STI Update: Epidemiology, Prevention and Treatment

1
STI Update Epidemiology, Prevention and Treatment

• Gary Rogers MBBS, MGPPsych, PhD
• Associate Professor of Medical Education
• School of Medicine
• Griffith University
• Queensland
• Australia

2
Brainstorm

• What are the most common sexually transmissible
  infections in the Pacific Islands currently?
• What are the most significant sexually
  transmissible infections in the Pacific Islands
  currently?

3
Most common?

1. Human papilloma virus infection
2. Syphilis
3. Genital herpes
4. Genital chlamydiosis
5. HIV
6. Gonorrhoea
7. Hepatitis B
8. Trichomoniasis

4
Prevalence in Pacific
Condition Prevalence Islands Comments
Human Papilloma Virus 25.6 (20.9 HR) Hawaii1 Routine OB-GYN appoinments and normal cervical cytology 15 annual incidence (50-80 lifetime prevalence)
Syphilis 3.4 10 FJ,KB,SM,SI, TO,VT2 SI Seroreactivity lifetime prevalence
Genital herpes 30 27.4 Vanuatu3 PNG4 Preganant women HSV-2 seroprevalence (HSV-1 seroprevalence 100) Remote villages (HSV-2 sero)
HIV 0.013 21 PICTs5 (excl PNG) SPC data based on diagnosed cases population

• Goodman MT et al. Prevalence, Acquisition, and
  Clearance of Cervical Human Papillomavirus
  Infection among Women with Normal Cytology
  Hawaii Human Papillomavirus Cohort Study. Cancer
  Res 68(21)8813-24, 2008.
• Cliffe SJ et al. Chlamydia in the Pacific Region,
  the Silent Epidemic. Sex Trans Dis 35(9)801-6,
  2008
• Haddow LJ et al. Herpes Simplex Virus Type 2
  (HSV-2) Infection in Women Attending an Antenatal
  Clinic in the South Pacific Island Nation of
  Vanuatu. Sex Trans Dis 34(5)258-61
• Suligoi B et al. Infection with human
  immunodeficiency virus, herpes simplex virus type
  2, and human herpes virus 8 in remote villages of
  southwestern Papua New Guinea. Am J Trop Med Hyg.
  72(1) 336, 2005.
• SPC. Cumulative reported HIV, AIDS and AIDS
  deaths cases, incidence rates and gender, plus
  cases with missing details, 2007

5
Prevalence in Pacific
Condition Prevalence Islands Comments
Human Papilloma Virus 25.6 (20.9 HR) Hawaii1 Routine OB-GYN appoinments and normal cervical cytology 15 annual incidence (50-80 lifetime prevalence)
Syphilis 3.4 10 FJ,KB,SM,SI, TO,VT2 SI2 Seroreactivity lifetime prevalence
Genital herpes 30 27.4 Vanuatu3 PNG4 Preganant women HSV-2 seroprevalence (HSV-1 seroprevalence 100) Remote villages (HSV-2 sero)
HIV 0.013 21 PICTs5 (excl PNG) SPC data based on diagnosed cases population

1. Goodman MT et al. Prevalence, Acquisition, and
   Clearance of Cervical Human Papillomavirus
   Infection among Women with Normal Cytology
   Hawaii Human Papillomavirus Cohort Study. Cancer
   Res 68(21)8813-24, 2008.
2. Cliffe SJ et al. Chlamydia in the Pacific Region,
   the Silent Epidemic. Sex Trans Dis 35(9)801-6,
   2008
3. Haddow LJ et al. Herpes Simplex Virus Type 2
   (HSV-2) Infection in Women Attending an Antenatal
   Clinic in the South Pacific Island Nation of
   Vanuatu. Sex Trans Dis 34(5)258-61
4. Suligoi B et al. Infection with human
   immunodeficiency virus, herpes simplex virus type
   2, and human herpes virus 8 in remote villages of
   southwestern Papua New Guinea. Am J Trop Med Hyg.
   72(1) 336, 2005.
5. SPC. Cumulative reported HIV, AIDS and AIDS
   deaths cases, incidence rates and gender, plus
   cases with missing details, 2007

6
Prevalence in Pacific
Condition Prevalence Islands Comments
Human Papilloma Virus 25.6 (20.9 HR) Hawaii1 Routine OB-GYN appoinments and normal cervical cytology 15 annual incidence (50-80 lifetime prevalence)
Syphilis 3.4 10 FJ,KB,SM,SI, TO,VT2 SI2 Seroreactivity lifetime prevalence
Genital herpes 30 27.4 Vanuatu3 PNG4 Preganant women HSV-2 seroprevalence (HSV-1 seroprevalence 100) Remote villages (HSV-2 sero)
HIV 0.013 21 PICTs5 (excl PNG) SPC data based on diagnosed cases population

1. Goodman MT et al. Prevalence, Acquisition, and
   Clearance of Cervical Human Papillomavirus
   Infection among Women with Normal Cytology
   Hawaii Human Papillomavirus Cohort Study. Cancer
   Res 68(21)8813-24, 2008.
2. Cliffe SJ et al. Chlamydia in the Pacific Region,
   the Silent Epidemic. Sex Trans Dis 35(9)801-6,
   2008
3. Haddow LJ et al. Herpes Simplex Virus Type 2
   (HSV-2) Infection in Women Attending an Antenatal
   Clinic in the South Pacific Island Nation of
   Vanuatu. Sex Trans Dis 34(5)258-61
4. Suligoi B et al. Infection with human
   immunodeficiency virus, herpes simplex virus type
   2, and human herpes virus 8 in remote villages of
   southwestern Papua New Guinea. Am J Trop Med Hyg.
   72(1) 336, 2005.
5. SPC. Cumulative reported HIV, AIDS and AIDS
   deaths cases, incidence rates and gender, plus
   cases with missing details, 2007

7
Prevalence in Pacific
Condition Prevalence Islands Comments
Human Papilloma Virus 25.6 (20.9 HR) Hawaii1 Routine OB-GYN appoinments and normal cervical cytology 15 annual incidence (50-80 lifetime prevalence)
Syphilis 3.4 10 FJ,KB,SM,SI, TO,VT2 SI2 Seroreactivity lifetime prevalence
Genital herpes 30 27.4 Vanuatu3 PNG4 Preganant women HSV-2 seroprevalence (HSV-1 seroprevalence 100) Remote villages (HSV-2 sero)
HIV 0.013 21 PICTs5 (excl PNG) SPC data based on diagnosed cases population

1. Goodman MT et al. Prevalence, Acquisition, and
   Clearance of Cervical Human Papillomavirus
   Infection among Women with Normal Cytology
   Hawaii Human Papillomavirus Cohort Study. Cancer
   Res 68(21)8813-24, 2008.
2. Cliffe SJ et al. Chlamydia in the Pacific Region,
   the Silent Epidemic. Sex Trans Dis 35(9)801-6,
   2008
3. Haddow LJ et al. Herpes Simplex Virus Type 2
   (HSV-2) Infection in Women Attending an Antenatal
   Clinic in the South Pacific Island Nation of
   Vanuatu. Sex Trans Dis 34(5)258-61
4. Suligoi B et al. Infection with human
   immunodeficiency virus, herpes simplex virus type
   2, and human herpes virus 8 in remote villages of
   southwestern Papua New Guinea. Am J Trop Med Hyg.
   72(1) 336, 2005.
5. SPC. Cumulative reported HIV, AIDS and AIDS
   deaths cases, incidence rates and gender, plus
   cases with missing details, 2007

8
Prevalence in Pacific
Condition Prevalence Islands Comments
Human Papilloma Virus 25.6 (20.9 HR) Hawaii1 Routine OB-GYN appoinments and normal cervical cytology 15 annual incidence (50-80 lifetime prevalence)
Syphilis 3.4 10 FJ,KB,SM,SI, TO,VT2 SI2 Seroreactivity lifetime prevalence
Genital herpes 30 27.4 Vanuatu3 PNG4 Preganant women HSV-2 seroprevalence (HSV-1 seroprevalence 100) Remote villages (HSV-2 sero)
HIV 0.013 21 PICTs5 (excl PNG) SPC data based on diagnosed cases population

1. Goodman MT et al. Prevalence, Acquisition, and
   Clearance of Cervical Human Papillomavirus
   Infection among Women with Normal Cytology
   Hawaii Human Papillomavirus Cohort Study. Cancer
   Res 68(21)8813-24, 2008.
2. Cliffe SJ et al. Chlamydia in the Pacific Region,
   the Silent Epidemic. Sex Trans Dis 35(9)801-6,
   2008
3. Haddow LJ et al. Herpes Simplex Virus Type 2
   (HSV-2) Infection in Women Attending an Antenatal
   Clinic in the South Pacific Island Nation of
   Vanuatu. Sex Trans Dis 34(5)258-61
4. Suligoi B et al. Infection with human
   immunodeficiency virus, herpes simplex virus type
   2, and human herpes virus 8 in remote villages of
   southwestern Papua New Guinea. Am J Trop Med Hyg.
   72(1) 336, 2005.
5. SPC. Cumulative reported HIV, AIDS and AIDS
   deaths cases, incidence rates and gender, plus
   cases with missing details, 2007

9
Prevalence in Pacific
Condition Prevalence Islands Comments
Human Papilloma Virus 25.6 (20.9 HR) Hawaii1 Routine OB-GYN appoinments and normal cervical cytology 15 annual incidence (50-80 lifetime prevalence)
Syphilis 3.4 10 FJ,KB,SM,SI, TO,VT2 SI Seroreactivity lifetime prevalence
Genital herpes 30 27.4 Vanuatu3 PNG4 Preganant women HSV-2 seroprevalence (HSV-1 seroprevalence 100) Remote villages (HSV-2 sero)
HIV 0.013 21 PICTs5 (excl PNG) SPC data based on diagnosed cases population

• Goodman MT et al. Prevalence, Acquisition, and
  Clearance of Cervical Human Papillomavirus
  Infection among Women with Normal Cytology
  Hawaii Human Papillomavirus Cohort Study. Cancer
  Res 68(21)8813-24, 2008.
• Cliffe SJ et al. Chlamydia in the Pacific Region,
  the Silent Epidemic. Sex Trans Dis 35(9)801-6,
  2008
• Haddow LJ et al. Herpes Simplex Virus Type 2
  (HSV-2) Infection in Women Attending an Antenatal
  Clinic in the South Pacific Island Nation of
  Vanuatu. Sex Trans Dis 34(5)258-61
• Suligoi B et al. Infection with human
  immunodeficiency virus, herpes simplex virus type
  2, and human herpes virus 8 in remote villages of
  southwestern Papua New Guinea. Am J Trop Med Hyg.
  72(1) 336, 2005.
• SPC. Cumulative reported HIV, AIDS and AIDS
  deaths cases, incidence rates and gender, plus
  cases with missing details to 2007, 2009.

10
Prevalence in Pacific
Condition Prevalence Islands Comments
Genital chlamydiosis 18 11-17 29 12.8 (40 FJ,KB,SM,SI, TO,VT1 Palau2 Fiji1 Tonga 20083 Samoa1 Pregnant women (SGS) Pregnant woman lt25 years)
Hepatitis B 10 11.8 Palau Tonga3 Pregnant women (SGS)
Gonorrhoea 1.7 1.2 (5.9 FJ,KB,SM,SI, TO,VT1 Tonga 20083 Samoa1 Pregnant women (SGS) Pregnant woman lt25 years)
Trichomoniasis 25.3 14.7 43.4 Vanuatu4 Vila Ambae Women having pap smears

1. Cliffe SJ et al. Chlamydia in the Pacific Region,
   the Silent Epidemic. Sex Trans Dis 35(9)801-6,
   2008
2. Gold J. Republic of Palau Second generation HIV
   and STI surveillance surveys 2005 - 2006 final
   report. PRHP, 2008.
3. Fonua L et al. Second generation HIV surveillance
   in antenatal clinic attendees and youth, Tonga.
   2008
4. Fotinatos N et al. Trichomonas vaginalis in
   Vanuatu Aust J Rural Health 16(1) 237, 2008.

11
Prevalence in Pacific
Condition Prevalence Islands Comments
Genital chlamydiosis 18 11-17 29 12.8 (40 FJ,KB,SM,SI, TO,VT1 Palau2 Fiji1 Tonga 20083 Samoa1 Pregnant women (SGS) Pregnant woman lt25 years)
Hepatitis B 10 11.8 Palau Tonga3 Pregnant women (SGS)
Gonorrhoea 1.7 1.2 (5.9 FJ,KB,SM,SI, TO,VT1 Tonga 20083 Samoa1 Pregnant women (SGS) Pregnant woman lt25 years)
Trichomoniasis 25.3 14.7 43.4 Vanuatu4 Vila Ambae Women having pap smears

1. Cliffe SJ et al. Chlamydia in the Pacific Region,
   the Silent Epidemic. Sex Trans Dis 35(9)801-6,
   2008
2. Gold J. Republic of Palau Second generation HIV
   and STI surveillance surveys 2005 - 2006 final
   report. PRHP, 2008.
3. Fonua L et al. Second generation HIV surveillance
   in antenatal clinic attendees and youth, Tonga.
   2008
4. Fotinatos N et al. Trichomonas vaginalis in
   Vanuatu Aust J Rural Health 16(1) 237, 2008.

12
Prevalence in Pacific
Condition Prevalence Islands Comments
Genital chlamydiosis 18 11-17 29 12.8 (40 FJ,KB,SM,SI, TO,VT1 Palau2 Fiji1 Tonga 20083 Samoa1 Pregnant women (SGS) Pregnant woman lt25 years)
Hepatitis B 10 11.8 Palau Tonga3 Pregnant women (SGS)
Gonorrhoea 1.7 1.2 (5.9 FJ,KB,SM,SI, TO,VT1 Tonga 20083 Samoa1 Pregnant women (SGS) Pregnant woman lt25 years)
Trichomoniasis 25.3 14.7 43.4 Vanuatu4 Vila Ambae Women having pap smears

1. Cliffe SJ et al. Chlamydia in the Pacific Region,
   the Silent Epidemic. Sex Trans Dis 35(9)801-6,
   2008
2. Gold J. Republic of Palau Second generation HIV
   and STI surveillance surveys 2005 - 2006 final
   report. PRHP, 2008.
3. Fonua L et al. Second generation HIV surveillance
   in antenatal clinic attendees and youth, Tonga.
   2008
4. Fotinatos N et al. Trichomonas vaginalis in
   Vanuatu Aust J Rural Health 16(1) 237, 2008.

13
Prevalence in Pacific
Condition Prevalence Islands Comments
Genital chlamydiosis 18 11-17 29 12.8 (40 FJ,KB,SM,SI, TO,VT1 Palau2 Fiji1 Tonga 20083 Samoa1 Pregnant women (SGS) Pregnant woman lt25 years)
Hepatitis B 10 11.8 Palau Tonga3 Pregnant women (SGS)
Gonorrhoea 1.7 1.2 (5.9 FJ,KB,SM,SI, TO,VT1 Tonga 20083 Samoa1 Pregnant women (SGS) Pregnant woman lt25 years)
Trichomoniasis 25.3 14.7 43.4 Vanuatu4 Vila Ambae Women having pap smears

1. Cliffe SJ et al. Chlamydia in the Pacific Region,
   the Silent Epidemic. Sex Trans Dis 35(9)801-6,
   2008
2. Gold J. Republic of Palau Second generation HIV
   and STI surveillance surveys 2005 - 2006 final
   report. PRHP, 2008.
3. Fonua L et al. Second generation HIV surveillance
   in antenatal clinic attendees and youth, Tonga.
   2008
4. Fotinatos N et al. Trichomonas vaginalis in
   Vanuatu Aust J Rural Health 16(1) 237, 2008.

14
Prevalence in Pacific
Condition Prevalence Islands Comments
Genital chlamydiosis 18 11-17 29 12.8 (40 FJ,KB,SM,SI, TO,VT1 Palau2 Fiji1 Tonga 20083 Samoa1 Pregnant women (SGS) Pregnant woman lt25 years)
Hepatitis B 10 11.8 Palau Tonga3 Pregnant women (SGS)
Gonorrhoea 1.7 1.2 (5.9 FJ,KB,SM,SI, TO,VT1 Tonga 20083 Samoa1 Pregnant women (SGS) Pregnant woman lt25 years)
Trichomoniasis 25.3 14.7 43.4 Vanuatu4 Vila Ambae Women having pap smears

1. Cliffe SJ et al. Chlamydia in the Pacific Region,
   the Silent Epidemic. Sex Trans Dis 35(9)801-6,
   2008
2. Gold J. Republic of Palau Second generation HIV
   and STI surveillance surveys 2005 - 2006 final
   report. PRHP, 2008.
3. Fonua L et al. Second generation HIV surveillance
   in antenatal clinic attendees and youth, Tonga.
   2008
4. Fotinatos N et al. Trichomonas vaginalis in
   Vanuatu Aust J Rural Health 16(1) 237, 2008.

15
Prevalence in Pacific
Condition Prevalence Islands Comments
Genital chlamydiosis 18 11-17 29 12.8 (40 FJ,KB,SM,SI, TO,VT1 Palau2 Fiji1 Tonga 20083 Samoa1 Pregnant women (SGS) Pregnant woman lt25 years)
Hepatitis B 10 11.8 Palau2 Tonga3 Pregnant women (SGS)
Gonorrhoea 1.7 1.2 (5.9 FJ,KB,SM,SI, TO,VT1 Tonga 20083 Samoa1 Pregnant women (SGS) Pregnant woman lt25 years)
Trichomoniasis 25.3 14.7 43.4 Vanuatu4 Vila Ambae Women having pap smears

1. Cliffe SJ et al. Chlamydia in the Pacific Region,
   the Silent Epidemic. Sex Trans Dis 35(9)801-6,
   2008
2. Gold J. Republic of Palau Second generation HIV
   and STI surveillance surveys 2005 - 2006 final
   report. PRHP, 2008.
3. Fonua L et al. Second generation HIV surveillance
   in antenatal clinic attendees and youth, Tonga.
   2008
4. Fotinatos N et al. Trichomonas vaginalis in
   Vanuatu Aust J Rural Health 16(1) 237, 2008.

16
Prevalence in Pacific
Condition Prevalence Islands Comments
Genital chlamydiosis 18 11-17 29 12.8 (40 FJ,KB,SM,SI, TO,VT1 Palau2 Fiji1 Tonga 20083 Samoa1 Pregnant women (SGS) Pregnant woman lt25 years)
Hepatitis B 10 11.8 Palau2 Tonga3 Pregnant women (SGS)
Gonorrhoea 1.7 1.2 (5.9 FJ,KB,SM,SI, TO,VT1 Tonga 20083 Samoa1 Pregnant women (SGS) Pregnant woman lt25 years)
Trichomoniasis 25.3 14.7 43.4 Vanuatu4 Vila Ambae Women having pap smears

1. Cliffe SJ et al. Chlamydia in the Pacific Region,
   the Silent Epidemic. Sex Trans Dis 35(9)801-6,
   2008
2. Gold J. Republic of Palau Second generation HIV
   and STI surveillance surveys 2005 - 2006 final
   report. PRHP, 2008.
3. Fonua L et al. Second generation HIV surveillance
   in antenatal clinic attendees and youth, Tonga.
   2008
4. Fotinatos N et al. Trichomonas vaginalis in
   Vanuatu Aust J Rural Health 16(1) 237, 2008.

17
Prevalence in Pacific
Condition Prevalence Islands Comments
Genital chlamydiosis 18 11-17 29 12.8 (40 FJ,KB,SM,SI, TO,VT1 Palau2 Fiji1 Tonga 20083 Samoa1 Pregnant women (SGS) Pregnant woman lt25 years)
Hepatitis B 10 11.8 Palau Tonga3 Pregnant women (SGS)
Gonorrhoea 1.7 1.2 (5.9 FJ,KB,SM,SI, TO,VT1 Tonga 20083 Samoa1 Pregnant women (SGS) Pregnant woman lt25 years)
Trichomoniasis 25.3 14.7 43.4 Vanuatu4 Vila Ambae Women having pap smears

1. Cliffe SJ et al. Chlamydia in the Pacific Region,
   the Silent Epidemic. Sex Trans Dis 35(9)801-6,
   2008
2. Gold J. Republic of Palau Second generation HIV
   and STI surveillance surveys 2005 - 2006 final
   report. PRHP, 2008.
3. Fonua L et al. Second generation HIV surveillance
   in antenatal clinic attendees and youth, Tonga.
   2008
4. Fotinatos N et al. Trichomonas vaginalis in
   Vanuatu Aust J Rural Health 16(1) 237, 2008.

18
Prevalence in Pacific
Condition Prevalence Islands Comments
Genital chlamydiosis 18 11-17 29 12.8 (40 FJ,KB,SM,SI, TO,VT1 Palau2 Fiji1 Tonga 20083 Samoa1 Pregnant women (SGS) Pregnant woman lt25 years)
Hepatitis B 10 11.8 Palau Tonga3 Pregnant women (SGS)
Gonorrhoea 1.7 1.2 (5.9 FJ,KB,SM,SI, TO,VT1 Tonga 20083 Samoa1 Pregnant women (SGS) Pregnant woman lt25 years)
Trichomoniasis 25.3 14.7 43.4 Vanuatu4 Vila Ambae Women having pap smears

1. Cliffe SJ et al. Chlamydia in the Pacific Region,
   the Silent Epidemic. Sex Trans Dis 35(9)801-6,
   2008
2. Gold J. Republic of Palau Second generation HIV
   and STI surveillance surveys 2005 - 2006 final
   report. PRHP, 2008.
3. Fonua L et al. Second generation HIV surveillance
   in antenatal clinic attendees and youth, Tonga.
   2008
4. Fotinatos N et al. Trichomonas vaginalis in
   Vanuatu Aust J Rural Health 16(1) 237, 2008.

19
Prevalence in Pacific
Condition Prevalence Islands Comments
Genital chlamydiosis 18 11-17 29 12.8 (40 FJ,KB,SM,SI, TO,VT1 Palau2 Fiji1 Tonga 20083 Samoa1 Pregnant women (SGS) Pregnant woman lt25 years)
Hepatitis B 10 11.8 Palau Tonga3 Pregnant women (SGS)
Gonorrhoea 1.7 1.2 (5.9 FJ,KB,SM,SI, TO,VT1 Tonga 20083 Samoa1 Pregnant women (SGS) Pregnant woman lt25 years)
Trichomoniasis 25.3 14.7 43.4 Vanuatu4 Vila Ambae Women having pap smears

1. Cliffe SJ et al. Chlamydia in the Pacific Region,
   the Silent Epidemic. Sex Trans Dis 35(9)801-6,
   2008
2. Gold J. Republic of Palau Second generation HIV
   and STI surveillance surveys 2005 - 2006 final
   report. PRHP, 2008.
3. Fonua L et al. Second generation HIV surveillance
   in antenatal clinic attendees and youth, Tonga.
   2008
4. Fotinatos N et al. Trichomonas vaginalis in
   Vanuatu Aust J Rural Health 16(1) 237, 2008.

20
Prevalence in Pacific
Condition Prevalence Islands Comments
Genital chlamydiosis 18 11-17 29 12.8 (40 FJ,KB,SM,SI, TO,VT1 Palau2 Fiji1 Tonga 20083 Samoa1 Pregnant women (SGS) Pregnant woman lt25 years)
Hepatitis B 10 11.8 Palau Tonga3 Pregnant women (SGS)
Gonorrhoea 1.7 1.2 (5.9 FJ,KB,SM,SI, TO,VT1 Tonga 20083 Samoa1 Pregnant women (SGS) Pregnant woman lt25 years)
Trichomoniasis 25.3 14.7 43.4 Vanuatu4 Vila Ambae Women having pap smears

1. Cliffe SJ et al. Chlamydia in the Pacific Region,
   the Silent Epidemic. Sex Trans Dis 35(9)801-6,
   2008
2. Gold J. Republic of Palau Second generation HIV
   and STI surveillance surveys 2005 - 2006 final
   report. PRHP, 2008.
3. Fonua L et al. Second generation HIV surveillance
   in antenatal clinic attendees and youth, Tonga.
   2008
4. Fotinatos N et al. Trichomonas vaginalis in
   Vanuatu Aust J Rural Health 16(1) 237, 2008.

21
Prevalence in Pacific
Condition Prevalence Islands Comments
Genital chlamydiosis 18 11-17 29 12.8 (40 FJ,KB,SM,SI, TO,VT1 Palau2 Fiji1 Tonga 20083 Samoa1 Pregnant women (SGS) Pregnant woman lt25 years)
Hepatitis B 10 11.8 Palau Tonga3 Pregnant women (SGS)
Gonorrhoea 1.7 1.2 (5.9 FJ,KB,SM,SI, TO,VT1 Tonga 20083 Samoa1 Pregnant women (SGS) Pregnant woman lt25 years)
Trichomoniasis 25.3 14.7 43.4 Vanuatu4 Vila Ambae Women having pap smears

1. Cliffe SJ et al. Chlamydia in the Pacific Region,
   the Silent Epidemic. Sex Trans Dis 35(9)801-6,
   2008
2. Gold J. Republic of Palau Second generation HIV
   and STI surveillance surveys 2005 - 2006 final
   report. PRHP, 2008.
3. Fonua L et al. Second generation HIV surveillance
   in antenatal clinic attendees and youth, Tonga.
   2008
4. Fotinatos N et al. Trichomonas vaginalis in
   Vanuatu Aust J Rural Health 16(1) 237, 2008.

22
Most significant?

1. Human papilloma virus infection
2. Syphilis
3. Genital herpes
4. Genital chlamydiosis
5. HIV
6. Gonorrhoea
7. Hepatitis B
8. Trichomoniasis

23
Significance

• In relation to the health of the population of a
  country or territory in general ...
• ... or of particular populations
• Determined by a range of factors
• Prevalence
• Severity of acute symptomatology
• Transmissibility preventability
• Curability
• Long term consequences or complications

24
Human Papilloma Virus

• Non-enveloped DNA virus
• Replicates exclusively in epithelial cells
• Transmitted by skin to skin contact with
  microabrasions
• Enters cell and modifies cell cycle to maxmise
  further transmissibility
• Naturally cleared in months to years
• Median duration of infection 8 months, 9
  persistent after 2 years1
• Persistence related to
• Infection with multiple types
• Infection with high risk types

1. Ho GY et al. Natural history of cervicovaginal
   papilloma virus infection in young women. N Engl
   J Med 338(7)423-8, 1998

25
HPV associated disease

• gt100 genetically related types
• Different types adapted for different skin areas
• Types 16 18 (and others) strongly associated
  with cervical carcinoma
• Types 6 11 (and others) associated with visible
  anogenital warts
• Some types also associated with anal, penile and
  oral cancers
• Islands experience of cancer of cervix and
  anogenital warts

26
HPV genital warts
27
Genital warts diagnosis
28
Genital warts treatment

• Lots of different approaches nothing is
  perfect!
• Most treatment is cosmetic not curative
• Very high recurrence rates
• Imiquimod cream (Aldara)
• Induces local immune response
• 5 cream applied 3x/week for up to 16 wks
• Response is delayed
• Lower recurrence rate
• Contraindicated in pregnancy
• Expensive!

29
First line treatment in your centre?

1. Podophylotoxin
2. Diathermy
3. Cryotherapy
4. Imiquimod
5. Surgical excision
6. Nothing
7. Something else

30
My favourite treatment
31
HPV Cervical cancer
32
HPV Cervical cancer
Population Period Incidence/100,000
French polynesian women 1990-1995 23.21
Hawaiian Indigenous Asian women 1973-96 6.42
Hawaiian white women 1973-96 6.92
US white women 1973-96 6.32
Global estimate 2002 16

1. Gleize L et al. Cancer registry of French
   Polynesia Results for the 19901995 period among
   native and immigrant population. European Journal
   of Epidemiology 16 661-7, 2000.
2. Frish M, Goodman MT. Human Papillomavirus-Associat
   ed Carcinomas in Hawaii and the Mainland U.S.
   Cancer 88(6)1464-9, 2000.
3. GLOBOCAN database.

33
HPV Cervical cancer
Population Period Incidence/100,000
French polynesian women 1990-1995 23.21
Hawaiian Indigenous Asian women 1973-96 6.42
Hawaiian white women 1973-96 6.92
US white women 1973-96 6.32
Global estimate 2002 16

1. Gleize L et al. Cancer registry of French
   Polynesia Results for the 19901995 period among
   native and immigrant population. European Journal
   of Epidemiology 16 661-7, 2000.
2. Frish M, Goodman MT. Human Papillomavirus-Associat
   ed Carcinomas in Hawaii and the Mainland U.S.
   Cancer 88(6)1464-9, 2000.
3. GLOBOCAN database.

34
HPV Cervical cancer
Population Period Incidence/100,000
French polynesian women 1990-1995 23.21
Hawaiian Indigenous Asian women 1973-96 6.42
Hawaiian white women 1973-96 6.92
US white women 1973-96 6.32
Global estimate 2002 16

• Importance of screening programs
• Potential impact of HPV vaccines
• Islands experience with Ca cervix, screening
  programs and HPV vaccines (Gardasil, Cervarix)

1. Gleize L et al. Cancer registry of French
   Polynesia Results for the 19901995 period among
   native and immigrant population. European Journal
   of Epidemiology 16 661-7, 2000.
2. Frish M, Goodman MT. Human Papillomavirus-Associat
   ed Carcinomas in Hawaii and the Mainland U.S.
   Cancer 88(6)1464-9, 2000.
3. GLOBOCAN database.

35
Genital herpes

• Caused by two types of DNA viruses herpes simplex
  1 2 (HSV 1 2 HHV 1 2)
• Other herpesviruses that cause human diseases
• HHV3 (Varicella zoster) Chickenpox/shingles
• HHV4 (Ebstein-Barr virus) infectious
  mononucleosis
• HHV5 (Cytomegalovirus)
• HHV6 7 (Roseola infantum)
• HHV8 (Kaposis sarcoma)

36
Genital herpes

• HSV spread by skin to skin or mucosa to mucosa
  contact with friction
• Primary infection at site of entry then lifelong
  infection of sensory dorsal ganglia supplying
  infected skin/mucosa
• Originally
• HSV1 oral cold sores
• HSV2 genital herpes
• Now primary HSV1 is common cause of genital
  herpes in developed countries

37
Genital herpes

• 1 26 days (usually 6 8 days) after first
  acquisition primary infection
• Complications of primary infection include
  urinary retention, aseptic meningitis and rarely
  transverse myelitis
• First clinical episode is not always primary
  infection

38
Genital herpes
39
Clinical course of episode

• Prodromal tingling ? vesicles ? ulcers ? crusts ?
  healing
• All takes 5 7 days but active HSV infection is
  the first 48 hours after that it is just
  healing
• Need to treat episode within first 48 hours or
  not worth it (except in people with HIV)

40
Genital herpes
41
Genital herpes HIV
Relative risk of acquiring HIV based on HSV2
serology, adjusted for age and sexual behavior
Freeman EE et al. Herpes simplex virus 2
infection increases HIV acquisition in men and
women systematic review and meta-analysis of
longitudinal studies. AIDS 20(1) 7383, 2006
42
Genital herpes HIV

• HSV ulcers often coalesce and persist in people
  with HIV

43
Genital herpes treatment
Setting Drug Duration
First episode aciclovir 200mg 5x/day valaciclovir 500mg 1g 2x/day famciclovir 250mg 3x/day 5 10 days
Episodic therapy for recurrent disease (patient initiated) aciclovir 200mg 5x/day valaciclovir 500mg 2x/day famciclovir 125mg 2x/day 5 days 3 days 5 days
Continuous suppressive therapy aciclovir 400mg 2x/day valaciclovir 500mg 1g daily famciclovir 250mg 2x/day All safe and effective for long term use but expensive!
44
Genital herpes treatment
Setting Drug Duration
First episode aciclovir 200mg 5x/day valaciclovir 500mg 1g 2x/day famciclovir 250mg 3x/day 5 10 days
Episodic therapy for recurrent disease (patient initiated) aciclovir 200mg 5x/day valaciclovir 500mg 2x/day famciclovir 125mg 2x/day 5 days 3 days 5 days
Continuous suppressive therapy aciclovir 400mg 2x/day valaciclovir 500mg 1g daily famciclovir 250mg 2x/day All safe and effective for long term use but expensive!
45
Genital herpes treatment
Setting Drug Duration
First episode aciclovir 200mg 5x/day valaciclovir 500mg 1g 2x/day famciclovir 250mg 3x/day 5 10 days
Episodic therapy for recurrent disease (patient initiated) aciclovir 200mg 5x/day valaciclovir 500mg 2x/day famciclovir 125mg 2x/day 5 days 3 days 5 days
Continuous suppressive therapy aciclovir 400mg 2x/day valaciclovir 500mg 1g daily famciclovir 250mg 2x/day All safe and effective for long term use but expensive!

• Some evidence of survival benefit in people with
  HIV who have HSV if HSV treated
• Continuous suppressive therapy certainly
  worthwhile if symptomatic

46
Take a break!
47
Syphilis

• Caused by a spirochaete (spiral bacterium)
  Treponema pallidum
• Transmitted by skin to skin or mucous membrane
  contact with abrasion
• Four classical stages
• Primary
• Secondary
• Latent
• Tertiary
• Early syphilis is not always classical

48
Primary syphilis

• 9 90 days after exposure
• Appearance of chancre at site of exposure
• Usually single, painless, indurated, sharply
  defined edges
• Can often be missed (if not penile!)
• Disappears in 3 to 6 weeks if not treated

49
Chancres
50
Secondary syphilis

• 6 weeks to 6 months after primary infection
• In 1/3rd chancre will still be present
• Fever, malaise, headache, myalgia
• Rash in 80-90
• Classically dark pink macules
• The great mimic
• Can affect palms and soles
• Transient or can last weeks

51
Secondary syphilis
52
Secondary syphilis

• Mouth ulcers multiple
• Can coalesce ? snail track ulcers
• Rash on scalp can cause hair loss
• Genital lesions condylomata lata
• Rarely neurological complications
• Aseptic meningitis
• Cranial nerve palsies
• More common in people with HIV
• Rarely glomerulonephritis, hepatitis

53
Secondary syphilis
54
Secondary syphilis
55
Latent syphilis

• Asymptomatic
• Now divided into
• Early latent
• Six months to 2 years (1 year in USA)
• Still considered infectious syphilis
• Late latent
• gt 2 years (1 year in USA) and asymptomatic
• Condsidered late syphilis
• Can still be transmitted from mother to child

56
Tertiary syphilis

• Four to 30 years from primary infection
• Approximately 1/3rd of patients untreated
• Gummatous (benign)
• Cardiovascular
• Neurosyphilis

57
Tertiary syphilis
58
Diagnosis of syphilis

• Dark ground illumination of fluid from chancre
• T. pallidum PCR from chancre fluid
• Serological testing
• Non-treponemal tests
• VDRL (Venereal Disease Research Laboratories)
• RPR (Rapid Plasma Reagin)
• Treponemal specific tests
• T. Pallidum haemagglutination assay (TPHA)
• Flourescent treponenal Ab absorbtion (FTA-ABS)
• Treponemal IgG immunoassays

59
Syphilis serology

• Non-specific tests (RPR or VDRL) are either
  reactive or non-reactive ...
• But can measure level of reactivity through
  dilution
• Useful for monitoring response to treatment
• 11 Reactive with 11 dilution (half half)
  but non-reactive at 12 dilution (1/3 to 2/3)
• 164 Still reactive when serum diluted 164
  ie very high reactivity level
• RPR or VDRL can be falsely positive but seldom
  gt14, TP specific test will differentiate

60
Dilution
Reactive
titre 11
Non-reactive
61
Dilution
Reactive
titre 14
Non-reactive
62
Syphilis serology
RPR/VDRL RPR/VDRL titre TPHA
Active infection gt18
Latent syphilis Often lt14
False positive Usually lt14 -
Successful treatment or - 2 titres decrease (e.g. from 116 to 14)
63
Syphilis serology
RPR/VDRL RPR/VDRL titre TPHA
Active infection gt18
Latent syphilis Often lt14
False positive Usually lt14 -
Successful treatment or - 2 titres decrease (e.g. from 116 to 14)
64
Syphilis serology
RPR/VDRL RPR/VDRL titre TPHA
Active infection gt18
Latent syphilis Often lt14
False positive Usually lt14 -
Successful treatment or - 2 titres decrease (e.g. from 116 to 14)
65
Syphilis serology
RPR/VDRL RPR/VDRL titre TPHA
Active infection gt18
Latent syphilis Often lt14
False positive Usually lt14 -
Successful treatment or - 2 titres decrease (e.g. from 116 to 14)
66
Congenital syphilis

• Occurs when woman with secondary or early latent
  becomes pregnant or woman has secondary syphilis
  during pregnancy
• 40 stillborn
• 40-70 of survivors infected (in utero), of whom
  12 will die in infancy
• Liver, spleen and bony abnormalities
• Hutchisons triad deafness, Hutchinsons teeth,
  interstitial keratitis

67
Congenital syphilis
68
Syphilis treatment
Stage First choices Penicillin allergy
Early Primary Secondary Early latent benzathine penicillin 2.4 million units IM stat1 procaine penicillin 0.6 million units IM daily x 10 days doxycycline 100mg 2x/day x 14 days azithromycin 500mg daily x 10 days2
Late latent Benign tertiary Cardiovascular benzathine penicillin 2.4 million units IM weekly x 3 weeks procaine penicillin 0.6 million units IM daily x 21 days doxycycline 100mg 2x/day x 28 days ceftriaxone 500mg IM daily x 14 days
Neurosyphilis 2 4 million units aqueous benzylpenicillin IV four hourly x 10 14 days Doxycycline 200mg 2x/day x 28 30 days ceftriaxone 1 2g IM daily x 14 days

1. ? Use weekly for 3 weeks in people with HIV
2. Azithromycin resistant treponemes are emerging
   may no longer be appropriate

69
Syphilis treatment
Stage First choices Penicillin allergy
Early Primary Secondary Early latent benzathine penicillin 2.4 million units IM stat1 procaine penicillin 0.6 million units IM daily x 10 days doxycycline 100mg 2x/day x 14 days azithromycin 500mg daily x 10 days2
Late latent Benign tertiary Cardiovascular benzathine penicillin 2.4 million units IM weekly x 3 weeks procaine penicillin 0.6 million units IM daily x 21 days doxycycline 100mg 2x/day x 28 days ceftriaxone 500mg IM daily x 14 days
Neurosyphilis 2 4 million units aqueous benzylpenicillin IV four hourly x 10 14 days Doxycycline 200mg 2x/day x 28 30 days ceftriaxone 1 2g IM daily x 14 days

1. ? Use weekly for 3 weeks in people with HIV
2. Azithromycin resistant treponemes are emerging
   may no longer be appropriate

70
Syphilis treatment
Stage First choices Penicillin allergy
Early Primary Secondary Early latent benzathine penicillin 2.4 million units IM stat1 procaine penicillin 0.6 million units IM daily x 10 days doxycycline 100mg 2x/day x 14 days azithromycin 500mg daily x 10 days2
Late latent Benign tertiary Cardiovascular benzathine penicillin 2.4 million units IM weekly x 3 weeks procaine penicillin 0.6 million units IM daily x 21 days doxycycline 100mg 2x/day x 28 days ceftriaxone 500mg IM daily x 14 days
Neurosyphilis 2 4 million units aqueous benzylpenicillin IV four hourly x 10 14 days Doxycycline 200mg 2x/day x 28 30 days ceftriaxone 1 2g IM daily x 14 days

1. ? Use weekly for 3 weeks in people with HIV
2. Azithromycin resistant treponemes are emerging
   may no longer be appropriate

71
Chlamydia trachomatis

• Gram-negative bacterium
• Obligate intracellular pathogen
• Cannot survive or replicate outside of cells
• Formally classified as rickettsia
• Causes genital infection and eye disease
  (trachoma)
• Transmitted by fluid (and cell) transfer during
  vaginal, anal and oral sex
• Asymptomatic in 75 of genitally infected
  females and 50 of genitally infected males

72
Chlamydia trachomatis
73
Chlamydia complications

• Pelvic inflamatory disease (40 of
  untreated women)
• Female Infertility
• Early spontaneous abortion
• Premature labour
• Neonatal eye disease
• Epididymitis
• Male infertility
• Islands experience of complications?

74
Chlamydia diagnosis

• Rapid tests are insensitive and have little value
  in asymptomatic screening
• Nucleic acid testing on swabs or first pass urine
  is gold standard
• Stand displacement assay (BD Probetec) now
  available in multiple Pacific Island under Global
  Fund project islands experience so far?

75
Chlamydia treatment
Setting First line Alternatives
Uncomplicated infection in males or females azithromycin 1g stat doxycycline 100mg 2x/day x 7 days erythromycin base 500 mg 4x/day x 7days erythromycin ethylsuccinate 800 mg 4x/day x 7days amoxycillin 500 mg 3x/day x 7days ofloxacin 300 mg 2x/day x 7days tetracycline 500 mg 4x/day x 7days
Pelvic inflamatory disease azithromycin 1g stat AND doxycycline 100mg 2x/day x 14 days AND metronidazole 400mg 2x/day x 14 days Add ceftriaxone 250mg IM stat if gonorrhoea cannot be excluded
Pregnancy erythromycin base 500 mg 4x/day x 7days erythromycin ethylsuccinate 800 mg 4x/day x 7days amoxycillin 500 mg 3x/day x 7days Doxycycline, tetracycline and orfloxacin are contraindicated in pregnancy Azithromycin has not been shown to be efficaceous in pregnancy Erythromycin estolate is not safe in preganacy (hepatotoxicity)
76
Chlamydia treatment
Setting First line Alternatives
Uncomplicated infection in males or females azithromycin 1g stat doxycycline 100mg 2x/day x 7 days erythromycin base 500 mg 4x/day x 7days erythromycin ethylsuccinate 800 mg 4x/day x 7days amoxycillin 500 mg 3x/day x 7days ofloxacin 300 mg 2x/day x 7days tetracycline 500 mg 4x/day x 7days
Pelvic inflamatory disease azithromycin 1g stat AND doxycycline 100mg 2x/day x 14 days AND metronidazole 400mg 2x/day x 14 days Add ceftriaxone 250mg IM stat if gonorrhoea cannot be excluded
Pregnancy erythromycin base 500 mg 4x/day x 7days erythromycin ethylsuccinate 800 mg 4x/day x 7days amoxycillin 500 mg 3x/day x 7days Doxycycline, tetracycline and orfloxacin are contraindicated in pregnancy Azithromycin has not been shown to be efficaceous in pregnancy Erythromycin estolate is not safe in preganacy (hepatotoxicity)
77
Chlamydia treatment
Setting First line Alternatives
Uncomplicated infection in males or females azithromycin 1g stat doxycycline 100mg 2x/day x 7 days erythromycin base 500 mg 4x/day x 7days erythromycin ethylsuccinate 800 mg 4x/day x 7days amoxycillin 500 mg 3x/day x 7days ofloxacin 300 mg 2x/day x 7days tetracycline 500 mg 4x/day x 7days
Pelvic inflamatory disease azithromycin 1g stat AND doxycycline 100mg 2x/day x 14 days AND metronidazole 400mg 2x/day x 14 days Add ceftriaxone 250mg IM stat if gonorrhoea cannot be excluded
Pregnancy erythromycin base 500 mg 4x/day x 7days erythromycin ethylsuccinate 800 mg 4x/day x 7days amoxycillin 500 mg 3x/day x 7days Doxycycline, tetracycline and orfloxacin are contraindicated in pregnancy Azithromycin has not been shown to be efficaceous in pregnancy Erythromycin estolate is not safe in preganacy (hepatotoxicity)
78
Chlamydia treatment
Setting First line Alternatives
Uncomplicated infection in males or females azithromycin 1g stat doxycycline 100mg 2x/day x 7 days erythromycin base 500 mg 4x/day x 7days erythromycin ethylsuccinate 800 mg 4x/day x 7days amoxycillin 500 mg 3x/day x 7days ofloxacin 300 mg 2x/day x 7days tetracycline 500 mg 4x/day x 7days
Pelvic inflamatory disease azithromycin 1g stat AND doxycycline 100mg 2x/day x 14 days AND metronidazole 400mg 2x/day x 14 days Add ceftriaxone 250mg IM stat if gonorrhoea cannot be excluded
Pregnancy erythromycin base 500 mg 4x/day x 7days erythromycin ethylsuccinate 800 mg 4x/day x 7days amoxycillin 500 mg 3x/day x 7days Doxycycline, tetracycline and orfloxacin are contraindicated in pregnancy Azithromycin has not been shown to be efficaceous in pregnancy Erythromycin estolate is not safe in preganacy (hepatotoxicity)
79
Chlamydia treatment
Setting First line Alternatives
Uncomplicated infection in males or females azithromycin 1g stat doxycycline 100mg 2x/day x 7 days erythromycin base 500 mg 4x/day x 7days erythromycin ethylsuccinate 800 mg 4x/day x 7days amoxycillin 500 mg 3x/day x 7days ofloxacin 300 mg 2x/day x 7days tetracycline 500 mg 4x/day x 7days
Pelvic inflamatory disease azithromycin 1g stat AND doxycycline 100mg 2x/day x 14 days AND metronidazole 400mg 2x/day x 14 days Add ceftriaxone 250mg IM stat if gonorrhoea cannot be excluded
Pregnancy erythromycin base 500 mg 4x/day x 7days erythromycin ethylsuccinate 800 mg 4x/day x 7days amoxycillin 500 mg 3x/day x 7days Doxycycline, tetracycline and orfloxacin are contraindicated in pregnancy Azithromycin has not been shown to be efficaceous in pregnancy Erythromycin estolate is not safe in preganacy (hepatotoxicity)
80
Chlamydia treatment
Setting First line Alternatives
Uncomplicated infection in males or females azithromycin 1g stat doxycycline 100mg 2x/day x 7 days erythromycin base 500 mg 4x/day x 7days erythromycin ethylsuccinate 800 mg 4x/day x 7days amoxycillin 500 mg 3x/day x 7days ofloxacin 300 mg 2x/day x 7days tetracycline 500 mg 4x/day x 7days
Pelvic inflamatory disease azithromycin 1g stat AND doxycycline 100mg 2x/day x 14 days AND metronidazole 400mg 2x/day x 14 days Add ceftriaxone 250mg IM stat if gonorrhoea cannot be excluded
Pregnancy erythromycin base 500 mg 4x/day x 7days erythromycin ethylsuccinate 800 mg 4x/day x 7days amoxycillin 500 mg 3x/day x 7days Doxycycline, tetracycline and orfloxacin are contraindicated in pregnancy Azithromycin has not been shown to be efficaceous in pregnancy Erythromycin estolate (Ilosone) is not safe in preganacy (hepatotoxicity)
81
Gonorrhoea
http//www.spc.int/hiv/osshhm/
82
Hepatitis B

• DNA virus
• Body fluid transmission
• Transmissibility varies with viral load

• HBeAg positivity highly transmissible
• Transmitted from mother to child at time of
  delivery
• 20 if HBeAg negative
• 90 if HBeAg positive

83
Hepatitis B

• 10 prevalence in most Pacific Islands
  endemic
• If acquired at birth 95 develop lifelong
  infection
• If acquired later 70-95 clear infection and
  develop immunity
• If lifelong infection, 40 will die from
  cirrhosis or liver cancer
• Islands experience with HBV and immunisation

84
Trichomoniasis

• Caused by protozoan
• Trichomonas vaginalis
• At least 50 asymptomatic
• Causes vaginitis in women
• Causes urethritis in men (rarely)
• Yellowish fishy discharge
• Strawberry cervix

85
Trichomoniasis

• Diagnosed on wet mount of vaginal discharge
• see moving organisms
• must be done straight away
• 2 3 x increase in risk of HIV acquisition1
• Treated with metronidazole or tinidazole

1. Sorvillo F. Trichomonas vaginalis, HIV, and
   African-Americans. Emerging Infectious Diseases
   7(6)927-32, 2001

86
Most significant?

1. Human papilloma virus infection
2. Syphilis
3. Genital herpes
4. Genital chlamydiosis
5. HIV
6. Gonorrhoea
7. Hepatitis B
8. Trichomoniasis

87
Questions?
88
Case study - Anna

• 20 year old woman presents in early in her first
  pregnancy (LMP 8 weeks ago)
• Lives with her husband of two years and his
  family
• Monogamous
• Husband is a seafarer currently away
• PH ?infectious mono 18 months ago
• Urine ßHCG positive
• Nausea and breast tenderness no other symptoms
• Never had a pap-smear

89
Further management

1. Work out her dates and book her delivery
2. Organise an ultrasound
3. Do a speculum examination
4. Do some blood tests
5. Something else

90
Case study - Anna
91
Further management

1. Swab for MCS
2. First pass urine for chlamydia gonorrhoea
3. Treat with clotrimazole (Canesten)
4. Do a wet mount of vaginal discharge
5. Something else

92
Gram stain microscopy
93
Wet mount
94
Blood tests

1. Haemoglobin
2. HBsAg
3. RPR
4. HIV Ab
5. All of the above

95
Case study - Anna

• Chlamydia NA positive
• Gonorrhoea NA positive
• HBsAg ve, HBsAb ve, HBcAbve
• What does this mean?
• RPR reactive 116
• What does this mean?
• TPHA reactive
• No history of syphilis symptoms
• No old sera available
• HIV rapid test (Abbott Determine) reactive

96
AnnaManagement

• Counselling support
• Chlamydia
• Amoxycillin 500mg 3x/day for 7 days
• Gonorrhoea
• ceftriaxone 250mg IM stat
• Trichomoniasis
• metronidazole 400mg 2x/day for 7 days at start of
  second trimester (14 weeks)

97
AnnaManagement

• Syphilis
• Benzathine pencillin 2.4 million units IM weekly
  for 3 weeks
• HIV
• Confirmatory testing ASAP
• Careful counselling in meantime
• If confirmed, initiate antiretroviral therapy at
  start of second trimester (14 weeks)
• Testing and management of husband
• Papsmear once trichomonas and gonorrhoea
  effectively treated.

98
Criteria for effective ART

• Questions and further discussion

1. A local partnership between public health
   services, clinical services and community
   organisations exists to ensure a continuum of
   care and support for people taking treatment,
   including support for ART adherence
2. A core multidisciplinary HIV care team has
   received appropriate training
3. Diagnostic services available to perform HIV
   antibody tests and essential routine tests to
   monitor for drug toxicity
4. An adequate patient record system exists