PREVENTING MOTHER TO CHILD TRANSMISSION OF HIV A Practical Guide

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					                  PREVENTING
                MOTHER-TO-CHILD
              TRANSMISSION OF HIV
              A Practical Guide to the
                  Prevention and
               Treatment of Sexually
               Transmitted Infections
                       2nd Edition




American International Health Alliance
                                                              Preventing
                                                            Mother-to-Child
                                                          Transmission of HIV
                                                        A Practical Guide to the
                                                            Prevention and
                                                         Treatment of Sexually
                                                         Transmitted Infections
                                                                        2nd Edition




This guide was developed using the most recent treatment information available at the time of production by profes-
sionals in Ukraine for colleagues working in similar healthcare settings. In the rapidly changing field of HIV care and
treatment, information can become outdated quickly. We encourage users to compare this data and its date of issuance
with the latest information found on www.aidsknowledgehub.org and other relevant sites. AIHA disclaims any respon-
sibility for any errors, omissions, or other possible problems associated with this publication. February 2005.


                                                             This guide is made possible through support provided by
                                                             the US Agency for International Development (USAID),
                                                             Bureau for Europe and Eurasia. The opinions expressed
                                                             herein are those of the author(s) and do not necessarily
                                                             reflect the views of USAID.
                                   Since 1992, the American International Health Alliance (AIHA) has es-
                                   tablished and managed more than 100 volunteer-driven partnerships be-
                                   tween healthcare institutions in the United States and their counterparts
                                   in Central and Eastern Europe and Eurasia. AIHA partnerships involve
                                   the twinning of hundreds of health systems, educational institutions, and
      Developed by:                communities, as well as the participation of thousands of clinicians, ed-
  N.N. Nizova, MD, PhD,            ucators, and other health-related professionals. AIHA assistance has en-
        Professor,                 abled the US healthcare sector to help address local healthcare issues by
   Odessa State Medical            providing effective and coordinated assistance to the countries of these
        University                 regions. AIHA also sponsors a number of supportive and collaborative          AIHA’s Regional Model for Preventing
                                   activities, including conferences, workshops, and a multilingual Web-
    S.P. Posokhova, MD,            based clearinghouse of medical information. In an extraordinary               Mother-to-Child Transmission of HIV in
   Candidate in Medical            demonstration of private-public collaboration and commitment, the US
Sciences, Assistant Professor,     health sector is contributing more than one dollar in resources ranging       Odessa, Ukraine
       Odessa Oblast               from equipment and supplies to in-kind time for every federal dollar
      Clinical Hospital            provided in support of the twinning programs.
                                   AIHA’s twinning partnerships have made many important contributions
 Edited by V. Zaporozhan,          to health reform efforts in Central and Eastern Europe and Eurasia,           Central and Eastern Europe and Eurasia are currently
         MD, PhD,                  including: (1) restructuring national, oblast (state), and city healthcare
  member of the Ukrainian
                                                                                                                 experiencing the fastest increase of HIV infection in
                                   delivery systems by, for example, organizing regional perinatal and emer-
Academy of Medical Science         gency networks; reorganizing key in- and outpatient hospital services at      the world, bringing the total number of people living
                                   institutional and multi-institutional levels; and introducing new levels of
        Odessa 2002                                                                                              with the virus in the region to 1.5 million.1 Although
                                   care and services including hospice care and home health visits by nurs-
                                   es; (2) developing a network of more than 25 free-standing Women’s            the number of children born to HIV-positive mothers
         2nd edition,              Wellness Centers that provide comprehensive health care tailored to the
        Odessa 2005                specific needs of women; (3) reorganizing and improving health profes-
                                                                                                                 in this area is still relatively low, two-thirds of the re-
                                   sions education by establishing some of the first residency-based training    ported cases are in Ukraine2 (population: 48 million,
                                   programs in the region for family physicians and other primary care
                                   providers; (4) supporting the development of the region’s first schools       2002).3 According to UNAIDS statistics, HIV
                                   and programs in health management, health administration, and public          prevalence in Ukraine is approaching 1% of the adult
                                   health; (5) establishing new skills-based training centers and programs
                                   for the in-service training of physicians, nurses, feldshers, and adminis-    population.4 The number of children born to HIV-
                                   trators, such as the region’s first programs in basic emergency care, dis-    positive women in the country increased nearly 90%,
                                   aster response, infection control, and neonatal resuscitation; (6) opening
                                   more than 23 high-quality, model Primary Care Centers that provide            from 737 reported cases in 2000, to 1,379 in 2002.5
                                   comprehensive medical care and emphasize community-based health
                                                                                                                 The percentage of HIV cases registered among preg-
                                   promotion and wellness programs; (7) developing successful “healthy
                                   communities/healthy cities” twinning relationships that enable commu-         nant women has also skyrocketed, in some regions
                                   nities to address their own unique health and social welfare problems; (8)
                                   creating more than 130 Learning Resource Centers to promote evidence-
                                                                                                                 rising above 0.4 percent.6
                                   based clinical practices and offer support to the dozens of nursing and
                                   other associations created to encourage professional development and
                                   broad health reform initiatives; and (9) developing a number of opera-        Odessa oblast has one of the highest HIV infection
                                   tional comprehensive, community-based model programs that target              rates in the country (361.3 per 100,000 people oblast-
                                   specific health priorities such as tuberculosis, cardiovascular disease,
                                   family violence, post-traumatic stress syndrome, diabetes, asthma, and        wide)7 and the number of children infected through
                                   preventing the risk of mother-to-child transmission of HIV.                   vertical transmission has grown significantly during the
                                   AIHA operates primarily under cooperative agreements with the United
                                                                                                                 last three years, with the number of births to HIV-
                                   States Agency for International Development (USAID)—the US govern-
Cover photo: Suzanne E. Grinnan.   ment agency that finances programs and projects that promote broad-           positive mothers rising from 0.8% in 2001 to 1.0% in
Image of mother and child          based and sustainable economic growth worldwide—and the US Depart-
courtesy of Barbara Comnes,        ment of Health and Human Services, Health Resources and Services
                                                                                                                 2003.8 For comparison, in 2001, 0.4% of pregnant
Painet Inc.                        Administration (HRSA). Additional funding has been provided through           women tested positive for HIV in Ukraine; in 2002,
Translation by EnRus Translation   grants from the US Department of Energy, the Library of Congress’s Open
Agency (www.enrus.ru), Moscow.     World Leadership Center, and various foundations. (February 2005)             0.5% of pregnant women had a positive status.9



                                                                                                                 Prevention and Treatment of Sexually Transmitted Infections
In response to this public health crisis, AIHA initiat-    and massing a body of evidence-based resources and
ed a pilot project in 2001 aimed at preventing             informational materials.
mother-to-child transmission (MTCT) of HIV in
Odessa. Supported by USAID, AIHA’s project is an           Tasked with developing a cadre of well-trained,
integral part of a larger effort involving international   knowledgeable, and skilled professionals who will
donors including UNAIDS, WHO, UNICEF, Médecins             work in close collaboration with community-based
Sans Frontiéres (MSF; also known as Doctors With-          organizations dedicated to providing care and social
out Borders), and Ukrainian government agencies            support to HIV-positive individuals, the Knowledge
and nongovernmental organizations. MSF, for exam-          Hub will be part of a synergistic network that includes
ple, is providing Odessan women with supplies, such        international experts, two similar centers—one fo-
as antiretroviral (ARV) drugs and infant formula           cusing on harm reduction and the other on surveil-
crucial to preventing MTCT, and AIHA is cooperat-          lance—and a cadre of strategic partners including
ing closely with MSF to provide related technical as-      AIDS Foundation East West (AFEW), International
sistance and training for healthcare workers to            Association of Physicians in AIDS Care (IAPAC),
Odessa healthcare institutions.                            and AIDS Healthcare Foundation-Global Immunity
                                                           (AHF-GI).
In 2003, the World Health Organization Regional
Office for Europe (WHO/Euro) joined with AIHA to           AIHA’s project in Odessa focuses primarily on imple-
establish the independent, non-governmental Re-            menting systemic and institutional changes related to
gional Knowledge Hub for Care and Treatment of             the prevention and treatment of HIV/AIDS by:
HIV/AIDS in Eurasia. Operating with funds provid-
ed by Deutsche Gesellschaft für Technische Zusam-            ❙ reorganizing and strengthening clinical service
menarbeit (GTZ) and USAID, the Knowledge Hub                   delivery to ensure that measures to stop vertical
serves as a crucial capacity-building mechanism for            transmission of the disease are integrated into
reaching WHO’s “3 by 5” targets for the region.                the obstetric, pediatric, and new family-centered
                                                               primary care systems;
Based in Ukraine at the Kiev Medical Academy of
Post Graduate Education and closely affiliated with          ❙ revising treatment protocols to ensure that they
the Ukrainian National AIDS Center, the main objec-            are evidence based and effective within the re-
tive of the Knowledge Hub is to create the human               gion’s changing social and economic context; and
resource capacity necessary to provide care to HIV-
infected individuals by developing expertise among           ❙ developing training materials and curricula for
healthcare professionals, cultivating training capacity,       health professionals in important areas such as



        Preventing Mother-to-Child Transmission of HIV     Prevention and Treatment of Sexually Transmitted Infections
    counseling, obstetrics, occupational health,          these important areas, additional emphasis is being
    women’s health, pediatric care, and family            placed on nursing, pediatrics, and laboratory
    planning.                                             support, as well as the development of high-quality
                                                          primary care for mother and child.
This effort builds upon more than a decade of highly                                                                 [P]reliminary results
successful AIHA programmatic activity throughout          As is the case in other AIHA twinning programs, US
Ukraine, in general, and in Odessa, in particular.        institutions and health professionals involved in the      at the end of 2002
                                                          Ukraine PMTCT project are voluntarily providing
With USAID support, AIHA is applying its propri-          professional support and material resources—               indicated a 75%
etary twinning methodology—supplemented by                including basic workplace infection control barriers
expert resources—to the prevention of mother-to-          and other important supplies—matching US
                                                                                                                     decrease in
child transmission (PMTCT) project in Odessa.             government funding on a dollar-for-dollar basis.           HIV-positive infants
Boulder Community Hospital and its collaborating
institutions, including the University of Colorado        As a result of the coordinated efforts by AIHA and         born to HIV-positive
Health Sciences Center and Children’s Hospital of         others, the Odessa Oblast Hospital has been able to
Denver, are serving as the lead US partners under a       quickly demonstrate dramatic success in the preven-        women at the
subgrant from AIHA. These partners, working closely       tion of MTCT; preliminary results at the end of 2002
with their counterparts in the Odessa Oblast Health       indicated a 75% decrease in HIV-positive infants born
                                                                                                                     hospital.
Administration, the State Medical University of           to HIV-positive women at the hospital.10 Having
Odessa, and the Odessa Oblast Hospital—one of the         demonstrated initial success in preventing MTCT
largest public hospitals in the region—are providing      among participating women, the project is increasingly
training and capacity building related to the model       focused on systematically identifying all women in the
program. In addition, AIHA is drawing upon the            city and oblast who are at risk, enrolling them in fami-
expertise of individual health professionals and key      ly planning and prenatal services, and ensuring 100%
public institutions across the United States to supple-   case management through delivery and postdelivery.
ment and expand upon this training and to provide         The project is also striving to provide all HIV-positive
expertise in the are of HIV/AIDS treatment and care.      mother/child pairs with high-quality family care and, if
                                                          necessary, specialized treatment.
Training to date has been specifically designed to
increase the proficiency of medical professionals         In 2003, AIHA established the Southern Ukraine
from Odessa in the areas of obstetrics and gynecology,    AIDS Education Center (SUAEC) in Odessa to
neonatology, counseling, and clinical practice guide-     disseminate the PMTCT model through hands-on,
lines. While future training will continue to focus on    skills-based and methodological trainings. SUAEC



        Preventing Mother-to-Child Transmission of HIV    Prevention and Treatment of Sexually Transmitted Infections
                                                                             ‘Reproductive Health 2001–2003’,” Report to the Conference on
currently serves as a regional training center for the                       Monitoring and Assessment of the Vertical Transmission Prevention
                                                                             Program in Ukraine, Kiev, Ukraine (in Ukrainian), April 2003.
Knowledge Hub in the areas of PMTCT and                                6.    R.A. Moiseyenko, “Prevention of HIV Transmission from Mother to
pediatric AIDS.                                                              Child in Ukraine,” report to the Regional Conference for Eastern
                                                                             Europe and Central Asia “Care, Support, and Treatment for People
                                                                             Living with HIV/AIDS,” November 2002, Ukraine [Доклад на
An overall goal of AIHA’s model PMTCT project is to                          региональной конференции для стран Восточной Европы и
develop materials that can be used throughout the                            Центральной Азии “Уход, поддержка и лечение для людей,
                                                                             живущих с ВИЧ/СПИДом”, ноябрь 2002, Украина].
region. Companion products are a critical output of the                7.    Ukrainian AIDS Center Reports, 2003.
project, and collaboration and consensus-building                      8.    Annual Reports of Odessa Oblast AIDS Center, 2001-2003 [Годовые
                                                                             отчеты Одесского областного центра СПИДа, 2001-2003].
with the Ukrainian Ministry of Health and others is
                                                                       9.    Ministry of Health of Ukraine, Organization of PMTCT System in
a key component of the project’s work plan. Practical                        Ukraine, 2003.
materials such as this guide are being developed                       10.   Ministry of Health of Ukraine,“Organization of Mother-to-Child
                                                                             Transmission Prevention System in Ukraine: An Overview,” Preven-
using a collaborative approach in which the Ukrain-                          tion of HIV Infection in Infants Review Meeting, Kiev, Ukraine,
ian authors’ drafts are circulated to US counterparts                        September 16–18, 2003.
for review and comment. All documents are made
available in both English and Russian.

Companion products and further information about
the model PMTCT project, the Regional Knowledge
Hub for the Care and Treatment of HIV/AIDS in
Eurasia, USAID, and AIHA’s partnership programs,
and the HRSA-funded HIV/AIDS Twinning Center
Program in Africa, Asia, and the Caribbean can be
found at www.aiha.com. Further information about
the Regional Knowledge Hub for the Care and Treat-
ment of HIV/AIDS in Eurasia can be found at
www.aidsknowledgehub.org (July 2004).

References
1. UNAIDS/WHO, AIDS epidemic update. December 2003.
2. R. Malyuta, “HIV Infection Among Women and Children: Review of
   Epidemic Development in Europe and NIS,” presentation, May, 2003.
3. Intergovernmental Statistical Committee of the CIS
   [Межгосударственный статистический комитет СНГ], 2003.
4. UNAIDS, Report on the Global HIV/AIDS Epidemic, 2002.
5. R.A. Moiseyenko, “Implementation of the National Program,




         Preventing Mother-to-Child Transmission of HIV                Prevention and Treatment of Sexually Transmitted Infections
Acknowledgements

The authors wish to extend their thanks for the
review of the first edition of this guide to:

• Jill K. Davies, MD, assistant professor, Division
  of Maternal Fetal Medicine, Department of
  Obstetrics and Gynecology, University of
  Colorado School of Medicine, Denver, Colorado

• Kay Kinzie, RN, pregnancy coordinator, Denver
  Children’s Hospital, Denver, Colorado

• Laure Lisk, RN, MS, director, Women and
  Family Services, Boulder Community Hospital,
  Boulder, Colorado

• Charles Steinberg, MD, physician, director,
  Beacon Clinic, Boulder Community Hospital,
  Boulder, Colorado

• Mary Macsalka, MD, physician, Boulder
  Community Hospital, Boulder, Colorado

The authors also wish to thank Barbara Fisher,
vice president, Boulder Community Hospital, for
her contribution to this project.



Prevention and Treatment of Sexually Transmitted Infections
Table of Contents

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i
Glossary of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . iii
Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

Chapter 1: Introduction and
Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Goals and Scope of the Practical Guide . . . . . . . . . . 3

Chapter 2: Primary Prevention of STIs
Procedures and Methods of Prevention . . . . . . . . . . 5
   Prevention of Sexual Transmission . . . . . . . . . . . . 5
   Prevention of Transmission via Injection . . . . . . . 5
Levels of STI Prevention . . . . . . . . . . . . . . . . . . . . . . 9

Chapter 3: Treatment of STIs
Classification of STIs . . . . . . . . . . . . . . . . . . . . . . . . 17
   Classification of Sexually
   Transmitted Infections . . . . . . . . . . . . . . . . . . . . 18
Syndromic Approach to Diagnosis
and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Procedures for Diagnosis and Treatment . . . . . . . . 22
   Chancroid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
   Genital Herpes Simplex Virus (HSV)
   Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
   Syphilis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31




Prevention and Treatment of Sexually Transmitted Infections
                                                     Table of Contents


   Syphilis During Pregnancy . . . . . . . . . . . . . . . . . 34
Diseases Characterized by Urethritis
and Cervicitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
   Urethritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
   Recurrent and Persistent Urethritis . . . . . . . . . . 37
   Cervicitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Diseases Characterized by Vaginal Discharge . . . . 39                           Preface
   Managing Vaginal Discharge . . . . . . . . . . . . . . . 39
   Bacterial Vaginosis (BV) . . . . . . . . . . . . . . . . . . . 41
   Trichomoniasis . . . . . . . . . . . . . . . . . . . . . . . . . . 42         Sexually transmitted infections (STIs) are wide-
   Vulvovaginal Candiasis . . . . . . . . . . . . . . . . . . . 43               spread throughout the world. They include more
   Pelvic Inflammatory Disease (PID) . . . . . . . . . . 45                      than 20 sexually transmitted pathogens, including
Pregnant Women and STIs . . . . . . . . . . . . . . . . . . . 48                 bacteria, viruses, protozoa, yeast infections, and
   Screening Pregnant Women for STIs . . . . . . . . . 49                        arthropods.
Sexual Violence and STIs . . . . . . . . . . . . . . . . . . . . . 51
   Sexual Violence and STIs . . . . . . . . . . . . . . . . . . 53               The fight against STIs remains one of the highest
                                                                                 public health priorities in most countries of the
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57          world. Incidence of acute STIs is high in both
                                                                                 industrialized and developing countries. If an STI
Appendix                                                                         is not diagnosed and treated early, it can cause
STD Treatment Guidelines for Adults and                                          serious complications and sequelae, including
Adolescents, 2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . 59       infertility in both men and women, miscarriage,
                                                                                 premature birth, ectopic pregnancy, cancer of the
                                                                                 genitals and rectum, small fetus size for gestational
                                                                                 age, and infection of the child during pregnancy
                                                                                 (i.e., congenital syphilis), birth (i.e., gonococcal
                                                                                 conjunctivitis), and in the postnatal period (i.e.,
                                                                                 with syphilis or gonorrhea through contact).

                                                                                 The appearance of the human immunodeficiency
                                                                                 virus (HIV) and the proliferation of the HIV
                                                                                 epidemic throughout the world have focused
                                                                                 particular attention on the problem of STIs. A
                                                                                 direct link has been discovered between the spread



           Preventing Mother-to-Child Transmission of HIV                        Prevention and Treatment of Sexually Transmitted Infections   i
                                                                 Preface    Glossary of Terms



     of traditional STIs and the spread of HIV. It has                      GLOSSARY OF TERMS
     been established that the risk of transmission of                      Acquired Immune Deficiency Syndrome
     HIV by sexual contact increases in the presence of                     (AIDS): The terminal stage of HIV infection.
     any STI, not only those STIs that involve genital
     ulcerations.1                                                          Chancroid: STI caused by the bacterium
                                                                            Haemophilus ducreyi in which genital ulcers form.
     In the last decade, the considerable knowledge and
     expertise accumulated in the fight against HIV in-                     Chlamydiosis: Infection caused by the bacterium
     fection and STIs has enables the development of                        Chlamydia trachomatis; one of the causes of dis-
     effective prevention and medical care—care that                        charge from the vagina, urethra, and the eyes of a
     must be implemented at the global, regional, and                       newborn.
     local levels.2-4
                                                                            Congenital syphilis: Syphilis transmitted from
     The protocols found in this guide are based on the                     mother to child during pregnancy.
     clinical standards for the diagnosis and treatment
     of STIs developed by the US Centers for Disease                        Conjunctivitis: Inflammation of the mucous
     Control and Prevention (CDC) adapted to condi-                         membrane of the eyes and eyelids.
     tions existing in Ukraine.5
                                                                            Counseling: A confidential conversation between
     References                                                             a counselor and client aimed at providing psycho-
     1. Guidelines for the Management of Sexually Transmitted Infections,   logical support for and giving information on a
        WHO, 2001, www.who.int/hiv/pub/sti/pub6/en/.
                                                                            particular topic to the client. Counseling helps
     2. ibid.
     3. US Centers for Disease Control and Prevention (CDC), “Guidelines    clients develop skills for overcoming the difficul-
        for Treatment of Sexually Transmitted Diseases,” Morbidity and      ties of life circumstances and enables them to
        Mortality Weekly Report 47 (RR-1); pp. 1-118, January 23, 1998,
        www.cdc.gov/epo/mmwr/preview/mmwrhtml/00050909.htm.                 make critical decisions based upon accurate and
     4. WHO/UNAIDS, Sexually Transmitted Diseases: Policies and             complete information. In relation to HIV, counsel-
        Principles for Prevention and Care,
                                                                            ing can help prevent the spread of the infection by
        www.unaids.org/publications/documents/impact/std/una97e6.pdf.
     5. CDC, 1998, op. cit.                                                 encouraging a client’s sense of responsibility for
                                                                            his/her behavior and, when necessary, guiding
                                                                            him/her to change risky lifestyle behaviors.

                                                                            Ectopic pregnancy: Pregnancy outside the
                                                                            uterine cavity (usually in a fallopian tube);



ii             Preventing Mother-to-Child Transmission of HIV               Prevention and Treatment of Sexually Transmitted Infections   iii
                                        Glossary of Terms     Glossary of Terms/Acronyms



     life-threatening condition that can lead to              Sexually transmitted infections (STIs):
     massive internal bleeding.                               Infections that are transmitted from one person to
                                                              another during intercourse or intimate contact.
     Epididymitis: Inflammation of the epididymis, usu-
     ally caused by a gonorrheal or chlamydial infection.     Syndrome: Specific combination of subjective
                                                              and objective symptoms.
     Genital ulcers: Name of a syndrome during
     which ulcers or erosions appear in the genital area;     Syphilis: STI caused by Treponema pallidum;
     usually observed in syphilis and chancroid.              one of the causes of genital ulcers (hard chancres)
                                                              during the onset of the illness.
     Gonorrhea: STI caused by Neisseria gonorrhoeae;
     widespread cause of discharge from the urethra or        Trichomoniasis: STI caused by Trichomonas vagi-
     vagina, and also from the eyes of a newborn.             nalis; one of the causes of typical vaginal discharge.

     Herpes: Disease caused by the herpes simplex             Urethritis: Inflammation of the urethra, usually
     virus, in which vesicles, erosions, and small            caused by the causative agents of gonorrhea or
     ulcers form on mucous membranes and the skin.            chlamydiosis.

     HIV: Human immunodeficiency virus; a retro-              ACRONYMS
     virus that causes AIDS. In this guide, HIV refers to     AIDS: acquired immunodeficiency syndrome
     HIV-1, since cases of vertical transmission of HIV-
     2 are extremely rare.                                    BV: bacterial vaginosis


     Ophthalmia neonatorum: Conjunctivitis occur-             CSF: cerebrospinal fluid
     ring in infants less than one month of age, usually as
     a result of gonorrhea l or chlamydial infection.         HBsAg: hepatitis B surface antigen


     Pelvic inflammatory diseases: Encompasses                HBeAg: hepatitis Be antigen
     the entire range of inflammatory occurrences in the
     area of the upper reproductive tract in women—           HBV: hepatitis B virus
     endometritis, salpingitis, tubo-ovarian abscess,
     pelvic peritonitis—both as distinct clinical entities    HIV: human immunodeficiency virus
     and in any possible combination.



iv          Preventing Mother-to-Child Transmission of HIV    Prevention and Treatment of Sexually Transmitted Infections   v
                                                Acronyms



     HSV: herpes simplex virus


     IA: immunoabsorbent assay
                                                             Chapter 1: Introduction
     IDU: injecting drug user
                                                             and Background
     IT: immunofluorescence test


     PCR: polymerase chain reaction                          According to the most recent documents of the
                                                             WHO and UNAIDS, the widespread prevalence of
     PHT: passive hemagglutination test                      STIs makes them a high priority among public
                                                             health issues. The appearance of HIV and the
     PID: pelvic inflammatory disease                        phenomenally rapid pandemic of the fatal disease it
                                                             causes, AIDS, brought about an urgent reappraisal
     RPR: rapid plasma reagin                                of STI control strategies.1

     RVVC: recurrent vulvovaginal candidiasis                The predominant mode of HIV and other STI
                                                             transmission is sexual. Other transmission routes
     STI: sexually transmitted infection                     are blood, blood products, donated organs and
                                                             tissues, and prenatal transmission from an infected
     UN: United Nations                                      mother to her fetus or newborn during pregnancy.
                                                             STIs increase the risk of HIV transmission. For
     UNAIDS: Joint United Nations Program on                 this reason, the early detection and effective treat-
     HIV/AIDS                                                ment of STIs are important parts of strategy to
                                                             prevent HIV transmission.
     UNICEF: United Nation’s Children’s Fund
                                                             The main objectives of STI control are to:
     WHO: World Health Organization                          ❙ prevent the transmission of infections via
                                                               sexual contact
                                                             ❙ prevent the development of acute diseases,
                                                               complications, and long-term effects
                                                             ❙ reduce the risk of HIV infection




vi          Preventing Mother-to-Child Transmission of HIV   Prevention and Treatment of Sexually Transmitted Infections   1
                                                                                                      Chapter 1       Introduction and Background



                                          These objectives can be achieved through primary                            GOALS AND SCOPE OF THE
                                          prevention directed at reducing incidence                                   PRACTICAL GUIDE
                                          and secondary prevention directed at reducing                               This guide was developed to reduce the incidence
                                          prevalence by shortening the periods of STI                                 of STIs and to improve primary and secondary
                                          treatment of acute diseases, thus minimizing the                            prevention and treatment of STIs in the city of
                                          probability of complications or long-term effects.                          Odessa and the oblast Odessa.

                                          At this time, efforts to improve medical care for                           The use of this guide at clinics, as well as at der-
                                          people with STIs are focused primarily on provid-                           matological, venereal, and prenatal care facilities,
                                          ing effective treatment. In situations in which, for                        can serve as an important tool in reducing the in-
                                          various reasons, a large number of infected people                          cidences of STIs and preventing the transmission
                                          either do not receive treatment or are not cured,                           of HIV infection.
                                          this approach has little effect. The figure below
                                          shows the proportion of patients who make a full                            This guide defines a set of procedures for medical
                                          recovery from STIs.                                                         personnel to use in the prevention and treatment
                                                                                                                      of STIs. It is intended for use by obstetricians and
                                                                                                                      gynecologists, midwives, nurses, family
     INFECTED
                                                                                                                      physicians, venereologists, dermatologists, and
     PERSONS WHO KNOW THEY ARE ILL                                                                                    internists specializing in infectious diseases.
    PERSONS WHO HAVE SOUGHT MEDICAL CARE
                                                                                                                      This guide is recommended for use in women’s
     PERSONS WHO HAVE BEEN DIAGNOSED WITH AN STI
                                                                                                                      counseling centers, clinics, maternity hospitals,
     COMPLETED A COURSE OF TREATMENT                                                                                  and dermatology and venereal disease treatment
    CURED                                               NOT CURED                                                     facilities in the city of Odessa and the Odessa
                                                                                                                      oblast.
    Figure 1. Proportion of persons cured of STIs.
    Note: The proportion of persons cured depends on actions taken by the infected persons themselves or the health
    care professionals at each stage.




2                                                    Preventing Mother-to-Child Transmission of HIV                   Prevention and Treatment of Sexually Transmitted Infections   3
Chapter 2: Primary
Prevention of STIs


PROCEDURES AND METHODS OF
PREVENTION2

                      PREVENTION OF SEXUAL TRANSMISSION
    Prevention method           • Abstain from sexual contact with an infected partner
                                • Use a new condom for each act of sexual contact

    Recommended for             • Persons being treated for STIs or those whose partners are
                                  undergoing such treatment
                                • Persons who wish to avoid the possible consequences of sexual
                                  contact (e.g., STI, HIV, and pregnancy)




                PREVENTION OF TRANSMISSION VIA INJECTION
    Prevention method           • Do not, under any circumstances, use injection equipment that
                                  has been used by another person
                                • If needles can be obtained legally, obtain sterile needles
                                • Persons who use injection equipment that has been used by others
                                  should first clean the equipment with bleach and water

    Recommended for             • Injecting drug users



Note: Disinfection with bleach does not make syringes and
needles sterile and does not ensure complete inactivation of HIV,
however, among injecting drug users (IDUs) who share infection
equipment, but regularly and thoroughly disinfect it, the
likelihood of HIV infection is lower.

Adapted from: 1998 Guidelines for Treatment of Sexually Transmitted
  Diseases.




Prevention and Treatment of Sexually Transmitted Infections                                          5
                                                                   Chapter 2     Primary Prevention of STIs



                         Male Condoms                                            ❙ Put the condom on after the penis is erect and
                         When used consistently and correctly, condoms are         before any genital contact with the partner. The
                         an effective method of preventing many STIs, in-          foreskin should be pulled back before the
                         cluding HIV. Because they do not cover all contact        condom is put on.
      [C]ondoms are      surfaces, condoms are more effective in preventing
                         infections transmitted through contact with mu-         ❙ When putting the condom on, squeeze the tip
     more effective in   cous membranes than through skin contact. When            so that no air remains in it. Leave a little room
                         high-quality condoms are used, breakage usually           at the end of the condom for the sperm. Unroll
preventing infections    only occurs if a condom is used incorrectly, not          the condom along the full length of the penis.

 transmitted through     because it is defective. Please note that condom
                         usage applies to vaginal, anal, and oral sexual         ❙ If the condom breaks or slips, stop immediately
contact with mucous      contact.                                                  and put on a new condom. If a condom slips
                                                                                   off, breaks, or leaks sperm, it is most often the
     membranes than      Advise patients that for maximum STI prevention,          result of human error versus a defect in the
                         condoms must be used consistently and according           condom.
through skin contact.    to the following rules:
                                                                                 ❙ After ejaculation, the penis must be removed
                         ❙ Use a condom with each act of sexual contact.           before it becomes soft. When withdrawing the
                           Open the condom package carefully. Remember             penis, hold the condom firmly at its base to
                           that teeth, fingernails, and jewelry can damage         prevent sperm from leaking.
                           the condom. Use only water-based lubricants
                           with a condom. Oil-based lubricants—petrole-          ❙ Do not reuse the condom.
                           um jelly and lotions containing fats—reduce
                           the protective qualities of the condom. Keep          Ongoing public education regarding the critical
                           condoms in a cool, dry place; do not keep             importance of using condoms for protection
                           condoms in a pocket or in a compartment in a          against STIs is strongly recommended.
                           car because the high temperature will destroy
                           the material from which the condom is made.           Vaginal Spermicides, Contraceptive
                           Do not use a condom after its expiration date         Sponges, and Diaphragms
                           (shown on the box or the individual condom            Research has shown that the use of vaginal
                           package). Never use a condom that is stuck            spermicides without condoms reduces the risk of
                           together or torn.                                     cervical gonorrhea and chlamydiosis. Vaginal
                                                                                 contraceptive sponges also protect against cervical



 6                              Preventing Mother-to-Child Transmission of HIV   Prevention and Treatment of Sexually Transmitted Infections   7
                                                                   Chapter 2     Primary Prevention of STIs



                        gonorrhea and chlamydiosis, but using them in-           ing HIV. Nonbarrier contraceptive methods offer
                        creases the risk of candidiasis. Diaphragms protect      no protection against HIV or other STIs.

Vaginal spermicides,    against gonorrhea, chlamydiosis, and trichomiasis.
                                                                                 Women who are taking hormonal contraceptives,
                                                                                                                                          Nonbarrier
       contraceptive    Vaginal spermicides, contraceptive sponges, and          have been surgically sterilized, or have had a           contraceptive
                        diaphragms do not protect women against HIV              hysterectomy should be counseled on the use of
       sponges, and     infection.                                               condoms and the risk of STIs including HIV               methods offer no
                                                                                 infection.
     diaphragms do      In January 2003, the Food and Drug Administra-                                                                    protection against
                        tion (FDA) issued a statement calling for warnings       LEVELS OF STI PREVENTION4
         not protect    on the labels of over-the-counter vaginal contra-        The following WHO and UNAIDS recommenda-
                                                                                                                                          HIV or other STIs.
     women against      ceptives containing nonoxynol-9, advising con-           tions clearly define the goals and objectives of
                        sumers that nonoxynol-9 does not protect against         primary and secondary prevention of STIs.
       HIV infection.   the transmission of HIV or other STIs. The warn-
                        ing should also indicate that the use of vaginal         Primary Prevention
                        contraceptives containing nonoxynol-9 causes             The goal of primary prevention is to prevent
                        irritation to the mucous membranes of the vagina,        infection and disease. This can be achieved by
                        which increases the risk of transmission of HIV          promoting
                        and other STIs. Nonoxynol-9 works by destroying
                        the cell membranes of spermatozoa. Under                 ❙ safer sexual behavior and
                        laboratory conditions, it has been demonstrated
                        that this substance destroys the cell membranes of       ❙ the use of condoms in penetrative sexual acts.
                        certain STI pathogens and also has an antiviral
                        effect on certain viruses. On the basis of these         Remember that only primary prevention activities
                        data, it was concluded that nonoxynol-9 also             can prevent the presently incurable STIs that re-
                        destroys the membranes of cells in the mucous            sult from viral infections. Providing medical care
                        membranes of the vagina and the cervix, which            for STIs offers excellent opportunities to promote
                        increases the risk of STI transmission.3                 primary prevention through health education,
                                                                                 treatment, and effective cure of the individuals
                        Nonbarrier Contraception, Surgical                       who are at increased risk of contradicting or
                        Sterilization, and Hysterectomy                          transmitting an infection. The treatment and cure
                        Women who are not at risk for pregnancy assume           of a patient with an STI constitutes primary
                        that they are not at risk for contracting STI, includ-   prevention for that person’s sex partner.



 8                             Preventing Mother-to-Child Transmission of HIV    Prevention and Treatment of Sexually Transmitted Infections                   9
                                                                     Chapter 2    Primary Prevention of STIs



Remember that only       The majority of HIV prevention recommendations           care to people who are infected with or have been
                         apply equally to STIs, but certain distinctions          exposed to an STI. Secondary prevention should
 primary prevention      should be explained in public education materials:       include:

       activities can    ❙ Many STIs can be treated successfully.                 ❙ efforts to encourage people to seek medical
         prevent the                                                                care; these efforts should be directed not only
                         ❙ Early treatment is essential to prevent                  at people with STI symptoms, but also at peo-
 presently incurable       complications.                                           ple at increased risk of contracting an STI,
                                                                                    including HIV;
STIs that result from    ❙ Certain STIs may not have noticeable symptoms,
                           particularly in women, as a result of which the        ❙ accessible, acceptable, and effective medical
     viral infections.     STI is not diagnosed until complications appear.         care, including diagnostic services and effective
                                                                                    treatment for both symptomatic and asympto-
                         Health education materials should contain a                matic STI patients and their sex partners; and

                         ❙ clear description of the symptoms of STIs;             ❙ psychological support services and counseling
                                                                                    for patients with STIs and HIV.
                         ❙ questionnaire to evaluate the individual’s risk of
                           STI infection and the risk of infecting sex part-      Partner Notification
                           ners with STIs (if the results of the survey indi-     Whenever an STI is diagnosed at any treatment
                           cate the possible presence of STI, counseling on       facility, it is necessary to address the issue of noti-
                           STIs is recommended); and                              fying the patient’s sex partner(s). Health profes-
                                                                                  sionals should ensure that partner notification is
                         ❙ list of institutions that provide counseling on STIs   voluntary and noncoercive and that confidentiali-         Particular care
                           (i.e., primary care centers), specialized medical      ty is maintained. Particular care should be taken
                           facilities, and voluntary counseling centers.          to observe the rights and dignity of the patient          should be taken to
                                                                                  and his/her partner(s). It should always be kept
                         Potential patients must also be assured that they        in mind that the effect of notification on the            observe the rights
                         are being treated with respect and their confiden-
                         tial information will not be disclosed.
                                                                                  patient and their partner may be different
                                                                                  depending on his or her gender.
                                                                                                                                            and dignity of the
                                                                                                                                            patient and his/her
                         Secondary Prevention                                     Partner notification means informing the part-
                         Secondary prevention involves providing medical          ner(s) of an STI patient about the possibility of         partner(s).

10                              Preventing Mother-to-Child Transmission of HIV    Prevention and Treatment of Sexually Transmitted Infections                    11
                                               Chapter 2     Primary Prevention of STIs



     infection and offering treatment and psychological      formation of personal identity. The primary fea-
     support. Partner notification should aim to treat       tures of maturation are emancipation, personal
                                                             self-affirmation, and development of relationships
     ❙ all of the STI patient’s sex partners—at least        with contemporaries. Experts describe more than
       those he/she has been with in the previous            10 types of adolescent behavior, but these four are
       three months, and                                     the most important:6

     ❙ the partner(s) for all of the STIs diagnosed in       ❙ Emancipation, or the release from adult supervi-
       the “primary” patient.                                  sion, is one of the primary features of puberty,
                                                               where the dominant idea in all relationships with
     Partner Notification Methods                              adults is to prove one’s personal significance and
     Patient referral: After appropriate health                freedom. The adolescent tries to resolve issues
     education and counseling, the patient is given the        independently, particularly those that concern
     opportunity to contact his/her sex partner(s) and         him/her personally, such as with whom to spend
     ask them to come in for an examination and                time, where, and for how long; how to dress; etc.
     treatment.                                                Relationships between parents and children be-
                                                               come less trustful, as if the adolescent is putting up
     Referral by medical staff: The patient is asked to        a wall to keep adults out of his/her internal world.
     provide the health professional with the name(s)
     and address(es) of the partner(s). The health pro-      ❙ Association with peers is characterized by a
     fessional then invites the partner(s) to come in for      shift in authority away from the family and to
     examination and treatment.                                fellow adolescents. Here, the laws of the group
                                                               become dominant. Groups of adolescents form
     Prevention Work Among Adolescents                         according to interests (sports, entertainment,
     Several reasons explain the rapid spread of STIs          music, dance) or by location. When an adoles-
     among adolescents: casual sex, frequent change of         cent joins one group or another, he/she strives
     partners, disinclination to use condoms, flippant         to comply with its rules of behavior. Thus, if
     attitudes toward their own health, and finally, the       smoking, drinking alcohol, or sex with multiple
     frequently asymptomatic course of the disease and         partners is popular in the group, the adolescent
     delay in seeking medical treatment.5                      follows the laws of the group, even if he/she
                                                               does not want to, for one purpose: to maintain
     Puberty is a critical age not only in the develop-        standing and “be grown up.” The leader of the
     ment of the reproductive system but also in the           group is usually a peer or an older adolescent.



12          Preventing Mother-to-Child Transmission of HIV   Prevention and Treatment of Sexually Transmitted Infections   13
                                               Chapter 2     Primary Prevention of STIs



       By studying the behavior of adolescents, psy-         that only the patient has the right to decide whether
       chologists have proposed an original method of        anyone other than the physician will know about
       influencing a group through its leader. The           his/her problems is a way to emphasize from the
       leader is taught about preventing contraception       start that the meeting is confidential. Physicians
       and protecting one’s self against STIs. As the        should be tolerant of loud clothing, multicolored
       main authority figure the leader then introduces      hair, or excessive makeup, even if the patient’s ap-
       new rules of behavior in the group and it be-         pearance seems provocative. Physicians should treat
       comes prestigious to use contraceptives, protect      adolescents as equals and with respect; discussions
       one’s self from STIs, and not to smoke or drink.      should touch on all aspects of the adolescent’s life in
                                                             which the physician is interested. During the con-
     ❙ Opposition is resistance and disinclination to        versation, it should be emphasized—preferably
       submit to adult rules of behavior. The adoles-        more than once—that the patient will make the fi-
       cent may internally agree with arguments made         nal decision on all issues discussed with the physi-
       by parents, teachers, doctors, and other adult        cian, and the physician should avoid speaking with a
       authority figures, but by virtue of his/her char-     moralizing tone.7
       acter (or convictions) the adolescent acts in the
       opposite way, especially if the advice or request     The condom is currently the only sufficiently ef-
       sounds dogmatic.                                      fective means of preventing STI transmission and
                                                             HIV infection from sexual contact. Therefore,
     ❙ Imitation is when the adolescent blindly              explaining the need to use a condom every time
       imitates his/her idol—movie star, sports figure,      one engages in sexual contact is one of the main
       etc.—in style of dress, manner of speaking, and       goals of prevention work. Studies show that
       way of interacting.                                   condom use has increased in the last decade, espe-
                                                             cially among young people. However, the same
     Physicians who work with adolescents must under-        studies show that for many young people, condom
     stand these typical behavioral patterns and take        use has not yet become a hard and fast rule. They
     them into account when talking with adolescents. It     stop using condoms to demonstrate trust in their
     is very important for young patients to think of        partner or as a sign of a closer relationship. As a
     their physician as a friend and helper when talking     result, the number of people who use condoms
     about such intimate issues as contraception and STI     during contact with new partners is growing, but
     protection. Discussions with adolescents should take    at the same time a significant number of young
     place with no other people present, unless the ado-     people do not use condoms each time they engage
     lescent wants someone else to be there. Explaining      in sexual contact.



14          Preventing Mother-to-Child Transmission of HIV   Prevention and Treatment of Sexually Transmitted Infections   15
                                               Chapter 2



     Experts believe that the following methods can
     increase the likelihood that adolescents will use
     condoms:
                                                             Chapter 3: Treatment of
     ❙ Giving the adolescent an adequate understand-
       ing of his/her risk of contracting an STI or HIV      STIs
     ❙ Eliminating negative attitudes about
       condoms
                                                             CLASSIFICATION OF STIS
     ❙ Continually reminding the adolescent about            In recent years, perceptions about STIs have
       how to use a condom correctly                         changed considerably as a result of changes in
                                                             sexual behavior, contraceptive use, urbanization,
     ❙ Promoting positive perceptions of safe sex            and other social, medical, and demographic
                                                             factors. In addition, the current situation has been
     ❙ Making adolescents and young people feel              exacerbated by international tourism; changes in
       responsible for their health and the health of        the age structure of the population; changing
       their sex partners                                    attitudes toward sex and prostitution; and the
                                                             appearance of antibiotic-resistant strains of
     ❙ Teaching girls to stand up for their decision to      pathogens.
       have their partner use a condom each time they
       engage in a sexual act

     ❙ Providing condoms to adolescents




16          Preventing Mother-to-Child Transmission of HIV   Prevention and Treatment of Sexually Transmitted Infections   17
                                                                                                                       Chapter 3    Treatment of STIs



                                               There are currently more than 20 STIs. They are                                      Methods of fighting STIs are based on the follow-        It should be noted
                                               highly contagious, spread relatively rapidly among                                   ing principles:
                                               certain population groups, and are classified in the                                                                                          that the course of
                                               chart.                                                                               ❙ Promote primary prevention and increase public
                                                                                                                                      awareness about the need to seek medical care          STIs can be much
                                                                                                                                      when the first symptoms of a disease appear.
       CLASSIFICATION OF SEXUALLY TRANSMITTED INFECTIONS                                                                                                                                     more severe in
     Disease Name
                                           Classic Venereal Infections
                                                                       Causative Agent
                                                                                                                                    ❙ Provide accessible and effective medical care,         HIV-infected
                                                                                                                                      including:
     Syphilis                                                          Treponema pallidum
     Gonorrhea                                                         Neisseria gonorrhoeae
                                                                                                                                       s Correct diagnosis                                   patients, and the
     Chancroid (soft chancre)                                          Haemophilus ducreyi                                             s Effective treatment
     Venereal lymphogranulomatosis                                     Chlamydia trachomatis                                           s Training and counseling on how to reduce risk       effectiveness of
     Granuloma inguinal (venereal)                                     Calymmatobacterium granulomatis
                                                                                                                                       s Recommendations on the most acceptable

                                                                                                                                          forms of treatment                                 traditional therapy
                                STIs Primarily Affecting Genital Organs
     Disease Name
     Urogenital chlamydiosis
                                                                       Causative Agent
                                                                       Chlamydia trachomatis
                                                                                                                                       s Providing access to condoms

                                                                                                                                       s Encouraging sex partners to share informa-
                                                                                                                                                                                             can be significantly
     Urogenital trichomoniasis
     Urogenital candidiasis
                                                                       Trichomonas vaginalis
                                                                       Candida albicans
                                                                                                                                          tion about STIs                                    reduced.
                                                                                                                                       s Monitoring the effectiveness of treatment
     Urogenital mycoplasmosis                                          Mycoplasma hominis
     Genital herpes                                                    Herpes simplex virus                                               (including serological data)
     Papillomavirus infections                                         Papillomavirus hominis
                                                                                                                                       s Identifying latent diseases
     Molluscum contagiosum of the genitals                             Molluscovirus hominis
     Bacterial vaginosis                                               Gardnerella vaginalis
     Urogenital shigellosis                                            Shigella species                                             It should be noted that the course of STIs can be
     Pubic pediculosis (phthiriasis)                                   Phthirus pubis
                                                                                                                                    much more severe in HIV-infected patients, and
     Scabies                                                           Sarcoptes scabiei
                                                                                                                                    the effectiveness of traditional therapy can be
                                 STIs Primarily Affecting Other Organs                                                              significantly reduced.
     Disease Name                                                      Causative Agent
     Acquired immunodeficiency                                                                                                      SYNDROMIC APPROACH TO
     syndrome (AIDS)                                                   Human immunodeficiency virus (HIV)
     Hepatitis B, hepatitis C                                          Hepatitis B virus, Hepatitis C virus                         DIAGNOSIS AND TREATMENT
     Cytomegaly                                                        Cytomegalovirus hominis                                      WHO and UNAIDS strongly recommend the use
     Amebiasis                                                         Entamoeba histolytica
                                                                                                                                    of syndromic diagnosis and treatment of STIs.8
     Lambliasis                                                        Lamblia intestinalis


                                                                                                                                    Making an etiological diagnosis of an STI (i.e.,
     Source: Ministry of Health of Ukraine, UNICEF, Prevention of Mother-to-Child HIV Transmission, training module (Kiev, 2001).
                                                                                                                                    detecting the pathogen) presents certain problems



18                                                          Preventing Mother-to-Child Transmission of HIV                          Prevention and Treatment of Sexually Transmitted Infections                    19
                                                                      Chapter 3   Treatment of STIs



WHO and UNAIDS            for many medical institutions. Establishing etiology    development of complications and long-term effects,
                          takes time and resources. Moreover, the sensitivity     slows the spread of STIs in the community, and pro-
strongly recommend        and specificity of commercial diagnostic instru-        vides a unique opportunity for targeted educational
                          ments varies considerably, which reduces the            efforts to prevent HIV infection. Providing adequate
the use of syndromic      reliability of laboratory diagnoses of STIs. A          treatment to STI patients the first time they seek
        diagnosis and     laboratory must be staffed by qualified personnel       medical care is very important from the perspective
                          who have received special training in performing        of public health. When an adolescent patient seeks
     treatment of STIs.   the technically complex tests required for STI          care, an opportunity arises to influence the develop-
                          diagnosis; the operation of a laboratory should         ment of sexual behavior and encourage the patient        Providing adequate
                          also be subject to independent quality control.         to seek medical care in the future.
                                                                                                                                           treatment to STI
                          In developing countries, very few medical institu-      The use of standardized treatment regimens is
                          tions have the laboratory equipment and qualified       strongly recommended, as it ensures the adequate         patients the first time
                          personnel necessary to be able to perform etiolog-      treatment of patients at all levels of medical care.
                          ical diagnosis of STIs. To solve this problem, a        A standardized treatment approach simplifies the
                                                                                                                                           they seek medical
                          syndromic STI treatment approach has been               training of health professionals and the monitor-        care is very
                          developed for and introduced in many developing         ing of medical treatment, slows the development
                          countries. The syndromic approach is based on           of antibiotic-resistant STI pathogens, and ensures       important from the
                          diagnosis of various syndromes (specific combina-       the reasonable use of drugs.11
                          tions of clinical signs) and treatment of the pri-                                                               perspective of public
                          mary range of pathogens capable of causing a            Selection of Drugs for Treatment
                          particular syndrome. To assist health professionals,    The drugs prescribed for treatment of STIs               health.
                          WHO has developed simple procedures for treat-          should meet the following criteria to the extent
                          ment of patients with various syndromes.9               possible:12
                                                                                  ❙ high degree of effectiveness (minimum 95%)
                          The protocols presented in this chapter are based       ❙ low cost
                          on recommendations from the CDC’s Guidelines            ❙ acceptable side effects and good tolerance
                          for Treatment of STIs.10                                ❙ low probability or prolonged period of
                                                                                    development of resistance
                          Need to Develop and Follow Standard                     ❙ single-dose treatment
                          Recommendations for Treatment                           ❙ can be taken perorally
                          Effective treatment is one of the primary tools for     ❙ not counterindicated for pregnant and breast-
                          fighting STIs, because treatment prevents the             feeding women



20                               Preventing Mother-to-Child Transmission of HIV   Prevention and Treatment of Sexually Transmitted Infections                   21
                                               Chapter 3     Treatment of STIs



     Drugs should be selected from the official list of      Physicians often need to treat a patient before test
     necessary drugs; the capabilities and experience of     results are available. In such circumstances, the
     the health professionals should be considered           clinician should treat for the diagnosis considered
     when selecting a treatment regimen.                     most likely. If the diagnosis is unclear, treatment for
                                                             syphilis is recommended, or if the patient lives in a
     PROCEDURES FOR DIAGNOSIS                                region in where H. ducreyi is a frequent cause of
     AND TREATMENT                                           genital ulcers, and especially if it is not possible to
     Treatment of Patients with Genital Ulcers               confirm or rule out a diagnosis of chancroid or
     Genital herpes, syphilis, or chancroid is found in      syphilis by laboratory methods, combined treat-
     the majority of young, sexually active patients who     ment for syphilis and chancroid should be given.
     present with genital ulcers. More than one disease      Even after a complete diagnostic evaluation, at least
     may be present in these patients. Each of these         25% of patients who have genital ulcers have no
     infections increases the risk of contracting HIV.       laboratory-confirmed diagnosis.

     A diagnosis based only on the patient’s medical         Chancroid
     history and a physical examination is often inac-       Chancroid increases the risk of HIV, which is why
     curate; therefore, evaluation of a patient with gen-    cases of HIV infection among patients who have
     ital ulcers should include a serologic test for         chancroid are frequent. Approximately 10% of
     syphilis and a diagnostic evaluation for herpes.        chancroid copatients were infected with
     Laboratory diagnosis of patients with genital ul-       T. pallidum or HSV.
     cers includes:
                                                             To confirm a diagnosis of chancroid, H. ducreyi must
     ❙ Darkfield examination or direct                       be cultured, but even with the use of special culture
       immunofluorescence test for T. pallidum               media, the sensitivity of the culture method is ≤80%.
                                                             For purposes of treatment selection and subsequent
     ❙ Culture or antigen test for HSV                       observation, a probable diagnosis of chancroid can be
                                                             made if the following criteria are met:
     ❙ Culture for H. ducreyi
                                                             ❙ The patient has one or more painful ulcers.
     HIV testing
     Patients who have genital ulcers caused by              ❙ No T. pallidum infection has been found in the
     T. pallidum or H. ducreyi or who have herpes              patient by darkfield examination of the ulcer
     infection should be tested for HIV.                       exudate or by a serologic test for syphilis



22          Preventing Mother-to-Child Transmission of HIV   Prevention and Treatment of Sexually Transmitted Infections   23
                                                  Chapter 3     Treatment of STIs



       performed at least seven days after the onset                                                                     CHANCROID
       of the ulcers is negative.                                        Clinical                 One or more painful ulcers        Regional (most often in the groin area)      Supporation of swollen lymph
                                                                                                                                       swollen and painful lymph nodes                  node in groin

     ❙ The clinical picture, characteristics of genital
                                                                    Laboratory Data                 H. ducreyi on special               T. pallidum infection is not detected in the patient by darkfield
       ulcers, and regional adenopathy (if present) are                                                 culture media               examination of ulcer exudates or a serologic test for syphilis performed at
                                                                                                                                                     least seven days after onset of ulcers.
       typical for chancroid and a test for HSV is
       negative.                                                  Treatment            Azithromycin                  Ceftriaxone                    Ciprofloxacin                         Erythromycin
                                                                   Regimen              1 g orally in a          250 mg intramuscularly         500 mg orally twice a day            preparation 500 mg orally
                                                                                         single dose,               in a single dose,                 for 3 days,                     4 times a day for 7 days
     The combination of a painful ulcer and painful,                                          or                           or                             or
     swollen, regional lymph nodes that is found in a third
     of all patients, indicate a diagnosis of chancroid. Sup-                                                                             Contraindicated for pregnant and lactat-
     puration of lymph nodes is a pathognomonic sign.                                                                                     ing women and for persons <18 years

                                                                     Testing for HIV                                                                                               Repeat after three months,
                                                                                                 Immediately after diagnosis                      Negative
     Treatment                                                                                                                                                                    simultaneously repeating the
                                                                                                                                                                                         test for syphilis
     With effective treatment of chancroid, clinical man-
     ifestations disappear and the pathogen is eradicated
                                                                                                                                          Longer treatment                  Erithromycin for seven days is
     from the body, which prevents further transmission                                                      Positive
                                                                                                                                               course                   recommended for HIV-infected patients
     of the disease. In advanced cases, scars may remain
     despite successful treatment. All four protocols de-              Follow-up                     Reexamination after                         Symptomatic                         Objective improvement in
                                                                                                        3 to 7 days                           improvement for first                   first 7 days after start
     scribed in the chart are effective for the treatment                                                                                           3 days                                  of treatment
     of chancroid in HIV-positive patients. The advan-




                                                                                                                                          {
     tage of azithromycin and ceftriaxone is the use of a                               No clinical improvement is evident
                                                                                                                                                      Incorrect Diagnosis
     single-dose therapy. Several strains with intermedi-                                                                                             Patient has associated STI
     ate resistance to ciprofloxacin and erythromycin                                                                                                 Patient infected with HIV
                                                                                                                                                      Noncompliance with doctor’s directions
     have been detected worldwide.
                                                                                                                                                      H. ducreyi strain causing infection is
                                                                                                                                                      resistant to prescribed antimicrobial therapy
     Special Considerations
     Pregnancy                                                                                                                    < two weeks
                                                                                        Ulcer healing time                                                                               Ulcers under foreskin
     At present, there are no data on the safety of                                                                               > two weeks
     azithromycin for pregnant or lactating women.                                                                                                                                           Large ulcers

     Ciprofloxacin is contraindicated during pregnancy.
                                                                                                                  Examination and prescription of treatment regimen regardless of whether infection symptoms are
     There are also no data on the adverse effect of chan-           Sex partner(s)                                present or whether partners had sexual contact with the patient during the 10 days preceding
     croid on the course of pregnancy or on the fetus.                                                                                         the onset of symptoms in the patient.




24           Preventing Mother-to-Child Transmission of HIV     Prevention and Treatment of Sexually Transmitted Infections                                                                                      25
                                                  Chapter 3   Treatment of STIs



     HIV infection                                                            GENITAL HERPES SIMPLEX VIRUS (HSV) INFECTION
     HIV-positive patients with chancroid should be
                                                                 Definition                 Recurrent, incurable viral disease
     monitored. Such patients may need a longer course
     of treatment than patients with negative HIV test           Pathogen                   Herpes virus serotypes (1 and 2)
     results. Healing may be slower among HIV-positive
     patients, and any given treatment protocol may
                                                                 First Clinical Episode of Genital Herpes
     prove to be ineffective for them. Because there are
     so few data on the effectiveness of the recommend-          Laboratory                 5–30% of first episodes of genital herpes are caused by HSV-1, but symptomatic
     ed protocols with ceftriaxone and azithromycin for          Diagnostics                recurrences are much less frequent for HSV-1 than for HSV-2 genital infections.
                                                                                            Therefore, identification of the infecting strain has prognostic importance and is
     HIV-positive patients, they should be used only                                        essential for proper counseling of patients.
     when the patient can be monitored. The seven-day
                                                                Treatment                   Antiviral Therapy
     protocol for erythromycin is recommended for
                                                                                            Acyclovir 400 mg orally 3 times a day for 7-10 days, or
     treating HIV-positive patients.                                                        Acyclovir 200 mg orally 5 times a day for 7-10 days, or
                                                                                            Famciclovir 250 mg orally 3 times a day for 7-10 days, or
                                                                                            Valacyclovir 1 g orally 2 times a day for 7-10 days.
     Genital Herpes Simplex Virus (HSV)                                                     Note: Treatment may be continued past the 10-day treatment course if healing of
     Genital herpes is a recurring, incurable, viral dis-                                   herpes eruptions is incomplete.
     ease. Two serotypes of HSV have been identified:
                                                                 Counseling                 • Patients must be told about the nature of the disease with emphasis on the possibil-
     HSV-1 and HSV-2. Most cases of genital herpes                                              ity of recurrences, the shedding of the virus even in the absence of symptoms, and
     are caused by HSV-2.                                                                       the possibility of sexual transmission of the virus.
                                                                                            •   Patients must be advised to abstain from sex when clinical manifestations or
                                                                                                prodromal symptoms are present and to inform their sexual partner(s) that they
     In most people infected with HSV-2, the disease is                                         have genital herpes. The use of condoms during all sexual activity with new or
                                                                                                uninfected partners must be recommended.
     virtually asymptomatic and is not diagnosed, but
                                                                                            •   Sexual transmission of HSV can occur during asymptomatic periods. Asymptomatic
     the virus is shed intermittently in the genital tract.                                     viral shedding occurs more often in patients who have genital HSV-2 infections than
                                                                                                in those who have HSV-1 infections and in patients who have HSV-1 infections and
     Many cases of genital herpes are transmitted by
                                                                                                in patients whose first episode of genital herpes occurred in the past 12 months.
     individuals who are unaware of their infection or                                          Such patients should be educated about preventing the spread of the infection.
     who do not believe it is necessary to take precau-                                     •   The risk of neonatal infection must be explained to all patients, including men.
                                                                                                Women of childbearing age who have genital herpes must inform the physician
     tions in periods of remission.                                                             caring for them during pregnancy of the HSV infection.
                                                                                            •   It must be explained to patients that a) taking antiviral drugs episodically during
                                                                                                recurrences may reduce the duration of the clinical manifestations and b) perma-
     The use of antiviral drugs reduces the frequency of                                        nent suppressive antiviral therapy can reduce the intensity or prevent recurrences.
     recurrences when taken permanently (long-term
     suppressive therapy) or the severity of clinical
     manifestations when taken episodically at the first
     sign of infection.             continued on page 30



26           Preventing Mother-to-Child Transmission of HIV   Prevention and Treatment of Sexually Transmitted Infections                                                             27
                                                                                                             Chapter 3      Treatment of STIs




                            HSV INFECTION (continued)                                                                                                HSV INFECTION (continued)

     Reoccurrence of HSV Infection                                                                                                                      Sex partners of herpes patients who have symptoms of herpes infection should be asked
                                                                                                                              Sex Partner(s)
                                                                                                                                                        to come in for an examination and receive appropriate treatment.

 Predisposing Factors         Most patients with a first episode of genital HSV-2 infection will have recurrences.            Pregnant Women            The first clinical episode of genital herpes during pregnancy may be treated with
                                                                                                                                                        acyclovir (oral). If a life-threatening maternal HSV infection is present (for example,
                                                                                                                                                        disseminated infection, encephalitis, pneumonia, or hepatitis), intravenous acyclovir is
                              When treatment is started during the prodromal period or during the first day after the                                   prescribed. Treatment with acyclovir in late stages of pregnancy may reduce the number
 Treatment                                                                                                                                              of cesarean deliveries among women who suffer frequent recurrences of genital herpes
                              onset of lesions, episodic therapy with antiviral drugs is effective for many patients with
                              a recurrent infection. If episodic drug therapy is chosen for treatment of recurrences, the                               or who experienced the first episode of genital herpes during the pregnancy by decreas-
                              patient should be provided with antiviral drugs or be issued a prescription for them so                                   ing the frequency of recurrences.
                              that the patient can begin treatment at the first signs of prodrome or genital lesions.
                                                                                                                                                        The risk for mother-to-child transmission of the infection is high (30-50%) if the woman
                                                                                                                              Perinatal Infection
                              Acyclovir 400 mg orally 3 times a day for 5 days, or                                                                      had the first episode of genital herpes in late pregnancy and low (3%) if the woman has
                              Acyclovir 200 mg orally 5 times a day for 5 days, or                                                                      recurrent herpes or if the first episode of genital herpes occurred in the first half of the
                              Acyclovir 800 mg orally 2 times a day for 5 days, or                                                                      pregnancy.
                              Famciclovir 125 mg orally 2 times a day for 5 days, or
                              Valacyclovir 500 mg orally 2 times day for 5 days.                                                                        If the woman has no symptoms of genital herpes or its prodrome, she can deliver
                                                                                                                                                        vaginally. Cesarean section does not totally eliminate the risk for HSV infection in the
                                                                                                                                                        neonate.
                               Ongoing suppressive antiviral therapy reduces the frequency of genital herpes
                               recurrences by ≥ 75% in patients who have frequent recurrences (i.e., six or
                                                                                                                                                        Infants exposed to HSV during delivery, as confirmed by virus culturing or presumed
                               more recurrences per year). The safety and efficacy of daily treatment have
                                                                                                                                                        based on examination of lesions, must be monitored carefully.
                               been reported among patients receiving acyclovir for six years, and
                               valacyclovir and famciclovir for one year. Suppressive therapy with acyclovir re-
                                                                                                                                                        However, infants born to mothers who were infected with genital herpes late in pregnancy
                               duces but does not eliminate shedding of the virus in the absence of symptoms.
                                                                                                                                                        are highly susceptible to infection; for this reason, some specialists recommend treating
                                                                                                                                                        such infants with acyclovir. During pregnancy such women and later their newborns
                               Acyclovir 400 mg orally twice a day, or
                                                                                                                                                        should be treated in consultation with an infection specialist. All newborns with signs of
                               Famciclovir 250 mg orally twice a day, or
                                                                                                                                                        neonatal herpes should be examined promptly, evaluated, and prescribed a treatment
                               Valacyclovir 500 mg orally once a day, or
                                                                                                                                                        regimen with parenteral acyclovir. The regimen of choice is acyclovir 30-60 mg/kg/day
                               Valacyclovir 1,000 mg orally once a day.
                                                                                                                                                        for 10-21 days.
                               Patients with very frequent recurrences ( ≥10 episodes per year) generally require
                               a high dose of valacyclovir (over 500 mg per day). Valacyclovir and famciclovir are            HIV                       Lesions caused by HSV may be severe, painful, and atypical. Episodic treatment of
                               comparable to acyclovir in clinical outcome. However, valacyclovir and famciclovir are                                   recurrences or prolonged suppressive therapy with antiviral drugs is often effective.
                               easier to administer, which is important for prolonged use.
                                                                                                                                                        Treatment must be continued until a clinical effect is achieved.

                               Severe Disease                                                                                                           Famciclovir 500 mg/twice a day is effective in reducing the frequency of recurrences
                               Patients who have severe disease or complications necessitating hospitalization—                                         and the indicators of shedding of the virus in the period of remission.
                               disseminated infection, pneumonia, hepatitis, or central nervous system complications
                               (meningitis, encephalitis) must take the drugs intravenously.                                                            For severe cases, intravenous administration of acyclovir in a dose of 5 mg/kg every
                                                                                                                                                        eight hours may be necessary. If lesions persist in patients receiving acyclovir treatment,
                               Acyclovir 5-10 mg/kg of body weight every eight hours for five to seven days or until                                    resistance of the HSV strain to acyclovir should be suspected.
                               symptoms resolve.
                                                                                                                                                        Foscarnet in a dose of 40 mg/kg of body weight IV every eight hours until total clinical
                                                                                                                                                        resolution is often effective in the treatment of acyclovir-resistant genital herpes. Topical
                                                                                                                                                        use of 1% cidofovir gel directly on the lesions once a day for five days may also improve
                                                                                                                                                        the condition.




28                                               Preventing Mother-to-Child Transmission of HIV                             Prevention and Treatment of Sexually Transmitted Infections                                                            29
                                                    Chapter 3      Treatment of STIs



     However, these drugs do not eradicate the latent                                                         SYPHILIS
     virus and do not alter the risk, frequency, or severi-
     ty of recurrences after the drug is discontinued.              Pathogen                   T. pallidum

     Randomized trials indicate that three antiviral
                                                                    Diagnosis                  Early Syphilis
     drugs are clinically effective for the treatment of                                       • Darkfield microscopy
     genital herpes: acyclovir, valacyclovir, and famci-                                       • Direct immunofluorescence stain test of fast smears prepared from material obtained
                                                                                                  from sites suspected of syphilis
     clovir. Valacyclovir is a valine ester of acyclovir with                                  • Serologic reaction: a) flocculation/precipitation tests with nontreponemal (cardiolipin)
     enhanced absorption when taken orally. Famci-                                                antibody, similar to the VDRL and RPR tests used in other countries, and b)
                                                                                                  immunofluorescence reaction (IFR) and passive hemagglutination reaction (PHGR)
     clovir, a prodrug of penciclovir, also has high oral
                                                                                               The use of only one method is insufficient for diagnosis. Regular serologic tests should be
     bioavailability. Topical therapy with acyclovir is
                                                                                               performed using the same method (for example, RPR) and advisably by the same labora-
     substantially less effective than the systemic drug,                                      tory. The validity of VDRL and the rapid test for the nontreponeme (cardiolipin) antibody
                                                                                               (RPR) is the same, but quantitative results of these two tests should not be compared
     and for this reason its use is not recommended.                                           directly, because the RPR titers are often slightly higher than titers obtained using VDRL.

                                                                                               HIV-positive patients may have inadequate serologic test results (i.e., too high, too low,
     Syphilis                                                                                  and constantly changing titers). Other diagnostic methods (for example, biopsy and
     Syphilis is a systemic disease caused by T. pallidum.                                     direct microscopy) must be used for such patients with clinical signs suggestive of
                                                                                               syphilis.
     Patients who have syphilis may seek treatment for
     clinical manifestations of the primary infection (i.e.,
                                                                                               The diagnosis of neurosyphilis can be based on various combinations of serologic test
     an ulcer or chancre at the infection site), secondary                                     results, cytosis or protein concentration in cerebrospinal fluid (CSF), or RPR with CSF with
     infection (i.e., a rash, mucocutaneous lesions, or                                        or without clinical manifestations. The CSF leukocyte count is usually elevated (more than
                                                                                               5 leukocytes/mm3) in neurosyphilis; the leukocyte count is also a sufficiently accurate
     adenopathy), or tertiary infection (i.e., disorders of                                    indicator of the effectiveness of treatment. RPR with CSF is the standard serologic test for
     cardiac activity, vision, or hearing, neurological symp-                                  CSF; and if a positive result is obtained in the absence of a significant amount of blood in
                                                                                               the CSF, this indicates neurosyphilis. IFR with CSF is less specific (i.e., more false-positive
     toms, and gummatous lesions). The infection may                                           results) for neurosyphilis than RPR with CSF. However, this test is regarded as very
     also be detected by serologic testing in the latent stage.                                sensitive, and some specialists believe that a negative IFR with CSF rules out syphilis.



     Latent syphilis acquired within the preceding year is          Treatment                  Parenteral penicillin G is preferred for all stages of syphilis. Patients allergic to penicillin,
                                                                                               including pregnant women at any stage of syphilis and patients with neurosyphilis, must
     referred to as early latent syphilis. All other cases of                                  be desensitized and treated with penicillin.
     latent syphilis are either late latent syphilis or syphilis
                                                                                               The Jarisch–Herxheimer reaction—an acute febrile reaction, often accompanied by
     of unknown duration. Theoretically, treatment of                                          headache, myalgia, and other symptoms—may occur within the first 24 hours after the
     the late latent syphilis, as well as of tertiary syphilis,                                start of syphilis treatment; patients should be warned about this. The Jarisch–Herxheimer
                                                                                               reaction often occurs in patients with early syphilis. Antipyretics may be recommended, but
     may require a longer course of treatment because the                                      there is no method to prevent the reaction. In pregnant patients, the Jarisch–Herxheimer
                                                                                               reaction may cause premature birth or fetal distress. However, this should not be a reason
     microorganisms are dividing more slowly. However,                                         to cancel or delay treatment.
     the clinical significance of this approach is not yet
     clear.                              continued on page 35



30           Preventing Mother-to-Child Transmission of HIV        Prevention and Treatment of Sexually Transmitted Infections                                                                 31
                                                                                                     Chapter 3      Treatment of STIs




                      SYPHILIS (continued)                                                                                                        SYPHILIS (continued)

 Sex Partner(s)     Persons who had contact with the patient within the 90 days preceding the last diagnosis                             Latent Syphilis in HIV-positive Persons
                    of primary, secondary, or early latent syphilis might be infected even if they have the
                    serologic test is negative. Such persons should be treated presumptively.
                                                                                                                      Diagnostic                HIV-positive patients with early latent syphilis should be treated according to the
                    Persons who had contact with the patient more than 90 days before the last diagnosis of           Considerations            recommendations for HIV-negative patients with primary or secondary syphilis.
                    primary, secondary, or early latent syphilis should be treated for syphilis if the serologic
                    test cannot be performed immediately and the opportunity for follow-up of such persons                                      HIV-positive patients with late latent syphilis or syphilis of unknown duration should have
                    is doubtful.                                                                                                                a CSF examination before the beginning of treatment.

                    For purposes of notifying and treating sex partners, patients with syphilis of unknown
                    duration who have a high nontreponemal (cardiolipin) antibody titer (i.e., ≥1:32) are             Treatment                 Patients with late latent syphilis or syphilis of unknown duration and normal CSF results
                    considered to have early syphilis. However, serologic titers should not be used to                                          can be treated with a dose of 7.2 million units of benzathine penicillin G (3 weekly doses
                    differentiate early from late latent syphilis for the purpose of determining treatment                                      of 2.4 million units each). Patients who have CSF consistent with neurosyphilis must be
                    (see section regarding treatment of latent syphilis).                                                                       treated according to the appropriate regimen.

                    Long-term sex partners of patients who have late syphilis should be evaluated clinically
                    and serologically for syphilis and treated on the basis of the findings of the evaluation.        Follow-up                 Clinical and serologic examination must be repeated at 6, 12, 18, and 24 months after
                                                                                                                                                therapy. If at any time clinical symptoms develop or the nontreponemal (cardiolipin) an-
                    Time periods before treatment used for identifying sex partners at risk for infection:
                                                                                                                                                tibody titer rises fourfold, a repeat CSF examination must be performed and treatment
                    a) three months plus duration of symptoms for primary syphilis, b) six months plus
                                                                                                                                                administered accordingly. If over 12-24 months the nontreponemal (cardiolipin) anti-
                    duration of symptoms for secondary syphilis, and c) one year for early latent syphilis.
                                                                                                                                                body titer fails to decline fourfold, the CSF examination should be repeated and appro-
                                                                                                                                                priate treatment administered.
                  Primary and Secondary Syphilis
                      in HIV-positive Persons

 Treatment          Treatment with a single dose of benzathine penicillin G 2.4 million units IM is
                    recommended.

                    Some experts recommend additional treatment (for example, three weekly doses of
                    benzathine penicillin G, as in late stages of syphilis) or other antibiotics in addition to
                    2.4 million units of benzathine penicillin IM.

 Follow-up          HIV-positive patients must be evaluated clinically and serologically to verify the effective-
                    ness of treatment 3, 6, 9, 12, and 24 months after treatment.

                    CSF examination and repeated treatment must be recommended for patients whose non-
                    treponemal (cardiolipin) antibody titer does not decrease fourfold within 6-12 months.
                    Most experts recommend retreatment of patients with benzathine penicillin G in a dose
                    of 7.2 million units (three weekly doses of 2.4 million units each) if the CSF examina-
                    tions are normal.




32                                    Preventing Mother-to-Child Transmission of HIV                                Prevention and Treatment of Sexually Transmitted Infections                                                          33
                                                                                               Chapter 3        Treatment of STIs




             SYPHILIS DURING PREGNANCY                                                                          DISEASES CHARACTERIZED BY
                                                                                                                URETHRITIS AND CERVICITIS
 Diagnosis     All women must be screened serologically for syphilis during the early stages of pregnancy.
               If the woman belongs to a population group that receives virtually no prenatal care,             Urethritis
               screening with VDRL/RPR and treatment (if the test is positive) must be done immediately         Infectious urethritis, or inflammation of the ure-
               after pregnancy is diagnosed. The serologic testing must be performed twice: in the third
               trimester (at 28 weeks gestation) and at delivery.                                               thra, is characterized by purulent or mucopurulent
                                                                                                                discharge from the urethra and a burning sensa-
               All women who deliver a stillborn infant after 20 weeks of gestation should be tested for        tion during urination. Urethritis is frequently
               syphilis.                                                                                        asymptomatic. In men, the primary pathogens of
                                                                                                                urethritis are N. gonorrhoeae and C. trachomatis. A
               No infant should leave the maternity home if the woman has not been tested                       physical examination is recommended to make the
               serologically for syphilis at least once during pregnancy.
                                                                                                                precise diagnosis. If it is not possible to perform
                                                                                                                laboratory tests (i.e., microscopic examination of a
 Treatment
               Penicillin in doses appropriate for the stage of syphilis.                                       Gram-stained smear), patients must be treated for
               Some experts recommend administering additional doses of penicillin.                             both infections. To avoid the additional costs of
               Women with primary, secondary, or early latent syphilis may be administered 2.4 million
               units of benzathine penicillin intramuscularly one week after the first dose. Ultrasonic
                                                                                                                treating patients with nongonococcal urethritis,
               signs of fetal syphilis (i.e., hepatomegaly and hydrops) indicate a greater risk of              health professionals should try to distinguish
               ineffective fetal treatment.
                                                                                                                gonococcal and nongonococcal urethritis when
               Women treated for syphilis during the second half of pregnancy have a high risk for
               premature labor and/or fetal distress because of the Jarisch–Herxheimer reaction. These          making the diagnosis.
               women must be advised to consult an obstetrician/gynecologist after a treatment course
               if they notice uterine contractions or a decrease in fetal activity. The possibility of such a
               rare complication as stillbirth is not a reason to delay treatment. All patients with syphilis
               must be offered testing for HIV infection.



 Follow-up     The antibody titer must be determined in the third trimester and at delivery. Serologic
               testing may be repeated monthly in women at high risk for repeat infection or in regions
               in which syphilis is encountered often. Clinical signs and the antibody titer should be
               appropriate for the stage of the disease. In most cases, women will deliver before their
               serologic response to treatment can be assessed accurately.




34                                Preventing Mother-to-Child Transmission of HIV                                Prevention and Treatment of Sexually Transmitted Infections   35
                                                                                                            Chapter 3     Treatment of STIs



                                          URETHRITIS                                                                                                        RECURRENT AND PERSISTENT URETHRITIS
 Diagnostic Criteria    A diagnosis of urethritis is made if the patient has any of the following symptoms:                  Treatment                                               Objective signs of urethritis must be detected to initiate antimicrobial therapy.
                        • Mucopurulent or purulent discharge.
                        • A preparation made from urethral secretions and Gram stained reveals five or more leuko-
                                                                                                                             If the patient did not comply with the initial treat-
                                                                                                                             ment regimen or had contact with an untreated           Treat repeatedly using the initial treatment regimen
                            cytes in the field of vision when the ocular is placed in oil (immersion microscopy). Gram
                            stain microscopy is sufficiently sensitive and specific for diagnosis of urethritis and for      sex partner
                            establishing the presence or absence of gonococcal infection. The diagnosis of gonococcal                                                                Metronidazole 2 g orally in a single dose, plus
                            infection is made when Gram-negative diplococci are discovered inside the leukocytes.            If the patient complied with the treatment regimen
                                                                                                                                                                                        Erythromycin base 500 mg orally 4 times a day for 7 days, or
                        • Positive leukocyte esterase test on first-void urine or observation of ≥10 leukocytes in the       and repeated sexual contact can be ruled out
                                                                                                                                                                                        Erythromycin ethylsuccinate 800 mg orally 4 times a day for 7 days
                            field of vision in a microscopic examination of a preparation made from the sediment of
                            first-void urine.


 Etiology               C. trachomatis (i.e., 23%–55% of cases)           Mycoplasma genitalium                           Cervicitis
                        N. gonorrhoeae                                    T. vaginalis                                    Mucopurulent cervicitis is characterized by the
                        Ureaplasma urealyticum                            HSV
                                                                                                                          presence of purulent or mucopurulent endocervical
 Treatment              Must begin immediately upon diagnosis.                                                            exudates that are visible in the cervical canal in a
                                                                                                                          mirror exam or endocervical smear. Some experts
                        Recommended Treatment Regimen
                        Azithromycin 1 g orally in a single dose or                                                       also diagnose cervicitis in cases of increased cervical
                        Doxycycline 100 mg orally twice a day for 7 days                                                  bleeding. Although mucopurulent cervicitis is occa-
                        Alternative Treatment Regimen                                                                     sionally diagnosed on the basis of an increase in the
                        Erythromycin base 500 mg orally 4 times a day for 7 days or
                                                                                                                          number of polymorphonuclear leukocytes in a
                        Erythromycin ethylsuccinate 800 mg orally 4 times a day for 7 days or
                        Ofloxacin 300 mg twice a day for 7 days                                                           Gram-stained smear, this method is not included in
                        If the patient can only take erythromycin for some reason but does not tolerate it well, one
                                                                                                                          the diagnostic standards—it has low positive
                        of the following treatment regimens may be used:                                                  prognostic value—and is not performed in all labo-
                        Erythromycin base 250 mg orally 4 times a day for 14 days, or
                        Erythromycin ethylsuccinate 400 mg orally 4 times a day for 14 days                               ratories. Mucopurulent cervicitis is frequently asymp-
                                                                                                                          tomatic, but some women experience pathological
 Follow-up              Patients must be instructed:                                                                      vaginal bleeding, for example, after sexual inter-
                        • To consult a physician if symptoms persist or recur after the treatment course has ended
                        • To abstain from sexual intercourse until therapy is complete                                    course. Mucopurulent cervicitis can be caused by
                                                                                                                          C. trachomatis and N. gonorrhoeae, but in most cases
 Partner Notification   Patients should refer all sexual partner(s) with whom they had sexual relations during the
                        last 60 days for examination and treatment.                                                       the pathogen is not identified. Mucopurulent cervici-
                                                                                                                          tis can persist despite a repeated course of antibiotic
                                                                                                                          therapy. Because persistent mucopurulent cervicitis
                                                                                                                          cannot be explained by recurrence of or new infec-
                                                                                                                          tion with C. trachomatis and N. gonorrhoeae,
                                                                                                                          noninfectious factors (i.e., ectropion inflammation)
                                                                                                                          may play a role in the pathogenesis of this disease.



36                                               Preventing Mother-to-Child Transmission of HIV                           Prevention and Treatment of Sexually Transmitted Infections                                                                       37
                                                                                                                        Chapter 3      Treatment of STIs



                                                   CERVICITIS
                                                                                                                                       Patients with mucopurulent cervicitis should be
         Pathogen                               C. trachomatis                              N.gonorrhoeae                              tested for C. trachomatis and N. gonorrhoeae,
                                                                                                                                       using the most specific and sensitive methods.
                                     Treatment of                       Uncomplicated                          Treatment of
                                   Pregnant Women                    Forms of the Disease                    Pregnant Women
                                                                                                                                       DISEASES CHARACTERIZED BY
     Azithromycin               Erythromycin base                    Cefixime 400 mg                     Single-dose of                VAGINAL DISCHARGE
  1 g orally in a single dose   500 mg orally 4 times a day           orally in a single dose            cephalosporin:
          or                           for 7 days                         or
                                                                                                                                       Management of Patients with Vaginal
                                                                                                            a) Ceftizoxime
      Doxycycline                       or                       Ceftriaxone 125 mg IM                      500 mg intramuscularly,    Infections
100 mg orally twice a day for        Amoxicillin                         in a single dose
                                500 mg orally 3 times a day              or
                                                                                                            b) Cefotaxime              Vaginitis is usually characterized by a vaginal
          7 days                                                                                            500 mg intramuscularly,
                                       for 7 days                Ciprofloxacin 500 mg                                                  discharge, itching, vulvar irritation, and vaginal
                                                                      orally in a single dose               c) Cefotetan
 Alternative treatment
                                                                          or                                1 g intramuscularly, and   odor. The three diseases most frequently associated
       regimens                  Alternative treatment
                                                                    Ofloxacin 400 mg                        d) Cefoxitin
                                       regimens
Erythromycin base                                                     orally in a single dose               2 g intramuscularly with
500 mg orally 4 times a day     Erythromycin base                         Plus
                                                                                                            probenecid 1 g orally
       for 7 days               250 mg orally 4 times a day         Azithromycin 1 g                                                                               MANAGING VAGINAL DISCHARGE
           or                          for 14 days                    orally in a single dose
                                                                        or
                                                                                                       If cephalosporins                                             Patient complains about vaginal discharge
     Erythromycin                        or
                                                                                                       are not tolerated:
     ethylsuccinate                Erythromycin                   Doxycycline 100 mg
800 mg orally 4 times a day        ethylsuccinate                     orally twice a day for           Spectinomycin 2 g
                                                                                                                                                                                   Lower abdominal pain
       for 7 days               800 mg orally 4 times a day                   7 days                    intramuscularly in a single
                                       for 7 days                                                                 dose.                                                             STI symptoms in sex
           or                                                      Alternative treatment
                                                                                                                                                         No                               partner                              Yes
       Ofloxacin                         or                              regimens
300 mg orally twice a day for      Erythromycin                                                          Erythromycin or
                                                                    Spectinomycin 2 g                                                                                  Association with risk factors:
          7 days                   ethylsuccinate                                                          amoxicillin
                                                                 intramuscularly in a single dose.                                                                     • Under 21 years of age
                                 400 mg 4 times a day for                                             is recommended for treatment
                                                                                                                                                                       • Single
                                                                     Single dose of                    of presumptive or diagnosed          Vaginitis                                                                                Cervicitis
                                        14 days                                                                                                                        • Two or more than one sexual partners
                                                                     cephalosporin:                          infection caused by
                                        or                                                                                                                               within last three months
                                   Azithromycin
                                                                     a) Ceftizoxime                      C. trachomatis in pregnant                                    • New sex partner within last three months
                                                                     500 mg IM,                                    women.
                                      1 g orally in a
                                       single dose                   b) Cefotaxime                                                                                      Purulent or mucopurulent secretions in cervi-
                                                                     500 mg IM,                                                                                         cal canal (on endocervical swab specimen)
                                                                     c) Cefotetan
                                                                     1 g IM, and                                                            Yes                           Elevated cervical bleeding during                                No
                                                                     d) Cefoxitin                                                                                         gynecological examination
                                                                     2 g IM with probenecid
                                                                     1 g orally;                                                                  • Homogeneous, white, noninflammatory discharge that smoothly coats the vaginal walls;
                                                                     Single dose of                                                               • The presence of “key” cells on microscopic examination;
                                                                        quinolone                                                                 • pH of vaginal secretions > 4.5;
                                                                     a) Enoxacin                                                                  • Fishy odor of vaginal discharge before and after addition of 10% KOH.
                                                                     400 mg orally,
                                                                                                                                          Causes: Trichomoniasis, candidiasis,                               Causes: Gonorrhea, chlamydiosis
                                                                     b) Lomefloxacin
                                                                     400 mg orally,                                                       bacterial vaginosis
                                                                                                                                                                                                             Examination of sex partner
                                                                     c) Norfloxacin
                                                                     800 mg orally



38                                                          Preventing Mother-to-Child Transmission of HIV                             Prevention and Treatment of Sexually Transmitted Infections                                           39
                                               Chapter 3     Treatment of STIs



     with vaginal discharge are trichomoniasis (caused                                                   BACTERIAL VAGINOSIS (BV)
     by T. vaginalis), bacterial vaginosis (caused by a
     replacement of the normal vaginal flora—an
     overgrowth of anaerobic microorganisms and
                                                                     Nonpregnant women
     Gardnerella vaginalis), and candidiasis (caused by                                                        High-risk pregnant women                  Low-risk pregnant women
                                                                                                              (history of premature delivery)                (i.e., no history of
     C. albicans). Mucopurulent cervicitis caused by                                                                                                        premature delivery)
     C. trachomatis or N. gonorrhoeae can sometimes
     cause vaginal discharge. Although vulvovaginal                                                            The screening and treatment should be
                                                                   Metronidazole 500 mg                                                                      Metronidazole
     candidiasis is not usually transmitted sexually, it           orally twice a day for 7 days, or            conducted at the earliest stage of the            250 mg orally
                                                                 Clindamycin cream 2%.                             second trimester of pregnancy.            3 times a day for 7 days.
     is included in this section because it is often
                                                                One full applicator (5 g) intravaginally at         The recommended regimen is
     diagnosed in women being evaluated for STIs.                       bedtime for 7 days, or                        metronidazole                        Alternative treatment
                                                                                                                  250 mg orally 3 times a day for                regimens
                                                                 Metronidazole gel 0.75%.
                                                                                                                               7 days.
                                                                 One full applicator (5 g) intravaginally                                                    Metronidazole
     Bacterial Vaginosis (BV)                                                                                                                                2 g orally in a single dose;
                                                                         twice a day for 5 days
     BV is a clinical syndrome resulting from replace-                                                             Alternative treatment
                                                                                                                                                         Clindamycin 300 mg orally
                                                                                                                         regimens
     ment of the normal H2O2-producing Lactobacillus                  Alternative treatment                                                                    twice a day for 7 days;
                                                                            regimens                                 Metronidazole                        Metronidazole gel
     species in the vagina with high concentrations of                                                               2 g orally in a single dose,          0.75%, one full applicator (5 g)
                                                                 Metronidazole 2 g orally,                              or                                          intravaginally,
     anaerobic bacteria (i.e., Prevotella sp and Mobilun-            in a single dose, or                      Clindamycin 300 mg orally                       twice a day for 5 days.
     cus sp), G. vaginalis, and M. hominis. BV is the most     Clindamycin 300 mg orally twice                         twice a day for 7 days.
     prevalent cause of vaginal discharge or malodor;                        a day for 7 days.

     however, half of the women who suffer from BV
     are asymptomatic. The cause of the microbial
     alteration is not clear. Although BV is associated
     with having multiple sexual partners, it is unclear
     whether BV results from acquisition of a sexually       Trichomoniasis
     transmitted pathogen. Women who have never              Trichomoniasis is caused by the protozoan
     been sexually active are rarely affected. Treatment     T. vaginalis. Most men who are infected with
     of the male sexual partner has not been beneficial      T. vaginalis do not have symptoms of the infection,
     in preventing recurrences of BV.                        but a small number of them develop urethritis.
                                                             By contrast, women with trichomonisis generally
                                                             experience symptoms. T. vaginalis usually causes a
                                                             diffuse, malodorous, yellow-green discharge
                                                             accompanied by vulvar irritation. Many women
                                                             have more subtle symptoms. Vaginal trichomoni-



40          Preventing Mother-to-Child Transmission of HIV   Prevention and Treatment of Sexually Transmitted Infections                                                                 41
                                                                              Chapter 3     Treatment of STIs



                         TRICHOMONIASIS                                                                              VULVOVAGINAL CANDIASIS
 Pathogen            T. vaginalis                                                             Pathogen               C. albicans, occasionally other Candida spp, Torulopsis spp, or
                                                                                                                     other yeasts.
 Clinical Features   Profuse, malodorous, yellow-green vaginal discharge and
                     vulvar irritation. Symptoms are subtle in many women.                    Clinical Features      Pruritus, vulvovaginal erythema, and vaginal discharge. Other
                                                                                                                     symptoms may include vaginal dryness, vulvar burning, dyspareunia,
                                                                                                                     and external dysuria. None of these symptoms should be regarded
 Pregnancy           May cause adverse pregnancy outcomes, particularly                                              as specific.
                     premature rupture of membranes and preterm delivery.

                                                                                              Diagnosis              Gram stain of a native vaginal discharge specimen demonstrates
 Treatment                                                                                                           yeasts or pseudohyphae
                     Recommended Treatment
                                                                                                                     or
                     Regimen
                     Metronidazole 2 g orally in a single dose                                                       Bacteriological culture or other test yields positive result of a yeast
                                                                                                                     species.
                          Alternative treatment regimens
                                                                 If a treatment method is                            Candida vaginitis is associated with a normal vaginal pH (≤ 4.5).
                                    Metronidazole                ineffective, the patient
                                 500 mg twice a day for 7 days   should be retreated with
                                                                                              Treatment              Recommended treatment regimens
                                                                 metronidazole in a dose
                                                                 of 500 mg twice a day                               Intravaginal agents:
                     Pregnancy
                     Metronidazole may be prescribed,            for 7 days. If the                                  Butoconazole 2% cream 5 g intravaginally for 3 days, or
                     2 g orally in a single dose                 effect is not achieved,                             Clotrimazole 1% cream 5 g intravaginally for 7-14 days, or
                                                                 the metronidazoleshould                             Clotrimazole 100-mg vaginal tablet for 7 days, or
                                                                 be prescribed in a dose                             Clotrimazole 100-mg vaginal tablet, 2 tablets for 3 days, or
                                                                 of 2 g once a day for                               Clotrimazole 500- mg vaginal tablet, 1 tablet in a single dose, or
                                                                 3 to 5 days.                                        Miconazole 2% cream 5 g intravaginally for 7 days, or
                                                                                                                     Miconazole 200-mg vaginal suppositories, 1 suppository for 3 days, or
                                                                                                                     Miconazole 100-mg vaginal suppositories, 1 suppository for 7 days, or
                                                                                                                     Nystatin 100,000-unit vaginal tablet, 1 tablet for 14 days, or
                         asis might be associated with adverse pregnancy                                             Tioconazole 6.5% ointment, 5 g intravaginally in a single application, or
                                                                                                                     Terconazole 0.4% cream, 5 g intravaginally for 7 days, or
                         outcomes, particularly premature rupture of the
                                                                                                                     Terconazole 0.8% cream 5 g intravaginally for 3 days, or
                         membranes and preterm delivery.                                                             Terconazole 80-mg vaginal suppositories, one suppository for 3 days

                                                                                                                     Oral preparations:
                         Vulvovaginal Candidiasis                                                                    Fluconazole 150-mg oral tablet, 1 tablet in a single dose
                         Vulvovaginal candidiasis is caused by C. albicans or,
                         much more rarely, other Candida spp, Torulopsis spp,                                        Only topical azole therapy should be used to treat pregnant
                                                                                                                     women. Of those treatments that have been investigated for
                         or other yeasts. An estimated 75% of women will                                             use during pregnancy, the most effective are butoconazole,
                                                                                                                     clotrimazole, miconazole, and terconazole. Many experts
                         have at least one episode of vulvovaginal candidiasis,
                                                                                                                     recommend seven days of therapy during pregnancy.
                         and 40-45% will have two or more episodes. A small
                         percentage of women (probably <5%) experience
                         recurrent vulvovaginal candidiasis. Typical symp-



42                                    Preventing Mother-to-Child Transmission of HIV        Prevention and Treatment of Sexually Transmitted Infections                                          43
                                                 Chapter 3     Treatment of STIs



     toms include itching and vaginal discharge. Other                                  PELVIC INFLAMMATORY DISEASE (PID)
     symptoms may include vaginal dryness, vulvar burn-
                                                                  Definition                 Inflammatory disorders of the upper genital tract, including any combination of
     ing, dyspareunia, and external dysuria. None of these                                   endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis.
     symptoms should be regarded as specific.
                                                                  Pathogens                  N. gonorrhoeae, C. trachomatis, M. hominis, U. urealyticum, and microorganisms that
     Recurrent Vulvovaginal Candidiasis (RVVC)                                               are frequently part of vaginal flora (i.e., anaerobes, G. vaginalis, H. influenzae, enteric
                                                                                             Gram-negative rods, and Streptococcus agalactiae).
     RVVC, which is usually defined as four or more
     episodes of symptomatic vulvovaginal candidiasis
                                                                  Minimum                    • Lower abdominal tenderness
     annually, affects a small number of women (prob-             Diagnostic Criteria        • Adnexal tenderness
     ably <5%). The pathogenesis of RVVC has not                                             • Cervical motion tenderness

     been studied adequately. Risk factors include un-
     controlled diabetes mellitus, immunosuppression,             Additional Criteria        •   Elevated temperature (>38.3°C)
                                                                                             •   Abnormal cervical and vaginal discharge
     and corticosteroid use. In some women who have                                          •   Elevated ESR
     RVVC, the candidiasis becomes more acute after                                          •   Elevated C-reactive protein
                                                                                             •   Laboratory confirmation of cervical infection with N. gonorrhoeae or C. trachomatis
     repeated courses of treatment with topical or sys-
     temic antibacterials. However, this association has
                                                                  Definitive Criteria        • Histopathologic evidence obtained on endometrial biopsy
     not been proven in the majority of women. Most
                                                                                             • Transvaginal sonography or other imaging techniques showing thickened fluid-filled
     women who have RVVC have no apparent predis-                                                tubes with or without free pelvic fluid or tubo-ovarian complex
                                                                                             • Laparoscopic abnormalities consistent with PID
     posing factors.

                                                                  Criteria for               •   Possible surgical emergencies such as appendicitis
     Pelvic Inflammatory Disease (PID)
                                                                  Hospitalization            •   Pregnancy
     PID encompasses the entire range of inflammatory                                        •   Patient does not respond clinically to oral antimicrobial therapy
                                                                                             •   Patient unable to follow and tolerate outpatient oral treatment
     disorders of the upper genital tract in women,                                          •   Severe nausea, vomiting, and high fever
     endometritis, salpingitis, tubo-ovarian abscess, and                                    •   Tubo-ovarian abscess
                                                                                             •   Immunodeficiency (i.e., HIV infection with low CD4 counts, immunosuppressive
     pelvic peritonitis as separate clinical entities and in                                     therapy, or another disease)
     any possible combination; most cases of PID are
     caused by sexually transmitted pathogens, especially         Treatment Regimens         Treatment regimens should provide empiric, broad-spectrum coverage of all possible
     N. gonorrhoeae and C. trachomatis. However,                                             pathogenic microorganisms (N. gonorrhoeae, C. trachomatis, anaerobic microorganisms,
                                                                                             Gram-negative facultative bacteria, and streptococci).
     microorganisms that are often part of the vaginal
     flora (e.g., anaerobes, G. vaginalis, H. influenzae,
     enteric Gram-negative rods, and Streptococcus
     agalactiae) can also cause PID. In addition, M.
     hominis and U. urealyticum can cause PID.



44           Preventing Mother-to-Child Transmission of HIV    Prevention and Treatment of Sexually Transmitted Infections                                                                 45
                                                                                                        Chapter 3       Treatment of STIs




            PELVIC INFLAMMATORY DISEASE (PID) continued                                                                               PELVIC INFLAMMATORY DISEASE (PID) continued

 Parenteral Treatment   Parenteral Treatment Regimen A                                                                    Peroral Treatment        Alternative oral treatment regimens
                        Cefotetan 2 g IV every 12 hours, or                                                               (continued)              Amoxicillin/clavulanic acid plus doxycycline was effective in obtaining a
                        Cefoxitin 2 g IV every 6 hours plus Doxycycline 100 mg IV or orally every 12 hours                                         rapid clinical response in a single clinical trial; however, gastrointestinal
                                                                                                                                                   symptoms can limit the successful use of this treatment regimen.
                        Parenteral therapy may be discontinued 24 hours after a patient improves clinically, and oral
                        therapy with doxycycline (100 mg twice a day) should continue further for 14 days.
                                                                                                                          Follow-up                A follow-up examination should be performed within 72 hours.
                        When tubo-ovarian abscess is present, metronidazole with doxycycline is used for continued
                                                                                                                                                   Clinical improvement should occur within three days after initiation of therapy
                        therapy, because this provides more effective coverage of anaerobic microorganisms.
                                                                                                                                                   (i.e., defervescence, reduction in direct or rebound abdominal tenderness, and decline
                                                                                                                                                   in uterine, adnexal, and cervical motion tenderness).
                        Parenteral Treatment Regimen B
                                                                                                                                                   Patients who do no demonstrate improvement within this time period usually require
                        Clindamycin 900 mg intravenously every 8 hours plus
                                                                                                                                                   additional diagnostic tests, surgical intervention, or both.
                           Gentamicin loading dose intravenously or intramuscularly (2 mg/kg of body weight),
                           followed by a maintenance dose (1.5 mg/kg) every 8 hours. Single daily dosing may be used
                                                                                                                                                   Repeated screening for C. trachomatis and N. gonorrhoeae four to six weeks after
                           instead.
                                                                                                                                                   therapy is completed.
                        Parenteral therapy may be discontinued 24 hours after the patient’s clinical state improves,
                        and oral therapy may be continued:                                                                                         If polymerase chain reaction (PCR) or LCR is used to document a test of cure,
                        Doxycycline 100 mg orally twice a day or                                                                                   re-screening should be delayed for one month after completion of therapy.
                        Clindamycin 450 mg orally 4 times a day to complete a full 14 days of treatment.

                        When tubo-ovarian abscess is present, clindamycin is used because it provides more                Management of            Sexual partner(s) should be examined and treated if they had sexual contact with the
                        effective coverage of anaerobic microorganisms.                                                   Sexual Partner(s)        patient within 60 days of the onset of symptoms in the patient.

                                                                                                                                                   Sexual partner(s) should be treated empirically with regimens effective against both of
                        Alternative Parenteral Regimen                                                                                             these infections (C. trachomatis, N. gonorrhoeae), regardless of the apparent etiology
                        Ofloxacin 400 mg intravenously every 12 hours plus                                                                         of PID or pathogenic microorganisms isolated from the infected patient.
                           Metronidazole 500 mg intravenously every 8 hours or
                        Ampicillin/Sulbactam 3 g intravenously every 6 hours plus
                           Doxycycline 100 mg intravenously or orally every 12 hours plus                                 Pregnancy                Because of the high risk of maternal morbidity, fetal death, and preterm
                           Metronidazole 500 mg intravenously every 8 hours                                                                        deliveries, pregnant women who have suspected PID should be
                                                                                                                                                   hospitalized and treated parenterally with antibiotics.

 Peroral Treatment      Patients who do not respond to oral therapy within 72 hours should be reevaluated to              HIV                      Should be managed actively using one of the parenteral antimicrobial regimens.
                        confirm the diagnosis and be administered parenteral therapy on either an outpatient or
                        inpatient basis.

                        Regimen A
                        Ofloxacin 400 mg orally twice a day for 14 days plus
                           Metronidazole 500 mg orally twice a day for 14 days.

                        Regimen B
                        Ceftriaxone, 250 mg IM once or
                        Cefoxitin 2 g IM plus probenecid 1 g orally in a single dose concurrently once or
                        Other parenteral third-generation cephalosporins (for example, ceftizoxime or
                        cefotaxime) plus
                           Doxycycline 100 mg orally twice a day for 14 days (include this treatment regimen with
                           one of the above regimens).




46                                            Preventing Mother-to-Child Transmission of HIV                            Prevention and Treatment of Sexually Transmitted Infections                                                          47
                                                 Chapter 3     Treatment of STIs



     PREGNANT WOMEN AND STIS                                                     SCREENING PREGNANT WOMEN FOR STIS
     Intrauterine or perinatally transmitted STIs can
     have fatal or severely debilitating effects on a fetus.
     Pregnant women and their sexual partner(s)                                                         First prenatal visit   Third trimester    At delivery

     should be counseled about STIs, including about
     the risk of perinatal infections.
                                                                                                          Serologic test

     Recommended Screening Tests
     ❙ A serologic test for syphilis must be performed on
       all pregnant women at their first prenatal visit. If
       the woman does not intend to be under observa-
       tion during her pregnancy—or she belongs to a
       population group that generally does not seek
                                                                Syphilis

                                                                           {     Populations in which
                                                                                 prenatal care is not
                                                                                       effective
                                                                                                         Screening with
                                                                                                          use of rapid
                                                                                                         plasma reagin
                                                                                                                                   Repeat



                                                                                                                                 Women who
                                                                                                                               have a negative
                                                                                                                                                    Repeat




       medical care—screening should be performed                HbsAg                                    Serologic test        result, but who
                                                                                                                               are at high risk
       immediately after confirmation of pregnancy. For
                                                                                                                                   for HBV
       patients at high risk, syphilis screening should be
       repeated in the third trimester. No infant should
       be discharged from a maternity hospital unless          N. gonorrhoeae                               Risk group           Risk group

       the mother has had a serological test for syphilis
       at least once during the pregnancy, and preferably
                                                                C. trachomatis                                                   Risk group
       again at delivery. All women who deliver a still-
       born infant should be tested for syphilis.
                                                                     HIV                                    All women
     ❙ It is advisable to perform a serologic test for
       hepatitis B surface antigen (HBsAg) in the
       blood serum of all pregnant women during                  Pap Smear                                  All women

       their first prenatal visit. HBsAg testing must be
       repeated late in the pregnancy for women who
                                                                    Risk group          All women
       were HBsAg negative at the time of the first
       test, but who are at high risk for hepatitis B in-
       fection (i.e., injecting drug users and women
       who have concomitant STIs).




48          Preventing Mother-to-Child Transmission of HIV     Prevention and Treatment of Sexually Transmitted Infections                                      49
                                                                    Chapter 3     Treatment of STIs



                         ❙ A test for N. gonorrhoeae must be performed at the     ❙ Pregnant women who have either a primary
                           first prenatal visit for women at risk or for women      genital herpes infection, hepatitis B virus
                           living in areas with high rates of N. gonorrhoeae. A     cytomegalovirus infection, or group B
                           repeat test should be performed during the third         streptococcal infection, and women with
                           trimester for those at regular risk for infection.       syphilis who are allergic to penicillin must be
                                                                                    referred to a specialist for treatment.
                         ❙ A test for C. trachomatis must be performed in
                           the third trimester for women at risk (for ex-         ❙ In the absence of clinical manifestations during
                           ample, women aged <25 years and women who                the third trimester, cultures for herpes simplex
                           have new or multiple sexual partners or whose            virus (HSV) are not indicated for women who
                           partner has other partners) to prevent postpar-          have a history of recurrent genital herpes. How-
                           tum complications in the mother and chlamy-              ever, obtaining cultures at the time of delivery
                           dial infection in the infant. Screening during           may be useful in providing proper neonatal
                           the first trimester may help prevent adverse ef-         care. A preventative cesarean section is not
                           fects of chlamydia during pregnancy.                     indicated for women who do not have active
                                                                                    genital lesions at the time of delivery.
      A test for HIV     ❙ A test for HIV infection should be offered to all
                           women during the first prenatal visit.                 SEXUAL VIOLENCE AND STIS
 infection should be                                                              The identification of STIs in sexually active adults
                         ❙ A test for bacterial vaginosis (BV) may be con-        who have survived sexual assault is more important
offered to all women       ducted in the second trimester for women who           for the psychological and medical management of
     during the first      are at high risk for preterm labor (e.g., those        the patient than for legal purposes because the in-
                           who have a history of a previous preterm deliv-        fection could have been acquired before the assault.
       prenatal visit.     ery) even if they are asymptomatic. Current evi-
                           dence does not support universal testing for BV.       Trichomoniasis, BV, chlamydiosis, and gonorrhea
                                                                                  are the most frequently diagnosed infections in
                         ❙ A Pap smear must be obtained during the first          women who have been sexually assaulted. Because
                           prenatal visit if the woman has not had a Pap          the prevalence of these STIs among sexually active
                           smear in the prior year.                               women is high, their presence after an assault does
                                                                                  not necessarily signify acquisition during the
                         Other Recommendations                                    assault. Chlamydial and gonococcal infections are
                         Other recommendations concerning the manage-             of special concern because of the possibility of
                         ment of patients with STIs:                              ascending infection. In addition, vaccination



50                              Preventing Mother-to-Child Transmission of HIV    Prevention and Treatment of Sexually Transmitted Infections   51
                                               Chapter 3     Treatment of STIs



     against hepatitis B prevents the infection from                                          SEXUAL VIOLENCE AND STIS
     developing in women to whom the virus was
                                                                                                                                                                                       Repeated
     transmitted during an assault.                                         Initial examination                                               Prophylaxis
                                                                                                                                                                                        testing




                                                                                                                 }
     Examination for STIs                                                Bacteriologic culture for                      Ceftriaxone 125 mg IM in a
     Initial Examination                                                    N. gonorrhoeae                              single dose plus
     An initial examination should include:                                                                                 Metronidazole 2 g orally in
                                                                         Bacteriologic culture for                          a single dose plus
                                                                             C. trachomatis                                 Azithromycin 1 g orally in a
     ❙ Bacteriologic tests for N. gonorrhoeae and C.                                                                        single dose or doxycycline 100 mg
                                                                                                                            orally twice a day for 7 days
       trachomatis from specimens collected from any                          If not possible

       sites of penetration or attempted penetration. If
       a bacteriologic test for chlamydiosis cannot be               Nucleic acid amplification test

       performed, the nucleic acid amplification                                                                                                                                           Bacteriologic
                                                                Confirmed by a method based on a different                                 Prophylactic treatment not                       culture for
       method is an acceptable substitute. The nucleic           diagnostic principle. Enzyme immunoassay                                          prescribed
                                                                                                                                                                                       N. gonorrhoeae
                                                                                                                                                                                       C. trachomatis
       acid amplification method is highly sensitive,           and direct fluorescent antibody tests are not
                                                                                                                                                                                       T. vaginalis
                                                                      recommended for this purpose.
       and if a positive result is obtained, the diagnosis
       should be verified by a method based on a dif-               Examination of native specimen
                                                                   and culturing of vaginal specimen
       ferent diagnostic principle. Enzyme immunoas-                   for T. vaginalis infection.
       say and direct fluorescent antibody tests are not
       recommended because they more frequently                           If vaginal discharge or
                                                                                                                                                  Clinical management should
                                                                             malodor is evident
       produce false negative results; false positive                                                                                              be approached according to
                                                                                                                                                    guidelines on occupational
       results have also been reported with these                                                                                                 mucous membranes exposure
                                                                        Examination of specimen
       methods.                                                            for BV and yeasts


     ❙ Microscopic examination of a native specimen




                                                                                                                        Results negative
                                                                   Collection of a serum                        HIV                                                                   Serologic tests
                                                                   sample for immediate                                                                                               repeated after
       and culturing of the vaginal material for                                                           Syphilis
                                                                       evaluation for                                                                                             6, 12, and 24 weeks
       T. vaginalis. If vaginal discharge and malodor
                                                                                                          Hepatitis B
       are evident, the native specimen should be
       examined for the presence of BV and yeasts.                                                                                                 Immunization against hepatitis B
                                                                                                                                                     during the initial examination.
                                                                                                                                                   Subsequent doses of the vaccine
     ❙ Collection of a serum sample for immediate                                                                                                   should be given after 1–2 and
                                                                                                                                                             4–6 months.
       evaluation for HIV, hepatitis B, and syphilis.




52          Preventing Mother-to-Child Transmission of HIV   Prevention and Treatment of Sexually Transmitted Infections                                                                                   53
                                                                          Chapter 3     Treatment of STIs



                            Follow-up Examinations                                      Risk of Acquiring HIV Infection
 Although it is often       Although it is often difficult for patients to com-         Although seroconversion has been reported among
                            ply with follow-up examinations several weeks               persons whose only known risk factor was sexual
 difficult for patients     after an assault, such examinations are essential to        assault or attempted assault, the risk of acquiring
                            a) detect new infections acquired during or after           HIV through sexual assault is very low. The proba-
        to comply with      the assault, b) continue hepatitis B immunization,          bility of HIV transmission from an HIV-positive
              follow-up     if indicated, and c) provide counseling and                 person during a single act of sexual contact depends
                            treatment for other STIs.                                   on many factors. These factors may including the
          examinations                                                                  type of sexual contact (oral, vaginal, or anal); the      Although
                            Follow-up Examination after Sexual Assault                  presence of oral, vaginal, or anal trauma; site of
         several weeks      Examination for STIs should be repeated two                 exposure to ejaculate; the viral load in the ejaculate;   HIV-antibody
                            weeks after the assault. Because infectious agents          and the presence of an STI in both parties.
       after an assault,    acquired during the assault may not have produced                                                                     seroconversion has
     such examinations      a sufficient concentration of microorganisms to re-
                            sult in positive test results at the initial examination,
                                                                                        The likelihood of HIV transmission may also be
                                                                                        affected by postexposure therapy with antiretrovi-
                                                                                                                                                  been reported
      are essential . . .   cultures, a native specimen, and other tests should         ral agents. A study involving healthcare workers          among persons
                            be repeated two weeks after the assault unless pro-         who had exposure to HIV-infected blood showed
                            phylactic treatment has already been provided.              that postexposure preventive therapy with                 whose only known
                                                                                        zidovudine reduces the risk of HIV infection.
                            Serologic tests for syphilis and HIV infection                                                                        risk factor was
                            should be repeated 6, 12, and 24 weeks after the            On the basis of these study results and the biologi-
                            assault if initial test results were negative.              cal likelihood that antiretroviral agents would be
                                                                                                                                                  sexual assault or
                                                                                        effective in preventing HIV infection, postexposure
                                                                                                                                                  attempted assault,
                            Counseling                                                  preventive therapy has been recommended for
                            At the initial examination and, if indicated, at            health-care workers after hazardous exposure to           the risk for acquiring
                            follow-up examinations, patients should be told:            HIV-infected materials. However, it is not known
                                                                                        whether these findings can be extrapolated to oth-        HIV infection
                            ❙ About the symptoms of STIs and the need for               er types of exposure to HIV-infected bodily fluids,
                              immediate examination if they occur                       including sexual assault. No recommendations can          through sexual
                                                                                        be made on the basis of available information
                            ❙ To abstain from sexual contact until the                  regarding the appropriateness of postexposure
                                                                                                                                                  assault is low.
                              preventive treatment has been completed                   antiretroviral therapy after sexual exposure to HIV.




54                                  Preventing Mother-to-Child Transmission of HIV      Prevention and Treatment of Sexually Transmitted Infections                    55
                                                Chapter 3



     Healthcare providers who consider offering post-
     exposure therapy to their patients should take into
     account the likelihood of exposure to HIV, the
     potential benefits and risks of such therapy, and
     the interval between the exposure and initiation of
     therapy. Because timely determination of the HIV         References
     status of the assailant is not possible in many cases
     of sexual assault, the healthcare provider should
     assess the nature of the assault, any available infor-   1.    WHO/UNAIDS, Sexually Transmitted Diseases: Policies
                                                                    and Principles for Prevention and Care, www.unaids.org/
     mation about HIV-risk behaviors exhibited by                   publications/documents/impact/std/una97e6.pdf.
     persons who are sexual assailants (e.g., high-risk       2.    US Centers for Disease Control and Prevention (CDC),
     sexual practices and injection drug use), and the              “Guidelines for Treatment of Sexually Transmitted Dis-
                                                                    eases,” Morbidity and Mortality Weekly Report 47 (RR-1),
     local epidemiological situation for HIV infection.             pp. 1-118, January 23, 1998, www.cdc.gov/epo/mmwr/
                                                                    preview/mmwrhtml/00050909.htm.
                                                              3.    Informational Letter from the Food and Drug
     If postexposure antiretroviral prophylaxis is                  Administration, January 16, 2003; www.fda.gov/bbs/
     offered, the following issues should be discussed              topicsANSWERS/2003/ans01191.html.
     with the patient:                                        4.    WHO/UNAIDS, Sexually Transmitted Diseases: Policies
                                                                    and Principles for Prevention and Care.
                                                              5.    CDC, 1998.
     ❙ The unknown effectiveness and known toxicity           6.    I.S. Dolzhenko, Problems of Contraception and Family
                                                                    Planning for Adolescents, RMJ 9 (6), 2001,
       of antiretroviral drugs                                      www.rmj.ru/rmj/t9/n6/254.htm.
                                                              7.    ibid.
     ❙ The critical need for frequent dosing of the           8.    WHO/UNAIDS, Sexually Transmitted Diseases: Policies
                                                                    and Principles for Prevention and Care.
       medications                                            9.    WHO, Guidelines for the Management of Sexually Trans-
                                                                    mitted Infections, 2001, www.who.int/hiv/pub/sti/pub6/en/.
                                                              10.   CDC, 1998, op. cit.
     ❙ The need for careful observation                       11.   WHO, 2001, op. cit.
                                                              12.   ibid.
     ❙ The importance of strict compliance with the
       drug regimen                                           Additional Reading
                                                              AIHA, Women’s Health Centers Manual, 1998.
                                                              Ministry of Health of Ukraine, UNICEF, Prevention of
     ❙ The need to begin treatment immediately to               Mother-to-Child HIV Transmission, training module,
       ensure maximum effectiveness                             Kiev, 2001.




56          Preventing Mother-to-Child Transmission of HIV    Prevention and Treatment of Sexually Transmitted Infections        57
                                            Additional Reading


     WHO, STD Case Management Workbook, 1995.
     UNAIDS, Report on the Global HIV/AIDS Epidemic, 2000.        APPENDIX: STD
     WHO/UNAIDS, Guidelines for STI Surveillance (Geneva,
        1999).                                                    TREATMENT GUIDELINES
     Sexually Transmitted Infections, Syndromic Approach to STD
        Management, Journal of Sexual Health and HIV 74           FOR ADULTS AND
        (Supp. 1), 1998.
                                                                  ADOLESCENTS, 2002*

                                                                  These guidelines for the treatment of patients with
                                                                  STDs reflect the 2002 CDC STD Treatment
                                                                  Guidelines and the Region IX Infertility Clinical
                                                                  Guidelines. The focus is primarily on STDs
                                                                  encountered in office practice. These guidelines
                                                                  are intended as a source of clinical guidance;
                                                                  they are not a comprehensive list of all effective
                                                                  regimens. Notes for these charts are found on
                                                                  page 66.




                                                                  * Source: California STD/HIV Prevention Training Center




58            Preventing Mother-to-Child Transmission of HIV      Prevention and Treatment of Sexually Transmitted Infections   59
                                                                                           Appendix      STD Treatment Guidelines for Adults and Adolescents, 2002


 DISEASE/SYNDROME                                        RECOMMENDED REGIMENS                             DOSE/ROUTE                             ALTERNATIVE REGIMENS
 Chlamydia
      *Uncomplicated Infections Adults/Adolescents1      • Azithromycin or                                1 g po                                 •   Erythromycin base 500 mg po qid 7 d or
                                                         • Doxycycline2                                   100 mg po bid    7d                    •   Erythromycin ethylsuccinate 800 mg PO qid   7 d or
                                                                                                                                                 •   Ofloxacin2 300 mg po bid 7 d or
                                                                                                                                                 •   Levofloxacin2 500 mg po qd 7 d
      Pregnant Women3                                    • Azithromycin or                                1 g po                                 • Erythromycin base 250 mg po qid     14 d or
                                                         • Amoxicillin or                                 500 mg po tid   7d                     • Erythromycin ethylsuccinate 800 mg po qid   7 d or
                                                         • Erythromycin base                              500 mg po qid   7d                     • Erythromycin ethylsuccinate 400 mg po qid   14 d
 Gonorrhea4
      Uncomplicated Infections Adults/Adolescents        • Cefixime5 or                                   400 mg po                              •   Spectinomycin4,5 2 g IM or
                                                         • Ceftriaxone plus4 chlamydia                    125 mg IM                              •   Ciprofloxacin2,4,6 500 mg po or
                                                           recommended regimen listed above                                                      •   Ofloxacin2,4,6 400 mg po or
                                                                                                                                                 •   Levofloxacin2,4,6 250 mg po or
                                                                                                                                                 •   Azithromycin6 2 g po
      Pregnant Women                                     • Ceftriaxone or                                 125 mg IM                              • Spectinomycin4,5 2 g IM
                                                         • Cefixime5 plus4 chlamydia                      400 mg po
                                                           recommended regimen listed above
 Pelvic Inflammatory Disease             7
                                                         Parenteral8                                                                             Parenteral8
                                                         • Either Cefotetan or                            2 g IV q 12 hrs                        • Either Ofloxacin2,9 400 mg IV q 12 hrs or
                                                           Cefoxitin plus                                 2 g IV q 6 hrs                           Levofloxacin2,9 500 mg IV qd plus
                                                              Doxycycline2 or                             100 mg po or IV q 12 hrs                    Metronidazole 500 mg IV q 8 hrs or
                                                         • Clindamycin plus                               900 mg IV q 8 hrs                      • Ampicillin/Sulbactam 3 g IV q 6 hrs plus
                                                              Gentamicin                                  2 mg/kg IV or IM followed by                Doxycycline2 100 mg po or IV q 12 hrs
                                                                                                          1.5 mg/kg IV or IM q 8 hrs
                                                         Oral/IM                                                                                 Oral
                                                         • Either Ceftriaxone or                          250 mg IM                              • Either Ofloxacin2,9 400 mg po bid 14 d or
                                                         • Cefoxitin with Probenecid plus Doxycycline2    2 g IM                                   Levofloxacin2,9 500 mg QD 14 d plus
                                                                                                          1 g po                                      Metronidazole 500 mg po bid 14 d
                                                                                                          100 mg po bid    14 d
 Mucopurulent Cervicitis7                                • Azithromycin or                                1 g po                                 •   Erythromycin base 500 mg po qid 7 d or
                                                         • Doxycycline2                                   100 mg po bid    7d                    •   Erythromycin ethylsuccinate 800 mg PO qid   7 d or
                                                                                                                                                 •   Ofloxacin2,9 300 mg po bid 7 d or
                                                                                                                                                 •   Levofloxacin2,9 500 mg po qd 7 d
 Nongonococcal Urethritis7                               • Azithromycin or                                1 g po                                 •   Erythromycin base 500 mg po qid 7 d or
                                                         • Doxycycline2                                   100 mg po bid    7d                    •   Erythromycin ethylsuccinate 800 mg PO qid   7 d or
                                                                                                                                                 •   Ofloxacin2 300 mg po bid 7 d or
                                                                                                                                                 •   Levofloxacin2 500 mg po qd 7 d
 Epididymitis7                                           Likely due to Gonorrhea or Chlamydia
                                                         • Ceftriaxone plus                               250 mg IM
                                                              Doxycycline                                 100 mg po bid    10 d
                                                         Likely due to enteric organisms
                                                         • Ofloxacin9 or                                  300 mg po bid   10 d
                                                         • Levofloxacin9                                  500 mg po qd    10 d
* Notes for these charts are found on page 66.

60                                               Preventing Mother-to-Child Transmission of HIV          Prevention and Treatment of Sexually Transmitted Infections                             61
                                                                                           Appendix   STD Treatment Guidelines for Adults and Adolescents, 2002


  DISEASE/SYNDROME                                       RECOMMENDED REGIMENS                          DOSE/ROUTE                             ALTERNATIVE REGIMENS
  *Trichomoniasis10                                      • Metronidazole                               2 g po                                 • Metronidazole 500 mg po bid    7d

  Bacterial Vaginosis
       Adults/Adolescents                                • Metronidazole or                            500 mg po bid 7 d                      • Metronidazole 2 g po or
                                                         • Clindamycin cream11 or                      2%, one full applicator (5g)           • Clindamycin 300 mg po bid       7 d or
                                                                                                         intravaginally qhs 7 d
                                                         • Metronidazole gel                           0.75%, one full applicator (5g)        • Clindamycin ovules 100 mg intravaginally qhs    3d
                                                                                                         intravaginally bid 5 d
       Pregnant Women                                    • Metronidazole or                            250 mg po tid     7d
                                                         • Clindamycin                                 300 mg po bid     7d
  Chancroid                                              • Azithromycin or                             1 g po                                 • Erythromycin base 500 mg po tid      7d
                                                         • Ceftriaxone or                              250 mg IM
                                                         • Ciprofloxacin2                              500 mg po bid     3d
  Lymphogranuloma Venereum                               • Doxycycline2                                100 mg po bid     21 d                 • Erythromycin base 500 mg po qid       21 d or
                                                                                                                                              • Azithromycin 1 g po qd  21 d
  Human Papillomavirus
       External Genital/Perianal Warts                   Patient Applied
                                                         • Podofilox12 0.5% solution or gel or                                                • Intralesional interferon or
                                                         • Imiquimod13 5% cream                                                               • Laser surgery
                                                         Provider Administered
                                                         • Cryotherapy or
                                                         • Podophyllin12 resin 10%-25% in
                                                           tincture of benzoin or
                                                         • Trichloroacetic acid (TCA) or
                                                           Bichloroacetic acid (BCA) 80-90% or
                                                         • Surgical removal
       Mucosal Genital Warts                             • Cryotherapy or                              Vaginal, urethral meatus, and anal
                                                         • TCA or BCA 80-90% or                        Vaginal and anal
                                                         • Podophyllin13 resin 10-25% in               Urethral meatus only
                                                           tincture of benzoin or
                                                         • Surgical removal                            Anal warts only
                                14
  Herpes Simplex Virus
       First Clinical Episode of Herpes                  •   Acyclovir or                              400 mg po tid 7-10 d
                                                         •   Acyclovir or                              200 mg po 5/day 7-10 d
                                                         •   Famciclovir or                            250 mg po tid 7-10 d
                                                         •   Valacyclovir                              1 g po bid 7-10 d
       Episodic Therapy for Recurrent Episodes           •   Acyclovir or                              400 mg po   tid 5 d
                                                         •   Acyclovir or                              200 mg po   5/day 5 d
                                                         •   Acyclovir or                              800 mg po   bid 5 d
                                                         •   Famciclovir or                            125 mg po   bid 5 d
                                                         •   Valacyclovir or                           500 mg po   bid 3-5 d
                                                         •   Valacyclovir                              1 g po qd     5d

* Notes for these charts are found on page 66.




62                                               Preventing Mother-to-Child Transmission of HIV       Prevention and Treatment of Sexually Transmitted Infections                               63
                                                                                          Appendix   STD Treatment Guidelines for Adults and Adolescents, 2002


  DISEASE/SYNDROME                                       RECOMMENDED REGIMENS                         DOSE/ROUTE                                   ALTERNATIVE REGIMENS
       Supressive Therapy                                •   Acyclovir or                             400 mg po bid
                                                         •   Famciclovir or                           250 mg po bid
                                                         •   Valacyclovir or                          500 mg po qd
                                                         •   Valacyclovir                             1 g po qd
  *HIV Infection15
       Episodic Therapy for Recurrent Episodes           •   Acyclovir or                             400 mg po tid 5-10 d
                                                         •   Acyclovir or                             200 mg po 5/day 5-10 d
                                                         •   Famciclovir or                           500 mg po bid 5-10 d
                                                         •   Valacyclovir                             1 g po bid 5-10 d
       Supressive Therapy                                • Acyclovir or                               400-800 mg po bid-tid
                                                         • Famciclovir or                             500 mg po bid
                                                         • Valacyclovir                               500 mg po bid
  Syphilis
       Primary, Secondary, and Early Latent              • Benzathine penicillin G                    2.4 million units IM                         •   Doxycycline2,16 100 mg po bid 2 weeks or
                                                                                                                                                   •   Tetracycline2,16 500 mg po qid 2 weeks or
                                                                                                                                                   •   Ceftriaxone16 1 g IM or IVqd 8-10 d or
                                                                                                                                                   •   Azithromycin16 2 g po
       Late Latent and Unknown Duration                  • Benzathine penicillin G                    7.2 million units, administered as           • Doxycycline2,16 100 mg po bid      4 weeks or
                                                                                                        3 doses of 2.4 million units IM,           • Tetracycline2,16 500 mg po qid     4 weeks
                                                                                                        at 1-week intervals
       Neurosyphilis17                                   • Aqueous crystalline penicillin G           18-24 million units daily,                   • Procaine penicillin G, 2.4 million units
                                                                                                        administered as 3-4 million                  IM qd 10-14 d plus
                                                                                                        units IV q 4hrs 10-14 d,                       Probenecid 500 mg po qid        10-14 d or
                                                                                                                                                   • Ceftriaxone16 2 g IM or IV qd     10-14 d
  Pregnant Women18
       Primary, Secondary, and Early Latent              • Benzathine penicillin G                    2.4 million units IM                         • None
       Late Latent and Unknown Duration                  • Benzathine penicillin G                    7.2 million units, administered as           • None
                                                                                                        3 doses of 2.4 million units IM,
                                                                                                        at 1-week intervals
       Neurosyphilis17                                   • Aqueous crystalline penicillin G           18-24 million units daily, administered as   • Procaine penicillin G,
                                                                                                        3-4 million units IV q 4 hrs 10-14 d           2.4 million units IM qd 10-14 d plus
                                                                                                                                                       Probenecid 500 mg po qid 10-14 d
  HIV Infection
       Primary, Secondary and Early Latent               • Benzathine penicillin G                    2.4 million units IM                         • Doxycycline2,16 100 mg po bid      2 weeks or
                                                                                                                                                   • Tetracycline2,16 500 mg po qid     2 weeks
       Late Latent, and Unknown Duration18 with          • Benzathine penicillin G                    7.2 million units, administered as 3 doses     • None
         Normal CSF Exam                                                                                of 2.4 million units IM, at 1-week intervals
       Neurosyphilis17                                   • Aqueous crystalline penicillin G           18-24 million units daily, administered as   • Procaine penicillin G,
                                                                                                        3-4 million units IV q 4 hrs 10-14 d           2.4 million units IM qd 10-14 d plus
                                                                                                                                                       Probenecid 500 mg po qid 10-14 d
* Notes for these charts are found on page 66.




64                                               Preventing Mother-to-Child Transmission of HIV      Prevention and Treatment of Sexually Transmitted Infections                                     65
                                                           Appendix



     Appendix STD Treatment Guideline
     Notes
     1.    Women with chlamydia should be rescreened 3-4 months
           after treatment.
     2.    Contraindicated for pregnant and nursing women.
     3.    Test-of-cure follow-up is recommended because the regi-
           mens are not highly efficacious (Amoxicillin and Ery-
           thromycin) or the data on safety and efficacy are limited
           (Azithromycin).
     4.    Co-treatment for chlamydia infection is indicated unless
           chlamydia infection is ruled out using sensitive technolo-
           gy or if 2 g Azithromycin dose is used.
     5.    Not recommended for pharyngeal gonococcal infection.
     6.    Test-of-cure follow-up is recommended to ensure patient
           does not have an untreated infection from a resistant
           gonorrhea strain.
     7.    Testing for gonorrhea and chlamydia is recommended
           because a specific diagnosis may improve compliance and
           partner management.
     8.    Discontinue 24 hours after patient improves clinically and
           continue with oral therapy for a total course of 14 days.
     9.    If gonorrhea is documented, test-of-cure follow-up is
           recommended to ensure patient does not have untreated
           resistant gonorrhea infection.
     10.   Documented infection with treatment failure should be
           evaluated for metronidazole-resistant T. vaginalis.
     11.   Might weaken latex condoms and diaphragms because
           oil-based; not recommended in pregnancy.
     12.   Contraindicated during pregnancy.
     13.   Safety in pregnancy has not been well established.
     14.   Counseling about natural history, asymptomatic shed-
           ding, and sexual transmission is an essential component
           of herpes management.
     15.   If lesions persist or recur while receiving antiviral thera-
           py, HSV resistance should be suspected and a viral isolate
           should be obtained for testing.
     16.   Because efficacy of these therapies has not been estab-
           lished and compliance of some of these regimes difficult,
           close follow-up is essential. If compliance or follow-up
           cannot be ensured, then patient should be desensitized
           and treated with benzathine penicillin.
     17.   One dose of 2.4 million units of Benzathine penicillin G
           recommended at completion of neurosyphilis therapy.
     18.   Patients allergic to penicillin should be treated with peni-
           cillin after desensitization.




66            Preventing Mother-to-Child Transmission of HIV
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