Sexually Transmitted Infection
(Emerging STIs)
Presentation Outline
1.
2.
3.
4.
5.
Global and Myanmar STIs burden
Basics Facts about STIs
Principles in STIs Management
STIs prevention
STIs in specific population groups
1.Global and Myanmar STIs Burden
STIs in Global Health Setting
• Multiple neglected pandemics lead to significant global disease burden.
• acquired every day worldwide.
• Primarily caused by Chlamydia trachomatis, Neisseria gonorrhoeae, Treponema
pallidum (syphilis) and Trichomonas vaginalis
How many people do you think acquire any
STI every day?
A. > 250,000
B. > 500,000
C. > 750,000
D. > 1 million
STIs in Global Health Setting
~156 M
Trichomoniasis
> 1 M acquired STIs
every day
1M Pregnant
women
estimated to be
infected with
syphilis (2016)
> 350,000
adverse birth
outcomes
~128 M
Chlamydia
374 M new
cases among
15-49 years
(2020)
Including
200,000
stillbirths and
newborn deaths
Ref: WHO Facts sheet, Sexually Transmitted Diseases Nov 2021
~82.4 M
Gonorrhoea
7.1 M
Syphilis
New Cases of Four Curable STIs (2020)
Ranking
1. Trichomonas
2. Chlamydia
3. Gonorrhea
4. Syphilis
Ref :Global progress report on HIV, viral hepatitis and sexually transmitted infections, 2021
WHO estimates: 357 million new cases of curable sexually transmitted
infections in 2012
Data source: Global Health Sector Strategy on Sexually Transmitted Infections 2016–2021
Incidence of Four curable STIs ( 2020 )
(Syphilis, Trichomonas, Gonorrhea and Chlamydia)
Reference : WHO Facts sheet ,Sexually Transmitted Diseases Nov 2021
14 % of total death caused by infection, digestive
diseases and cancer.
Ref: Global progress report on HIV, viral hepatitis and sexually transmitted infections, 2021
HPV infections
• 1 in 7 women is estimated
to have HPV infection.
• HIV enhances HPVinduced carcinogenesis
• Women living with HIV
have a six-fold increase
in risk of cervical cancer
HPV Infection
(291 Millions)
Cases of
Cervical
Cancer(570,000)
Cervical Cancer
Death(~300,000)
Ref : WHO STI progress report global 2021,
WHO Facts sheet, Sexually Transmitted Diseases Nov 2021,
Risk of HIV
transmission
Drug
resistance
Risk of
cancer
Concerns About
STI
Infertility,
Pregnancy
complications
Stigma and
Discrimination
Supply Issue
SUSTAINABLE DEVELOPMENT GOAL 3
Ensure healthy lives and promote well-being for all at all ages
• By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected
tropical diseases and combat hepatitis, water-borne diseases and other
communicable diseases
Global Targets for STIs control
2030 Targets
• 90% reduction
TP/GC
• PMTCT syphilis
• ↑HPV vaccine
coverage
Ref : The World Health Organization’s (WHO’s) global health-sector strategy on sexually transmitted infections (2016–2021)
STI Burden in Myanmar
People Receiving STIs Treatment by Key Populations
(2013 − 2019)
# of people receiving STIs treatment
90,000
80,000
70,000
60,000
50,000
40,000
30,000
20,000
10,000
2013
FSW
Clients of FSW
2014
MSM
2015
PWID
Data Source: NAP STD teams report
2016
Calendar Year
Prisoner
2017
2018
Regular Partners of KP
2019
Other pop
No. of cases
Syphilis cases (2014-2019)
10000
9000
8000
7000
6000
5000
4000
3000
2000
1000
0
2014
2015
Syphilips(a) Primary
2016
2017
Syphilips(b) Secondary
Data Source: NAP STD teams report
2018
2019
latent syphilis
Genital Ulcers cases (2014-2019)
800
700
No. of cases
600
500
400
300
200
100
0
2014
2015
Chancroid
2016
Genital Herpes
Data Source: NAP STD teams report
2017
2018
Genital warts
2019
Genital Discharge cases (2014-2019)
2000
No. of cases
1500
1000
500
0
2014
2015
2016
Gonorrhea
Trichomonas Infection
Bacterial Vaginosis
Data Source: NAP STD teams report
2017
2018
2019
Non Gonococcal Urethritis/Cervicitis
Genital Candidiosis
Percentage
Syphilitic index (2019)
1.00%
0.90%
0.80%
0.70%
0.60%
0.50%
0.40%
0.30%
0.20%
0.10%
0.00%
0.45%
Syphilitic index
Syphilis Index - Prevalence of Syphilis infection in Primigravida
Take Home Message
• Neglected pandemics with significant global disease burden.
• New cases of 374 million (Trich , Chlamydia , GC and Syphilis )
• STIs are associated with a several-fold increased risk of transmitting HIV
• Possible Mother-to-child transmission of STIs especially syphilis and Myanmar is
on the way for the elimination of congenital syphilis infection.
• Drug resistance, especially for gonorrhea, is a major threat to reducing the impact
of STIs
• In Myanmar, Health seeking is decreasing while case load is increasing and alarming.
2. Basics Facts about STIs
Definition of STIs and STD
• Sexually Transmitted Infections (STIs), previously known as venereal disease
caused by a wide range of organisms including bacteria, viruses, protozoa, and ectoparasites.
• Sexually transmitted Diseases (STDs) refers to a disease that derived from STIs.
Classification of STIs
Major / Minor
Classical / current (or) modern
1st generation / 2nd generation / 3rd generation
STIs
Curable / uncurable
Bacterial / viral / protozoal / fungal
Genito-Ulcerative / Genito-urinary discharge / Genital
inflammatory / others
STIs nomenclature
VD
(Venereal Diseases)
5 Classical Venereal Diseases
(Syphilis, Gonorrhea, Chancroid, Lymphogranuloma venerum, G .inguinale)
Also known as First generation STDs.
STD
In 1983 … WHO changed the name to STD.
STIs
In 1991…Changed the name from STD to STIs.
New Emerging STI known as second generation STDs (e.g. HIV, HPV)
Sequale of STIs
Late sequalae of development of malignancies following STIs.
(3rd Generation STD).
Major Vs Minor STIs
Major STIs
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
Syphilis
Gonorrhoea
Chlamydia
Genital Herpes
HIV/AIDS
Chancroid
LGV
Granuloma Inguinalae
Minor STIs
1.
2.
3.
4.
5.
6.
7.
8.
Trichomoniasis (TV)
Candidiasis
Bacteria Vaginosis
Urethritis / Cervicitis
Genital Warts
Molluscum contagiosum
Genital Scabies
Genital Mycosis
STIs Associated Syndromes
(1) Genital ulcerative diseases
(2) Genito - urinary discharges
- Urethral discharges
- Vaginal discharges
(3) Scrotal swelling
(4) Lower abdominal pain in female
(5) Inguinal Bubo
(6) Opthalmia neonatorum
(Neonatal Conjunctivitis)
Modes of transmission
Classical 5 ways
1. Sexual contact…(Heterosexual, homosexual, bisexual)
2. Skin contact
3. Clothing and utensils
4. From mother to fetus (vertical)
5. Blood transfusion
Which one of the following STD is not
matching correctly with the causal organism?
A. Chancroid : Haemophilus ducreyi
B. Donovanosis : Klebsiella granulomatosis
C. Syphilis : Treponema pallidum
D. Genital lice : Sarcoptes pubis
E. Gonorrhoea : Neisseria gonorrhoeae
Causal Organisms of STIs
Bacteria
•
•
•
•
•
Chancroid (Haemophilus ducreyi)
Chlamydia (Chlamydia trachomatis)
Gonorrhoea (Neisseria gonorrhoeae)
Syphilis (Treponema pallidum)
Donovanosis (Klebsiella
granulomatosis)
Parasites
Crab louse public Lice(Pthirus pubis)
Scabies (Sarcoptes scabiei)
Protozoal
Trichomoniasis (Trichomonas vaginalis)
Fungal
Candida albicans
Viral
Viral Hepatitis (HBV)
Herpes Simplex(HSV2)
HIV
HPV
Molluscum contagiosum
Take Home Message
• STIs classifications and causal organisms for the specific STIs
• Different between VD , STD and STIs
• 5 Classical ways of STIs Transmission should be cleared.
• Need to know the STI specifics syndrome that are linked with syndromic
approaches of STI management
3. Principles in STIs Management
Populations at High Risk for STIs
1. Female Sex Workers/Male Sex Workers (Direct, Indirect,
Institutional (Brothel) Based, Freelance)
2. Partners of STIs carriers and symptomatic patients
3. MSMs
4. PWIDs (People who used drugs)
5. Mobile Population… Migrant Workers
STD Transmission dynamics and Epidemics
General population
Bridging
population
Core transmitters
STI Causation Triad
Agent Factors
Drug resistance
Asymptomatic transmission
Mixed Infections
Host Factors
Age – High (20-24 Age group)
Sex
Female ( asymptomatic and
Severe complication)
Male (High Morbidity)
Education
Low RH knowledge
Socio economic status
Sexuality and Promiscuity
Addictive Drugs
Demographic Factors
Developing countries
Population explosion
Rural to urban migration
Urbanization, industrialization
and globalization
(Civilization leads to
Syphilisation)
Disaster
STIs care Cascade
STIs population
Symptomatic
Seeking care
Correct Diagnosis
Correct Treatment
Treatment completed
Cured
Partner treated
Influencing factors in STIs Management
Patients Related
Factors
•
•
•
•
•
asymptomatic infections especially in women
Stigma
Limited Health care-seeking behavior
Low Health Education level
Work nature of patient (e.g. FSW at brothel)
Provider Related
Factors
•
•
•
•
•
•
Discrimination
Lack of simple, cheap diagnostic tests for STDs
Potential for blaming and violence
Unavailability of effective drugs
Limited provision of counselling and health education
Provider knowledge about STIs Management
Management
Should be in Comprehensive package.
• STIs Prevention ( Outreach, Peer Education, Health Education etc.)
• Achieve early diagnosis of STIs and linkage to treatment
• Reach partners and offer them treatment
• Offer HIV testing and link with HIV prevention (eg PrEP, condom
promotion etc.)
Linkage between HIV/AIDS and STD
Take Home Message
• Need to know who are Populations at High Risk for STIs
• STIs Cascades – STIs cures rate is low and many factors are determined.
• STIs can contribute to the spread of HIV
• STIs Prevention and management is in comprehensive package
approach in joint with other services ( HIV testing, PrEP)
• Keep in mind for the stigma and discrimination (still happening, delays
the treatment accessibility).
4. STI Prevention
Prevention Strategies for Sexually Transmitted
Infections
(a) Primary Prevention
(b) Secondary Prevention
(c) Tertiary Prevention
Primary Prevention
Health Education
• Targeted population
(Key populations ,
Youth, Out-of-school
Youth Etc.)
• Use easily accessible
mass media and social
media
• Sexual and RH
education
• Correct and consistent
use of condom
Pre-Exposure Prophylaxis
1. Vaccination
(Hep A, Hep B and HPV
vaccination)
2. Medical Intervention
Doxycycline once daily
prophylaxis for STIs
For HIV,
• Daily PrEP
• Event-Driven PrEP (EDPrEP)
• Dapivirine vaginal ring (DPVVR)
• CAB LA
Post-Exposure
prophylaxis
For STIs
Doxycycline 200mg PEP
For HIV
PEP according to the
national guideline
•
•
•
•
Daily PrEP
Event-Driven PrEP (ED-PrEP)
Dapivirine vaginal ring (DPV-VR)
CAB LA
Primary Prevention
Treatment as
Prevention
Safe Sex behavior
VMMC*
Proper and consistent
use of
• Male condom
• Female condom
Topical Microbicides and
Spermicides
• Dapivirine vaginal ring
• Tenofivir Gel
• Can reduce the HIV
and STI transmission
• Need to be combined
with other prevention
methods
• U = U (Undetectable equals
Untransmittable)
• Treatment of the STIs
patients and partners can
further prevent spread of
STIs
• Cervical Diaphragm
• Use of Lubricant gel
• Abstinence and
Reduction of Number of
Sex Partners
*VMMC – Voluntary male medical circumcision
Secondary
Prevention
Provision of early and effective Treatment and
care for infected and affected persons.
Promotion of Health care seeking behavior
• Persons with symptoms of STDs.
• Persons with risk of acquiring STDs, including HIV infection.
• Reduce the Stigma and Discrimination ( KP friendly clinic)
Provision of clinical services
• accessible
• acceptable
• effective
• Feasible
Support and counseling services
• Comprehensive counseling , partners tracing and treatment
Tertiary
Prevention
To prevent the development of
complications and sequelae.
• Provision of clinical services for early diagnosis and effective treatment
(dissemination of service points, Accessible and KP-friendly service points)
• Provision and upgrade of laboratory facilities (availability of lab-based
diagnosis of STI in STI clinic and KPSC)
• Provide Clinical services for the Complication and sequalae ( E.g. Cervical
cancer screening)
• Rehabilitation program
Take Home Message
• Health Education on the effective and innovative ways depends on the
situation.
• Prevention of STIs need to be comprehensive and in package approach.
• Know the available services in your region (provide or refer)
• HIV and STIs prevention should be performed in combination.
• Offer HIV testing, PrEP and Condom
• Early and effective treatment could reduce further transmission of HIV
(U=U) and STIs.
5. STIs in other specific Population
Groups
STIs in some Special Population Groups
Need to consider for some specific population groups
1. Children
2. Women sex with women (WSW)
3. Transgender Person
Children
• Close cooperation among clinicians, laboratorians, and child-protection
authorities.
• Need to prompt report to the respective parties , when indicated
• Certain diseases (e.g., gonorrhea, syphilis, HIV, chlamydia, and
trichomoniasis), if acquired after the neonatal period, this strongly indicate
sexual contact.
• For other diseases (e.g., HSV, HPV and anogenital warts, and vaginitis), the
association with sexual contact is not as clear.
WSW
Women sex with women (WSW)
• WSW -variations in sexual identity, practices, and risk
behaviors.
• Should not be presumed to be at low or no risk for STIs
• Effective screening requires and need to engage in a
comprehensive prevention package.
WSW
• Risky Practices involving digital-vaginal or digital-anal contact, particularly
with shared penetrative sex items with possible transmission through infected
cervicovaginal or anal secretions.
• HPV can be transmitted through skin-to-skin contact, and sexual transmission.
• Cervical cancer screening should be offered to all women, regardless of sexual
orientation or practices.
• Young adult WSW should be offered HPV vaccination
WSW
• Trichomonas is a relatively common infection among WSW with
prevalence rates higher than for chlamydia or gonorrhea.
• The relatively frequent practice of oro-genital sex among WSW might place
them at higher risk for genital infection with HSV-1.
• BV is common among women, and even more among women with female
partners
TG & Gender
Diverse Persons
• Lack of medical provider knowledge lead to barriers to care services
• (High rates of Stigma and discrimination )
• Need to create welcoming environments that facilitate disclosure of
gender identity and sexual orientation.
• Transgender persons are at high risk for sexual violence.
• Clinicians can improve sexual health screening and counseling by
asking for their choice of terminology or modifying language.
• HIV Testing and Preventive services should be offered .
Transgender
Women
male at birth but has the gender
identity of a female.
• Providers should have knowledge of patients’ current anatomy
and patterns of sexual behavior
Most transgender women have not undergone genital-
affirmation surgery and might retain a functional penis.
Neovaginal STIs especially HSV and genital warts in penile-
inversion vaginoplasty.
Transgender Women
• C. trachomatis infection should be considered in procedures that involved
penile skin and grafts with urethra mucosa/abdominal peritoneal lining
• N. gonorrhoeae in both penile-inversion and colo-vaginoplasty engage in insertive
oral, vaginal, or anal sex as well as receptive oral or anal sex.
• Transgender women who have had vaginoplasty surgery should undergo
routine STIs screening for all exposed sites (e.g., oral, anal, or vaginal).
• Need to Offer HIV testing and prevention packages (HIV testing, PrEP,
condom promotion)
penile-inversion vaginoplasty.
Transgender
Men
Female at birth but has the gender
identity of a male.
•Lower prevalence of HIV infection than TG women-(HIV prevalence 2% )
•Providers should consider the anatomic diversity among transgender men
because a person can undergo a metoidioplasty (a procedure to increase the
length of the clitoris), with or without urethral lengthening, and might not have a
hysterectomy and oophorectomy.
•Still at risk for bacterial STIs, HPV, HSV, HIV, and cervical cancer.
Transgender Men
TG Men
• Discomfort with medical examinations and fear of discrimination
• who undergo hysterectomy without removal of the cervix remain
at risk for cervical cancer.
• Providers should be aware that conducting a speculum might be
technically difficult after metoidioplasty surgery because of
narrowing of the introitus.
• Need to Offer STI /HIV testing and prevention packages (HIV
testing, PrEP, condom promotion)
Take Home Message
• Trichomonas is a relatively common infection among WSW.
• Should not be presumed to be at low or no risk for STIs in WSW and
Transgender.
• Promote the STIs prevention together with HIV Prevention, testing and condom.
• Certain diseases (e.g., gonorrhea, syphilis, HIV, chlamydia, and trichomoniasis),
if acquired after the neonatal period, this strongly indicate sexual contact.
• Provide need to know the Behavioral and Anatomical natures of WSW and
Transgender peoples.
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