women in the early stages of syphilis who
are not treated, an estimated two-thirds of pregnancies end in abortion, stillbirth, or neonatal infection.
INDICATIONS AND OPPORTUNITIES FOR SCREENING
• Screening for syphilis during pregnancy should be done at the first antenatal visit, or as early as possible.
• Women who do not attend antenatal clinic should be tested at delivery. Although this will not prevent congenital
syphilis, it permits early diagnosis and treatment of newborns.
• Because of the serious complications of syphilis in pregnancy, the first priority should be to ensure universal antenatal
screening.
• Women who have had a spontaneous abortion (miscarriage) or stillbirth should also be screened for syphilis
• Men and women with STI syndromes other than genital ulcer should be screened for syphilis. However screening is
unnecessary for patients with ulcers who should be treated syndromically for both syphilis and chancroid without
testing.
Recommended screening tool
• Rapid plasma reagin (RPR) is the preferred tests for syphilis screening. RPR can be performed without microscope.
These tests detect almost all cases of early syphilis but false positives are possible.
Note: All patients who are reactive to RPR should be treated.
RECOMMENDATIONS
• Patients should receive their test results the same day before leaving the clinic.
• Patients with reactive (positive) results should be treated immediately
• All patients must be asked for a history of allergy to penicillin
• Sex partners of those found with positive results should also be treated without prior testing.
2. CERVICAL INFECTIONS
Cervical infections are much less common than vaginal infections, especially among women who use reproductive
health services, and are usually asymptomatic. The cervix is the most common site of infection for gonorrhoea and
chlamydia. Even if a woman is asymptomatic, it may be possible to detect signs of infection on careful speculum
examination. Speculum examination may also reveal signs of other infections, including cervical ulcers and genital warts.
Indications and opportunities for screening
Screening may be done:
• Any time a speculum examination is performed for other reasons;
• People with frequent exposure to STIs, such as sex workers, should be screened regularly
• For HIV positive clients in every scheduled visit
• For clients seeking FP services
Available screening tools
• Syndromic screening through history and physical examination
• Careful speculum examination may detect many (but not all) cervical infections.
Recommended approach
• Assess for any symptomatic abnormal vaginal discharge and genital ulcer
• A careful speculum examination should be done to look for signs of cervical infection. Some asymptomatic internal
ulcers and genital warts may also be detected on speculum examination.
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Table 7.3. Clinical criteria for cervical infection
Screening method Signs Management

Speculum examination • Mucopurulent discharge When any of these signs are
• detects some cases of cervical infection. (non-clear,yellowish discharge from endocer present, patient should be treated
vix). for both gonorrhoea and chlamydia.
• Friability (easy bleeding) when the cervix is Note: at least half the women
touched with a swab.
with cervicitis do not have these Signs.
Cervical infection is usually asymptomatic and women without vaginal discharge are as likely to have gonorrhea and/
or chlamydial infections. Despite lack of symptoms, consequences can be severe if infection reaches the upper genital
tract for the case of gonorrhoea or chlamydia and cervical cancer in case of HPV.
SESSION TWO: STIS MANAGEMENT IN MARPs
After completing the session, participants will be able to:
• Describe special considerations or principles when managing FSWs with STIs;
• Discuss reasons behind health care providers behavior towards FSWs and ways to improve the HCPs behavior
towards FSWs
• Describe the management of STI treatment services and the different approach including syndromic management,
asymptomatic screening
The Ethiopia HIV investment case identifies female sex workers and their clients like, long distance drivers and daily
laborers, as Most At Risk Population (MARPS) for HIV and sexually transmitted infections. According to 2013 national
MARPS survey, the HIV prevalence among FSW is 24.7% and 4.9% in truck drivers. The prevalence of syphilis is four times
higher than the general population. The reported vaginal discharge and genital ulcer in the last 12 months among the
FSWs was 11.5 % and 7.9 % respectively and 9-12% prevalence of STI among daily laborers.
Most of the health facilities which are equipped and oriented to serve the general public are not friendly to carry out
management of STIs among MARPS specially, female sex workers. As a result, Female Sex workers find it difficult to
access clinical services in public, private, NGO and faith based health facilities. Moreover, Female sex workers are often
reluctant to attend regular clinics because they are often badly treated, stigmatized or rejected. Therefore, the following
guiding principles are worth considering ensuring increased uptake and friendly HIV/STI services to female sex workers
and their clients. The services needs to be guided by the principle of four A’s, which is Accessible, Acceptable, Affordable
and Appropriate.
Accessible Services
The service delivery outlet health facilities are expected to be conveniently located (e.g. near the identified “hotspots”
and transport routes) and open at hours that are acceptable to the targeted groups. E.g. female sex workers usually work
during the night and don’t seek health services early in the morning. In addition STI prevention and control activities
should integrated with other routine health care in major developmental corridors to address laborers. Accessible
interventions limit the number of logistical barriers, thereby increasing the number of individuals seeking health services.
Acceptable Services
The health facilities should not only be accessible but also be acceptable to MARPs. The environment should be friendly
for MARPS
Some reasons for Health Care provider’s behavior towards FSWs
• Religious beliefs
• Personal principles, moral judgment
• Societal norms and values
• Fear
• Poor understanding and poor knowledge
• Inadequate skills to work with FSWs.
Health care provider code of conduct

Every individual has the need and desire for proper medical care for a variety of reasons
throughout their lives and FSWs are no different and deserve the same health care as anyone
else.
Under the current code of conduct for health providers in Ethiopia, every patient has the right to
“confidentiality” about their medical issues and anything they share with a medical practitioner
unless they are causing harm to another human being or someone is causing harm to them,
“privacy,” during any medical exams or tests and “equal treatment” without judgment for their behavior or identity.
Affordable services
The services at the health facilities need to be at affordable cost for female sex workers. A large barrier to accessing
services by female sex workers is the cost of services and transportation to and from service delivery sites. Since most
female sex workers engage in sex work due to economic needs, health facilities are advised to offer affordable service to
ensure all female sex worker have access to the HIV/STI package of services.
Appropriate Services
Health Services must be culturally appropriate and based on the needs of the local MARPS. Service providers should be
trained on the specific health needs of MARPS.
In summary, Health care providers at all service delivery points should take into consideration the following principles
which contribute to effectiveness and sustainability of HIV/STI/ interventions:
• Respect female sex workers’ human rights and accord them basic dignity (e.g. services are voluntary)
• Respect female sex workers’ and their clients views, knowledge and life experiences
• Ensure interventions do no harm
• Recognize that female sex workers’ and their clients are part of the solution, as they are usually highly motivated to
improve their health and well-being
• Include clients/partners/controllers/gatekeepers
• Adapt to the diversity of female sex workers’ and their clients settings and people involved
Service delivery outlets for female sex workers and their clients
All public, private, NGO and faith based health facilities are expect to provide MARPS/female sex workers friendly STI/HIV
services as per the guideline.
Management of STI services for Female Sex Workers and their clients
Management of FSWs and their clients attending health facilities encompasses:
• Making a diagnosis through syndromic approach or asymptomatic screening;
• Providing appropriate antimicrobial agents for the infection
• Providing education on treatment compliance;
• Providing information on the nature of the infection and the ways of preventing infection;
• Demonstrating the correct use of condoms;
• Providing condoms and emphasizing consistent condom use; counselling to improve condom-negotiating skills;
• Arranging for treatment of regular partners (whenever possible); and
• Arranging for follow-up examinations and regular attendances for medical check-ups.
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Syndrome Diagnosis and Treatment

The management of FSWs and their clients present with symptomatic STIs is the same with the general population
which is, syndromic STI management.
Special Consideration for STI Screening and Treatment
Female Sex workers should be screened for symptomatic STI syndrome and provided treatment for STIs based on
national syndromic management guidelines on regular basis(quarterly.)
Regular screening provides an opportunity to detect and treat STIs early as well as provide risk reduction counseling and
access to condoms.
Module 08
PRACTICAL CONSIDERATION
IN MANAGING STIs
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Module VIII: PRACTICAL CONSIDERATION IN MANAGING STIs

Learning Objective
• Explain the difference between education and counseling
• Explain why education and counseling are so vital in STls case management
• Recall a range of communication skills for education and counseling
• Discuss sexual practices and sexual behavior
• Identify the main education topics for patients with STls
• Identify key issues for HIV testing and counseling
• List the benefits of using condoms
• Recall the basic steps for putting on condoms and demonstrate this to a patient.
STls control programmes should aim to reduce the rate of new infections through a combination of strategies, including
behavior change, risk reduction, condom use and treatment of patients with STls. Health education and counseling for
STls are important for individuals to appreciate their own responsibilities and opportunities to reduce STls transmission.
A person who presents for STls treatment at a health institute is assumed to be receptive for education and counseling
messages. Education should cover the nature of the infection, its consequences and risk reduction to prevent both
transmission to others and acquisition of future infections.
The education process needs to be carried out effectively and appropriately to have the desired effect. If the patient is
not educated and/ or counseled about the infection, he/she is at higher risk of becoming re-infected and/or spreading
the infection to sexual partners. A person who is made aware through appropriate health education is more likely to be
cooperative and receptive of the health care provider’s advice. This module attempts to provide some insight into the
provision of health education and counseling as part of service provider day-to-day interactions with patients. Indeed,
every health care provider should be equipped with the appropriate basic knowledge of STls in order to give health
education and counseling to patients. However, counseling is a special skill that requires proper training. This module
will only provide the basic concepts of counseling and does not presume to make one a counselor.
SESSION ONE: PATIENT EDUCATION AND COUNSELING
Health education and counseling are closely linked. Both activities may take place at the same time. In health education,
the aim is to make the patient better informed, so that he/she can make an informed choice of sexual behavior and
practices. Counseling relates more to issues of anxiety and coping with the infection or its biomedical as well as social
consequences.
Health education is the provision of accurate and truthful information so that a person can become knowledgeable
about the subject and make an informed choice.
For example, a young woman with a STis needs to know how she contracted the infection in order to decide to change
her sexual practice. The service provider should inform her about STIs and their prevention.
Counseling is a two-way interaction between a client and a provider. It is an interpersonal, dynamic communication
process that involves a kind of contractual agreement between a client and a counselor who is trained to an acceptable
standard and who is bound by a code of ethics and practice. It requires empathy, genuineness and the absence of any
moral or personal judgment.
Counseling aims to encourage healthy living and requires the client to explore important personal issues and to identify
ways of living with the prevailing situation
In STls and HIV, the counseling process assesses and addresses the client’s needs to enable the person to cope with any
anxiety and stress brought about by the diagnosis. The counseling process should also evaluate the person’s risk of STls
transmission and explore preventive behavior in future. So, counseling helps clients understand themselves better as
individuals, exploring their feelings, attitudes, values and beliefs. Equipped with the right knowledge, the client should
seek to change behavior as a result of counseling.
THE IMPORTANCE OF EDUCATION AND COUNSELING

Education and counseling are important for several reasons:
• Patients are more likely to comply with treatment if they understand why it is important to do so .A person with STls
has a high likelihood of being re-infected and hence preventing re-infection requires sustained behavior change.
• Patients often need education and counseling to enable them to change behavior and adopt safer sexual practices.
Health care providers have a unique opportunity to discuss safer sex and prevention strategies with patients who have
sought health care and advice. This link between treatment and prevention is very important because:
• It reaches people when they are ready: the patient has come to you
• The patient’s initial visit is a unique opportunity for patient education. Often the only time that patients are interested
to learn about a disease or its prevention is upon hearing that they, or someone they know, are faced with that
disease
CONTENTS OF HEALTH EDUCATION FOR STI PATIENTS
The health education should include providing information on the nature of the infection, its consequences, importance
of complying with treatment regimens, how to reduce risk through condom use (including demonstrating the correct
way to use a condom and promoting condom use) and contact treatment/partner management
As with any other type of patient, people with STls need to know about their condition and its management because
the goals of patient education are to:
• Help the patient resolve any current infections
• Prevent future infections
• Make sure that sex partners are also treated and educated.
As a health care provider, you may feel uncomfortable using certain words about sexual matters. It is important to
become familiar with using these words so you can feel comfortable when you speak to and educate your patients.
Following are issues you need to address on educating patients about STls:
1. Explain the STI and its treatment
The first issue is to explain what a sexually transmitted infection is. It is important that the patient understands that the
infection is transmitted mainly through sexual intercourse with an infected person. Explain that sexually transmitted
organisms can be bacterial (e. g. the gonococcus), parasitic (e. g. trichomonas virginals or pubic lice), or viral (e. g. herpes
simplex virus or HIV). Then explain which STls the patient has and what treatment will be necessary - the name of the
medication and how much to take, how often and for how long.
2. Educate on prevention of future infection
Once you are sure that the patient understands what infection they have and what treatment to follow, he or she next
needs to appreciate the risk of becoming re-infected. This means that you assist the patient to assess his/her own risk
level.
3. THE NEED TO TREAT SEXUAL PARTNER/S
Remember; always inform patients how important it is to have all their known sex partners treated.
Reassure the patient that you will maintain confidentiality and discuss how they can persuade the partner(s) to attend
for treatment. Stress that treatment will benefit both partner/s because there will be no risk of re- infection and the
partner/s, who may not be aware of the infection, will have the STls treated and avoid future serious complications.
COUNSELLING FOR STls
Counseling helps clients understand themselves better as individuals. It explores feelings, attitudes, values and beliefs.
Equipped with the correct information and knowledge, the client should seek to change behavior as a result of
counseling. There are certain basic requirements for counseling to be acceptable. For many people, if not all, issues of a
sexual matter can be uncomfortable to discuss.
It is important to recognize that it will have taken considerable courage for someone to seek help for STls or HIV and they
may have many expectations (positive and negative) about the session or the messages that you will provide.
We need to be aware of cultural beliefs and how they influence behavior, thought and feelings. This means that the
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conditions and the environment must facilitate talking about sex. The environment must provide privacy, ensure
confidentiality and professionalism. The communication must take cultural, gender and language issues into account.
We recommend that you use simple language rather than” impressive” medical terms. There must be respect for age
and seniority within the cultural norms.
Health care providers need to develop a number of basic skills to conduct an effective and satisfying counseling session.
Counselors must be empathetic and able to communicate clearly with calm and steady control over their emotions.
They need to have good verbal and non-verbal communication skills.
TIPS FOR COUNSELING WITH ACTIVE LISTENING
It is important to:
• Have eye contact - it shows interest
• Use more of open-ended questions, they allow clients to express themselves
• Check your understanding by summarizing (paraphrasing)
• Nod and use acknowledgment sounds that convey interest and keep the conversation flowing, but avoid unnecessarily
interrupting your client
• Use a tone of voice that shows interest
• Listen to feelings as well as facts.
BASIC CONSIDERATIONS DURING COUNSELING OF PATIENTS WITH STls
Key issues that a service provider need to consider during counseling of patients with STls includes:
• Risk assessment
• Behavior that the patient should make a change
• Barriers to changing behaviors.
1. Assessing the patient’s risk level
If you have taken the patient’s history, you may already have enough information to assess the risk of re infection.
Checklist for risk assessment
Personal sexual behavior Partner(s) sexual behavior
• Number of sexual partners in the past three month. • Does the patient’s partner(s): have sex with other partners?
• Sex with a new or different partner in the last three Personal drug use
month • Use of alcohol or other drugs before and during sex.
• The exchange of sex for money, goods or drugs • Sharing needles.
Other personal risk factors Patient’s protective behavior
• Use of skin-piercing instruments such as needles • What the patient does to protect him/ herself from STls.
(Injections, tattoos), scarification or body-piercing- • Use of condoms: when and how, with whom, why.
tools, circumcision knives. • Safe sexual activities the patient might practice: when and how, with whom,
why
Helping the patient identify his/her risk factors

Once you have a clear idea of the patient’s risk level, you need to help the patient identify what risks he or she has been
taking in the past, then work together to explore options for safer sex.
Options for safer sex include:
• Abstinence from sexual intercourse: a preventive strategy that should be encouraged, especially in the young and in
couples when one partner is being treated for STls.
• Limiting sexual partners to one faithful partner.
• Using condoms consistently and correctly
Continually check for misconceptions when discussing sexual behavior with a patient. Few patients have a complete or
accurate picture of either the causes of STls or how to avoid infection, and accurate information is often mixed with local
beliefs. It is clear that a patient with inaccurate beliefs about the causes of STls may have a false sense of security and so
run an even greater risk of re-infection.
Some of the common beliefs about STls/HIV include:
• The idea that certain people, such as married women, young girls or boys or ‘clean’ partners, are usually free from
infection.
• Taking any antimicrobials before or after sex offers protection
• Urinating, washing or douching after sex protects against all STls
• Some STls like gonorrhea are acquired if one urinates facing the moon
• Some STls are acquired if one sits on a hot stone
Make sure that the patient understands that he or she became infected through unprotected sex with an infected
partner.
2. The behavior that the patient needs to change
Once the patient understands how he or she was infected and is aware of the risk of re-infection, the next steps are
perhaps the service provider’s most challenging tasks. These are the need for the client to change sexual behavior, the
barriers to such change and establishing the changes that the client intends to make.
It is a good idea to give the patient the opportunity to identify what changes might be possible in his or her own life.
Assist the client to rate the importance of changing the risky behavior and his/her confidence in succeeding.
Having asked the client to identify ways they might change and explored any barriers to doing so, you can now help the
patient to decide which change would be easiest and/or most effective - and how to put it into practice.
The change most likely to succeed is the one that fits most easily with the client’s present lifestyle and that best
overcomes any relevant barriers.
It is not quite enough simply to have the client agree and choose a particular safe behavior. We can all say we will do
something - but will we? Ask how they will put it into practice and when and what they will do if, for any reason, they
are tempted to practice risky sex.
3. Barriers to behavior change
All health care providers are aware of the difficulty of changing a person’s behavior. Life would be easy if people
responded to health messages by doing as they were advised, but many do not. Why? This is because awareness of
health messages and knowledge alone are not enough to change behavior. To make real changes, we need first to
overcome ‘barriers to change’ in our life and experience.
Barriers to behavior change include:
Gender barriers
Essentially, these can arise from the different expectations and values relating to male and female sexuality.
• Women may sometimes have little control over when, with whom, and under what circumstances they have sex.
They might therefore not be in a position to protect themselves, even if they so wish or have the means (e. g. a
condom).
• For men, the expectations can be very different, although young men in particular can be under peer and social
pressure to conform to local male norms.
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Cultural practices
Cultural practices may help or hinder the client’s ability to behavior change. Consider the possible barriers to behavior
change in relation to: age differences at marriage, wife inheritance, and puberty rites, child-rearing and so on, as well as
the values of family and community.
Religion
Religion may, under some circumstances, contribute to adoption of safer sexual behavior. However, it can pose major
barriers to change if it discourages open discussion about sexuality and use of protective measures.
Poverty, social disruption and civil unrest
These barriers force women and girls in particular (but, sometimes, boys) into exchanging sex for material favors or even
for survival. In less extreme situations, lack of access to education and employment may force women to exchange sex
with a number of partners in return for food, shelter and clothing for themselves and their children.
TECHNIQUES OF EDUACTION AND COUNSELLING
Essentially, patients and clients need to make three decisions:
• To comply with treatment,
• To change their sexual behavior
• To have their sexual partners treated.
It is not enough to simply inform a patient of all these issues and urge him or her to comply with suggestions. Many
patients may fail to comply with treatment advice, even when the advice is given clearly and accurately.
So information and advice is not enough. We need to educate each patient. In fact, education is crucial to the success
of the whole management of STls. Once the patient or client has assimilated the basic facts they will need to make
important decisions about their lifestyles. Counseling will help them make such decisions.
HELPING PATIENTS AND CLIENTS ACHIEVE A DESIRE TO CHANGE
We can achieve this in a number of ways. First, the communication skills we explored in Module 3 are important: your
use of open questions, facilitation, summarizing and checking, reassurance, direction, empathy and expression of
partnership. These are essential for asking questions and helping the patient deal with emotions.
As you begin to educate, counsel and motivate your patient to change, you will need these
Additional skills:
• Explanation and instruction
• Modeling
• Reinforcing strengths you see in the patient
• Helping the patient explore choices
• Rehearsing what the patient will do or say
• Confirming the patient’s decisions
1. INSTRUCTION AND EXPLANATION
These are skills that many service providers use most of the time.
Instruction:
Telling patients what to do or how to do something, such as use a condom or take medication:
“Remember to complete the whole course of tablets, right to the last one. ..”
Explanation:
Telling patients how or why something should be done:
“You have pain low in your tummy because of an infection passed to you during sexual intercourse ...”
Even here it may be possible to develop your skills a little more.
For example:
Are you communicating clearly and simply?
Do you adapt your pace and language to the needs of the patient?
How can you find out if you are communicating effectively? The best way is to give the patient or client time to ask
questions. If they seem anxious or confused, stop and check:
“Is what I’m saying making sense to you?”
Also, ask them to summarize what you’ve said:
“I’ve covered a lot of information and I want to be sure I’ve done so clearly. Please tell me what you need to do in your
own words. “
2. MODELLING
This skill enables you to present examples of how the recommended behavior or treatment has been successful in other
cases. In other words you are offering positive models for change.
3. REINFORCING STRENGTHS
This means pointing out a strength or positive attribute that you see in the patient - something that will help him or her
recovers or prevent the recurrence of STls.
Yohannes : “OK, like I know it’s important but... I don’t think I could get used to it at all ... “
Service provider: “It may seem difficult but I noticed you walked 10 kilometers to get here for treatment of your infection.
That means you are a very determined person. You can use this determination to keep you safe. “
4. EXPLORING CHOICES
This is about reviewing the patient’s alternatives or steps towards curing the current STls or preventing another one.
The patient can then decide which is best and feasible. Offering a choice also empowers the patient, who feels more in
control of the decision that he/she will make. The patient may have a sense of ‘ownership’ of the decision:
Service provider: “For today Amina, I’d like you to make a choice. Would you prefer to avoid sex until you have finished
the treatment or to ask your husband to use condoms?”
Amina: That’s easy: no sex for a while. that won’t be a problem because he knows I’m not feeling well. It’ll give me time
to think about things a bit. “
Service provider: “that’s a good idea.“
5. REHEARSING DECISIONS
When you feel sure that the patient has reached a decision on the appropriate safe behavior(s), it is important to ask him
or her to work through the steps to put the decision into practice. Here is an example:
Service provider: “Very good Yohannes. How are you going to explain this to your girlfriends? “
Yohannes: Well, I could start by saying there are lots of bad diseases around and that we must be careful to avoid them. “
Service provider: “That sounds good. Go on. “
Rehearsal is also useful when you want to check that the patient has understood your instructions on treatment.
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6. CONFIRMING DECISIONS
This is a useful way to conclude the interview. You have helped the patient to prepare for what he/she will do after
leaving the health facility. Asking the patient to confirm a decision helps him or her to feel motivated on leaving the
facility. Having reinforced the decision to you, he/she is much more likely to practice safer sex than before:
Service provider: “You’re being very brave, Amina and that’s important. Go over your plans with me once again. “
Amina: “Get better; take all the tablets, find time to talk to my husband about a few things. And he needs treatment
too… “
Service provider: “Yes, well done. And you will come and see me again if you need to?”
Amina: Yes. I will. “
SESSION TWO: HIV TESTING AND COUNSELING
Offering HIV testing and counseling
Testing for HIV is recommended and should be offered to all persons who seek assessment and treatment for STIs.
Encouraging patients with STI cases to receive HIV testing and counseling is an effective way to help control the further
spread of HIV. The conditions for testing must respect the client’s human rights and pay respect to confidentiality and
ethical principles.
During Provider initiated HIV testing and counseling, provide pre test information for consent and post test counseling
based on test result.
Pre-test Information
The relevant information that should be provided includes:
• The reasons why HIV testing and counseling is being recommended for STI patients.
• The clinical and prevention benefits of HIV testing
• The available services in the case of either -negative or -positive test result, including availability of ART.
• The confidentiality of result other than heath care providers directly involved in providing services to the patient.
• The right to decline the offered test and declining an HIV test will not affect the patient’s access to other medical
services.
• The right of the client to ask the health care provider any concern or questions.
Post-test counseling
All clients undergoing HIV testing should be provided with post-test counseling in person (as individual or couple): The
form of the post-test counseling session depends on the test result;
For positives, sessions will focus on
• Meaning of HIV positive result
• Coping with the test result
• Importance of medical care and treatment
• Disclosure and partner testing
• Prevention messages and positive living
• Referral and linking for care for care and treatment.
The post-test counseling session for negatives should include
• Meaning of test result. Patient should be retested after 3 month if they have STIs
• Prevention message (risk-reduction plan to remain negative).
For more information see, the national guideline for comprehensive HIV prevention, care and treatment
SESSION THREE: EDUCATING AND PROVIDING CONDOM

Condoms help people to have safer sex by preventing direct contact of the genitals with either vaginal or seminal fluids.
Using condoms is especially important if the patient has sex with more than one partner or with one partner who has
other sexual partners or with a new partner. However it is not enough to know that condoms are important. Patients
must also know how to use them properly and consistently. Many people resist the idea of using condoms, not only
because of the embarrassment or cost of buying them, but also due to misconceptions and myths about them. For
instance, they think that condoms spoil sex or that they are too big or too small. There are often myths about them -
such as the condom itself is infected with STls and HIV. People may also associate them with illicit sex - rather than for
use with a regular partner.
Condoms are an important option for any sexually active person for both pregnancy prevention and disease prevention.
In addition, they have other benefits. These are factors that can be cited in condom promotion.
DEMONSTRATING THE USE OF CONDOMS
It is important to first demonstrate its use and then ask the patient to practice the same method, helping him or her to
get it right. This means that you will need a supply of condoms and a penile model.
In your demonstration:
• Stress the importance of carrying condoms all the time - the patient should never be without one
• Show the expiry or manufacture date and explain that the condom should not be out-of-date, smelly, sticky or hard
to unroll
• Explain how to open the package carefully, using the tear-point
• Show the correct side of the condom to insert over the penis, explaining that it will not roll down if placed the other
way
• Show how to hold the tip of the condom to press out air, before rolling it all the way down the erect penis
• Emphasize that the condom must be rolled right down to its base
• Explain that the condom should be removed just as the penis begins to lose its erection and that the patient should
hold it carefully at the base and slide it off slowly
• Explain that the patient should dispose of it safely.
Certain other tips you might want to give the patient:
• The importance of not using oil or oil-based lubricants such as petroleum jelly, because they damage latex condoms
(water-based lubricants such as glycerin and K-Y Jelly are safe, as are most Spermicidal foams)
• The need to dispose of condoms hygienically
• Condoms should not be re-used.
Female Condoms
Female condoms are becoming more widely available and have the advantage for women that their use is more in
their control than use of male condoms. One type of female condom is currently in the market, under various names. It
is made of polyurethane plastic, which is sturdier than latex. Only one size is made and fitting by a health care provider
is not required. Unlike male latex condoms which are weakened by oiled based lubricants the female condom may be
used with any type of lubricant without its strength being affected. It is pre-lubricated but users may add more lubricant.
Famale condoms offer a similar level of protection as male condoms, but they are more expensive.
Do exercise 8.1 on page 98 to explore useful skills during counseling of patient with STI
MODULE 09
PARTNER/S MANAGEMENT
MODULE IX PARTNER/S) MANAGEMENT

Learning Objective:
By the end of this session, participants will be able to:
• Explain why partner management is such an important part of STI case management
• Describe its possible impact on the individuals concerned
• Distinguish two possible approaches to contacting partners
• List the issues to discuss with the index patient
• Review the educational and motivational skills needed when educating STI patients on the need to treat partners
• Treat patient’s partners.
SESSION ONE: APPROACHES TO PARTNER MANAGEMENT
Treatment of all the patient’s sexual partners for the same STls as the patient, and treating any new STls identified are the
main features of partner management. As the management is syndromic, the treatment must be given presumptively
and the partner treated even if there are no symptoms or signs of STls. Identifying the source have no particular value
because the aim is to treat all partners or all those partners we can reach - and their partners in turn. When taking
patients’ history and educating and counseling them, you know the importance of showing respect, responding to
emotions and helping patients to overcome barriers and change behavior. Awareness of having STls can affect a patient’s
relationships, lifestyle - even his/her income, as we have discussed in earlier modules. In this final stage of the interview,
we must explain to the patient that his or her partners also need to be treated. For many patients this is
Uncomfortable news. Indeed, it might cause far-reaching damage to the individuals concerned.
If the purpose of partner(s) management is to treat as many of the patient’s sexual partners as possible,
There are two approaches to contacting sexual partners:
• By the patient: this is known as patient referral or passive contact tracing
• By service provider: this is known as provider referral or active contact tracing.
Passive contact tracing (also known as patient referral)
In passive contact tracing it is the patient who takes responsibility for contacting partners and asking them to come
for treatment. An infected patient is encouraged to notify partner(s) of their possible infection without the direct
involvement of health care providers. The patient referral system is the most commonly used method because of its low
cost and practicability. News of STI can be especially damaging when a patient or partner hears of their partner’s for the
first time. Such events might lead to marital breakdown, divorce, verbal or physical abuse, loss of home or livelihood, or
even ostracism from the social group. Because of these and other reasons, many patients might feel unwilling or unable
to discuss STI with partners, so the service provider’s aim is to help the patient decide what to do. An index patient might
approach partner/s in several ways:
ΞΞ By directly explaining about the STI infection and the need for treatment;
ΞΞ By accompanying a partner to the health facility ;
ΞΞ By giving each partner a notification card asking him or her to attend the centre.
The success of patient referral is absolutely dependent on index patient and partner motivation and the quality and
appropriateness of counseling received by the index patient. Moreover, its success depends on the skills of the service
provider: what you say to the patient, how you say it and, equally important, how you listen to the patient and respond
to what he or she says. The service provider needs to:
ΞΞ Explain that all the patient’s partners need to be treated so that the patient is not reinfected and his/her partners
don’t suffer the consequences of untreated STIs
ΞΞ Remind the patient how to avoid re-infection
ΞΞ Help the patient learn how to communicate with partners
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Active contact tracing (also known as provider referral)

This is where a member of the health team contacts the partners of a patient with STI. Provider referral can be perceived
as a threat to patient confidentiality if the patient is not informed in advance that this might occur.
Provider referral is resource intensive, since it requires trained personnel with dedicated time to pursue partner
notification activities.
If the index case is volunteer and agreed ,it is highly advisable to devise mechanism with health extension workers and
the index case on how to bring the partner/s to health facility.
SESSION TWO: PATIENT REFERRAL CARDS
A referral card is useful to help identify the necessary treatment for any partner referred by a patient with STls. A service
provider cannot treat a patient’s partner unless he/she knows who the patient was or can identify the partner’s syndrome.
Patient referral cards can help to resolve this problem and many health facilities use them for this purpose. The card can
contain any extra information that is required, but should never threaten anyone’s confidentiality or risk them being
stigmatized.
A referral card could be extremely useful to help identify the necessary treatment for any partner referred by a patient
with STls. The card can contain any extra information that is required, but should never threaten anyone’s confidentiality
or risk them being stigmatized. If the centre uses patient referral cards, it is strongly advised that the health worker
should giving one or more to every patient with a STls syndrome. It is much easier to do this than it is to remember to
ask if a new patient has been referred to you by someone else.
The following is an example of a patient referral model card
Name of the Facility(put the initials)

Index case card No.:
Room No:
Appointment date:
If you are not able to come on this day,

Please come as soon as you can.
Coming on appointed time is always best
FRONT
Dx:
UD GUD VD LAP IB SS NC
Dear Colleague,
Please provide services based on the national guidelines to the
Person who comes with this card.
Date: Signature:
Name of provider: (put the initials)
BACK
SESSION THREE: MANAGING PARTNERS

We deal with the partners of patients in exactly the same way as with the original or ‘index’ patient: taking their history,
treating and educating them and managing their partners, in turn.
Partner management
INDEX PATINT TREATMENT OF PARTNER
Urethral discharge Treat for gonorrhea & Chlamydia
Vaginal discharge with risk assessment positve (cervicitis) Treat for gonorrhea Chlamydia
Vaginal discharge with risk assessment negative ( vaginitis) No partner treatment needed
PID Treat for gonorrhea & Chlamydia
Scrotal swelling Treat for gonorrhea & Chlamydia
Inguinal bibo Treat for LGV, Chancroid and GI
Neonatal conjunctivtis Treat for LGV and Chlamydia
Genital uncer Treat for syphilis & Chancroid
NB: Any additional STI diagnosed on the partner/s should be also treated
Treatment for HSV is not necessary for asymptomatic partner/s
MODULE 10
STIs PROGRAM MANAGEMENT
MODULE X STIs PROGRAM MANAGEMENT

SESSION ONE: PROGRAM MANAGEMENT AND COORDINATION IN STIS
By the end of this session the health provider should be able to:
• To discuss STI program implementation in the country
• To describe the essential components of STIs program
• Provide integrated comprehensive syndromic STIs management .
• To describe the STIs drugs supply chain management channel .
• Describe pre-packed STIs KIT components and effectively utilize it.
A Program is defined as a group of related projects managed in a coordinated way to obtain benefits and control not
available from managing them individually.
Program management is thus the centralized management of a program to achieve the program’s strategic benefits
and objectives.
Essential components of STIs program
• Clinical care (service delivery points)
• Advocacy and social mobilization
• Leadership and coordination
• Procurement and supply management
• STI surveillance
• Monitoring and Evaluation
Clinical care
The Standard mode of STI clinical care service in Ethiopia is Syndromic management. All health centers, hospitals, private
clinics are expected to implement syndromic management modality at all levels. As the main reason for adopting
Syndromic management is not skill gradient across different levels of health professionals, all health cadres are expected
to practice syndromic management as per the national guideline. STI service should be integrated with the routine care.
All service delivery points should be equipped with trained staff, job aids and necessary equipments for effective service
integration.
Components of Quality STIs Service Delivery
• STI service should be integrated with the routine care. All health facilities are expected to offer STI services in their
major OPDs like adult OPD, Obstetrics and Gynecology OPD, ART clinic, ANC, FP, Neonatology/Immunization units.
• Identified health care facility should provide defined package of services for prevention and management of STI. This
standard seeks to ensure that all components of an evidence based package of services are delivered at the facilities
according to level of care.
• Identified health facilities should deliver quality services: All the essential ingredients leading to provision of STI
services should be in place in order to deliver services as per national guidelines.
• The facilities should have a friendly environment for those seeking STI services: The attitudes, behaviors and practices
of health care staff have a significant impact on the health seeking behavior of their clients. The perceived value
of client-provider interactions, privacy, confidentiality and non-judgmental attitudes are key attributes for effective
service utilization. Service providers should always be sensitive to the needs of STI clients.
• The community should be fully informed about causation, transmission, and prevention of STI and presence of
STI services: There is frequently a culture of silence about STIs. Women, especially adolescent girls, hesitate to talk
about these diseases and also delay seeking treatment. Prevailing gender inequities also impact treatment-seeking
behaviors. There is a lack of knowledge about causes, routes or modes of transmission and prevention. Service
providers should therefore ensure effective communication programs for improved treatment seeking behavior and
also for risk perception and reduction.
• Focused behavior change communication (BCC) programs should target specific population groups to enhance
health seeking behaviors. In addition, effective use should be made of mass communication and HDA for the
awareness and availability of quality STI services. This should be combined with condom promotion and should be
part of STIs/HIV/AIDS awareness campaigns. Periodic support and supervision of STI service providers helps to ensure
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the quality of services, recording and reporting. Strengthening support and supervisory systems is thus a key element
of quality service delivery
Leadership and Coordination of STIs activities
Program coordination of STI is similar to the program coordination in other programs in the health system. It will follow
the same structure put in place by the national health strategy for other components of the health system.
Primary level facilities are accountable to woreda health offices. Woreda health offices are responsible to oversee the
overall STI prevention and treatment activities in health centers. Program management at private facilities shall be
performed according to the structure put in place for monitoring and evaluation of private facilities in the respective
regions. Recording and reporting of STI prevention and treatment activities in primary level facilities is towards woreda
health offices like other programs. Woreda health offices will report to RHBs and RHBs to FMOH. Woreda health offices
are expected to examine routine reports and reports from integrated supportive supervision (ISS) to identify best
practices and possible challenges. This will help program managers to design appropriate strategies for improving the
STI prevention and control within the district. Woreda health offices are also expected to work with partners and RHB to
continuously support capacity building of health professionals working on the STI program.
Hospitals are under the direct supervision by regional health bureau in most regions. Hospitals shall report STI prevention
and treatment activity report to the RHB through on quarterly bases. Besides all the possible challenges regarding STI
service delivery are expected to be communicated with RHB primarily. On the other hand RHB should look out the
services in hospitals via integrated supportive supervision as per the recommendation for other programs in the health
system. In addition to supervising hospitals directly, RHB is also expected to overlook the overall program coordination,
guideline availability, quality of cadre of the program in all districts and make corrective actions timely.
The FMOH is responsible to lead the national STI program. This includes, revision technical guidelines timely, designing/
strengthening the national STI surveillance system in close collaboration with EPHI, Support PFSA through quantification
and procurement of STI drugs. The FMOH is the only responsible body to publish national status report to represent the
country in international reports like other programs. Thus it is imperative that facilities follow the existing structures in
the health system to report their activities so that FMOH will have realistic representation of the national status. FMOH
will also make an overall assessment of training needs and facilitate National TOTs to help regions to have sufficient pool
of trainers to cascade meaningful capacity building activities.
Procurement and distribution of STIs drugs and supplies
STI logistics and Supply Chain Management is one of the critical components for the successful implementation of STI
program. Procurement and distribution of drugs, reagents and supplies including STI drugs is the primary responsibility
of PFSA. However, FMOH uses the national facility level reports and other studies to estimate disease burden and hence
help PFSA make a realistic quantification drug demand. Also PFSA uses its hubs in the respective regions to distribute
drugs and supplies along with drugs for other programs. Woreda health offices and RHBs can directly communicate
with issues related to drugs with PFSA.
Advocacy and Social mobilization
FMOH and RHBs are expected to coordinate advocacy for STI prevention and treatment through the use various health
educations tools. This includes preparing posters, IEC materials using mass media. The national technical working group
on STI can guide the content, focus, and variety of such communication materials.
District health offices shall coordinate community mobilization for the prevention of STI. This will be implemented
through the use of simple but basic guidelines tailored for use by HEW and HDA. Job aids for use by HEW and HDA can
be prepared by FMOH/RHB in collaboration with partners.
STIs Surveillance
EPHI in collaboration with FMOH will lead conduct regular drug sensitivity etiologic surveys to guide the syndromic
management modality. Moreover operational research regarding STI will also be conducted by EPHI in close collaboration
with FMOH and other partners.
SESSION TWO: STIs LOGISTICS AND SUPPLY CHAIN MANAGEMENT

Definition
Supply Chain is linkages of organizations, people, procedures and systems involved in getting products to customers.
It can also be defined as the management of the entire set of business processes that produces and delivers products/
services to the final customer. (World Bank)
Rationale
STI logistics and Supply Chain Management is one of the critical components for the successful implementation of STI
program. National STI Supply Chain Management shall include proper selection, quantification, procurement, storage,
distribution, rational use and reporting system for STI drugs and other related essential medical supplies. Availability of
STI medicines and medical supplies should be ensured at all levels including public, private and NGO service delivery
points.
Selection
General selection criteria of STI medicines and medical supplies include:
• National Guideline for STI Treatment
• STI screening protocol
• National Medicines Formulary
• Safety and efficacy
• Cost and Affordability
• Product availability
• Route of administration
Quantification and Forecasting
The quantification and forecasting of STI drugs and related medical supplies at national level shall be based on the
following assumptions:
• Consumption data/report of STI medicines and medical supplies from health facilities
• HMIS Data
• National STI case surveillance data
• EDHS data
• National MARPs survey and other surveillances data
Based on the above assumptions, Procurement Logistics and Management Unit (PLMU) of FMoH, PFSA and Partners
shall forecast STI medicines and medical supplies and submit annual requirements, based on the forecast result, to PFSA
so that procurement can be executed accordingly.
Procurement
PFSA and PLMU of FMoH shall work with partners to ensure coordinated annual procurement of STI medicines and
medical supplies based on the national forecast. Procurement coordination is required to avoid duplication of effort
and resource wastage. STI medicines and medical supplies shall be sourced from a licensed supplier to ensure the
requirements of safety, quality and efficacy are upheld and to avoid the risk of counterfeit and substandard products
entering the supply chain.
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Kiting of STIs medicines

STI management through pre packed treatment kits has been an approach to strengthen the syndromic approach of STI
treatment. In addition to the recommended drugs for the specific syndrome, the package comprises condoms, partner
referral card, information sheet on adherence and illustrative pictures. Currently, three types of Pre Packed STI treatment
kits (PPST), namely AddisCure, AddisCure Plus and Ulcure are in use in Ethiopia for the treatment of urethral discharge,
vaginal discharge and genital ulcer syndromes, respectively.
Kitting eases prescription, dispensing, storage, distribution and uses of STI medicines. Kitting of STI medicines shall be
done as per the repacking guidelines in Ethiopia. This will encompass appropriate premise, professionals, products and
practice.
Others STIs related Medical Supplies/equipments and Materials
Besides the required drugs for STI management, the system also needs to respond to job aids need of health facilities
to ensure provision of quality STI treatment services. Among the most important job aids required to support the STI
program need includes;
• Examination couch
• speculum
• Bed side lamp/torch
• Penile model
• National guideline
• STI treatment algorithm wall chart
• Flip chart
• Sample STI drug kit for counseling
• VDRL/RPR kit
• Condom supply for the promotion of correct and consistent condom use
• Emergency kit for treatment of anaphylaxis.
• Consumable items including disinfectant (e.g., dettol or jik), water for injection, syringes and needles, bucket, gloves
and cotton wool.
Distribution and storage
Distribution of STI medicines and medical supplies to health facilities will be integrated with other pharmaceuticals and
be managed by Integrated Pharmaceutical Logistics System (IPLS). Hospitals, health centers and clinics will quantify their
need every two months and submit to PFSA hubs using a combined order and consumption report form, named Report
and Requisition Form (RRF), for resupply of the STI medicines and medical supplies. A copy of consumption report from
health facilities is shared with Woreda Health Office (WoHO) and Regional Health Bureau (RHB). In addition to receiving
and compiling reports and orders of health facilities, WoHOs and RHBs should supervise health facilities on quarterly
bases to provide technical support and ensure appropriate stock management, ordering and reporting functions.
Many of STI patients will go to private health facilities for STI diagnosis and treatment. Hence, social marketing of pre
packed STI kits shall be available at the private retail outlets which are closely working with private health facilities/clinics.
PFSA will be responsible to kit and distribute STI medicines to private health facilities and pharmacies.
Stock rotation shall be done on the “FIRST EXPIRY- FIRST OUT” (FEFO) basis. Every product in the storage room shall be
stored according to the manufacturer label or recommendation.
Rational use of STIs medicines
The Drugs and Therapeutics Committee (DTC) at various levels shall be working in supervising, monitoring and STI
medicines use evaluation at facility level to ensure rational use. Regular continuing in-service education or training
for doctors, pharmacists, druggists and nurses both at private and government dispensaries and health facilities are
mandatory for the effective implementation of STI program.
List of essential medicines for STI management
Table 1: List of STI Medicines
STI Syndrome Preferred STI medicines Alternative STI medicines

Urethral discharge in men • Ceftriaxone • Cefoxitin
• Azithromycin • Doxycycline
• Metronidazole (capsule or tablet) • Erythromycin
• Spectinomycin
• Tetracycline
• Tinidazole
Vaginal discharge • Ceftriaxone • Doxycycline
(with or without STI risk) • Azithromycin • Cefoxitin
• Metronidazole • Erythromycin
• Clotrimazole • Fluconazole
• Spectinomycin
• Tinidazole
Genital Ulcer • Benz Penicillin • Erythromycin
• Acyclovir • Doxycycline
• Ciprofloxacin • Azithromycin
• Ceftriaxone
Scrotal swelling • Ceftriaxone • Cefoxitin
• Azithromycin • Erythromycin
• Spectinomycin
• Tetracycline
• Doxycycline
PID with or without sever presentation • Ceftriaxone • Spectinomycin
• Azithromycin • Cefoxitin
• Metronidazole • Chloramphenicol
• Tetracycline
• Tinidazole
• Doxycycline
Inguinal bubo • Ciprofloxacin • Erythromycin
• Doxycycline • Tetracycline
Neonatal conjunctivitis • Ceftriaxone • Spectinomycin
• Erythromycin
Capacity building on STI Drugs and medical supplies Supply Chain Management
Supply chain management of STI drugs and related supplies has to be strengthened by building the capacity of health
care workers at national, regional and facility level. Hence, heath managers and health care workers at all levels require
SCM training. The training shall include STI drugs and related supplies quantification, distribution, storage, rational uses
and consumption reporting and report flow.
The Objective of capacity building on SCM is to
• Create, enhance and promote uninterrupted supply of high-quality, low cost STI drugs and medical supplies that
flow through an accountable system.
• Develop capacity of health care workers for sustainable procurement, consumption reporting, distribution and
storage.
• Plan for STI drugs and supplies resource needs.
• Ensure rational use of STI drugs which includes good prescribing and dispensing practice, proper counseling of STI
drugs use and adherence
• Linking of patient to HF who requested for over the counter treatment not evaluated by clinicians
MODULE 11
MONITORING AND EVALUATION OF
STIs PROGRAM
MODULE XI: MONITORING AND EVALUATION OF STIs PROGRAM

Module Objectives:
By the end of this session the health provider should be able to:
• Describe benefit of monitoring and evaluation
• Record and report STIs syndromes
• Utilize STI data for program improvement
• Regularly monitor STI program
Introduction
Monitoring and evaluation are critical to the success of any program. Any program needs to have a defined goal and
objectives in order to design an efficient monitoring and evaluation system. The purpose of monitoring is to ensure that
work is progressing as planned and to anticipate or detect problems in implementation. Monitoring provides managers
with information about the level of achievement measured according to standards of performance, and allows them
to assess implementation by comparing actual progress to expenditure. Monitoring focuses on implementation
(adequate supplies, appropriate training, and performance of service providers) rather than on immediate outcomes
(such as changes in knowledge or behavior, changes in the health system) or impact (such as decrease in morbidity or
improvement in health).
SESSION ONE: MONITORING
Program monitoring can be made through periodic supportive supervision, regular review meetings, through analysis
various administrative reports and STI surveillance.
Supportive supervision and Review meeting
Supervision is a two-way process by which the supervisor observes and keeps in touch with the events, which enables
the service provider to give feedback, discuss and be reassured and supported. Supervision is the most important aspect
of monitoring in that it assesses performance and outputs in the light of the situation and the resources available.
Effective supervision narrows the margin between what exists and what potentially can be achieved on the basis of the
needs of the individual facilities and service providers.
STI program implementation should be well address and integrated with HIV and reproductive health program during
supportive supervision and review meeting at all level and feedbacks should be given to further strengthen the program
SESSION TWO: SURVEILLANCE OF SEXUALLY TRANSMITTED INFECTIONS
The five components of STI surveillance that are necessary for effective control programs are the following:
• Case reporting
• Prevalence assessment and monitoring
• Assessment of STI syndrome etiologies
• Antimicrobial resistance monitoring
• Special studies
1. CASE REPORTING
Case reporting has several purposes and uses:
• Assess disease burden
• Monitor trends in incidence
• Provide information required for management of patients and their sex partners
• Reporting the major STIs, to assist in planning and managing program efforts
The case definition for syndromic case reporting is as follows:
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STIs syndromomes case definitions
Genital ulcer syndrome - non-vesicular

Ulcer on penis, scrotum in men and on labia, vagina, or anal in women, with or without inguinal adenopathy.
Genital ulcer syndrome - vesicular
Vesicles on penis, scrotum in men and on labia, vagina, or anal in women .
Urethral discharge syndrome
Urethral discharge in men with or without dysuria.
Vaginal discharge syndrome
Abnormal vaginal discharge (indicated by amount, color and odor) with or without lower abdominal pain or specific symptoms or
specific risk factors
Lower abdominal pain in women
Symptoms of lower abdominal pain and pain during sexual intercourse with examination showing
Vaginal discharge, lower abdominal tenderness on palpation, or temperature >38 C.
Inguinal and femoral buboes
Localized enlargements of the lymph nodes in the groin area, which are painful and may be fluctuant.
Ophthalmianeonatorum
Conjunctivitis in a new-born who has not received ocular prophylaxis, occurring within one month after birth.
Scrotal swelling
Inflammation of the epididymis (epididymitis) usually manifests itself by acute onset of unilateral testicular pain and swelling, often
with tenderness of the epididymis and vas deferens, and occasionally with erythema and edema of the overlying skin.
NB:
• Only urethral discharge and genital ulcer disease (non-vesicular) are potentially useful for monitoring trends in STI
incidence. These syndromes usually represent recently acquired sexually transmitted infections. In contrast, usually
a high proportion of vaginal discharge cases are not caused by STIs, nor are a substantial proportion of cases of
lower abdominal pain in women, or of clinically apparent cervicitis. Vesicular ulcers, an indication of genital HSV
infection, are usually a recurrence of a herpes infection that was acquired years before. Many cases of genital warts
also represent a symptomatic recurrence of a persistent infection.
• Use of syndromic reports provides a poor assessment of disease burden and trends in women compared with
men. This is because a high proportion of STI infections in women cause no symptoms. In women , STI prevalence
assessment and monitoring are essential, even in resource-poor settings These syndromes are not pathogen-specific.
Studies of syndrome etiology also must be periodically performed to guide therapy.
• It will only be possible to use case reports of STI syndromes (i.e. genital ulcer disease and urethral discharge) for
monitoring trends in incidence when the structure and functioning of health services are stable and when reporting
practices are consistent over time. Proper recording and reporting is the cornerstone for effective case reporting.
Proper recording helps:
• To record and review overall progress of the program
• To celebrate the achievements as well as make plans for sustaining high performance or improving low performance.
The information collected should be analyzed and utilized to make decisions at the point of collection of information
and at higher levels.
Note:
You should be the first user of your data. So, use data at the local level to track progress and making improvements. Do not wait for
feedback from others.
Data elements
Core data elements that are essential to reporting a case should routinely be collected on registers and reporting forms.
Additional data elements may be collected at some sites, which can provide more detail on patient demographics, risk
characteristics and treatment. The selection of additional data elements will depend on the specific purposes for which
the data will be used.
The core data elements essential for case reporting are:
• Reporting period (MM/YY)
• SNO.
• Diagnosis
• Reporting site
• Sex
• Age group
The National HMIS includes theses key variables in the reporting (see below)
Reporting formats
For case reporting, hand-tabulated aggregate reports are used to transfer data from OPD register into HMIS reporting
format. Most HMIS data are generated at facilities. Facilities check and review data, then forward it to their designated
administrative office. The administrative office aggregates the data it receives, adds its own administrative data, monitors
its own performance based on these reported and self-generated data, and forwards the HMIS report to the next level
through e-mail, CD or Flash disk.
The administrative level that receives data from facilities aggregates the data by facility type and ownership. This
aggregation methodology is maintained throughout the reporting chain so that even at the federal level it is possible to
disaggregate data by facility type and ownership.
91
Comprehensive International Bodies

FMOH
Specialized Hospital WHO, UN, etc
Specialtv Center Council of Ministers

RHB ZHD Other Ministers
Development Partners
General Hospital
Regional Council
Primary Hospital
Specialty Clinic
Sub-city/ woreda/
town health offices
Medium Clinic
Primary Clinic Woreda Council
Health Center
Kebele Council
Health Post
Routine Supervisory (fixed) Channel- monthly/ quarterly /annual

priority epdemic alert (fixed) Channel- Immediate/ Weekly
Partnership(Variable) Channel - monthly/ quarterly /annual

(illustrative destinations -report destinations may be added orreduced)
A standardized reporting form is used by all public and private facilities in the country (See the national recording and
reporting form Annexed )
Data quality
The three critical components of data quality are completeness (the proportion of reported cases with complete
information), validity (among reported cases, the proportion of each data element that is reported correctly), and
timeliness (the time intervals between the steps in surveillance).These minimum criteria should always guide activities
related to monitoring data quality. Supportive supervision by woreda health offices, RHBs and MOH, periodic examination
of reporting formats at all levels and routine examination of recording and reporting forms the facilities are some of the
techniques used for monitoring data quality. The HMIS focal person and performance monitoring team at all levels are
responsible for monitoring data quality
Confidentiality
Patient privacy and data integrity must be maintained. Patient data should only be disclosed to individuals authorized
to conduct public health surveillance or other special surveys.
Analysis and interpretation of case reports

STIs case data should be analyzed at quarterly and annual intervals.
Quarterly/annual analysis will consist of the following:
• Comparison of the most recent quarterly number of case reports with the same quarter during the previous year.
• Examination of quarterly/annual trends in the number of reported cases and prevalence for the past 1-2 years, overall,
by the following categories:
ΞΞ regions/districts
ΞΞ sex
ΞΞ age group
ΞΞ provider type (e.g., OPD, family planning, ANC, ART)
ΞΞ reporting site
2. PREVALENCE ASSESSMENT AND MONITORING
A second major component of STI surveillance is prevalence assessment and monitoring. The primary purposes of STI
prevalence assessment and monitoring are the following:
• Identify population subgroups with high prevalence of STIs
• Monitor trends in STI prevalence among defined populations. Prevalence data are of great use in STI program
planning, management, and evaluation because they can be used to:
ΞΞ Identify population subgroups at high risk for STI/HIV infection
ΞΞ Guide funding and resource allocation for STI and HIV prevention programs
ΞΞ Monitor effectiveness of STI and HIV prevention programs
ΞΞ Develop national estimates of STIs
3. ASSESSMENT OF SYNDROME ETIOLOGIES
The primary purposes of assessing syndrome etiologies are to:
• Provide data for guiding STI syndromic management
• Assist in the interpretation of syndromic case reports, and the assessment of disease burden due to specific pathogens.
These data also may be used to evaluate syndromic management algorithms for urethral discharge and genital ulcers.
Assessment of syndrome etiologies should be performed every three years.
4. MONITORING ANTIMICROBIAL RESISTANCE
In view of the substantial use of drugs for treatment of gonococcal infections and increasing rates of resistance world-
wide, it is important to monitor antimicrobial resistance in Neisseria gonorrhea as a core component of STI surveillance.
.Appropriate therapy of gonococcal infection is necessary to achieve microbiologic cure, relieve signs and symptoms
of infection, prevent complications (which include pelvic inflammatory disease, chronic pelvic pain, and infertility in
women),and interrupt transmission.
The principal objective of monitoring antimicrobial resistance in N. gonorrhoeae is to obtain data necessary for
developing guidelines for treatment. A second objective is to detect newly emerging resistance.
Demographic and risk information obtained through a sentinel system for monitoring antimicrobial resistance in N.
gonorrhoeae may also be used to further characterize risk factors for resistance and the local epidemiology of this
disease.
Antimicrobial resistance should be performed at least every 3-5 years.
93
5. SPECIAL STUDIES AS A COMPONENT OF STI SURVEILLANCE

Periodically, public health personnel or university collaborators may perform special studies to address important STI
surveillance issues that are not part of routine case reporting or prevalence assessments. Surveillance-related studies
that have been found to be useful are listed below.
• Assessment of health care-seeking behavior and its relationship to under detection and underreporting of STIs
• Assessment of partner notification rate and factor that affect notification
• Rapid assessment of STI prevalence in defined populations using new diagnostic tests (e.g. urine PCR and ligase chain
reaction (LCR) tests for chlamydia and gonorrhea; PCR testing of genital ulcer specimens for chancroid, syphilis, and
herpes)
• National probability sample survey of STI prevalence using serologic tests for syphilis (and other STIs) and urine tests
for chlamydia and gonorrhea.
• Assessment of antimicrobial resistance in Haemophilus ducreyi
• Incidence and prevalence of STI-related complications(PID, Ectopic pregnancy, Cervical cancer)
• Prevalence of viral STIs (e.g., HSV-2, human papillomavirus [HPV], and hepatitis viruses)
• Assessment of STI incidence and prevalence among persons who are HIV-positive
SESSION THREE: EVALUATION
The purpose of evaluation is to assess progress towards the programme objectives at any given point in time. It
assembles information from surveillance, monitoring and supervision to determine whether planned outcomes are
being achieved. The evaluation process will include epidemiological surveillance (trends, prevalence and incidence) in
order to estimate the degree of achievement of the STI prevention and control program.
Do exercise 11.1 on page 99 to exercise STIs data recording and reporting

ANNEXS
95
Annexs:1
Exercise 3.2
Skills practice (50 minutes)
Explain to participants to do role play exercise 3.2
Purpose practice communication skills for interviewing patients, so that trainees can interview real STI patients with
more confidence
practice gathering the relevant information listed on page …
Time 50 minutes
Activities The idea is that one person takes the part of an STI patient, while a second person plays the role of
service provider. A third person
observes the interaction and provides feedback to the service provider. You can rotate the roles, so
that each of you has the opportunity to take on all three roles.
The patient’s role
Your role is to take the part of a patient with STI who has attended the health facility for treatment.
Please decide who you are and
what your character is. The questions below may help you. Do not let your interviewer see your notes in
advance. Make your role-play
patient as realistic as you can: try to BE this person, responding honestly to the person interviewing you.
Do not try to make it easy or difficult for your interviewer.
• What is your name?
• Your sex and age?
• Describe your personality: outgoing or shy, and so on.
• Describe your beliefs, religion, education and occupation.
• What STI symptoms do you have? Anything else?
• How many sexual partners do you have?
• If you have just one sexual partner, do you know whether he/she has any other sexual partners?
• How do you feel about the health facility you are visiting?
• How do you feel about your symptoms, and about discussing them with someone else?
After the role-play, give your interviewer feedback on how well he or she has done:
• Concentrate especially on how you FELT as the patient: did the interviewer make you feel comfortable or put you at
ease? How did he or she do this?
• Did you say what you wanted to say? Has the service provider found out all the informationyou noted down?
• What questioning techniques did you respond to positively and which ones seemed negative? If some seemed nega-
tive, why?
The observer
The observer’s role is a very important one because you are going to give the ‘interviewer’ objective feedback on the
skills they have demonstrated during the role-play. As you observe, use the checklist below to make notes on what the
interviewer does.
In giving feedback to the interviewer, try to be as objective and helpful as you can. Be clear about what he or she has
done well and explain why. Also, be willing to criticize the interviewer, but in a positive way – in terms of what he or she
needs to practice or refine.
Observation checklist
Does the interviewer:
Treat the patient with respect?
Show he/she is listening by using appropriate non-verbal behaviour?
Obtain the patient’s permission to ask awkward, embarrassing questions?
Deal effectively with the patient’s emotions?
Use mainly open questions, limiting the number of closed questions?
Use these six verbal skills effectively?
• Facilitation
• Direction
• Summarizing and checking
• Empathy
• Reassurance
• Partnership.
Ask questions relating to the four areas of information required?
• General details
• Present illness
• Medical history
• Sexual history.
The service provider
The role-play should last about five minutes. During the exercise, try to use all the verbal and non-verbal skills explored in
the module, while remaining aware of the patient’s feelings and responding to these emotions. Try also to obtain as much
appropriate information about the patient as you can in the time available.
While the ‘patient’ is defining who he/she is, you might want to look over the observer’s checklist to see the sort of skills
you are expected to practice.
During the interview, you might find it helpful to refer to the module to remind you of the information
you need.
After the interview, you will receive feedback from the patient and then from the observer. The observer will concentrate
on your skills as listed on his or her checklist, while the patient will describe how he/she felt during the interview. He/she
will also tell you if you missed anything important about him/her.
97
Annexs:2
Case study 4.1
Exercise 4.1: Small group discussion on case studies
Purpose To help participants practice diagnosis and treatment of STI using flow-charts.
Materials Flip chart and Markers
Time 60 minutes
Activities Divide participants into three small groups (6-8 groups if possible) and instruct them to work on case studies.
For each case history, the group need to decide what flow-chart they use, how to take history, examine and treat the
patient.
Group I:
a) Mesfin is an adolescent boy of 15 years who lives in the slum area of a large town. He has been brought to the district
hospital because his scrotum is swollen and he is vomiting. What flow-chart do you use?
On examination, the scrotum is swollen and painful; the testes elevated and rotated. How do you manage this patient?
b) Gete took her four-day old baby to the clinic when she noticed that his right eye was swollen and there was pus in both
eyes (the right eye more than the left). What flow-chart do you use? What treatment do you offer, to whom?
c) Derartu, aged 22, attended the family planning clinic for her usual check-up while on the contraceptive pill. She tells the
nurse about a yellow, itchy vaginal discharge that she has had for the past four days. What flow-chart do you use?
Derartu says she has no abdominal pain or dysuria. She had her period two weeks ago and it was normal. Shyly, she
discloses that she had sex with an old school friend a week ago, and that she did not use a condom because she was on
the pill. She last had sex with her regular boyfriend a month ago, as he was out of town. For what do you treat Derartu?
Group II:
a) An 38 year old long distance truck driver named Markos attends your clinic complaining that he had a discharge
yesterday. What flow-chart do you use?
On examination, you didn’t find discharge upon milking the urethra, even 2hrs after urination. However you do find
solitary, non-vesicular ulcer on his penis. What do you do now? For what do you treat this patient?
b) 24 year-old HIV positive Almaz states that she began seeing Daniel, her new partner, three months ago. She is now
experiencing a dull persistent abdominal pain, which she thinks has been brought on by her excessive sexual activity with
Daniel. What flow-chart do you use?
Almaz tells you that her periods are normal and she has never been pregnant. She thought that there might be some
increase in what she considers to be normal vaginal discharge. On examination, she has no rebound tenderness or
guarding, but clearly feels pain when you palpate the lower abdomen.
What treatment do you give to her, using which flow-chart?
c) Reta says he noticed a slight pain in his left groin. Two days later, he noticed that it looked swollen. He has rushed to the
clinic after work. What flow-chart do you use?
On examination, you find that he has a small sore on his penis. His left groin is tender and you find fluctuant swollen mass.
How do you manage Reta?
Group III
Below are four case studies to give you more practice in diagnosing the cause or causes of vaginal discharge. Please
decide whether you need to treat each woman for vaginitis only, or for both vaginitis and cervical infection, or PID
a) Sara moved in with her present partner four months ago. She is 22 years old. In addition to the discharge, you found
lower abdominal tenderness. Her partner has no symptoms.
b) Genet complains of a slight vaginal discharge. She is 28 years old and has been married for eight years. Her third child
was born four months ago, so she’s been busy caring for him at home. Apart from this discharge, she feels well and has no
other symptoms.
c) Sara is 17 years old, living in an urban area. She reports a unusual vaginal discharge but no other symptoms. She has
lived with her current boyfriend for nine months.
d) 34 year-old Senait complains of a slight discharge of two weeks duration. She has not been with anyone since her
husband left home six months ago. She has no other symptoms.
Ask each group to assign a chairperson who moderates the discussion and a reporter who report on their group findings.
Provide each group with flip chart and Markers to present their responses.
Allow 20 minutes for the group to finalize the group work.
Allow each group to present their responses in plenary in 5 minutes, and then allocate 15 minutes for plenary discussion.
Annexs:3
Case study 8.1 small group discussion on counseling of STI (60 minutes)
Purpose Explore useful skills for service providers need to acquire during counseling of
patient with STI
Materials Flip chart and Markers
Time 45 minutes
Activities Divide participants into four small groups (4-5 groups if possible) and instruct them to work on the
questions sited below.
Group I:
Imagine you have taken the history and assessed the risks for each of the four STI patients that follow. Based
on the information you have been given, make notes in answer to these two questions:
• What risky behaviors should the patient aim to avoid in the future?
• What barriers to change might arise from the patient’s circumstances?
Hana is a 19-year-old sex worker who lives in a slum area of town. She has one small child who is often
sick. Hana is also using her earnings to help support her family who live in a remote village. Her families
disapprove of her job but eagerly accept the money that she sends home. She is afraid of AIDS but finds
that many of her clients refuse to use condoms. You have diagnosed a genital ulcer.
Group II:
Yohannes is a 24-year-old single man with a good job and his own home. He does not want to settle down
for a long time, describing himself as ‘a good time guy’. He has three sexual partners and sometimes has
casual sex too. However, he says he chooses women who are ‘clean’ or ‘married’, so he cannot understand
why he now has a urethral discharge. During the interview he admits that he often gets drunk.
Group III
Sara is 35, married with three teenage children. She relies on her husband’s income from factory work to
support the family. During the interview, she said that she has sex only with her husband. She responded
to your questions by saying that her husband often worked late at the factory and that he went for a drink
with friends occasionally: she could smell the alcohol on his breath. However she feels quite secure in his
faithfulness to her. She came to the centre with no idea of the cause of her abdominal pain – you have
diagnosed pelvic inflammatory disease.
99
Group IV
Tadios is a 47-year-old married man, living in a rural area. His eldest brother died recently and everyone in
the family suspects that he died of AIDS. His culture and religion dictate that Tadios will inherit his brother’s
36-year-old wife, taking her as his second wife. He has heard a lot about AIDS on the radio and so is fearful
that he and his first wife might be exposed to AIDS or STI. Presenting initially with bad head pains, Tadios
has really come to ask your help in resolving this problem.
Ask each group to assign a chairperson who moderates the discussion and a reporter who report on their
group findings. Provide each group with flip chart and Markers to present their responses.
Allow 15 minutes for the group to finalize the group work.
Allow each group to present their responses in plenary in 5 minutes, and then allocate 10 minutes for
plenary discussion.
Annexs:4
Exercise 11.1 group exercises on Recording and Reporting of STI cases.
Purpose To practice on STI data recording and reporting .
Materials OPD register and tally sheet format
Time 30 minutes
Activities Divide participants into four small groups (4-5 groups if possible) and instruct them to work on the questions
sited below.
Practicing recording using the OPD register format
1. a boy aged 13 who complains of urethral discharge;
2. a girl aged 12 who has a large genital ulcer;
3. a 30-year-old woman with vaginal discharge and confirmed risk behaviour;
4. a young man aged 25 with a genital ulcer;
5. 48 years old man who has scrotal swelling;
6. a girl aged 22 with genital ulcer;
7. a woman aged 31 with confirmed PID
8. 2 weeks old male neonates with neonatal conjunctivitis
9. A woman aged 36, who has a genital ulcer.
Reading tally sheet
To help you practice reading tally sheets, answer the questions below by referring to the OPD diagnosis and
attendance Tally Sheet
1. What are the total numbers of new STI syndromes recorded (i) for men and (ii) for women?
2. What are the total numbers of new cases of genital ulcer seen? Please segregate it with sex and
age
3. For genital ulcer cases, which sex and age group are most affected?
4. How many cases of urethral discharge in men are recorded?
5. How many cases of vaginal discharge are recorded?
Allow each group to do the exercise for 20 minutes and let one group to present for the larger group and the
other will forward their comments.
Annex:5
OPD REGISTER FOR HEALTH CENTERS/HOSPITALS

Identification Diagnosis HTC
HMIS disease
classification (if
Service patient admitted, don’t
Serial dateDD/ Woreda/ write diagnosis ,Write Result
number MM/YY MRN Age* Sex subcity admitted New Repeate Referred to √ Offered Performed (R/NR/I)
*Age in months(M) if under one year or in days(D), if under one month

√ Referred code 1 Hospital 2 Health center 3 Health post 4 MCH 5ART 6 SOPD
7 ObGyn 8 TB Clinic 9 Others
Annex:6
OPD Diagnosis and Attendance Tally

Woreda______________________ Facility ___________________________________________ Year______________________________
Months______________________________________________
Male Female
15 years 15 years
< 5years 5-14 years and olders < 5years 5-14 years and olders
Cases
Death
Cases
Death
Cases
Death
Cases
Death
Cases
Death
Cases
Death
Tally
Count
Tally
Count
Tally
Count
Tally
Count
Tally
Count
Tally
Count
Tally
Count
Tally
Count
Tally
Count
Tally
Count
Tally
Count
Tally
Count
code diagnosis
28 Sexually transmitted infection; Urethral discharge
Sexually transmitted infection; Persistant urethral
29 discharge
30 Sexually transmitted infection; genital ulcer
31 Sexually transmitted infection; Vaginal discharge
Sexually transmitted infection; Lower abdominal
32 syndrome (pelvic inflamatory syndrome-PID)
33 Sexually transmitted infection; Scrotal swelling
Sexually transmitted infection; Inguinal bubo (swollen
34 gland)
Sexually transmitted infection; Neonatal
35 conjunctivitis
36 Sexually transmitted infection; Neonatal Herpes
101
Annex:7
FEDERAL MINISTRY OF HEALTH OPD REPORT

Morbidity in OPD
Male Female
SNO Disease 0-4 Year 5-14 Years >=15 Years 0-4 Year 5-14 Years >=15 Years
126.1 Sexually transmitted infections: urethral discharge
Public Facilities – total
Health Centers
Hospitals
Private not for profit Facilities – total
Clinics
Hospitals
Clinics
Hospitals
126.2 Sexually transmitted infections: persistent/recurrent
urethral discharge in men
Health Centers
Hospitals
Clinics
Hospitals
Private for profit Facilities – total
Clinics
Hospitals
126.3 Sexually transmitted infections: genital ulcer
Health Centers
Hospitals
Clinics
Hospitals
Clinics
Hospitals
126.4 Sexually transmitted infections: vaginal discharge
syndrome
Health Centers
Hospitals
Clinics
Hospitals
Clinics
Hospitals
126.5 Sexually transmitted infections: Lower abdominal
pain syndrome (pelvic inflammatory disease PID)
Health Centers
Hospitals
Clinics
Hospitals
Clinics
103
126.6 Sexually transmitted infections: scrotal swelling
syndrome
Health Centers
Hospitals
Clinics
Hospitals
Clinics
Hospitals
126.7 Sexually transmitted infections: inguinal bubo
swelling (swollen glands)
Health Centers
Hospitals
Clinics
Hospitals
Clinics
Hospitals
126.8 Sexually transmitted infections: neonatal
conjunctivitis
Health Centers
Hospitals
Clinics
Hospitals
Clinics
Hospitals
126.9 Sexually transmitted infections: neonatal herpes
Health Centers
Hospitals
Clinics
Hospitals
Clinics
Hospitals
105
FEDERAL MINISTRY OF HEALTH

Final SYNDROMIC MANAGEMENT OF SEXUALLY TRANSMITABLE INFECTIONS REFERENCE

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SYNDROMIC

LIST OF ABBREVIATION  iii

INTRODUCTION TO TRAINING MANUAL  iv

INTRODUCTION TO SYNDROMIC APPROACH  16

HISTORY TAKING AND PHYSICAL EXAMINATION  22

DIAGNOSIS AND MANAGEMENT  29

STIs IN CHILDREN AND ADOLESCENTS  51

MANAGEMENT OF STIs NOT PRESENTING WITH TYPICAL SYNDROMES  55

STIs SCREENING AND STIs IN MARPs  62

PRACTICAL CONSIDERATION IN MANAGING STIs  68

STIs PROGRAM MANAGEMENT  81

MONITORING AND EVALUATION OF STIs PROGRAM  87

Dr Frehiwot Nigatu FMOH

AIDS Acquired Immunodeficiency Syndrome

MARPs Most At Risk Populations

MODULE I: INTRODUCTION TO STI PREVENTION AND CONTROL

SESSION ONE: INTRODUCTION TO STIs

population or core groups.

Transmission dynamic of Sexually Transmitted Infection at the Population

Figure 1. STI epidemiology model and care seeking behavior

presenting for treatment

population with symptoms

population with STIs

Sexually active population

Implications of the model for STIs Control:

SESSION FIVE: SEXUALLY TRANSMITTABLE INFECTIONS PREVENTION AND CONTROL

SESSION SIX: CHALLENGES OF STIs PREVENTION AND CONTROL

MODULE II. INTRODUCTION TO SYNDROMIC APPROACH

2. SYNDROMIC APPROACH TO STls MANAGEMENT

Diagnostic Approaches Advantages Challenges

Syndrome Symptoms Signs Most Common Causes

FREQUENTLY RAISED ISSUES ABOUT THE SYNDROMIC APPROACH

SESSION TWO: USING THE FLOW-CHARTS

This is an action box, here asking

Decisions like these ask you to

Take history and

Use approprate Educate and Counsel

Treat for gonorrhoes and Chlamydia

MODULE III: HISTORY TAKING AND PHYSICAL EXAMINATION

SESSION TWO: HISTORY TAKING

SESSION THREE PHYSICAL EXAMINATION

EXAMINING FEMALE PATIENTS FOR STls

MODULE IV: DIAGNOSIS AND MANAGEMENT

Figure 1. The algorithm of syndromic case management of urethral discharge syndrome

Urethral discharge syndrome flow chart in men

Complains of Urethral discharge or dysuria

Take history and Examine [Milk urethra if necessary]

Treat for GC and CT

Management of Urethral Discharge

Recommended Treatment for Urethral Discharge and Dysuria

Persistent/Recurrent Urethral discharge

Recurrent/Persistent Urethritis in men flow chart

Complains of Recurrent/Persistent Urethritis in men

Take history & Examine [Milk urethra if necessary]

TREATMENT OF PERSISTENT/RECURRENT URETHRITIS SYNDROME

SESSION TWO: GENITAL ULCERS SYNDROME

Tabel 1. Clinical Features of Acquired Syphilis by Stage of Infection

Stages of Infection Clinical Manifestations

Disease Etiology Complications

3. Chancroid H. ducreyi • Penile autoamputation

Figure 3. THE ALGORITHM OF SYNDROMIC CASE MANAGEMENT OF GENITAL ULCER SYNDROME

Patient complains of genital sore or ulcer

Take history and examine

LIST OF ABBREVIATION iii

INTRODUCTION TO TRAINING MANUAL iv

INTRODUCTION TO SYNDROMIC APPROACH 16

HISTORY TAKING AND PHYSICAL EXAMINATION 22

DIAGNOSIS AND MANAGEMENT 29

STIs IN CHILDREN AND ADOLESCENTS 51

MANAGEMENT OF STIs NOT PRESENTING WITH TYPICAL SYNDROMES 55

STIs SCREENING AND STIs IN MARPs 62

PRACTICAL CONSIDERATION IN MANAGING STIs 68

STIs PROGRAM MANAGEMENT 81

MONITORING AND EVALUATION OF STIs PROGRAM 87