UNIT SIX

INTRODUCTION TO STIs
PREVENTION & CONTROL
 Objectives
• Identify how STIs are transmitted and the factors
that influence transmission
• Explain:
• The magnitude of STI
• The complications of untreated STI
• Linkages of STIs with the spread of HIV/AIDS
• Strategies of STIs prevention and control
• Challenges of STI prevention and control
THE TRANSMISSION OF STIs
STI Transmission Dynamics
At Population Level

General population

Bridging population

Core
transmitters
 The Transmission of STIs

• The most common mode of transmission is

unprotected sex.
• Other forms of transmission are
- Mother to child
- Unsafe (un sterile ) use of needles or injections
- Blood transfusion
 Factors that increase the risk of
transmission of STI include:

1. Biological factor

2. Behavioral factor

3. Socio - cultural factors

 1. Biological Factors:

1.1. AGE
 Cont..

1.2. Sex

1.3. Immune status

 2. Behavioral Factors

2.1. Having more than one sexual partner

2.2. Changing sexual partner frequently
2.3. Having sex with causal partner, sex –
workers or their clients
2.4. Having unsafe penetrative sex with infected
partner
2.5. Use of alcohol or drugs before or during sex
 3. Socio - Cultural factors
• 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.
 Socio-Cultural Factors cont..
• Sexual violence tends to be directed more
towards women by men, making it difficult for
women to discuss STI 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
 Epidemiology of STIs
• STIs are major public health problems in all
countries

• Globally 340 million new cases of curable STIs

occur every year (69 million are in sub-Saharan
Africa.

• In many developing countries STIs are among

the top five disease for which adults seek health
services.
 Epidemiology Continued
• There is little information on the incidence &
prevalence of STIs in Ethiopia

• Total of 451,686 cases of STIs were reported

between June 1988 &June 2002 in Ethiopia

• Except for adult prevalence of HIV(3.5%) &

syphilis (2.7%) there is no actual information or
estimate on other STIs in Ethiopia
 The Accuracy of STI Statistics
• Reasons for underestimation:

people with symptom-free STIs do not seek

treatment
health facilities offering treatment for STIs may be
too far away for many people
people seeking other health care such as antenatal
services may not be routinely screened for STIs
many patients perceive a stigma in attending
traditional STI referral clinics, where anyone might
be perceived to be at risk of infection by STIs
The Accuracy of STI Statistics
• Reasons continued….
 Many people may choose to go to alternative
providers, both in the formal and informal sectors,
who do not report case numbers
 Lack of uniformity of reporting
 Cost of services
The accuracy of STI Statistics cont….

Symptomatic

Asymptomatic
 Distribution of STIs
• Prevalence higher in urban than rural

• Higher in unmarried & young adults (15-44 yrs)

• More frequent among females than males

between the ages of 14-19.
• After the age of 19, there is slight male
preponderance.
 Complications of STIs
CAUSE COMPLICATIONS

Gonococcal & Infertility in men & women,

chlamydial infections Epidedimitis, ectopic
pregnancy, chronic pelvic
pain, urethral stricture
Gonorrhea Blindness in infants,
Disseminated gonococcal
infection
Chlamydia Chlamydial pneumonitus in
infants
 Complications continued..
CAUSE COMPLICATIONS
Gonococcal, chlamydial & Pelvic & generalized
anaerobic infection peritonitis

Acquired syphilis Permanent brain &

Heart disease
Congenital syphilis Extensive organ & tissue
damage
Human papilloma virus Genital cancer, obstructed
labor
 Impacts of STIs

• Divorce &family

• Cost of STI drugs may place heavy financial

burden on families , communities, & the country
at large
STI/HIV
 The Link Between STI & HIV
• Certain STIs facilitate the transmission of HIV

• The presence of HIV can make people more

susceptible to the acquisition of STIs

• The presence of HIV increases the severity of

some STIs and their resistance to treatment
Influenced by co Infection With
HIV
• Syphilis can have atypical presentation with tendency
to rapidly progress to neuro syphilis

• Atypical lesions of chancroid are common

• Recurrent or persistent genital ulcers caused by HSV2

are common

• Human papilloma virus produces exophytic genital

warts that may be large & extensive
 Treatment of Conventional STIs is
Also Affected when HIV Infection
Co-Exist

• Risk of treatment failure with single injection of

benzathine pencillin in patients with primary syphilis

• Topical anti fungals are less effective

• Severe genital herpes may require suppression of

recurrence with acyclovir
 STRATEGIES FOR STIs
PREVENTION AND CONTROL
 The Main Aims of STIs Prevention and
Control are:-

1. Interrupting the transmission of STI

2. Prevent development of disease and complication

3. Reducing the risk of acquiring and transmission of

HIV
 Prevention and Control of STIs Involves:

1. Early diagnosis and treatment

2. Promotion of safer sexual behavior

3. Promotion of health care - seeking behavior

4. Targeting vulnerable groups

 Preventive Measures of STI
1. Primary prevention

2.Secondary prevention
 Primary prevention of STI
It is all about adopting safer sexual behavior and
includes:
1. Abstinence from all sexual activity
2. Delaying the age of sexual debut
3. Life – long monogamy and faithfulness
4. Engaging only in non – penetrative sex acts:
masturbation (mutual or self)
5. Engaging penetrative sex acts only with
condoms
 Secondary Prevention of STI
• Promoting STI care-seeking behavior, through:
1. Public education campaigns
2. Providing non-stigmatizing and non-discriminatory
health service
3. Providing quality STI care
4. Ensuring a continuous supply of highly effective
drugs
5. Insuring a continuous supply of condoms
 Secondary Prevention
 Rapid and effective treatment of people with STIs
through:
- comprehensive case management of STI syndromes
which includes:
1. To make correct diagnosis
2. To provide correct antimicrobial therapy for STI
syndrome
3. To educate on the nature of the infection and safer
sexual behavior
4. To educate on treatment compliance
5. To demonstrate the correct use of condoms and
provision of condoms
6. To advice on partner management
 Secondary Prevention

7.Training of service providers in syndromic

management of STIs

8. Integration of STIs service within primary care

 Secondary Prevention
 Case finding and screening through:
1. Examine minimally symptomatic women
2. Partner notification and treatment
3. Community – based screening
4. Targeting screening to those at higher risk of infection
 Provision of prophylactic antibiotics against major STIs
for victims of sexual violence
 CHALLENGES OF
CONTROLLING STIs

Challenges are due to:

1. Factors related to health system
2. Biological factor
3. Socio – cultural and behavioral factors
 Health System Factors
Health service may be:
- Unavailable or too far away
- Too expensive
- Considered to stigmatize those who visit
- Ill equipped in terms of staff and equipment
- Not user friendly
- May not be integrated within primary care
clinics
 Biological Factors

• 70%-80% of infected women may be

asymptomatic and so will not seek treatment

• Such people will continue to be infected,

risking complications and perhaps infecting
others
 Socio - cultural & Behavioral
Factors
Socio – cultural and behavioral factors include:

1.Reluctant to seek health care

2.Ignorance or missinformation

3.Preference for alternative health source

4.Reluctant to follow safer sex practice

 Social & Behavioral Factors cont…

5. The social stigma so often attached to STIs.

6. Failure to take full, prescribed course of

treatment for STI.

7. Difficulty of notifying sexual partner

INTRODUCTION TO SYNDROMIC
MANAGEMENT OF STIs
 Objectives
• List number of problems associated with classic
approaches to treating STIs

• Identify main features of syndromic case

management

• Outline various advantages of syndromic

approach

• List the steps in using flow chart

 APPROACHES TO STIs MANAGEMENT

Classical Approaches To STI

Management
• Etiologic diagnosis – using lab to identify the
causative agent

• Clinical diagnosis –using clinical experience to

identify causative agent
 Etiologic Management
• Advantages:-
Avoids over treatment

Conforms to traditional clinical training

Satisfies patients who feel not properly attended to

Can be extended as screening for the asymptomatics

 Problems of Etiologic Approach
• Requires skilled personnel & consistent supplies

• Treatment does not begin until results are

available

• It is time consuming & expensive

• Testing facilities are not available at primary

level
 Problems of Etiologic cont…
• Some bacteria fastidious &difficult to culture
(H.ducrey, C.trachomatis)

• Lab. results often not reliable

• Mixed infections often overlooked

• Miss-treated/untreated infections can lead to

complications and continued transmission
44
 Clinical Management
• Advantages:-
Saves time for patients
Reduces laboratory expenses
• Disadvantages:-
Requires high clinical acumen
Most STIs cause similar symptoms
Mixed infections are common &failure to treat
may lead to serious complications
Doesn’t identify asymtomatic STIs
 Syndromic Approach
• Syndrome – is group of symptoms patient
complains & clinical signs you observe during
examination.

• Different organisms that cause STIs give rise to

only limited number of syndromes .

• There are seven syndromes (aim is to identify

&manage accordingly)
 Identifying Syndromes
SYNDROME MOST COMMON CAUSE
Vaginal discharge Vaginitis(trichomniasis, candidisis)
Cervicitis(gonorrhea, chlamydia)

Urethral discharge in men Gonorrhea, chlamydia

Genital ulcer Syphilis, chancroid, herpes
Lower abdominal pain Gonorrhea, chlamydia, mixed
anaerobes
Scrotal swelling Gonorrhea, chlamydia
Inguinal bubo Chancroid
Neonatal conjuctivitis Gonorrhea, chlamydia
 Why Syndromic Approach?
• STI sign and symptoms are rarely specific to a particular
causative agent

• Laboratories are either non-existent or non functional

due to lack of resources

• Dual infections are quite common and both clinician

and laboratory may miss one of them

• Waiting time for lab. results may discourage some

patients

• Failure of cure at first contact

 Syndromic Management Key
Features
• Problem oriented (responds to patient’s
symptoms )

• Highly sensitive & does not miss mixed

infections

• Treats the patient at first visit

 Key Features cont…
• Can be implemented at primary health care
level

• Use flow charts with logical steps

• Provides opportunity & time for education

&counseling
 The Four Steps In Syndromic STI
Case Management
• History taking and examination

• Syndromic diagnosis and treatment, using flow charts

• Education and counseling on HIV testing and safer sex,

including condom promotion and provision

• Management of sexual partners

 Frequently Raised Issues on The
Syndromic Approach
• Issues related to scientific ground
– It is based on wide range of epidemiological studies
– Validation studies have confirmed comparable
accuracy of syndromic & LAB diagnosis with
limitation of syndromic management only to vaginal
discharge
 Frequently Raised Issues on The
Syndromic Approach
• Issues related to simplicity of management

– Simplicity allows other health workers other than

doctors to use the approach to make a diagnosis

– It allows health workers more time to offer

education for behavior change
 Frequently Raised Issues on The
Syndromic Approach
• Issues related to service provider’s clinical
skills and experience

– Studies have shown clinical judgment misses 50%

of cases

• Issues related to use of multiple drugs

– Studies have shown that it is less expensive
 Frequently Raised Issues on The
Syndromic Approach
• Issues related to the use of simple laboratory
tests such as Gram’s stain

– It should not be at the expense of delayed

treatment or at risk of patient non return

 Remember that effective treatment of people with

STIs is the best way of interrupting the cycle of
transmission
 Limitations of Syndromic
Management
• Misses sub-clinical infection

• Needs validation study

– Require prior research to determine the common
causes of particular syndromes

• Needs training
USING THE FLOW-CHARTS
 Syndromic Flow-Charts
• A flow chart is a diagram (map) representing steps to
be taken through a process of decision making

• Can be used at any health facility

– prompt treatment is provided at initial visit

– many people with STI have access to treatment
– provides opportunity for preventive & promotive
measures
Each Flow Chart Is Made Up of Three
Steps
• The clinical problem (patient’s presenting symptom)
– Problem box

• A decision to make usually by answering yes or no to a

question
– Decision box

• An action to take (what you need to do)

– Action box
 Clinical Problem Decision Box

Enlarged and Painful Inguinal

Lymph nodes?

Take History & Examine

Ulcer (s) Use Genital

Yes Ulcer Flow Chart
Present?

No

Action Box