Thursday, July 18, 2024

Chapter 24 Sexually Transmitted Diseases And Hiv/aids

Initial Management Of Hiv Infection

Sexually Transmitted Diseases (STDs), Causes, Signs and Symptoms, Diagnosis and Treatment.

It is advisable to refer HIV-infected persons to a single clinical resource for comprehensive care . Because of the limited availability of these facilities, it is often advisable to initiate evaluation and provide access to psychosocial services while planning for referral and continuation of medical care. Thus, brief consideration of initial management is in order.

Recently diagnosed HIV infection may not have been acquired recently. Persons with newly diagnosed HIV infection can be at any of the clinical stages of infection. Thus, it is important to be alert for signs and symptoms that suggest advanced infection, such as fever, weight loss, diarrhea, oral candidiasis, cough, or shortness of breath. These findings suggest the need for urgent referral.

Delayed And Inadequate Diagnosis

Delayed or inadequate diagnosis and treatment of STIs in LMICs result in high rates of complications. To a large extent, inadequacies in health service provision and health care seeking are responsible for the high levels of STIs and the high rates of complications and sequelae in LMICs . STI care is provided by a variety of health care providers, many of whom are poorly trained in STI case management, and the quality of care is often inadequate . Health care seeking for STIs is often delayed and inadequate, particularly among women, as a result of the asymptomatic nature of many STIs low levels of awareness of sexual health stigma associated with genital symptoms and tendency to seek care through traditional healers, home remedies , and pharmacies where drugs are dispensed by workers not trained in STI treatment.

Sexual Behaviors And Practices

Most of the data on sexual behaviors and practices come from HICs. However, the increased volume of travel, sex tourism, transactional and commercial sex, and role of technology in establishing these connections have expanded sexual networks beyond national boundaries . Moreover, population displacement in LMICs often affects sexual networks, for example, by allowing or forcing sexual mixing among groups that did not mix before the displacement .

Where available, systematically collected data on representative samples of the general population reflect increases in a number of risky behaviors, including the following: large numbers of sex partners, indiscriminate choice of sex partners, short periods between the time two people meet each other and the initiation of sexual activity, short time spent during the sexual encounter, lack or short duration of social links between sex partners, short duration of gaps between consecutive sex partners and sexual encounters, and a tendency for both partners to recruit each other for sex. These trends are observed particularly among younger cohorts. Moreover, sexual behaviors have been changing more rapidly for women than for men .

Data collected in LMICs over the past two decades have revealed the importance of sex work to the spread of STIs and the presence of MSM among sex workers . These key populations have high prevalence of STIs, including HIV/AIDS, and play an important role in spreading STIs to the general population.

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Community And Structural Interventions

STI prevention interventions can be implemented at the individual, risk group, or community level. Although this literature review is stratified by intervention modality and not by level of implementation, most of the interventions reviewed thus far were targeted to individuals or high-risk groups.

The MEMA kwa Vijana intervention, a random community intervention in the Mwanza Region of Tanzania, examined the impact of a multipronged intervention that included school-based sexual and reproductive health education, youth-friendly health services, peer condom promotion, and community activities. Although the intervention increased knowledge and decreased reported risk behaviors, it had no apparent effect on HIV or HSV-2 seroincidence, incidence of other STIs, or pregnancy outcomes at the end of the trial , and no effect on HIV after about 10 years .

  • Provision of training, workshops, and educational materials to pharmacy workers and clinicians
  • STI screening and treatment for female sex workers by mobile outreach teams
  • Provision of PPT using metronidazole to female sex workers with bacterial vaginosis
  • Condom promotion among female sex workers by mobile outreach teams and among the general population by social marketing of low-cost condoms .

Effectiveness Of Sti Prevention Interventions: Literature Review

Sexually transmitted

Over the past 20 years, many STI prevention interventions have been rigorously evaluated for effectiveness. In a review of STI prevention interventions evaluated by randomized controlled trials in HICs and LMICs, Wetmore, Manhart, and Wasserheit found that 44 of 75 interventions significantly reduced the risk of acquiring at least one STI. Interventions were organized according to modality, including behavior change, vaginal microbicides, male circumcision, partner services, treatment, and vaccines. The percentage of trials in which a statistically significant reduction in the risk of a laboratory-confirmed STI was observed in the intervention arm was highest for treatment, vaccines, and male circumcision, followed by behavioral interventions, partner services, and vaginal microbicides. These findings are consistent with those of Manhart and Holmes , in which 54 percent of the trials led to a significant reduction in STI acquisition, transmission, or complications.

In this summary of the literature, interventions were organized according to intervention modality using a structure adapted from Mayaud and Mabey . Specifically, interventions were organized as primary prevention , STI case management, partner notification and management, targeted interventions and periodic presumptive treatment , mass treatment, and community-level and structural interventions.

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Income And Income Inequality

Aral and others examined the association between two economic measuresincome and income inequality and STI burdenat the country level. For each country setting, income was measured using gross national income, and income inequality was measured using the Gini coefficient, which can range from 0 to 1 . The burden of STIs was negatively associated with income and positively associated with income inequality. Their analysis suggested that these two economic measures could explain almost half of the variation across countries in STI prevalence among low-risk groups .

These findings are consistent with other analyses in HICs. Bingham and others used the Gini coefficient to examine income inequality and gonorrhea incidence rates across 11 countries. Their analysis showed significant positive associations between income inequality and gonorrhea rates in women. Owusu-Edusei, Chesson, Leichliter, and others examined county-level data in the United States and found that racial disparities in income were associated with racial disparities in STI burden. One possible explanation is that racial income disparity contributes to residential segregation by race, which has been identified as a social determinant of STI risk .

Genital Herpes Simplex Virus Infection

Clinical presentation. Genital HSV is an incurable and recurrent viral infection. Characteristic genital lesions start as painful papules or vesicles. Often, the genital lesions have evolved into pustules or ulcers when the patient is seen in the office.

Primary HSV infection. With primary genital herpes, the ulcerative lesions persist for 415 days until crusting or reepithelization, or both, occurs. Pain, itching, vaginal or urethral discharge, and tender inguinal adenopathy are the predominant local symptoms. Primary HSV infection is associated with a high frequency and prolonged duration of systemic and local symptoms. Fever, headache, malaise, and myalgias are common. The clinical symptoms of pain and irritation from genital lesions gradually increase over the first 67 days, reach maximum intensity between days 7 and 11 of disease, and then recede gradually during the second or third week.

Recurrent HSV infection. In contrast to first episodes, recurrent HSV infection is characterized by symptoms, signs, and anatomic sites localized to the genital region. Local symptoms, such as pain and itching, are mild compared with the symptoms of initial infection, and the duration of the usual episode ranges from 8 to 12 days or less.

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Health And Economic Burden Of Stis

If left untreated, common STIs may cause complications, including pelvic inflammatory disease, ectopic pregnancy, postpartum endometriosis, infertility, and chronic abdominal pain in women adverse pregnancy outcomes, including abortion, intrauterine death, and premature delivery neonatal and infant infections and blindness urethral strictures and epididymitis in men genital malignancies proctitis, colitis, and enteritis in MSM arthritis secondary to gonorrhea and chlamydia liver failure and liver cancer secondary to hepatitis B virus myelopathy and lymphoma or leukemia due to human T-cell lymphotropic virus type 1 and central nervous system disease or meningoencephalitis secondary to syphilis or herpes simplex virus infection .

STI sequelae disproportionately affect women and children. STIs are one of the leading causes of morbidity and mortality, as measured by disability-adjusted life years for reproductive-age women in LMICs. Moreover, the health burden of STIs is often greatly underestimated. Although most cervical cancers are caused by human papillomaviruses , the millions of DALYs caused by cervical cancer are not included in estimates of mortality and morbidity due to STIs they are typically listed in estimates of cancer .

Screening And Treatment For Syphilis In Pregnancy

Complications: TORCH Infections, Chlamydia, Gonorrhea, HIV/AIDS – Maternity Nursing -@Level Up RN

The prevention of mother-to-child transmission of HIV and syphilis is addressed in of this volume . However, screening and treatment for syphilis in pregnancy warrants special mention here for several key reasons. First, the global burden of disease due to syphilis during pregnancy is comparable to that of mother-to-child transmission of HIV . Second, screening and treatment for syphilis in pregnancy is an inexpensive and highly cost-effective intervention . However, despite their low cost and favorable cost-effectiveness, screening for and treatment of syphilis in pregnancy are vastly underutilized in LMICs today .

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Ner Notification And Management

Alam and others conducted a systematic literature review of the feasibility and acceptability of partner notification for STIs in low-resource settings and summarized the evidence that partner notification interventions can yield positive outcomes. An RCT in Harare, Zimbabwe, involving men and women with a syndromically diagnosed STI found that a partner referral intervention significantly increased the likelihood that at least one partner would be reported, compared with standard care in which the treating clinician discussed partner referral . A randomized trial in Kampala, Uganda, involving men and women with a syndromically diagnosed STI found that a significantly higher percentage of partners were treated using patient-delivered partner medication compared with patient-based partner referral .

What Is The Treatment For Stds

STDs caused by bacteria or parasites can be cured with medicine. There is no cure for STDs caused by viruses, but treatment can relieve or eliminate symptoms and help keep the STD under control. Treatment also reduces the risk of passing on the STD to a partner. For example, although there is no cure for HIV, HIV medicines can prevent HIV from advancing to AIDS and reduce the risk of HIV transmission.

Untreated STDs may lead to serious complications. For example, untreated gonorrhea in women can cause pelvic inflammatory disease, which may lead to infertility. Without treatment, HIV can gradually destroy the immune system and advance to AIDS.

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What Are The Symptoms Of Stds

Symptoms of STDs may be different depending on the STD, and not everyone will experience the same STD symptoms. Examples of possible STD symptoms include painful urination , unusual discharge from the vagina or penis, and fever.

STDs may not always cause symptoms. Even if a person has no symptoms from an STD, it is still possible to pass the STD on to other people.

Talk to your health care provider about getting tested for STDs and ask your sex partner to do the same.

To find STD information and testing sites near you, call CDC-INFO at 1-800-232-4636 or visit CDC’s GetTested webpage.

Emerging Issues In Sexually Transmitted Diseases

Sexually Transmitted Infections (STIs) Anatomical Chart

There are several emerging issues in STD prevention:

  • Each state must address system-level barriers to timely treatment of partners of persons infected with STDs, including the implementation of expedited partner therapy for the treatment of chlamydial and gonorrheal infections.
  • Enhanced data collection on demographic and behavioral variables, such as the sex of an infected persons sex partner, is essential to understanding the epidemiology of STDs and to guiding prevention efforts.
  • Innovative communication strategies are critical for addressing issues of disparities, facilitating HPV vaccine uptake, and normalizing perceptions of sexual health and STD prevention, particularly as they help reduce health disparities.
  • It is necessary to coordinate STD prevention efforts with the health care delivery system to leverage new developments provided by health reform legislation.

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Hpv And Hbv Vaccination

Given the scarcity of published studies on the cost-effectiveness of interventions to prevent STIs in LMICs, the exceptionalism of HPV and HBV vaccination warrants mention. HPV vaccination is unique among STI prevention interventions in that its effectiveness has been demonstrated in RCTs, and its cost-effectiveness in LMICs has been analyzed extensively, as reviewed by Natunen and others and Levin and others . Similar data exist for HBV vaccination . However, young girls have limited access to HPV vaccine in poorer settings because of the high cost of the vaccine and other challenges associated with vaccinating . Nonetheless, Gavis support for HPV vaccines is expected to increase access in LMICs and eventually reduce the disproportionate burden of HPV-associated cancers in these settings.

How Can A Person Reduce The Risk Of Getting An Std

Sexual abstinence is the only way to eliminate any chance of getting an STD. But if you are sexually active, you can take the following steps to lower your risk for STDs, including HIV.

Choose less risky sexual behaviors.

  • Reduce the number of people you have sex with.
  • Do not drink alcohol or use drugs before and during sex.

Use condoms correctly every time you have sex.

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Why Is Sexually Transmitted Disease Prevention Important

The Centers for Disease Control and Prevention estimates that there are approximately 20 million new STD infections each yearalmost half of them among young people ages 15 to 24.3 The cost of STDs to the U.S. health care system is estimated to be as much as $16 billion annually.4 Because many cases of STDs go undiagnosedand some common viral infections, such as human papillomavirus and genital herpes, are not reported to CDC at allthe reported cases of chlamydia, gonorrhea, and syphilis represent only a fraction of the true burden of STDs in the United States.

Untreated STDs can lead to serious long-term health consequences, especially for adolescent girls and young women. CDC estimates that undiagnosed and untreated STDs cause at least 24,000 women in the United States each year to become infertile.5

Several factors contribute to the spread of STDs.

Factors Affecting Duration And Burden In Lmics

Straight Talk about Sexually Transmitted Diseases – Leena Nathan, MD | UCLAMDChat

In resource-poor settings, variables that affect the duration of infectiousness include adequacy of health worker training, attitudes of health workers toward marginalized groups, patient loads at health centers, availability of drugs and clinic supplies, and cost of care . Improvements in these factors would greatly improve STI-related services, reduce the duration of infectiousness, and decrease the incidence of STIs . However, in many LMICs, worsening economic conditions increasing burden of human immunodeficiency virus/acquired immune deficiency syndrome and occasional health crises, such as natural disasters, refugee situations, or epidemics like the recent Ebola outbreak in West Africa, can adversely affect these variables .

STIs can impose a considerable financial burden on those infected. For example, the cost of drugs is equivalent to several days wages in most LMICs . The direct costs associated with medical treatment of STI sequelae in LMICs have not been well defined, and the indirect costs associated with lost productivity due to STIs or STI sequelae are not known.

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Social Economic And Behavioral Factors

The spread of STDs is directly affected by social, economic, and behavioral factors. Such factors may cause serious obstacles to STD prevention due to their influence on social and sexual networks, access to and provision of care, willingness to seek care, and social norms regarding sex and sexuality. Among certain vulnerable populations, historical experience with segregation and discrimination exacerbates the influence of these factors.

Social, economic, and behavioral factors that affect the spread of STDs include:

Targeted Interventions And Periodic Presumptive Treatment

Interventions commonly target groups at high risk of STI acquisition and transmission. These interventions can include the provision of PPT, which is the systematic treatment of people at high risk with a combination of drugs targeting the prevalent curable STIs. As shown by four rigorous evaluations, PPT interventions can be highly effective in reducing the STI burden within targeted groups. In an RCT among female sex workers in Kenya, the provision of monthly prophylaxis substantially reduced the incidence of gonorrhea, chlamydia, and trichomoniasis, but not of HIV . Reductions of about 45 percent in the prevalence of cervical infection with gonorrhea and chlamydia were observed among commercial sex workers in the Lao Peoples Democratic Republic after monthly PPT over a three-month period . Substantial reductions in STIs were also observed among hotel-based sex workers in Bangladesh following the provision of monthly PPT over a nine-month period . PPT with vaginal suppositories containing metronidazole and miconazole among HIV-negative women with one or more vaginal infections in Kenya and in Birmingham, Alabama, significantly reduced the prevalence of bacterial vaginosis among women during 12 months of follow-up, compared with women receiving a placebo . Steen, Chersich, and de Vlas noted that reductions in gonorrhea and chlamydia on the order of 50 percent were common across the 15 studies included in their review of PPT of curable STIs among sex workers.

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