Genital ulcer

APPROACH TO A CASE OF GENITAL ULCER,

STIs:
Herpes simplex virus type 1 or 2 (HSV-1 or HSV-2)
Treponema pallidum spp. causing primary syphilis.
Haemophilus ducreyi causing chancroid.
Chlamydia trachomatis serotype L1, 2 or 3 causing lymphogranuloma venereum (LGV).
Klebsiella granulomatis causing granuloma inguinale (donovanosis)

Non–STI-related infections or conditions
Infectious non–STI-related causes of genital ulcers
Non - Infectious non–STI-related causes of genital ulcers

1. SEMINAR PRESENTATION APPROACH TO A CASE OF GENITAL ULCER MODERATOR DR.DEEPAK K.MATHUR

2. Definition Ulcerative, erosive, pustular or vesicular genital lesion(s ) with or without regional lymphadenopathy caused by a number of sexually transmitted infections (STIs) and non–STI-related conditions.

3. Etiology STIs: Herpes simplex virus type 1 or 2 (HSV-1 or HSV-2) Treponema pallidum  spp. causing primary syphilis. Haemophilus ducreyi causing chancroid . Chlamydia trachomatis  serotype L1, 2 or 3 causing lymphogranuloma venereum (LGV). Klebsiella granulomatis causing granuloma inguinale ( donovanosis ) Non–STI-related infections or conditions Infectious non–STI-related causes of genital ulcers Non - Infectious non–STI-related causes of genital ulcers

4. Infectious non–STI-related causes of genital ulcers

5. Non - Infectious non–STI-related causes of genital ulcers

6. APPROACHES Traditional clinical approach Laboratory-assisted approach Syndromic management approach

7. COMPARISON OF APPROACHES 6/ 7 Traditional clinical approach Lab. assisted approach Syndromic approach Interviews patient for symptoms Interviews patient for symptoms Interviews patient for symptoms Picks the relevant flowchart Does a clinical examination Does a clinical examination Does a clinical examination for finding signs Uses flowcharts as tools Uses clinical experience to identify symptoms and signs of a specific STI Collects samples for testing / refers to laboratory for tests Syndrome identification Treats for the specific STI Treats for STIs identified by the results of the laboratory tests Treats patient for the most common organisms responsible for that syndrome (usually 2-3 STIs) Educates patient for compliance and prevention, promotes condoms and emphasizes the importance of partner management Educates patient for compliance and prevention, promotes condoms and emphasizes the importance of partner management Educates patient for compliance and prevention, promotes condoms and emphasizes the importance of partner management

8. SYNDROMIC MANAGEMENT APPROACH Diagnosis is based on the identification of syndromes which are a combination of the symptoms the client reports and the signs the health care provider observes The recommended treatment is effective for all the diseases that could cause the identified syndrome Provides single-dose treatment as far as possible Comprehensive: it includes patient education and counseling

9. SYNDROMIC MANAGEMENT ADVANTAGES Fast—the patient is diagnosed and treated in one visit Highly effective Relatively inexpensive since it avoids use of laboratory tests No need for patient to return for lab results All possible STIs causing signs and symptoms are treated at once Scientifically tested in many part of the world Easy for health workers to learn and practice for patients Integrated into other primary health care services more easily Can be used by providers at all levels It standardizes treatment regimens

10. SYNDROMIC MANAGEMENT LIMITATIONS Not useful in asymptomatic individuals Over-treatment if patient has only one STI that causes a syndrome Financial cost of over-treatment, side-effects Increases potential for creation of antibiotic resistance especially if full course is not completed Not effective in some cases such as vaginal discharge

11. WHY DOES SYNDROMIC MANAGEMENT HAVE SPECIFIC RELEVANCE ? STI clients hesitant to approach doctors Often choose far-off doctors Do not prefer to revisit First visit may be the last chance If opportunity missed the first time – it is like pushing client towards HIV (2-9 times) Dealing with 1 STI case is an opportunity to treat at least 1 more case (may be more) IT IS A PUBLIC HEALTH PROBLEM not about one individual.

12. STEPS OF CLINICAL CASE MANAGEMENT History taking Clinical examination Laboratory tests Diagnosis Treatment Advice and counseling Follow up

13. Patient History General details Lesion history : Prodrome , initial presentation ( esp presence of vesicles) duration of lesion, pain, urethritis +/- , other systemic symptoms use of systemic or topical remedies(as it may alter the initial lesion),any history of similar symptoms in past / partners with similar symptoms In female patients h/o abortion or stillbirth In children h/o suggestive of sexual abuse have to be taken Medical history : HIV status, skin conditions, drug allergies & medications Sexual history : Gender of partners, number of partners,anal /vaginal/oral intercourse, venue for meeting partners, commercial sex exposure, partners with symptoms or signs, partners with known herpes simplex virus (HSV) or recent syphilis diagnosis Travel history : Geographical area where sexual intercourse has taken place.

14. INCUBATION PERIOD AND HEALING TIME IN GENITAL ULCER DISEASE Disease Incubation period % of STI-related GUD Spontaneous healing time On treatment Primary syphilis 9-90 days ( avg 3 weeks) >1% 3-8 weeks Never exceeds 3m 1-2 weeks Chancroid 1-14 days <1% Self limiting but may persist for yrs 1-2 weeks Herpes genitalis 5-21 days 80 - 95% 14-21 days 6-12 days LGV 3 – 30 days <1% 2-5 days - Donovanosis 1-180 days <1% No tendency for healing 3 weeks

15. Physical Exam: Lesion : Inspection and palpation of lesion Genital exam : Examine genital and perianal area Lymph node(s) exam General exam : Thorough examination of oral cavity and skin of torso, palms, and soles, LN(s), liver,spleen . In pts with syphilis exam CVS & CNS system

16. Inspection - No.,site,size,shape,edge,floor,surrounding skin Palpation – Base of ulcer , tenderness,induration,bleeding on manipulation,attachment to surrounding structure & per-rectal examination

17. CHARACTERISTIC SYPHILIS HERPES CHANCROID LGV DONOVANOSIS Primary lesion Papule Vesicle Pustule Papule, vesicle pustule Papule Number of lesions Usually 1 Multiple Multiple Single Variable Diameter 5-15 mm 1-2 mm Variable 2-10 mm Variable Edges Sharply demarcated elevated Erythematous Polycylic Undermined Ragged Elevated Round or oval Elevated Irregular Depth Superficial or deep Superficial Excavated Superficial Or deep Elevated Base Smooth Non-purulent Covered with serous eudate Erythematous Purulent Dirty grey Base Variable Red Velvety Bleeds easily Induration Button hole None not indurated not indurated not indurated

18. CHARACTERISTICS SYPHILIS HERPES CHANCROID LGV DONOVANOSIS Pain Absent Present Present Absent Absent Lymph nodes Bilateral Non-tender Firm,lead shot,non - suppurative Bilateral Tender Firm Non- suppurative Unilateral Tender Suppurative Uni - Locular Unilateral Tender Suppurative Multi- locular None Pseudo-bubo seen Recurrences No +(80%) No No No

19. Severe primary HSV infection with penile edema Syphilis

20. Donovanosis Chancroid

21. Chancroid Male, regional adenopathy Chancroid - Gram stain of H. ducreyi

22. LGV Life-cycle of LGV

23. Otherwise, per the CDC the following criteria fulfill probable diagnosis of chancroid : One or more painful genital ulcers No evidence of  T. pallidum  infection by darkfield examination or by serologic test for syphilis performed at least 7 days after onset of ulcers Clinical presentation, appearance of genital ulcers and, if present, regional lymphadenopathy are typical for chancroid A test for HSV performed on the ulcer is negative

24. INVESTIGATIONS

25. LAB DIAGNOSIS OF GENITAL ULCER LAB TEST SYPHILIS CHANCROID HERPES LGV DONOVANOSIS Microscopy Dark field direct immuno Fluorescence Gram stain Antigen detection by DFA Immuno peroxide Staining & ELISA Direct immuno -staining ELISA rapid assay Giemsa stain Tissue smear Culture Not available Enriched gonococcal agar base. Mueller Hinton agar +5% chocolate Horse blood Human diploid Fibroblast cell culture Green monkey kidney Cell culture HeLa-229 McCoy cells Baby hamster kidney cell BHK-21 none

26. LAB TEST SYPHILIS HERPES CHANCROID LGV DONOVANOSIS Collection Transport media Not available Thioyoglycolate hemin Medium containing L glutamine & bovine albumin At 4 C Swab wire shaftwith cotton tip Viral transport media at 4 C (freeze at 70 C if more time required) Swab plastic shaft with Rayon swab and cytobrush with plastic shaft none Serology 1.Non-treponemal Tests(VDRL/RPR) 2.Treponemal test (ELISA FTA- Abs,TPHA MHA-TP) ELISA Immuoblot techniques Monoclonal antibodies to HSV1 and HSV2,ELISA DNA hybridization CFT and immuno fluorescent antibody test Experimental

27. LAB TEST SYPHILIS HERPES CHANCROID LGV DONOVANOSIS Molecular techniques PCR PCR PCR PCR Not available Histopathology Perivascular Infiltrate of lymphocytes Plasma cells Accompanied by endarteritis obliterans 3 zones seen Surface zone- Narrow consisting of neutrophils fibrin,RBC’s Necrotic tissue Middle zone- Wide with newly formed blood vessels With marked proliferation of endothelial cells Deeper zone- Dense inflamm . of plasma cells & lymphoid cells Degeneration Of keratinocytes resulting of Acantholysis 2 types of degenerationseen 1.Ballooning 2.Reticular Small areas of Necrosis With Proliferating Epitheloid Cells With Stellate abscess Acanthosis Pseudo Carcinomatous Hyperplasia At edge of ulcer Dermis- dense Inflammation of histiocytes Plasma cells With absence Of lymphocytes Small neutrophillic Abscess, Donovan bodies

28. The preferred method of diagnosis is by crush impression prepared from the deep surface of excised tissue and stained with Giemsa stain. Histiocytic cells with up to 20 vacuoles containing clusters of organisms in various states of maturity are diagnostic. Immature unencapsulated forms often show bipolar condensation of chromatin resembling a closed safety pin.

29. Genital Ulcers – TREATMENT(NACO GUIDELINES 2007) If vesicles or multiple painful ulcers are present treat for herpes - Tab . Acyclovir 400mg orally, three times a day for 7 days If vesicles are not seen and only ulcer is seen, treat for syphilis and chancroid and counsel on herpes genitalis To cover syphilis give Inj Benzathine penicillin 2.4 million IU IM after test dose in two divided doses (with emergency tray ready) (In individuals allergic or intolerant to penicillin, Doxycycline 100mg orally, twice daily for 14 days) + Tab Azithromycin 1g orally single dose or Tab. Ciprofloxacin 500mg orally, twice a day for three days to cover chancroid Treatment should be extended beyond 7 days if ulcers have not epithelialized . Refer to higher centre If not responding to treatment Genital ulcers coexistent with HIV Recurrent lesion

30. GRANULOMA INGUINALE Doxycycline  100 mg BD for 21 days ALTERNATIVE REGIMENS Trimethoprim-sulfamethoxazole  double strength bid for 21 days Erythromycin 500 mg qid for 21 days Ciprofloxacin,tetracycline,azithromycin LYMPHOGRANULOMA VENEREUM Doxycycline  100 mg BD for 21 days Erythromycin 500 mg qid for 21 days

31. STI TREATMENT GUIDELINES *CDC 2010 *WHO 2011

32. Disease CDC2010 WHO 2011 COMMENT chancroid Azithromycin 1 g orally in a single dose OR Ceftriaxone 250 mg intramuscularly (IM) in a single dose OR Ciprofloxacin* 500 mg orally twice a day for 3 days* OR Erythromycin base 500 mg orally three times a day for 7 days Azithromycin , 1 g orally, as a single dose OR Ceftriaxone , 250 mg by intramuscular injection as a single dose OR Ciprofloxacin, 500 mg orally, twice daily for 3 days OR Erythromycin base, 500 mg orally 4 times daily for 7 days *Ciprofloxacin is contraindicated during pregnancy and lactation. *No adverse effects of chancroid on pregnancy outcome have been reported. *HIV-infected patients might require repeated or longer courses of therapy and treatment failures can occur. *Both are similar in dose & duration.

33. Disease CDC2010 WHO 2011 COMMENT Genital Herpes ( FIRST EPISODE) Acyclovir 400 mg orally three times a day for 7–10 days,OR Acyclovir 200 mg orally five times a day for 7–10 days , OR Famciclovir 250 mg orally three times a day for 7–10 days , OR Valacyclovir 1 g orally twice a day for 7–10 days Acyclovir 400 mg orally, 3 times daily for 7 days OR Acyclovir 200 mg orally, 5 times daily for 7 days OR Famciclovir 250 mg orally, 3 times daily for 7 days , OR Valaciclovir 1 g orally, twice daily for 7 days *Treatment can be extended if healing is incomplete after 10 days of therapy in CDC,otherwise similar in both Severe Disease Acyclovir 5–10 mg/kg IV every 8 hours for 2–7 days or until clinical improvement is observed, followed by oral therapy to complete at least 10 days of total therapy. Acyclovir, 5—10 mg/kg IV, every 8 hours for 5—7 days or until clinical resolution is attained * CDC-Duration 10 day (IV+ORAL) * WHO- 5-7 day, otherwise similar in both

34. Disease CDC2010 WHO 2011 COMMENT Suppressive Therapy for Recurrent Genital Herpes Acyclovir 400 mg orally twice a day OR Famiciclovir 250 mg orally twice a day OR Valacyclovir 500 mg orally once a day* OR Valacyclovir 1 g orally once a day Acyclovir, 400 mg orally, twice daily, for one year OR Valaciclovir , 500 mg orally, once daily, for one year OR Famciclovir , 250 mg orally, twice daily, for one year -Reduces the frequency of genital herpes recurrences by 70%–80% . * Valacyclovir 500 mg once a day might be less effective in patients who have very frequent recurrences (i.e., ≥10 episodes per year).

35. Disease CDC2010 WHO 2011 COMMENT Episodic Therapy for Recurrent Genital Herpes Acyclovir 400 mg orally TDS for 5 days OR 800 mg orally BD for 5 days OR 800 mg orally TDS for 2 days OR Famciclovir 125 mg orally BD for 5 days OR 1000 mg orally twice daily for 1 day OR 500 mg once, followed by 250 mg twice daily for 2 days Valacyclovir 500 mg orally twice a day for 3 days OR Valacyclovir 1 g orally once a day for 5 days Acyclovir, 400 mg orally, 3 times daily for 5 days OR Acyclovir, 200 mg orally, 5 times daily for 5 days OR Valaciclovir , 500 mg orally, twice daily for 5 days OR Famciclovir , 125 mg orally, twice daily for 5 days Effective episodic treatment of recurrent herpes requires initiation of therapy within 1 day of lesion onset or during the prodrome that precedes some outbreaks.

36. COUNSELING OF PERSONS WITH GENITAL HSV INFECTION Should be educated concerning natural history of disease with emphasis on - recurrent episodes asymptomatic viral shedding attendant risks of sexual transmission Persons experiencing 1 st episode of genital herpes should be advised that suppressive therapy is available & effective in preventing symptomatic recurrent episodes and that episodic therapy often is useful in shortening the duration of recurrent episodes. All persons with genital HSV infection should be encouraged to inform their current sex partners that they have genital herpes and to inform future partners before initiating a sexual relationship.

37. Sexual transmission of HSV can occur during asymptomatic periods. Asymptomatic viral shedding is more frequent in genital HSV-2 infection than genital HSV-1 infection and is most frequent during the first 12 months after acquiring HSV-2. All persons with genital herpes should remain abstinent from sexual activity with uninfected partners when lesions or prodromal symptoms are present. Episodic therapy does not reduce the risk for transmission & its use should be discouraged for persons whose partners might be at risk for HSV acquisition .

38. Infected persons should be informed that male latex condoms, when used consistently and correctly, might reduce the risk for genital herpes transmission. Sex partners of infected persons should be advised that they might be infected even if they have no symptoms. Type-specific serologic testing of the asymptomatic partners of persons with genital herpes is recommended to determine whether such partners are already HSV seropositive or whether risk for acquiring HSV exists. The risk for neonatal HSV infection should be explained.

39. Pregnant women who are not known to be infected with HSV-2 should be advised to abstain from intercourse with men who have genital herpes during the third trimester of pregnancy. Similarly, pregnant women who are not known to be infected with HSV-1 should be counseled to avoid genital exposure to HSV-1 during the third trimester (e.g., oral sex with a partner with oral herpes and vaginal intercourse with a partner with genital HSV-1 infection). Asymptomatic persons diagnosed with HSV-2 infection by type-specific serologic testing should receive the same counseling messages as persons with symptomatic infection. In addition, such persons should be educated about the clinical manifestations of genital herpes. When exposed to HIV, HSV-2 seropositive persons are at increased risk for HIV acquisition. Patients should be informed that suppressive antiviral therapy does not reduce the increased risk for HIV acquisition associated with HSV-2 infection

40. Management of Sex Partners The sex partners of patients who have genital herpes can benefit from evaluation and counseling. Symptomatic sex partners should be evaluated and treated in the same manner as patients who have genital lesions. Asymptomatic sex partners of patients who have genital herpes should be questioned concerning history of genital lesions and offered type-specific serologic testing for HSV infection.

41. Special Considerations Allergy, Intolerance, and Adverse Reactions Allergic and other adverse reactions to acyclovir, valacyclovir, and famciclovir are rare . HIV Infection Acyclovir, valacyclovir, and famciclovir are safe for use in immunocompromised patients in the doses recommended for treatment of genital herpes

42. HIV C0 -INFECTION Recommended Regimens for Daily Suppressive Therapy in Persons with HIV (CDC 2010) Acyclovir 400–800 mg orally twice to three times a day OR Famciclovir 500 mg orally twice a day OR Valacyclovir 500 mg orally twice a day Recommended Regimens for Episodic Infection in Persons with HIV(CDC2010) Acyclovir 400 mg orally three times a day for 5–10 days OR Famciclovir 500 mg orally twice a day for 5–10 days OR Valacyclovir 1 g orally twice a day for 5–10 days

43. HSV resistance All acyclovir-resistant strains are resistant to valacyclovir, and the majority are resistant to famciclovir. Foscarnet, 40 mg/kg IV every 8 hours until clinical resolution is attained, is frequently effective for treatment of acyclovir-resistant genital herpes. Intravenous cidofovir 5 mg/kg once weekly might also be effective.

44. Disease CDC2010 WHO 2011 COMMENT Granuloma Inguinale ( Donovanosis ) Doxycycline 100 mg orally twice a day Alternative Regimens Azithromycin 1 g orally once per week OR Ciprofloxacin 750 mg orally twice a day OR Erythromycin base 500 mg orally QID OR Trimethoprim-sulfamethoxazole one double-strength (160 mg/800 mg) tablet orally BD (All for at least 3 weeks and until all lesions healed) Azithromycin , 1 g orally on the first day, then 500 mg orally, once a day OR Doxycycline , 100 mg orally, twice daily OR Erythromycin, 500 mg orally, 4 times daily OR Tetracycline, 500 mg orally, 4 times daily OR Trimethoprim 80 mg/ sulfamethoxazole 400 mg, 2 tablets orally, twice daily (Treatment should be continued until all lesions have completely epithelialized ) -Healing typically proceeds inward from the ulcer margins -Patients should be followed clinically until signs and symptoms have resolved. -Persons who have had sexual contact with a patient who has granuloma inguinale within the 60 days should be offered therapy. -Value of empiric therapy in the absence of clinical signs and symptoms has not been established.

45. Special Considerations Pregnancy Pregnancy is a relative contraindication to the use of sulfonamides. Pregnant and lactating women should be treated with the erythromycin regimen, and consideration should be given to the addition of a parenteral aminoglycoside (e.g., gentamicin ). Azithromycin might prove useful for treating granuloma inguinale during pregnancy, but published data are lacking. Doxycycline and ciprofloxacin are contraindicated in pregnant women. HIV Infection Persons with both granuloma inguinale and HIV infection should receive the same regimens as those who are HIV negative; however, the addition of a parenteral aminoglycoside (e.g., gentamicin ) can also be considered .

46. Disease CDC2010 WHO 2011 COMMENT LGV Doxycycline 100 mg orally twice a day for 21 days Alternative Regimen Erythromycin base 500 mg orally four times a day for 21 days Doxycycline , 100 mg orally, twice daily for 14 days OR Erythromycin, 500 mg orally, 4 times daily for 14 days OR Tetracycline, 500 mg orally, 4 times daily for 14 days -Patients should be followed clinically until signs and symptoms have resolved -Management of Sex Partners If sexual contact within the 60 days should be treated with a chlamydia regimen ( azithromycin 1 gm orally single dose or doxycycline 100 mg orally twice a day for 7 days ).

47. Special Considerations Pregnancy Pregnant and lactating women should be treated with erythromycin. Azithromycin might prove useful for treatment of LGV in pregnancy, but no published data are available regarding its safety and efficacy. Doxycycline is contraindicated in pregnant women. HIV Infection Persons with both LGV and HIV infection should receive the same regimens as those who are HIV negative. Prolonged therapy might be required, and delay in resolution of symptoms might occur.

48. Disease CDC2010 WHO 2011 COMMENT Primary, Early Latent Syphilis(chancre redux ) Adults- Benzathine penicillin G 2.4 million units IM in a single dose Infants and Children- Benzathine penicillin G 50,000 units/kg IM, up to the adult dose of 2.4 million units in a single dose Benzathine benzylpenicillin G, 2.4 million IU by intramuscular injection as a single dose OR Procaine benzylpenicillin , 1.2 million IU by intramuscular injection, daily for 10 consecutive days OR Azithromycin , 2 g orally as a single dose . Alternative regimens for penicillin-allergic non-pregnant patients Azithromycin , 2 g orally single dose OR Doxycycline , 100 mg orally, twice daily for 14 days

49. Disease CDC2010 WHO 2011 COMMENT Syphilis During Pregnancy Pregnant women should be treated with the penicillin regimen appropriate for their stage of infection Pregnant patients who are allergic to penicillin should be desensitized and treated with penicillin N ot allergic to penicillin, should be treated with penicillin according to the dosage schedules recommended for the treatment of non-pregnant patients at a similar stage of the disease. Alternative regimen for penicillin-allergic pregnant patients- Azithromycin , 2 g orally as a single dose OR Erythromycin*, 500 mg orally, 4 times daily for 14 days

50. Syphilis and HIV coinfection Benzathine penicillin G 2.4 million units IM / week - 3 doses FEW POINTS – Atypical presentations common Compared with HIV-negative patients, HIV-positive patients who have early syphilis might be at increased risk for neurologic complications Have higher rates of treatment failure with currently recommended regimens.

51. FOLLOW-UP Herpes Simplex Virus Reexamination needed only if symptoms and signs do not resolve Syphilis HIV uninfected persons - Nontreponemal titers should be checked at 6, 12 and 24 months CSF analysis should occur if titers increase fourfold, an initially high titer (>1:32) fails to decline fourfold or signs/symptoms attributable to syphilis develop HIV infected persons - Nontreponemal titers should be checked at 3,6, 9, 12 and 24 months after therapy for those who are HIV infected For those affected with neurosyphilis , practitioners should re-evaluate CSF every six months until the cell count is normal All cases of confirmed syphilis should be reported to the state/local health department LGV & Granuloma Inguinale Follow patients until signs and symptoms have resolved. All cases of confirmed LGV should be reported to the state/local health department. Chancroid Patients should be examined 3-7 days into therapy.  If clinical improvement is not apparent consider an alternate diagnosis, treatment non-adherence or treatment failure due to antimicrobial resistance. All cases of confirmed chancroid should be reported to the state/local health department.

52. MANAGEMENT OF SEX PARTNERS Herpes Simplex Virus Offer serologic testing to determine whether infection has already occurred Counsel about the risk of transmission associated with subclinical shedding and prevention modalities for the future Syphilis Contacts of patients with: Early syphilis Routine history Physical examination for signs of syphilis Syphilis serology and HIV testing Administer empiric treatment for all contacts within the preceding 3 months (i.e., benzathine penicillin G 2.4 million U IM). Late latent syphilis Determine treatment based on syphilis serology Chancroid Sex partners of patients diagnosed with chancroid should be examined and treated if they had sexual contact in the past 10 days prior to the patient's onset of symptoms LGV Routine STD exam, including testing for chlamydia and treated with a chlamydia regimen ( azithromycin 1 gm orally single dose or doxycycline 100 mg orally twice a day for 7 days)for all contacts within the preceding 2 months Granuloma Inguinale Persons who have had sexual contact with a patient diagnosed with granuloma inguinale within 60 days before the onset of a patient's symptoms should have a clinical exam and empiric therapy

53. Educate and counsel the patient (group work) Nature of the infection and medication Promote safer sexual behaviour Demonstrate and provide condoms Compassionate and sensitive counselling Informing partner HIV testing Complications, i.e. infertility or incurable disease Preventing future infections Communicating with partner Confidentiality, disclosure Risk of violence or stigma

54. Management of Inguinal Bubo Treatment Cap . Doxycycline 100mg orally twice daily for 21 days (to cover LGV),Plus Tab Azithromycin 1g orally single dose OR Tab . Ciprofloxacin 500mg orally, twice a day for three days to cover chancroid A bubo should never be incised and drained at the PHC even if it is fluctuant, as there is a high risk of a fistula formation and chronicity . If bubo becomes fluctuant always refer for aspiration to higher centre. In severe cases with vulval edema in females, surgical intervention may be required for which they should be referred to higher centre.

55. Partner management Treat all partners who are in contact with client in last 3 months Partners should be treated for chancroid and LGV Tab Azithromycin 1g orally single dose + Cap Doxycycline 100mg orally, twice daily for 21 days Advise sexual abstinence during the course of treatment. Provide condoms, educate on correct and consistent use. Refer for voluntary counseling and testing for HIV, syphilis and Hepatitis B. Schedule return visit after 7 days and 21 days.

56. Detection & discrimination of HSV,H. ducreyi , T. pallidum and C.( Klebsiella ) granulomatis from genital ulcers. Mackay IM, Harnett G, Jeoffreys N, et al. Clin Inf Dis. 2006; 42(10):1431-8 GUMP was developed as an inhouse nucleic acid amplification technique targeting serious causes of GUD Amplification products from GUMP were detected by ELAHA GUMP-ELAHA was sensitive and specific in detecting a target microbe in 34.3% of specimens GUMP-ELAHA permitted comprehensive detection of common and rare causes of GUD and incorporated noninvasive sampling techniques

57. Consider 4Cs to improve treatment results and prevention Compliance- Avoid sexual contact during treatment and until partner has been treated & Ensure follow-up visit Counseling for prevention Condom use Contact management

58. THANK YOU