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Sexually Transmitted Infections Agis Terzidis, Paediatrician Spyridon Gialamas, Medical Doctor IFAKARA TTIHC 29 JUNE 2009 Socio - economic data • Population 37.440.000 ( 63% rural ) • Life expectancy at birth 46y. Infant mortality( 5 yrs.) 126/1000 births • HDI 0.43 • HIV morbidity 6.5% TB cases 479/100.000 - Malaria 1.207/100.000 • Population with no access to drinkable water 38% (20l/day- 1km max) • Malnutried population 44 % ( food intake ) Sexually Transmitted Infections • Bacterial – – – – – Neisseria gonorrhoeae Chlamydia trachomatis Treponema pallidum Haemophilus ducreyi Klebsiella granulomatis • Viral – – – – – Human immunodeficiency virus Herpes simplex virus type 2 Human papillomavirus Hepatitis B virus Cytomegalovirus • Parasitic – Trichomonas vaginalis – Candida albicans Most usual ways of STIs transmission child • STIs often exist without symptoms • Men and women with sexual partners who have STI symptoms should seek care and receive treatment, regardless of a lack of signs • STIs disproportionally affect women and adolescent girls • 1/20 adolescent girls gets a bacterial infection through sexual contact • 30-40% of female infertility cases due to postinfection damage of Fallopian tubes • 10-40% of women with untreated chlamydial infections develop symptomatic pelvic inflammatory disease • Condoms are one of the most effective methods of protection against STIs • Partner notification can prevent reinfection and reduce the wider spread • Sexual or economic conditions / sexual behaviours increase vulnerability to STIs Chlamydial infections Estimated new cases of chlamydial infections among adults, 1999 Basic facts about chlamydia • 70-75% of women symptom free • Clinical manifestations: urogenital tract, throat or rectum mucosal inflammation, neonatal eye infection/ pneumonia • Complications: chronic pelvic inflammatory disease, ectopic pregnancy, infertility • Diagnosis: costly equipment, not always available in developing countries Gonorrhoea Estimated new cases of gonorrhoea among adults, 1999 Basic facts about gonorrhoea • Up to 80% of women and 10% of men are asymptomatic • Clinical manifestations: urogenital tract, throat or rectum mucosal inflammation, neonatal eye infection Basic facts about gonorrhoea • Complications: – Women: infertility, ectopic pregnancy, chronic pelvic inflammatory disease, chronic pelvic pain – Men: urethral strictures – Both sex: septicaemia, arthritis, endocarditis, meningitis – New born: blindness • Diagnosis: costly equipment, not always available in developing countries Syphilis • Untreated early syphilis is responsible for 25% of stillbirths and 14% of neonatal deaths • 4-15% of pregnant women in Africa test positive for syphilis • 492.000 stillbirths per year could be prevented with effective screening, in Africa Estimated new cases of syphilis among adults, 1999 Basic facts about syphilis • Clinical manifestations: urogenital tract, mouth or rectum ulceration, disseminated mucocutaneous lesions, fever, general malaise, hair loss, mild hepatitis • Complications: pregnancy wastage, congenital syphilis, musculo-skeletal / cardiovascular and nervous system disorders • Diagnosis: simple, relatively cheap screening test, not always available in developing countries Estimated new cases of trichomoniasis among adults, 1999 Basic facts about trichomoniasis • Most common worldwide • 50% of women are symptomatic • Men: urethral infection, short duration • Men easily transmit the parasite to women, when infected Basic facts about trichomoniasis • Clinical manifestations: vaginitis, male urethritis • Complications: – no systemic complications – Vaginal infection facilitates the spread of HIV infection • Diagnosis: Test not always available in developing countries HPV infection • Virtually all cervical cancer cases are linked to genital infection with the human papilloma virus (HPV) • 500000 new cases, 250000 deaths per year • The new vaccine prevents the infection and the cancer of the cervix The link between STIs and HIV/AIDS 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 A global view of HIV infection 33 million people [30–36 million] living with HIV, 2007 New infections among children, 1990–2007 600 000 500 000 400 000 300 000 200 000 100 000 0 1990 1991 1992 1993 1994 1995 1996 19971998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year This bar indicates the range Child deaths due to AIDS, 1990–2007 500 000 400 000 300 000 200 000 100 000 0 1990 1991 1992 1993 1994 1995 1996 19971998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year This bar indicates the range Percentage of most-at-risk populations reached with HIV prevention programmes, 2005–2007 100 90 80 70 60 60.4%* (39 countries) 46.1%** % Median 50 (15 countries) 40.1%* (27 countries) 40 30 20 10 0 Sex workers Source: UNGASS Country Progress Reports 2008 Injecting drug users Men having sex with men * Percentage of sex workers and men having sex with men reported knowing where they can receive an HIV test and that they were given condoms. ** Percentage of injecting drug users who reported knowing where they could receive an HIV test and be provided with condoms and sterile injecting needles and syringes. Countries implementing one or more elements of the WHO Global Strategy for Prevention and Assessment of HIV Drug Resistance and the HIVResNet laboratory network (as of December 2007) Towards Universal Access – Scaling up priority HIV/AIDS interventions in the health sector. WHO/UNAIDS/UNICEF, June 2008 May 2006 Global Strategy on Prevention and Control of STIs by WHO, endorsed by the World Health Assembly Primary prevention of STIs • Health education and promotion of safer sex • Information campaigns on the association between HIV and other STIs • Promotion of condoms Secondary prevention of STIs • Promotion of early health care seeking behaviour • Accessible, effective and acceptable care • Education and counselling • Early detection and treatment of asymptomatic infections through case finding and screening Key features of syndromic case management 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 STI care more accessible as it can be implemented at primary health-care uses flowcharts that guide the health worker through logical steps provides opportunity and time for education and counselling Syndromic flowcharts Syndromes are easy to identify and it is possible to devise a flowchart for each one Flowchart is a diagram repr. steps to be taken through a process of decision making Service providers find them easy to use you can offer prompt treatment because patients with STIs are treated at their first visit many more patients with STIs have access to treatment there are opportunities for introducing preventive and promotive measures such as education - condom distribution A patient complains of a discharge from the penis Ph/ex discharge from the urethra. Sign and symptom together suggest urethral discharge syndrome ETIOLOGY Urethral discharge syndrome is commonly caused by gonorrhoea and/or chlamydial Can cause serious complications and/or facilitate HIV transmission and acquisition ESSENTIAL that we treat the patient for BOTH Thank you!