Lecture 2. STI For Lecturing

Sexually transmitted
illness (STIs)
Lecture 2
Sadat Mohammed (BSc, MPH/RH)
Email: [email protected]
June, 2024
Debre Berhan University
Learning objectives
Differentiate STI and STD
Discuss:
The magnitude of STI
The public health impact of STI
• Describe syndromic management of STIs
Strategies on prevention and control of STI
Challenges in the STIs prevention and control
Brain storming
• What makes the control of STI is less effective or not have the desire level of
impact?
• What are the Contributing factors increasing transmission of STIs?

Introduction
STI Vs STD
• Some people use the terms STI and STD interchangeably but
they actually have different meaning.
• STI – Infections acquired through sexual intercourse (may be
symptomatic or asymptomatic)
• STD – Symptomatic disease acquired through sexual intercourse
• STI is most commonly used because it applies to both
symptomatic and asymptomatic infections
Introduction
• STIs are caused by more than 30 different pathogens including
bacteria, viruses, protozoa, fungus and ecto-parasites.
 STI: infections of the genital tract of women and men
Three types
1. Sexually transmitted infections (STIs)
 Infections caused by organisms that are passed through sexual activity with an
infected partner.
 E.g Chlamydia, gonorrhea, hepatitis B and C, herpes, HPV, syphilis, trichomoniasis,
and HIV.
 2. Endogenous infections
 Infections that result from an overgrowth of organisms normally present in the vagina.
 not usually sexually transmitted,
 E.g bacterial vaginosis and candidacies.
6
 3. Iatrogenic infections
 Infections introduced into the reproductive tract by a medical procedure
such as menstrual regulation, induced abortion, IUD insertion, or
childbirth.
 These three types of RTIs overlap and should be considered together.

 Some STIs, like gonorrhea or Chlamydia, can be spread in the reproductive tract if
not treated prior to a procedure.
 In addition, some non-sexual infections, such as candidiasis, can be passed on

through sexual activity.
7
Main STI Pathogens
 Main Sexually  The main sexually
transmitted bacteria CLASSIFICAT transmitted viruses are:
IONS BASED
 Neisseria gonorrhoeae ON THE
 HIV (causes AIDS)
(causes gonorrhoea) CAUSATIVE  HSV (causes genital herpes)
AGENT
 Chlamydia trachomatis
(chlamydial infections)
3 Types  Human papilloma virus
(causes genital warts)
 Treponema pallidum
(causes syphilis)  Hepatitis B virus
 Haemophilus ducreyi  Cytomegalovirus
(causes chancroid)
The main parasitic organisms
Trichomonas vaginalis (causes vaginal trichomoniasis)
8
Epidemiology OF STIs
• HIV, viral hepatitis and sexually transmitted infections (STIs) are

major public health threats worldwide.
• More than 1 million sexually transmitted infections (STIs) are

acquired every day worldwide, the majority of which are
asymptomatic.
• Each year there are an estimated 374 million new infections with
1 of 4 curable STIs: chlamydia, gonorrhoea, syphilis and
trichomoniasis.
• More than 500 million people 15–49 years are estimated to have
a genital infection with herpes simplex virus (HSV or herpes).
EPIDEMIOLOGY OF STIs
• Human papillomavirus (HPV) infection is associated with over

311 000 cervical cancer deaths each year.
• Almost 1 million pregnant women were estimated to be

infected with syphilis, resulting in over 350 000 adverse birth
outcomes.
• More than 30 different bacteria, viruses and parasites are

known to be transmitted through sexual contact, including
vaginal, anal and oral sex.
• Some STIs can also be transmitted from mother-to-child during

pregnancy, childbirth and breastfeeding.
• Eight pathogens are linked to the greatest incidence of STIs.

• Of these, 4 are currently curable: syphilis, gonorrhoea,
chlamydia and trichomoniasis.
• The other 4 are incurable viral infections: hepatitis B, herpes

simplex virus (HSV), HIV and human papillomavirus (HPV).
Diagnosis of STIs
• STIs are often asymptomatic.

• When symptoms occur, they can be non-specific.
• Moreover, laboratory tests rely on blood, urine or anatomical
samples.
Diagnosis of STIs
• Accurate diagnostic tests for STIs (using molecular technology)

are widely used in high-income countries.
• These are especially useful for the diagnosis of asymptomatic

infections.
• However, they are largely unavailable in low- and middle-income

countries (LMICs) for chlamydia and gonorrhoea
Diagnosis of STIs
• On the other hand, inexpensive, rapid tests are available for

syphilis, hepatitis B and HIV.
• The rapid syphilis test and rapid dual HIV/syphilis tests are used
in several resource-limited settings.
Approaches to STI diagnosis
Classical approaches
 Etiologic diagnosis – using lab to identify the causative agent
 Clinical diagnosis –using clinical experience to identify causative agent
17
Etiologic diagnosis
Advantages Disadvantages
 Requires skilled personnel & consistent
 Avoids over treatment supplies
 Satisfies patients who feel not  Treatment does not begin until results are
properly attended to available
 Can be extended as screening for the  time consuming & expensive
asymptomatic  Testing facilities are not available at 10 level
 Lab. results often not reliable
 Mixed infections often overlooked
 Miss-treated/untreated infections can lead to
complications & continued transmission 18
Clinical Diagnosis:
Disadvantages:-
Advantages Advantages:-
 Requires high clinical acumen
 Saves time for patients  Most STIs cause similar symptoms
 Reduces laboratory expenses  Mixed infections are common &
failure to treat may lead to serious
complications
 Doesn’t identify asymptomatic
STIs
19
Syndromic management of STIs
• LMICs rely on identifying consistent, easily recognizable signs and

symptoms to guide treatment, without the use of laboratory tests.
• This approach – syndromic management – often relies on clinical

algorithms and allows health workers to diagnose a specific
infection based on observed syndromes (e.g., vaginal/urethral
discharge, anogenital ulcers, etc)
Syndromic: Treat the seven syndromes
SYNDROME MOST COMMON CAUSE
Vaginal discharge Vaginitis (trichomoniasis, candidacies)

Cervicitis (gonorrhea, Chlamydia)
Urethral discharge in men Gonorrhea, chlamydia
Genital ulcer Syphilis, chancroid, herpes
Lower abdominal pain Gonorrhea, chlamydia, mixed anaerobes
Scrotal swelling Gonorrhea, chlamydia

Inguinal bubo LGV, Chancroid
Neonatal conjunctivitis Gonorrhea, Chlamydia
22
Principles of Syndromic Approach
 STI sign & symptoms are rarely specific to a particular causative agent
 Laboratories are either non-existent or non functional due to lack of resources
 Dual infections are quite common & both clinician & laboratory may miss one of
them
 Waiting time for lab. results may discourage some patients
 Failure of cure at first contact
23
Advantages and disadvantages of syndromic management
of STIs
Advantages and disadvantages of syndromic management
of STIs
The Main Aims of STIs
Prevention
and Control are:-
• Interrupting the transmission of STIs

• Prevent development of disease and complications
• Reducing the risk of acquiring and transmitting HIV
26
Prevention and Control of STIs
Involves
• Early diagnosis and treatment

• Promotion of safer sexual behavior
• Promotion of health care-seeking behavior,
• Targeting vulnerable groups 27
Primary prevention
Safer sexual behaviors
• Abstinence from sexual activity altogether/

delaying the age of sexual debut
• Life-long mutual monogamy

• Correct and consistent use of condoms . 28
Secondary prevention
• Promoting STI care-seeking behavior,

• Early diagnosis and prompt and correct
treatment using comprehensive STI syndromic
management
• Case finding and screening:
• Integration of STI services within primary care
29
Biological factors
Factors increasing transmission
• Age, young age more susceptible
• Sex, women more easily infected than males
of STIs
• Immune status
• Biological factors
Behavioral factors
• Behavioral • Changing sexual partners frequently
• Having more than one sexual partner
• Socio-cultural factors
• Having sex with ‘casual’ partners, sex-workers or their
clients
Socio-cultural factors • Having unprotected penetrative sexual intercourse in a
• In most cultures women have very situation
little where either
decision partner has an infection
making
power over sexual practices and • Use of alcohol
choices, or other
including usedrugs
of before or during sex
condoms
• Women tend to be economically dependent on their male
partners and are therefore more likely to tolerate men’s risky
behaviour
• 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
Challenges of STIs Control and
prevention
• Health system factors
Biological factors
Socio-cultural & behavioral factors

Challenges of STIs Control and
prevention
Health service may be: • Health services may not have
• Unavailable, effective drugs
• Too far away, • Difficulty of partner
• Expensive, management
• Ill equipped,
• Services may not be integrated
• Not user friendly or considered within primary care clinics:
stigmatizing
maternal, child health, family
• There may be little emphasis on
education planning and ART clinics
Socio-cultural & behavioral factors
• Reluctance to seek health care • The social stigma often
• Ignorance or misinformation attached to STI
• A preference for alternative • Failure to take full prescribed

health care service course of treatment
• Reluctance to follow safe sex • Difficulty of notifying sexual

practices partners
Biological factors
70%-80% of infected women may be
asymptomatic and so will not seek treatment
Such people will continue to be infected, risking
complications and perhaps infecting others
34
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Sexually transmitted

• What are the Contributing factors increasing transmission of STIs?

 These three types of RTIs overlap and should be considered together.

 In addition, some non-sexual infections, such as candidiasis, can be passed on

• HIV, viral hepatitis and sexually transmitted infections (STIs) are

• More than 1 million sexually transmitted infections (STIs) are

• Human papillomavirus (HPV) infection is associated with over

• Almost 1 million pregnant women were estimated to be

• More than 30 different bacteria, viruses and parasites are

• Some STIs can also be transmitted from mother-to-child during

• Eight pathogens are linked to the greatest incidence of STIs.

• The other 4 are incurable viral infections: hepatitis B, herpes

• STIs are often asymptomatic.

• Accurate diagnostic tests for STIs (using molecular technology)

• These are especially useful for the diagnosis of asymptomatic

• However, they are largely unavailable in low- and middle-income

• On the other hand, inexpensive, rapid tests are available for

 Clinical diagnosis –using clinical experience to identify causative agent

• LMICs rely on identifying consistent, easily recognizable signs and

• This approach – syndromic management – often relies on clinical

SYNDROME MOST COMMON CAUSE

Vaginal discharge Vaginitis (trichomoniasis, candidacies)

Scrotal swelling Gonorrhea, chlamydia

• Interrupting the transmission of STIs

• Early diagnosis and treatment

Safer sexual behaviors

• Abstinence from sexual activity altogether/

• Life-long mutual monogamy

• Promoting STI care-seeking behavior,

• Health system factors

Socio-cultural & behavioral factors

• A preference for alternative • Failure to take full prescribed

• Reluctance to follow safe sex • Difficulty of notifying sexual

complications and perhaps infecting others

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