STIs. pptx

educative

1. Sexually Transmitted Infections

2. What is STI? Reproductive tract infections (RTIs) including sexually transmitted infections (STIs) present a huge burden of disease and adversely impact the reproductive health of people. RTIs occur in the genital tract and affect both women and men. Some RTIs, such as syphilis and gonorrhea, are sexually transmitted, but many are not. An STI is a disease acquired through sexual contact with a person who is infected. STIs predominantly result from an individual having unprotected sexual contact with a person who has an STI.

3. Burden of STIs More than 1 million sexually transmitted infections (STIs) are acquired every day worldwide, the majority of which are asymptomatic. Each year there are an estimated 374 million new infections with 1 of 4 curable STIs: chlamydia, gonorrhea, syphilis, and trichomoniasis. More than 500 million people 15–49 years are estimated to have a genital infection with herpes simplex virus (HSV or herpes). Human papillomavirus (HPV) infection is associated with over 311,000 cervical cancer deaths each year. Almost 1 million pregnant women were estimated to be infected with syphilis in 2016, resulting in over 350 000 adverse birth outcomes. STIs have a direct impact on sexual and reproductive health through stigmatization, infertility, cancers, and pregnancy complications and can increase the risk of HIV. Drug resistance is a major threat to reducing the burden of STIs worldwide.

4. Overview More than 30 different bacteria, viruses, and parasites are known to be transmitted through sexual contact, including vaginal, anal and oral sex. Some STIs can also be transmitted from mother to child during pregnancy, childbirth, and breastfeeding.  Eight pathogens are linked to the greatest incidence of STIs. Of these, 4 are currently curable: syphilis, gonorrhea, chlamydia, and trichomoniasis.   The other 4 are incurable viral infections: hepatitis B, herpes simplex virus (HSV), HIV, and human papillomavirus (HPV).

5. Scope of the problem STIs have a profound impact on sexual and reproductive health worldwide. More than 1 million STIs are acquired every day. In 2020, WHO estimated 374 million new infections with 1 of 4 STIs: chlamydia (129 million) gonorrhea (82 million) syphilis (7.1 million) trichomoniasis (156 million). In 2016, > 490 million people were estimated to be living with genital herpes 300 million women have an HPV infection, the primary cause of cervical cancer and anal cancer. An estimated 296 million people are living with chronic hepatitis B globally.

6. Consequences/ impact of STs STIs like herpes, gonorrhea, and syphilis can increase the risk of HIV acquisition. Mother-to-child transmission of STIs can result in stillbirth, neonatal death, low birth weight and prematurity, sepsis, neonatal conjunctivitis, and congenital deformities. HPV infection causes cervical and other cancers. Hepatitis B resulted in an estimated 820,000 deaths in 2019, mostly from cirrhosis and hepatocellular carcinoma. STIs such as gonorrhoea and chlamydia are major causes of pelvic inflammatory disease and infertility in women.

7. STIs and their routes of transmission Sexually transmitted infections (STIs) Route (s) of transmission Chancroid, Lymphogranuloma venereum, and Granuloma inguinale Sexual Chlamydia Sexual Cytomegalovirus Sexual, Gonorrhea Sexual, perinatal Hepatitis B Sexual, percutaneous, perinatal Hepatitis C Percutaneous, sexual, perinatal Herpes simplex Sexual HIV infection/ AIDS Sexual, percutaneous, perinatal Human papillomavirus Sexual Syphilis Sexual, perinatal

8. Location of STIs/RTIs Type of patient Body part Condition Man Penis & scrotum Genital warts, syphilis, chancroid, herpes Testis Gonorrhea, chlamydia Women Vulva, labia, vagina Syphilis, chancroid, herpes, genital warts Cervix Gonorrhea, chlamydia, herpes Vagina Bacteria vaginosis, yeast infection, trichomonas Uterus Gonorrhea, chlamydia, vaginal bacteria

9. Factors that facilitate transmission of STIs Risky sexual behaviors Having multiple partners Changing partners Practicing unsafe sex (condoms are not used due to dislike, unavailability, unaffordability, cultural/religious beliefs, or myths) Alcohol and drug abuse resulting in impaired decision-making about sexual matters Socioeconomic factors Occupation (professions that force persons to be away from their sexual partners for a long time) Sex work and transactional sex: exchanging sex for money, materials, and favors Lack of information on sexually transmitted infections

10. Factors that facilitate the transmission of STIs Cultural Female genital mutilation Rituals such as cleansing, widow inheritance Biological Age (adolescent/youth is at most risk) Gender (females are more likely to be infected than males) Political War and political instability, which creates mobility and migration that adversely influence changes in sexual behavior. Iatrogenic Infections are more common where there are many STIs and where healthcare providers do not have the training or supplies to perform procedures safely Postpartum and postabortion infections are more common where safe services and follow-up care are not available

11. Factors that facilitate the transmission of STIs Endogenous Yeast infection and bacterial vaginosis are common worldwide—influenced by environmental, hygienic, hormonal, and other factors Medical Resistance to common medicines used to treat STIs Poor adherence to medicine for an STI, i.e., not completing the full course of treatment

12. Syphilis

13. Key facts Most infections are asymptomatic or unrecognized. WHO estimates that 7.1 million adults between 15 and 49 years old acquired syphilis in 2020. Syphilis in pregnancy, when not treated, treated late, or treated with the incorrect antibiotic, results in 50−80% of cases with adverse birth outcomes. In 2016, 7 in every 1000 pregnant women had syphilis. Maternal syphilis cases led to an estimated 143, 000 early fetal deaths and stillbirths. Estimated 61,000 neonatal death 41,000 preterm or low birth weight births 109,000 infants with clinical congenital syphilis worldwide. Key populations such as gay men (7.5%) and other men who have sex with men are disproportionately affected. This is due to several factors such as high levels of stigma and discrimination and limited access to healthcare.

14. Overview Syphilis is a preventable and curable bacterial sexually transmitted infection (STI). If untreated, it can cause serious health issues. Many people with syphilis do not have symptoms or do not notice them. Syphilis is transmitted during oral, vaginal, and anal sex, in pregnancy and through blood transfusion. Syphilis in pregnancy may lead to stillbirth, newborn death, and babies born with syphilis (congenital syphilis). Correct and consistent use of condoms during sex can prevent syphilis. Rapid tests can provide results in a few minutes, which allows treatment initiation on the same clinic visit.

15. Transmission Syphilis is transmitted during: Oral sex through contact with infectious lesions Anal sex through contact with infectious lesions vaginal sex through contact with infectious lesions, During pregnancy through the placenta. Transmission typically occurs during early stages of the disease, i.e., up to 2 years after infection. NB: You cannot get syphilis through casual contact with objects, such as toilet seats, doorknobs, swimming pools, hot tubs, bathtubs , sharing clothing, or eating utensils

16. People at risk Sexually active people can get syphilis through vaginal, anal, or oral sex without a condom with a partner who has syphilis. Gay or bisexual man With HIV Taking pre-exposure prophylaxis ( PrEP ) for HIV prevention Have partner(s) who have tested positive for syphilis

17. Treponema pallidum Causative agent: Treponema pallidum Mode of transmission: sexual contact or perinatal ( mother to child)

18. Symptoms Many people with syphilis do not notice any symptoms. They can also go unnoticed by healthcare providers. Untreated, syphilis lasts many years. Syphilis has several stages. Primary syphilis ( first stage) Secondary syphilis Latent syphilis Tertiary syphilis

19. Primary syphilis Usually lasts around 21 days The lesion is a round, painless, usually hard sore (chancre) that appears on the genitals, anus, or elsewhere the chancre may not be noticed and will heal in 3–10 days The lesions usually resolve spontaneously within 3 to 12 weeks, with or without treatment. Progresses to the second stage if untreated.

20. Secondary syphilis Occurs when the hematogenous spread of an organism from the original chancre to generalized to areas such as the trunk and extremities Includes a non-itchy rash, usually on the palms and soles of the feet White or grey lesions appear in warm and moist areas, such as the labia or anus, at the site of the chancre Takes 1 – 6 months from chancre to trunk and extremities such as palms and soles of the feet. General signs and symptoms may include lymphadenopathy, arthritis, meningitis, hair loss, fever, malaise, and weight loss. Symptoms will go away without treatment.

21. Latency stage The period of latency sets in when the person who is infected has no signs or symptoms. Progresses to the third and final stage of syphilis (tertiary) after years if untreated Tertiary syphilis can lead to brain and cardiovascular diseases, among other conditions.

22. Tertiary stage This is the final stage in the natural history of the disease. It is estimated that between 20% and 40% of those infected do not exhibit signs and symptoms in this final stage. The stage presents as a slowly progressive inflammatory disease with the potential to affect multiple organs, The most common symptoms include aortitis, and neurosyphilis as evidenced by dementia, psychosis, paresis, stroke, or meningitis.

23. Babies born with syphilis can experience Rashes Inflammation in the organs Anaemia Bone and joint problems Neurological conditions including blindness, deafness, meningitis Developmental delays Seizures. Some of these symptoms may only be noticed later in life.

24. Diagnosis Syphilis diagnosis is based on the person’s clinical and sexual history, physical examination, laboratory testing, and sometimes radiology, as symptoms are not common or noticeable. Detect bacterium Treponema pallidum by: Microscope Indirect methods such as blood tests. Rapid test ( provide results in minutes, facilitating immediate treatment initiation) There is no current diagnostic test for congenital syphilis, use radiology if available and lab test.

25. Treatment Syphilis is treatable and curable. The early stage of syphilis is treated with a benzathine penicillin injection. As a second-line treatment, doctors may also use doxycycline, ceftriaxone, or azithromycin. NB: Doxycycline is not used for pregnant women . Penicillin is also used to treat later stages of syphilis, but more doses are required. Doses are usually given once per week for three weeks. Penicillin can prevent syphilis from being passed from a mother to a baby. Babies born with syphilis (congenital syphilis), or babies whose mothers had untreated syphilis, need to be treated right away to avoid serious health problems.

26. Complication Syphilis and HIV infection Syphilis increases the risk of acquiring HIV infection by approximately two-fold, as well as of other STIs, such as gonorrhea, chlamydia, and genital herpes, among others. Severe disease Without treatment, the tertiary phase of syphilis may lead to several complications decades after infection. At this stage, syphilis can affect multiple organs and systems, including the brain, nerves, eyes, liver, heart, blood vessels, bones and joints. Tertiary syphilis can also cause death.

27. Complication Neurosyphilis, ocular syphilis, and otosyphilis Neurosyphilis, ocular syphilis, and otosyphilis can occur at any stage of the disease. Neurosyphilis can cause strong headaches, serious muscular problems, and mental health issues, including dementia. Ocular syphilis can cause pain in the eye, blurry vision, sensitivity to light, or blindness. Otosyphilis affects the person’s hearing and balance. Congenital syphilis Untreated syphilis may lead to severe negative consequences, such as stillbirth, neonatal death, prematurity, low birth weight, and life-long health problems to the infected infant. Sixty-seven percent of women with untreated syphilis will have an adverse outcome of pregnancy, including 26% who will have fetal loss or a stillbirth. Syphilis is the second most common cause of stillbirth due to infectious diseases worldwide.

28. Prevention Syphilis is a preventable disease. Using condoms consistently and correctly is the best way to prevent syphilis and many other STIs. Syphilis can also spread through contact with other areas of the body not covered by a condom, including the genitals, anus, and mouth. People at higher risk of infection should be tested at least once a year. Pregnant women should be tested for syphilis at the first prenatal care visit and treated right away if the test result is positive. Congenital syphilis can only be prevented by diagnosing and treating the mother with penicillin. People diagnosed with syphilis should notify their sexual partners to prevent new infections.

29. Syphilis—Primary (Digital Chancre) Syphilis—Primary (Mouth Chancre) Syphilis—Primary (Anal Chancre) Syphilis—Primary (Genital Chancre)

30. Darkfield micrograph of Treponema pallidum. Primary stage syphilis sore (chancre) on the surface of a tongue. Lesions of secondary syphilis.

31. Secondary stage syphilis sores (lesions) on the palms of the hands. Referred to as "palmar lesions." Secondary stage syphilis sores (lesions) on the bottoms of the feet. Referred to as “plantar lesions.” Secondary syphilis rash on the back.

32. Primary stage syphilis sore (chancre) on glans (head) of the penis. Primary stage syphilis sore (chancre) inside the vaginal opening.

33. Further reading https://youtu.be/N1jyR2Ib0Ec https://www.cdc.gov/std/dstdp/sti-funding-at-work/success-stories/324986-A_FS_Success_Stories-508.pdf https://www.cdc.gov/std/syphilis/default.htm

34. Chlamydia

35. Key facts Chlamydia is a preventable and curable sexually transmitted infection caused by the bacterium Chlamydia trachomatis, which is primarily transmitted through vaginal, oral and anal sex. In 2020 there were an estimated 128.5 million new chlamydia infections among adults (15–49 years old) globally. Chlamydia infection is often asymptomatic, but common symptoms can include unusual urethral and vaginal discharge. If left untreated, chlamydia infection can lead to serious health problems including infertility in women. It also increases the risk of HIV infection.

36. Overview Chlamydia is a common sexually transmitted infection that can occur in both men and women. It is caused by a bacterium called  Chlamydia trachomatis . It is easily treated and cured with antibiotics. If not treated, chlamydia can cause serious problems, including infertility and ectopic pregnancy. In pregnant women, it can cause the baby to be born early (prematurity). Correct and consistent use of condoms during sex is the most effective way to prevent chlamydia.

37. Scope of the problem In 2020, an estimated 128.5 million new infections with Chlamydia trachomatis occurred worldwide among adults aged 15 to 49 years. The global prevalence among people aged 15–49 years was estimated to be 4.0% for women and 2.5% for men in 2020. Chlamydial infection is more common in young people. Lymphogranuloma venereum (LGV) is relatively rare, but there has been a resurgence in some countries, especially among gay men and other men who have sex with men. Another strain of Chlamydia causes trachoma but is transmitted by contact with discharge from the eye and nose, particularly among young children. Chlamydia is unlikely to lead to any long-term problems if treated early. However, without treatment, chlamydia can cause serious problems and may facilitate the transmission and acquisition of HIV and other STIs.

38. Signs and symptoms Many people with chlamydia have no symptoms or only mild symptoms. If symptoms occur, they may not appear until up to three weeks after having sex with someone who has chlamydia. In women, common symptoms include a change in vaginal discharge bleeding between menstrual periods or after sex pain or discomfort in the lower abdomen burning sensation when urinating. Urethritis Dysuria dyspareunia Vaginitis Cervicitis PID

39. Signs and symptoms Common symptoms in men include burning when urinating discharge from the penis pain or discomfort in the testicles. Urethritis Dysuria dyspareunia Anal infection in women and men can cause pain discharge bleeding. Chlamydia can also infect the throat often without symptoms. Infants born to mothers with chlamydia may experience eye infections or pneumonia. These can be treated with antibiotic medications for newborns.

40. Signs and symptoms of the LGV type The LGV type (Lymphogranuloma venereum ) of chlamydia can cause severe inflammation and can lead to genital ulcer, lymph node enlargement, or inflammation of the anorectal area with discharge, abdominal cramps, diarrhea, constipation, fever, or pain while passing stools.

41. Possible complications Chlamydia can cause serious problems if left untreated, particularly among women. Women may develop pelvic inflammatory disease (PID), experience abdominal and pelvic pain, and in later stages develop infertility and ectopic pregnancy (a pregnancy that occurs outside the womb). Men may develop a painful infection in their testicles (epididymitis, epididymal-orchitis). In rare cases, this can lead to infertility. Additionally, chlamydia may cause other symptoms, such as swollen joints (arthritis) and inflammation of the eyes.

42. Possible complications Infection with chlamydia can cause stigma and affect personal relationships. These effects are important but often not quantifiable. Neonatal infection can cause conjunctivitis (eye infection) and pneumonia, inefective Arthritis It can also cause preterm deliveries. LGV can be an invasive, systemic infection and, if it is not treated early, can lead to chronic oozing lesions around anorectal region, strictures, or reactive joint pain and swelling Oral ulceration can occur and might be associated with lymph node swelling.

43. Diagnosis Molecular tests are the gold standard for diagnosing C. trachomatis which can be performed in the lab. Some rapid diagnostic tests are available in the market, but currently they perform poorly compared to molecular tests. Sexual history taking and risk assessment are crucial before diagnosis. Clinical examination, speculum examination, and palpation can provide important clues to clinical diagnosis. In many primary healthcare settings where diagnostic capacity for detecting C. trachomatis is not available, a syndromic approach for case management is recommended.

44. Diagnosis Urine samples are commonly used for diagnosing chlamydia but are less sensitive than swab-collected samples from genital (vaginal or urethral), anal, and oropharyngeal sites. The collection of samples from different anatomic sites depends on sexual practices and medical history. Self-collection of samples is recommended as the test results are similar than those collected by a health provider. Because most cases are without symptoms, regular testing for individuals at increased risk of chlamydial infection, such as female sex workers, to prevent the development of complications and the spread of infection is recommended. In the presence of chlamydia tests for other sexually transmitted infections (such as HIV, syphilis, and gonorrhea) is recommended together with notification of sexual partner(s). For LGV diagnosis a specific- molecular test needs to be performed.

45. Treatment

46. Treatment Chlamydia is treatable and curable. Uncomplicated chlamydia is treated with antibiotic tablets including azithromycin or doxycycline. Repeated infections can occur if sexual partners are not treated, and if individuals have sex without condoms with someone who has the infection. People should wait 7 days after taking the medicine before having sex or, if not possible, use condoms correctly. They should notify their sexual partner(s) to get tested and treated, if necessary. Further reading on the treatment of chlamydia ( page 11 – 13) https://www.who.int/publications/i/item/978-92-4-154971-4

47. Prevention Consistent and correct use of condoms when having vaginal and anal sex is the only way to prevent chlamydial infection. If you are pregnant, getting tested for chlamydia and receiving prompt treatment if you test positive can prevent transmission to the baby. There are no vaccines for the prevention of chlamydial infection.

48. Pap smear showing chlamydia in the vacuoles. Magnified 500X This photomicrograph reveals McCoy cell monolayers with Chlamydia trachomatis. Magnified 200X

49. Human papillomavirus and cancer

50. Human Papillomavirus and Cancer Human papillomavirus (HPV) is the name of a group of 200 known viruses. They do not cause concerns in most people, but infection with some high-risk types is common and can cause genital warts or cancer. In 90% of people the body controls the infection by itself. Persistent HPV infection with high-risk HPV types is the cause of cervical cancer and is associated with cancers of the vulva, vagina, mouth/throat, penis and anus. In 2019, HPV caused an estimated 620,000 cancer cases in women and 70,000 cancer cases in men. Prophylactic vaccination against HPV can prevent these cancers. In addition, HPV screening and treatment of pre-cancer lesions an effective way to prevent cervical cancer.

51. Overview Human papillomavirus (HPV) is a common sexually transmitted infection. Almost all sexually active people will be infected at some point in their lives, usually without symptoms. HPV can affect the skin, genital area, and throat. Condoms help prevent HPV but do not offer total protection because they do not cover all the genital skin. HPV usually goes away on its own without treatment. Some HPV infections cause genital warts. Others can cause abnormal cells to develop, which go on to become cancer. Cancers from HPV can be prevented with vaccines.

52. Symptoms Most people will not have any symptoms from an HPV infection. The immune system usually clears HPV from the body within a year or two with no lasting effects. Some HPV infections cause small rough lumps (genital warts) that can appear on the vagina, penis, or anus and rarely the throat. They may be painful, itchy bleed, or cause swollen glands. HPV infection that does not go away on its own can cause changes to cervical cells, which lead to precancers that may become cervical cancer if left untreated. It usually takes 15–20 years for cervical cancer to develop after HPV infection. The early changes in cervical cells and precancers mostly do not cause symptoms. Symptoms of cervical cancer may include bleeding between periods or after sexual intercourse or a foul-smelling vaginal discharge. These symptoms may be due to other diseases. People with these symptoms should speak to their healthcare provider.

53. Prevention Being vaccinated is the best way to prevent HPV infection, cervical cancer, and other HPV-related cancers. Screening can detect cervical precancers that can be treated before they develop into cancer. HPV vaccines should be given to all girls aged 9–14 years before they become sexually active. The vaccine may be given as 1 or 2 doses. People with reduced immune systems should receive 2 or 3 doses. Check with your healthcare provider to determine what is best for you. Using condoms during sex is an important way to prevent HPV infection. Voluntary male circumcision also reduces the risk of infection. Being a non-smoker or stopping smoking reduces the chances of developing persistent HPV infection.

54. Prevention Testing cells from a woman’s cervix for HPV is used to screen women for cervical cancer. Women should be screened every 5–10 years starting at age 30. Women living with HIV should be screened every 3 years starting at age 25. After a positive HPV test (or other screening method), a healthcare provider can look for changes on the cervix or precancers that could develop into cervical cancer if left untreated. Treatment of precancers prevents cervical cancer. Precancers rarely cause symptoms, which is why regular screening to check cervical health is important.

55. Treatment There is currently no treatment for HPV infection. Treatments exist for genital warts, cervical precancers, and cervical cancer. Non-cancerous genital warts and precancerous lesions in the cervix, vagina, vulva, anus, or penis can be removed or treated by ablation (freezing or heating) or with surgery. Currently, cancer of the cervix (cervical cancer) is the only HPV-caused cancer for which screening tests are available. Treatments for cancers caused by HPV (including cervical cancer) are more effective if diagnosed early. Treatment should begin quickly after diagnosis.

56. Cervical Cancer

57. Key facts Cervical cancer is caused by persistent infection with the human papillomavirus (HPV). Women living with HIV are 6 times more likely to develop cervical cancer compared to women without HIV. Cervical cancer is the fourth most common cancer in women globally with around 660 000 new cases and around 350 000 deaths in 2022. The highest rates of cervical cancer incidence and mortality are in low- and middle-income countries. This reflects major inequities driven by lack of access to national HPV vaccination, cervical screening and treatment services, and social and economic determinants.

58. Overview Globally, cervical cancer is the fourth most common cancer in women, In 2022, 660,000 new cases reported. About 94% of the 350, 000 deaths caused by cervical cancer occurred in low- and middle-income countries. Women living with HIV are 6 times more likely to develop cervical cancer compared to the general population. Estimated 5% of all cervical cancer cases are attributable to HIV 20% of children who lose their mother to cancer do so due to cervical cancer

59. Couse Human papillomavirus (HPV) is a common sexually transmitted infection that can affect the skin, genital area, and throat. Almost all sexually active people will be infected at some point in their lives, usually without symptoms. In most cases, the immune system clears HPV from the body. Persistent infection with high-risk HPV can cause abnormal cells to develop, which go on to become cancer. Persistent HPV infection of the cervix if left untreated, causes 95% of cervical cancers. Typically, it takes 15–20 years for abnormal cells to become cancer, but in women with weakened immune systems, such as untreated HIV, this process can be faster and take 5–10 years.

60. Risk factors The grade of oncogenicity of the HPV type Immune status The presence of other sexually transmitted infections Number of births Young age at first pregnancy Hormonal contraceptive use Smoking.

61. Sign and symptoms Cervical cancer can be cured if diagnosed and treated at an early stage of disease. Recognizing symptoms and seeking medical advice to address any concerns is a critical step. Women should see a healthcare professional if they notice: Unusual bleeding between periods, after menopause, or after sexual intercourse Increased or foul-smelling vaginal discharge Symptoms like persistent pain in the back, legs, or pelvis Weight loss, fatigue, and loss of appetite Vaginal discomfort Swelling in the legs.

62. Prevention Being vaccinated at age 9–14 years is a highly effective way to prevent HPV infection, cervical cancer, and other HPV-related cancers. Screening from the age of 30 (25 years in women living with HIV) can detect cervical disease, which when treated, also prevents cervical cancer. At any age with symptoms or concerns, early detection followed by prompt quality treatment can cure cervical cancer. HPV vaccines Being a non-smoker or stopping smoking Using condoms Voluntary male circumcision.

63. Cervical screening Women should be screened for cervical cancer every 5–10 years starting at age 30. Women living with HIV should be screened every 3 years starting at age 25. The global strategy encourages a minimum of two lifetime screens with a high-performance HPV test by age 35 and again by age 45 years. Precancers rarely cause symptoms, which is why regular cervical cancer screening is important, even if you have been vaccinated against HPV.

64. HPV Vaccines PV vaccines should be given to all girls aged 9–14 years before they become sexually active. The vaccine may be given as 1 or 2 doses. People with reduced immune systems should ideally receive 2 or 3 doses.

65. Treatment of precancers Treatments of precancers are quick and generally painless causing infrequent complications. Treatment steps include colposcopy or visual inspection of the cervix to locate and assess the lesion followed by: Thermal ablation, which involves using a heated probe to burn off cells; Cryotherapy, which involves using a cold probe to freeze off the cells; LEETZ (large loop excision of the transformation zone), which involves removing your abnormal tissues with an electrically heated loop; and/or A cone biopsy, which involves using a knife to remove a cone-shaped wedge of tissue.

66. Treating of cancer Features of quality care include: A multidisciplinary team ensuring diagnosis and staging (histological testing, pathology, imaging) take place before treatment decisions; Treatment decisions in line with national guidelines; and Interventions are supported by holistic psychological, spiritual, physical, and palliative care. Modelling estimates that by the year 2120: 74 million new cases of cervical cancer can be averted 62 million deaths can be avoided by reaching the elimination goal.

67. WHO Response Elimination is reducing the number of new cases annually to 4 or fewer per 100 000 women and sets three targets to be achieved by the year 2030 to put all countries on the pathway to elimination in the coming decades: 90% of girls vaccinated with the HPV vaccine by age 15 70% of women screened with a high-quality test by ages 35 and 45 90% of women with cervical disease receive treatment.

68. https://youtu.be/qF7pBzU4D20

69. Human papillomavirus and cancer

70. Gonorrhea

71. Key facts Gonorrhoea is a preventable and curable sexually transmitted infection caused by the bacterium Neisseria gonorrhoeae , which is primarily transmitted through vaginal, oral and anal sex. In 2020 there were an estimated 82.4 million new infections among adults globally. Most women with gonorrhoea do not have symptoms, and when they do, vaginal discharge is common, while most men present with discharge from their penis. If left untreated, gonorrhoea can lead to infertility in both men and women and other sexual and reproductive health complications. It also increases the risk of HIV infection. Antimicrobial resistance to gonorrhoea is a serious and growing problem, rendering many classes of antibiotics as ineffective with the risk of becoming untreatable.

72. Overview Gonorrhoea is a common sexually transmitted infection caused by a type of bacteria. It usually spreads through vaginal, oral and anal sex. Gonorrhoea is treatable and curable with antibiotics. Most cases of gonorrhoea can be prevented with regular and correct condom use. Gonorrhoea causes different symptoms in women and men. Women often feel no symptoms, but untreated infection can lead to infertility and problems during pregnancy. Common symptoms in men include pain or burning when urinating, discharge from the penis and sometimes pain in the testes. Gonorrhoea can be passed from a pregnant mother to her baby. Gonococcal infection increases the risk of getting and spreading HIV.

73. Scope of the problem Gonorrhoea is a common sexually transmitted infection caused by a type of bacteria. It usually spreads through vaginal, oral and anal sex. Gonorrhoea is treatable and curable with antibiotics. Most cases of gonorrhoea can be prevented with regular and correct condom use. Gonorrhoea causes different symptoms in women and men. Women often feel no symptoms, but untreated infection can lead to infertility and problems during pregnancy. Common symptoms in men include pain or burning when urinating, discharge from the penis and sometimes pain in the testes. Gonorrhoea can be passed from a pregnant mother to her baby. Gonococcal infection increases the risk of getting and spreading HIV.

74. Signs and symptoms Gonorrhoea can cause symptoms in the genitals, anus or throat. Men and women may experience different symptoms. Symptoms usually begin 1–14 days after sexual contact with an infected person. In men, common symptoms include pain or burn when urinating a white, yellow or greenish discharge from the penis painful or swollen testes.

75. Signs and symptoms Most women with gonorrhea do not have symptoms or do not notice them. If they occur, they can include pain or burning when urinating vaginal discharge vaginal bleeding between periods or during sexual intercourse. Anal infection in women and men can cause discharge bleeding itchiness soreness painful bowel movements.

76. Signs and symptoms Infants born to mothers with gonorrhoea may develop an eye infection. This causes redness, pain, soreness, ulcers, tearing, blindness, and joint infection This is preventable with eye medications for newborns.

77. Possible complications Untreated N. gonorrhoeae infections can lead to complications and sequelae in women, such as pelvic inflammatory disease (PID), ectopic pregnancy, and infertility. Complications in men are scrotal swelling, urethral stricture, and infertility. Neonatal conjunctivitis (eye infection) if untreated may lead to blindness. In rare cases, disseminated gonococcal infection can occur and it is manifested as fever and infection in multiple organs of the body such as skin, heart, joints, and meninges. Infection with gonorrhoea can cause stigma and affect personal relationships. These effects are important but often not quantifiable.

78. Diagnosis Sexual history taking and risk assessment. Use of speculum examination ( in women) and palpation can provide important clues. Molecular tests are the gold standard for diagnosing N. gonorrhoeae which can be performed in the lab or at the point of care. Gram stain microscopy is used in some laboratories. Syndromic approach in facilities where diagnostic capacity for detecting N. gonorrhoeae is not available. Urine samples are commonly used for diagnosing gonorrhoea. swabs from genital and other sites can be used depending on the location of symptoms, sexual practices, and medical history. Antimicrobial sensitivity testing for N. gonorrhoeae is done in cases of treatment failure to check if the pathogen is resistant to medications. Testing is usually coupled with tests for other sexually transmitted infections (such as HIV, syphilis, and chlamydia).

79. Treatment People with gonorrhoea should be treated as soon as possible. Gonorrhoea is treated with antibiotics called cephalosporins. These include: ceftriaxone, usually given by injection and is the preferred treatment cefixime, usually given orally with another antibiotic, azithromycin, but only when ceftriaxone is not feasible. People should wait 7 days after taking the medicine before having sex. They should notify their sexual partner(s) to get tested or treated.

80. Treatments can fail due to Not taking medications as directed Reinfection The bacterium becoming resistant to the drug Having another untreated infection with similar symptoms.

81. https://youtu.be/00--epqpVps

82. Prevention Most cases of gonorrhoea can be prevented with consistent and correct condom use in every sexual encounter. People with gonorrhoea should notify current and recent sexual partners to help prevent the spread of the disease. Antibiotic eye ointment is recommended for newborns to prevent gonococcal eye infections. There are no specific vaccines for the prevention of gonorrhoea. However, studies are showing promising results with the use of a meningococcal type B vaccine (4CMenB) that seems to offer cross-protection against gonorrhea.

83. meningococcal type B vaccine (4CMenB) https://pubmed.ncbi.nlm.nih.gov/36724329/ https://pubmed.ncbi.nlm.nih.gov/36724329/

84. WHO response The  Global Health Sector Strategies on HIV, viral hepatitis and STIs 2022–2030  aims to reduce the incidence of  N. gonorrhoeae  infection by 90% by 2030, compared to 2020 baseline. https://www.who.int/teams/global-hiv-hepatitis-and-stis-programmes/strategies/global-health-sector-strategies

85. Herpes

86. Herpes simplex virus Herpes simplex virus (HSV), known as herpes, is a common infection that can cause painful blisters or ulcers. There are two types of herpes simplex virus. Type 1 (HSV-1) mostly spreads by oral contact and causes infections in or around the mouth (oral herpes or cold sores). It can also cause genital herpes. Most adults are infected with HSV-1. Type 2 (HSV-2) spreads by sexual contact and causes genital herpes.

87. Key facts An estimated 3.7 billion people under age 50 (67%) globally have herpes simplex virus type 1 (HSV-1) infection, the main cause of oral herpes. An estimated 491 million people aged 15–49 (13%) worldwide have herpes simplex virus type 2 (HSV-2) infection, the main cause of genital herpes. Most HSV infections are asymptomatic or unrecognized, but symptoms of herpes include painful blisters or ulcers that can recur over time. Infection with HSV-2 increases the risk of acquiring and transmitting HIV infection.

88. Scope of the problem (burden) In 2016 (last available estimates), 3.7 billion people under the age of 50, or 67% of the global population, had HSV-1 infection (oral or genital). Most HSV-1 infections are acquired during childhood. Genital herpes caused by HSV-2 affects an estimated 491 million (13%) people aged 15–49 years worldwide (2016 data). HSV-2 infects women almost twice as often as men because sexual transmission is more efficient from men to women. Prevalence increases with age, though the highest number of new infections are in adolescents.

89. Transmission HSV-1 is mainly transmitted via contact with the virus in sores, saliva, or surfaces in or around the mouth. Less commonly, HSV-1 can be transmitted to the genital area through oral-genital contact to cause genital herpes. It can be transmitted from oral or skin surfaces that appear normal; however, the greatest risk of transmission is when there are active sores. People who already have HSV-1 are not at risk of reinfection, but they are still at risk of acquiring HSV-2.

90. Transmission HSV-2 is mainly transmitted during sex through contact with genital or anal surfaces, skin, sores, or fluids of someone infected with the virus. HSV-2 can be transmitted even if the skin looks normal and is often transmitted in the absence of symptoms. In rare circumstances, herpes (HSV-1 and HSV-2) can be transmitted from mother to child during delivery, causing neonatal herpes.

91. Symptoms Most people with herpes have no symptoms or only mild symptoms. Many people aren’t aware they have the infection and can pass along the virus to others without knowing. Symptoms can include painful, recurring blisters or ulcers, fever, body aches, and swollen lymph nodes. Symptoms may be different during the first episode (or ‘outbreak’) of infection than during a recurrent episode. If symptoms occur, they often begin with tingling, itching, or burning near where the sores will appear. Common oral herpes symptoms include blisters (cold sores) or open sores (ulcers) in or around the mouth or lips. Common genital herpes symptoms include bumps, blisters, or open sores (ulcers) around the genitals or anus. These sores and blisters are typically painful. Blisters may break open, ooze, and then crust over.

92. Signs and symptoms During their first infection, people may experience: fever body aches sore throat (oral herpes) headache swollen lymph nodes near the infection. People can have repeated outbreaks over time (‘recurrences’). These are usually shorter and less severe than the first outbreak.

93. Possible complication HSV-2 and HIV infection HSV-2 infection increases the risk of acquiring HIV infection by approximately three-fold. Additionally, people with both HIV and HSV-2 infection are more likely to spread HIV to others. HSV-2 infection is among the most common infections in people living with HIV. Severe disease In immunocompromised people, including those with advanced HIV infection, herpes can have more severe symptoms and more frequent recurrences. Rare complications of HSV-2 include meningoencephalitis (brain infection) and disseminated infection. Rarely, HSV-1 infection can lead to more severe complications such as encephalitis (brain infection) or keratitis (eye infection).

94. Possible complication Neonatal herpes Neonatal herpes can occur when an infant is exposed to HSV during delivery. Neonatal herpes is rare, occurring in an estimated 10 out of every 100,000 births globally. However, it is a serious condition that can lead to lasting neurologic disability or death. The risk for neonatal herpes is greatest when a mother acquires HSV for the first time in late pregnancy.

95. Treatment Medicines are often used to treat first or recurrent episodes of herpes. They can decrease how long symptoms last and how severe they are, but they can’t cure the infection. Treatment for recurrent episodes is most effective when started within 48 hours of when symptoms begin. Antiviral medicines commonly given include acyclovir, famciclovir, and valacyclovir. Taking a lower daily dose of one of these medicines can also decrease how often symptoms occur (‘outbreaks’).

96. Treatment Treatment is often recommended for people who get very painful or frequent recurrent episodes or who want to lower the risk of giving herpes to someone else. Medicines to help with pain related to sores include paracetamol (acetaminophen), naproxen, or ibuprofen. Medicines that can be applied to numb the affected area include benzocaine and lidocaine.

97. Treatment For people, whose oral herpes is activated by sunlight, avoiding sun exposure and wearing sunscreen can lower the risk of recurrences. To decrease symptoms of oral herpes, people can: drink cold drinks or suck on popsicles use over-the-counter pain medicines. For genital herpes, people can: sit in a warm bath for 20 minutes (without soap) wear loose fitting clothes use over-the-counter pain medicines.

98. Treatment There are ways to lower the risk of spreading herpes including: talk to your partner about having herpes don’t have sex if you have symptoms and always wear a condom don’t share items that touched saliva (oral herpes).

99. Suppressive Therapy for Recurrent HSV-2 Genital Herpes

100. Prevention People with symptoms of oral herpes should avoid oral contact with others (including oral sex) and sharing objects that touched saliva. Individuals with symptoms of genital herpes should abstain from sexual activity while experiencing symptoms. Both HSV-1 and HSV-2 are most contagious when sores are present but can also be transmitted when no symptoms are felt or visible. For sexually active people, consistent and correct use of condoms is the best way to prevent genital herpes and other STIs. Condoms reduce the risk; however, HSV infection can still occur through contact with genital or anal areas not covered by the condom. Medical male circumcision can provide life-long partial protection against HSV-2 infection, as well as against HIV and human papillomavirus (HPV).

101. Prevention People with symptoms suggestive of genital herpes should be offered HIV testing. Pregnant women with symptoms of genital herpes should inform their healthcare providers. Preventing the acquisition of HSV-2 infection is particularly important for women in late pregnancy when the risk for neonatal herpes is greatest.

102. Trichomoniasis

103. Trichomoniasis Trichomonas vaginalis is a preventable and curable sexually transmitted protozoan that infects the urogenital tract. Although the majority of infections are asymptomatic, more than 50% of women with Trichomonas vaginalis infection have vaginal discharge and about 10% of men have urethritis. The parasite is transmitted during oral, vaginal, and anal sex, and in some rare instances during delivery. Correct and consistent use of condoms during sex can prevent trichomoniasis. Transmission: Sexually active people can get trichomoniasis by having sex without a condom with a partner who has trichomoniasis.

104. Key facts Trichomoniasis is a common sexually transmitted infection (STI) caused by the protozoan Trichomonas vaginalis. It is treatable and curable. In 2020 there were approximately 156 million new cases of T. vaginalis infection among people aged 15–49 years old. In females, trichomoniasis is a common cause of vaginal discharge and is associated with poor birth outcomes and increased risk of pelvic inflammatory disease. In males, trichomoniasis is often asymptomatic and associated with increased risk of epididymitis, prostatitis and decreased sperm motility. Infection with T. vaginalis is also associated with increased risk of HIV acquisition.

105. Burden Trichomonas vaginalis is the most common non-viral STI. There were an estimated 156 million new cases of T. vaginalis infection among people aged 15–49 years old in 2020 globally in 2020 (73.7 million in females, 82.6 million in males). Approximately one-third of new infections in this age group occur in the WHO African Region, followed by the Region of the Americas.

106. Signs and symptoms Most infections in men and women are asymptomatic. Symptomatic women can have vaginal discharge (yellow in colour), which may appear purulent. Other symptoms include a red and sore vagina. The person with the infection can also feel pain during intercourse and urination. When T. vaginalis is present, a yellow or greenish and possibly frothy discharge can be observed in the vagina during a speculum examination by a health provider Men are often asymptomatic, but some experience penile irritation and urethritis.

107. Diagnosis Diagnosis based on signs and symptoms of vaginal or urethral discharge is often the most common approach in settings where laboratory diagnosis is not available. Nucleic acid amplification tests (NAAT) are the most sensitive laboratory diagnostic method for detecting T. vaginalis. While vaginal swabs are the preferred samples, endocervical samples, and urine can also be used for certain laboratory assays. Currently, NAAT is not widely available as a rapid point-of-care test. Before the emergence of point-of-care antigen tests and NAAT, the primary method for detecting T. vaginalis was through culture. To confirm the absence of infection, the cultures must be incubated for up to seven days, which is a challenge for this method’s use. In the past, diagnosing T. vaginalis often involved performing wet mount microscopy. While this is not the best method for trichomoniasis diagnosis, it is still commonly used in some settings.

108. Complications Perinatal outcomes Untreated T. vaginalis is linked to adverse birth outcomes, including low birth weight, preterm delivery and premature rupture of membranes. Although uncommon, perinatal transmission of T. vaginalis can occur, leading to vaginal and respiratory infections in newborns. HIV transmission T. vaginalis infections are linked to a 1.5 times increased risk of HIV acquisition. Other STIs Trichomonas vaginalis has been linked to the co-occurrence of various other STIs, including Chlamydia trachomatis, Neisseria gonorrhoeae, and human papillomavirus (HPV). It also demonstrates a similar epidemiologic connection with herpes simplex virus type 2 (HSV-2). Infection with T. vaginalis can alter the usual vaginal microbiota, making it more susceptible to the development of bacterial vaginosis (BV). Around 40–60% of women with T. vaginalis also experience BV, and those with BV have an increased risk of contracting T. vaginalis.

109. Prevention Trichomoniasis is a preventable condition. The most effective method to prevent trichomoniasis and various other STIs is by consistently and correctly using condoms. People diagnosed with trichomoniasis should inform their sexual partners to prevent further transmission. If that is not possible, they should request support from the health provider to notify their sexual partners.

110. WHO response The WHO Global health sector strategies on HIV, viral hepatitis and STIs 2022–2030 aims for a 50% reduction in new cases of trichomoniasis by 2030. WHO is updating recommendations for the treatment of T. vaginalis. https://www.who.int/teams/global-hiv-hepatitis-and-stis-programmes/strategies/global-health-sector-strategies/developing-ghss-2022-2030

111. Chancroid

112. Chancroid Chancroid also known as soft chancre Chancroid is a bacterial sexually transmitted infection (STI) Causative agent: Haemophilus ducreyi Highly cont agious but curable. Transmission: sex (anal, vaginal, oral)

113. Risk factors Anyone can get chancroid Highly prevalent in developing countries around the word Residing in endemic regions, lower socioeconomic status, prostitution, and drug abuse. Anyone having unprotected sex Uncircumcised men A significant cofactor in the transmission of HIV disease. As chancroid is an ulcerative disease, its lesions are more readily apparent and may increase the risk of HIV by as much as 50 – 300 times per unprotected sex.

114. Signs and symptoms Chancre Painful soft chancre Begins as a tender lesion that becomes pustular and later erodes to form an extremely painful and deep ulcer ( soft chancre) Men – 1 Women - > 1 Cervicitis dysuria Urethritis Dyspareunia Pain inguinal Lymphadenopathy develops 1 – 2 weeks Rupture lymph nodes called buboes The bubo raptures forming an ulcer

115. Diagnosis Gram stain Gram negative – turn red Cocco – round Bacili – rod Culture colonies of bacteria Antibiotics use culture to determine sensitivity Polymerase chain reaction test ( specifically the nucleic acid amplification test (NAAT)) Used to test the nucleus (DN) Haemophilus ducreyi acid Other tests include test for syphilis, HSV, gonorrhea, chlamydia and HIV

116. Treatment Ceftriaxone is the treatment of choice in pregnant women. Data suggests that ciprofloxacin presents a low risk to the fetus during pregnancy with potential toxic effects during breastfeeding. Surgical intervention: drainage of lymph nodes with either needle aspiration or incision. Sexual partners of the patients with chancroid should be examined and treated regardless of the presence of symptoms if they had sexual contact within 10 days preceding the onset of symptoms

117. Prevention Abstaining from sex completely Having sex with only one uninfected partner Block transmission ( having safe sex) Use condoms Dental dams Making sure pus from any infected area doesn’t touch you.

118. Granuloma Inguinale

119. Granuloma inguinale Donovanosis, also known as granuloma inguinale, is a bacterial infection of the genital region caused by Klebsiella granulomatis . It is chronic and progressive and causes genital ulcers.

120. Signs and symptoms Donovanosis lesions usually start as a painless papule or nodule. The lesion Develops a “beefy–red” appearance due to high vascularity and tends to bleed easily. The genitals are affected 90% and inguinal affected 10% of cases. No treated patients present with progressive lesions. Extragenital lesions occur on the lips, gums, cheek, palate, pharynx, larynx, and chest (6% of all time) Cutaneous lesions ( ulcers) Lymphadenopathy

121. Complications Neoplastic changes - 0.25% of getting squamous cell carcinoma and basal cell carcinoma. Elephantiasis of the genitals may develop secondary to lymphatic destruction. Increased risk of acquiring HIV. Osteomyelitis, polyarthritis, stenosis of the urethra, vagina, or anus, Vaginal bleeding Pathology, Penis, Granuloma Inguinale, Klebsiella Infections, Simulated Carcinoma of the Penis

122. Bacteria Vaginosis

123. Bacteria vaginosis Is a condition that happens when there is too much of certain bacteria in the vagina. This changes the normal balance of bacteria in the vagina. BV is because of an imbalance of “good” and “ harmful” bacteria in a vagina. It is the most common vaginal condition in women ages 15 – 44 Highly common in those who are sexually active.

124. Overview Bacterial vaginosis is the most common cause of vaginal discharge among women of reproductive age. BV prevalence varies across countries and population groups, but a recent systematic review and meta-analysis of the global BV prevalence among women of reproductive age range from 23–29% Sexually active women are predominately affected and associated with inconsistent condom use and new and increased number of sexual partners. BV increases the risk of acquiring HIV, transmission and acquisition of and transmission of other STIs and if left untreated can lead to adverse effects of pregnancy.

125. Pathophysiology In BV, the vaginal flora becomes altered through known and unknown mechanisms, causing an increase in the local pH. This may result from a reduction in the hydrogen peroxide–producing lactobacilli. Lactobacilli are large rod-shaped organisms that help maintain the acidic pH of healthy vaginas and inhibit other anaerobic microorganisms through the elaboration of hydrogen peroxide. Normally, lactobacilli are found in high concentrations in the healthy vagina. In BV, the lactobacilli population is reduced greatly, while populations of various anaerobes and Gardnerella vaginalis are increased.

126. Risk factors that may predispose patients to BV Rsk factors include Recent antibiotic use Decreased estrogen production of the host Wearing an intrauterine device (IUD) Douching Sexual activity

127. Signs and symptoms Vaginal odor ( most common) Recognized only after sexual intercourse The alkalinity of semen causes the release of amines from the vaginal discharge and causes a fishy odor Increased vaginal discharge typically, mild to moderate Most often gray, thin, and homogenous Vulvar irritation ( less common) Dysuria and dyspareunia

128. Diagnosis Comprehensive physical assessment to find out about the risk factors Lab studies Microscopic examination A pH level > 4.5 indicates infection, and pH is elevated in 90% of patients with BV Vaginal cultures

129. Treatment Pharmacotherapy BV can be treated and cured Best treatment with antibiotic metronidazole Advise patients to stop douching or using bubble baths or any other over-the-counter vaginal hygiene products. Wash only with hypoallergenic bar soaps or no soap at all. Avoid liquid soaps and body washes.

130. Treatment

131. To be continued … Genital warts HIV