Syndromic Management of Sexually Transmitable Infections Reference Manual (2) - 1
Syndromic Management of Sexually Transmitable Infections Reference Manual (2) - 1
Syndromic Management of Sexually Transmitable Infections Reference Manual (2) - 1
MANAGEMENT
OF SEXUALLY
TRANSMITABLE
INFECTIONS
PARTICIPANT
MANUAL
July 2015
SYNDROMIC
MANAGEMENT
OF SEXUALLY
TRANSMITABLE
INFECTIONS
PARTICIPANT
MANUAL
Content
PREFACE i
ACKNOWLEDGMENT ii
MODULE 01
INTRODUCTION TO STIs 6
MODULE 02
MODULE 03
MODULE 04
MODULE 05
MODULE 07
Module 08
MODULE 09
PARTNER/S MANAGEMENT 77
MODULE 10
MODULE 11
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:
List of abbreviation
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 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.
The development of this Participant manual and the accompanying trainers’ guide facilitate the standardization of
training package for syndromic management of STls 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
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%
4 Syndromic Management Of Sexually Transmittable Infections-participant manual
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 STsI (25 minutes)
• The link between STsI and 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)
• Daily evaluation (10 minutes)
Day 3
TIME ACTIVITY
8:30 - 9:00 Recap of Day 2 (30 minutes)
9:00 - 10:30 • Module 5 objectives (5 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)
• Module 7 objectives (5 minutes)
• 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)
• Module 8 objectives (5 minutes)
• 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)
• Daily evaluation (10 minutes)
• 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
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.
10 Syndromic Management Of Sexually Transmittable Infections-participant manual
Partner
Notification
Cure
Complete tretment
Correct treatment
correct diagnosis
Total population
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
Table 3.2. Sign and symptoms of the main STI syndromes and their causes
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).
20 Syndromic Management Of Sexually Transmittable Infections-participant manual
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
NO NO
Discharge Any other STIs?
confirmed?
YES
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
• 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.
26 Syndromic Management Of Sexually Transmittable Infections-participant manual
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.
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.
MODULE 04
DIAGNOSIS AND MANAGEMENT
30 Syndromic Management Of Sexually Transmittable Infections-participant manual
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
32 Syndromic Management Of Sexually Transmittable Infections-participant manual
NO NO Educate on RR
Discharge present? Other STIs? Promote and provide
condoms
YES
YES
Figure 2. The algorithm of syndromic case management of recurrent or persistent urethral discharge syndrome
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
34 Syndromic Management Of Sexually Transmittable Infections-participant manual
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.
36 Syndromic Management Of Sexually Transmittable Infections-participant manual
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
NO NO
Vesicular recurrent Solitary non-recurrent Educate on RR
Ulcers or > three ulcers Non - Vesicular ulcer, Promote and provide
condoms
YES
YES
Ulcers healed?
NO
YES Ulcers improved? Refer
YES
Educate and provide condoms
Offer HIV testing Continue Rx
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.
40 Syndromic Management Of Sexually Transmittable Infections-participant manual
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
VD or vulval/Itching /burning
Educate on risk reduction Promote &
provide condoms Recording and reporting
NO
YES
Is Risk assessment +ve Treat GC, CT, TV,BV
NO
NO
Educate, Offer HTC, Promote & provide condoms, Recording and reporting
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
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
44 Syndromic Management Of Sexually Transmittable Infections-participant manual
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
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
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
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
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
Bilateral or unilateral NO
Reassure mother
swollen eyelids with Advise to return if
purulent discharge necessary
YES
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
52 Syndromic Management Of Sexually Transmittable Infections-participant manual
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
• Ceftriaxone 250mg IM stat
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
56 Syndromic Management Of Sexually Transmittable Infections-participant manual
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
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)
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.
CLINICAL MANIFESTATIONS
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
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
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.
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
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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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
Learning objectives:
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.
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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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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
72 Syndromic Management Of Sexually Transmittable Infections-participant manual
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. ..”
74 Syndromic Management Of Sexually Transmittable Infections-participant manual
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.
75
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
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Do exercise 8.1 on page 98 to explore useful skills during counseling of patient with STI
MODULE 09
PARTNER/S MANAGEMENT
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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
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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
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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
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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.
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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
Regional Council
Primary Hospital
Specialty Clinic
Sub-city/ woreda/
town health offices
Medium Clinic
Health Center
Kebele Council
Health Post
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.
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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?
96 Syndromic Management Of Sexually Transmittable Infections-participant manual
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.
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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?
98 Syndromic Management Of Sexually Transmittable Infections-participant manual
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
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
Hospitals
Private not for profit Facilities – total
Clinics
Hospitals
Private for profit Facilities – total
Clinics
Hospitals
126.3 Sexually transmitted infections: genital ulcer
Public Facilities – total
Health Centers
Hospitals
Private not for profit Facilities – total
Clinics
Hospitals
Private for profit Facilities – total
Clinics
Hospitals
126.4 Sexually transmitted infections: vaginal discharge
syndrome
Public Facilities – total
Health Centers
Hospitals
Private not for profit Facilities – total
Clinics
Hospitals
Private for profit Facilities – total
Clinics
Hospitals
126.5 Sexually transmitted infections: Lower abdominal
pain syndrome (pelvic inflammatory disease PID)
Public Facilities – total
Health Centers
Hospitals
Private not for profit Facilities – total
Clinics
Hospitals
Private for profit Facilities – total
Clinics
103
126.6 Sexually transmitted infections: scrotal swelling
syndrome
Public Facilities – total
Health Centers
Hospitals
Private not for profit Facilities – total
Clinics
Hospitals
Private for profit Facilities – total
Clinics
Hospitals
126.7 Sexually transmitted infections: inguinal bubo
swelling (swollen glands)
Public Facilities – total
Health Centers
Hospitals
Private not for profit Facilities – total
Clinics
Hospitals
Private for profit Facilities – total
Clinics
Hospitals
126.8 Sexually transmitted infections: neonatal
104 Syndromic Management Of Sexually Transmittable Infections-participant manual
conjunctivitis
Public Facilities – total
Health Centers
Hospitals
Private not for profit Facilities – total
Clinics
Hospitals
Private for profit Facilities – total
Clinics
Hospitals
126.9 Sexually transmitted infections: neonatal herpes
Public Facilities – total
Health Centers
Hospitals
Private not for profit Facilities – total
Clinics
Hospitals
Private for profit Facilities – total
Clinics
Hospitals
105
FEDERAL MINISTRY OF HEALTH