STI Update: Epidemiology,
Prevention and Treatment
Gary Rogers
MBBS, MGPPsych, PhD
Associate Professor of Medical Education
School of Medicine
Griffith University
Queensland
Australia
Brainstorm
What are the most common sexually
transmissible infections in the Pacific
Islands currently?
What are the most significant
sexually transmissible infections in
the Pacific Islands currently?
Most common?
1.
2.
3.
4.
5.
6.
7.
8.
Human papilloma virus infection
Syphilis
Genital herpes
Genital chlamydiosis
HIV
Gonorrhoea
Hepatitis B
Trichomoniasis
39%
10%
23%
16%
10%
3%
0%
1
2
3
0%
4
5
6
7
8
Prevalence in Pacific
Condition
Prevalence
Islands
Comments
Human
25.6%
Papilloma Virus (20.9% HR)
Hawai’i1
Routine OB-GYN appoinments
and normal cervical cytology
15% annual incidence
(50-80% lifetime prevalence)
Syphilis
10%
FJ,KB,SM,SI,
TO,VT2
SI
Seroreactivity = lifetime
prevalence
30%
Vanuatu3
27.4%
PNG4
Preganant women
HSV-2 seroprevalence
(HSV-1 seroprevalence 100%)
Remote villages (HSV-2 sero)
0.013%
21 PICTs5
(excl PNG)
SPC data based on diagnosed
cases & population
Genital herpes
HIV
3.4%
1. Goodman MT et al. Prevalence, Acquisition, and Clearance of Cervical Human Papillomavirus Infection among Women with
Normal Cytology: Hawaii Human Papillomavirus Cohort Study. Cancer Res 68(21):8813-24, 2008.
2. Cliffe SJ et al. Chlamydia in the Pacific Region, the Silent Epidemic. Sex Trans Dis 35(9):801-6, 2008
3. Haddow LJ et al. Herpes Simplex Virus Type 2 (HSV-2) Infection in Women Attending an Antenatal Clinic in the South
Pacific Island Nation of Vanuatu. Sex Trans Dis 34(5):258-61
4. Suligoi B et al. Infection with human immunodeficiency virus, herpes simplex virus type 2, and human herpes virus 8 in
remote villages of southwestern Papua New Guinea. Am J Trop Med Hyg. 72(1): 33–6, 2005.
5. SPC. Cumulative reported HIV, AIDS and AIDS deaths: cases, incidence rates and gender, plus cases with missing details, 2007
Prevalence in Pacific
Condition
Prevalence
Islands
Comments
Human
25.6%
Papilloma Virus (20.9% HR)
Hawai’i1
Routine OB-GYN appoinments
and normal cervical cytology
15% annual incidence
(50-80% lifetime prevalence)
Syphilis
10%
FJ,KB,SM,SI,
TO,VT2
SI2
Seroreactivity = lifetime
prevalence
30%
Vanuatu3
27.4%
PNG4
Preganant women
HSV-2 seroprevalence
(HSV-1 seroprevalence 100%)
Remote villages (HSV-2 sero)
0.013%
21 PICTs5
(excl PNG)
SPC data based on diagnosed
cases & population
Genital herpes
HIV
3.4%
1. Goodman MT et al. Prevalence, Acquisition, and Clearance of Cervical Human Papillomavirus Infection among Women with
Normal Cytology: Hawaii Human Papillomavirus Cohort Study. Cancer Res 68(21):8813-24, 2008.
2. Cliffe SJ et al. Chlamydia in the Pacific Region, the Silent Epidemic. Sex Trans Dis 35(9):801-6, 2008
3. Haddow LJ et al. Herpes Simplex Virus Type 2 (HSV-2) Infection in Women Attending an Antenatal Clinic in the South
Pacific Island Nation of Vanuatu. Sex Trans Dis 34(5):258-61
4. Suligoi B et al. Infection with human immunodeficiency virus, herpes simplex virus type 2, and human herpes virus 8 in
remote villages of southwestern Papua New Guinea. Am J Trop Med Hyg. 72(1): 33–6, 2005.
5. SPC. Cumulative reported HIV, AIDS and AIDS deaths: cases, incidence rates and gender, plus cases with missing details, 2007
Prevalence in Pacific
Condition
Prevalence
Islands
Comments
Human
25.6%
Papilloma Virus (20.9% HR)
Hawai’i1
Routine OB-GYN appoinments
and normal cervical cytology
15% annual incidence
(50-80% lifetime prevalence)
Syphilis
10%
FJ,KB,SM,SI,
TO,VT2
SI2
Seroreactivity = lifetime
prevalence
30%
Vanuatu3
27.4%
PNG4
Preganant women
HSV-2 seroprevalence
(HSV-1 seroprevalence 100%)
Remote villages (HSV-2 sero)
0.013%
21 PICTs5
(excl PNG)
SPC data based on diagnosed
cases & population
Genital herpes
HIV
3.4%
1. Goodman MT et al. Prevalence, Acquisition, and Clearance of Cervical Human Papillomavirus Infection among Women with
Normal Cytology: Hawaii Human Papillomavirus Cohort Study. Cancer Res 68(21):8813-24, 2008.
2. Cliffe SJ et al. Chlamydia in the Pacific Region, the Silent Epidemic. Sex Trans Dis 35(9):801-6, 2008
3. Haddow LJ et al. Herpes Simplex Virus Type 2 (HSV-2) Infection in Women Attending an Antenatal Clinic in the South
Pacific Island Nation of Vanuatu. Sex Trans Dis 34(5):258-61
4. Suligoi B et al. Infection with human immunodeficiency virus, herpes simplex virus type 2, and human herpes virus 8 in
remote villages of southwestern Papua New Guinea. Am J Trop Med Hyg. 72(1): 33–6, 2005.
5. SPC. Cumulative reported HIV, AIDS and AIDS deaths: cases, incidence rates and gender, plus cases with missing details, 2007
Prevalence in Pacific
Condition
Prevalence
Islands
Comments
Human
25.6%
Papilloma Virus (20.9% HR)
Hawai’i1
Routine OB-GYN appoinments
and normal cervical cytology
15% annual incidence
(50-80% lifetime prevalence)
Syphilis
10%
FJ,KB,SM,SI,
TO,VT2
SI2
Seroreactivity = lifetime
prevalence
30%
Vanuatu3
27.4%
PNG4
Preganant women
HSV-2 seroprevalence
(HSV-1 seroprevalence 100%)
Remote villages (HSV-2 sero)
0.013%
21 PICTs5
(excl PNG)
SPC data based on diagnosed
cases & population
Genital herpes
HIV
3.4%
1. Goodman MT et al. Prevalence, Acquisition, and Clearance of Cervical Human Papillomavirus Infection among Women with
Normal Cytology: Hawaii Human Papillomavirus Cohort Study. Cancer Res 68(21):8813-24, 2008.
2. Cliffe SJ et al. Chlamydia in the Pacific Region, the Silent Epidemic. Sex Trans Dis 35(9):801-6, 2008
3. Haddow LJ et al. Herpes Simplex Virus Type 2 (HSV-2) Infection in Women Attending an Antenatal Clinic in the South
Pacific Island Nation of Vanuatu. Sex Trans Dis 34(5):258-61
4. Suligoi B et al. Infection with human immunodeficiency virus, herpes simplex virus type 2, and human herpes virus 8 in
remote villages of southwestern Papua New Guinea. Am J Trop Med Hyg. 72(1): 33–6, 2005.
5. SPC. Cumulative reported HIV, AIDS and AIDS deaths: cases, incidence rates and gender, plus cases with missing details, 2007
Prevalence in Pacific
Condition
Prevalence
Islands
Comments
Human
25.6%
Papilloma Virus (20.9% HR)
Hawai’i1
Routine OB-GYN appoinments
and normal cervical cytology
15% annual incidence
(50-80% lifetime prevalence)
Syphilis
10%
FJ,KB,SM,SI,
TO,VT2
SI2
Seroreactivity = lifetime
prevalence
30%
Vanuatu3
27.4%
PNG4
Preganant women
HSV-2 seroprevalence
(HSV-1 seroprevalence 100%)
Remote villages (HSV-2 sero)
0.013%
21 PICTs5
(excl PNG)
SPC data based on diagnosed
cases & population
Genital herpes
HIV
3.4%
1. Goodman MT et al. Prevalence, Acquisition, and Clearance of Cervical Human Papillomavirus Infection among Women with
Normal Cytology: Hawaii Human Papillomavirus Cohort Study. Cancer Res 68(21):8813-24, 2008.
2. Cliffe SJ et al. Chlamydia in the Pacific Region, the Silent Epidemic. Sex Trans Dis 35(9):801-6, 2008
3. Haddow LJ et al. Herpes Simplex Virus Type 2 (HSV-2) Infection in Women Attending an Antenatal Clinic in the South
Pacific Island Nation of Vanuatu. Sex Trans Dis 34(5):258-61
4. Suligoi B et al. Infection with human immunodeficiency virus, herpes simplex virus type 2, and human herpes virus 8 in
remote villages of southwestern Papua New Guinea. Am J Trop Med Hyg. 72(1): 33–6, 2005.
5. SPC. Cumulative reported HIV, AIDS and AIDS deaths: cases, incidence rates and gender, plus cases with missing details, 2007
Prevalence in Pacific
Condition
Prevalence
Islands
Comments
Human
25.6%
Papilloma Virus (20.9% HR)
Hawai’i1
Routine OB-GYN appoinments
and normal cervical cytology
15% annual incidence
(50-80% lifetime prevalence)
Syphilis
10%
FJ,KB,SM,SI,
TO,VT2
SI
Seroreactivity = lifetime
prevalence
30%
Vanuatu3
27.4%
PNG4
Preganant women
HSV-2 seroprevalence
(HSV-1 seroprevalence 100%)
Remote villages (HSV-2 sero)
0.013%
21 PICTs5
(excl PNG)
SPC data based on diagnosed
cases & population
Genital herpes
HIV
3.4%
1. Goodman MT et al. Prevalence, Acquisition, and Clearance of Cervical Human Papillomavirus Infection among Women with
Normal Cytology: Hawaii Human Papillomavirus Cohort Study. Cancer Res 68(21):8813-24, 2008.
2. Cliffe SJ et al. Chlamydia in the Pacific Region, the Silent Epidemic. Sex Trans Dis 35(9):801-6, 2008
3. Haddow LJ et al. Herpes Simplex Virus Type 2 (HSV-2) Infection in Women Attending an Antenatal Clinic in the South
Pacific Island Nation of Vanuatu. Sex Trans Dis 34(5):258-61
4. Suligoi B et al. Infection with human immunodeficiency virus, herpes simplex virus type 2, and human herpes virus 8 in
remote villages of southwestern Papua New Guinea. Am J Trop Med Hyg. 72(1): 33–6, 2005.
5. SPC. Cumulative reported HIV, AIDS and AIDS deaths: cases, incidence rates and gender, plus cases with missing details to 2007, 2009.
Prevalence in Pacific
Condition
Prevalence
Islands
Comments
Genital
chlamydiosis
18%
Pregnant women (SGS)
11-17%
29%
12.8%
(40%
FJ,KB,SM,SI,
TO,VT1
Palau2
Fiji1
Tonga 20083
Samoa1
Hepatitis B
10%
11.8%
Palau
Tonga3
Pregnant women (SGS)
Gonorrhoea
1.7%
Pregnant women (SGS)
1.2%
(5.9%
FJ,KB,SM,SI,
TO,VT1
Tonga 20083
Samoa1
25.3%
•14.7%
•43.4%
Vanuatu4
•Vila
•Ambae
Women having pap smears
Trichomoniasis
1.
2.
3.
4.
Pregnant woman <25 years)
Pregnant woman <25 years)
Cliffe SJ et al. Chlamydia in the Pacific Region, the Silent Epidemic. Sex Trans Dis 35(9):801-6, 2008
Gold J. Republic of Palau: Second generation HIV and STI surveillance surveys 2005 - 2006 final report. PRHP, 2008.
Fonua L et al. Second generation HIV surveillance in antenatal clinic attendees and youth, Tonga. 2008
Fotinatos N et al. Trichomonas vaginalis in Vanuatu Aust J Rural Health 16(1): 23–7, 2008.
Prevalence in Pacific
Condition
Prevalence
Islands
Comments
Genital
chlamydiosis
18%
Pregnant women (SGS)
11-17%
29%
12.8%
(40%
FJ,KB,SM,SI,
TO,VT1
Palau2
Fiji1
Tonga 20083
Samoa1
Hepatitis B
10%
11.8%
Palau
Tonga3
Pregnant women (SGS)
Gonorrhoea
1.7%
Pregnant women (SGS)
1.2%
(5.9%
FJ,KB,SM,SI,
TO,VT1
Tonga 20083
Samoa1
25.3%
•14.7%
•43.4%
Vanuatu4
•Vila
•Ambae
Women having pap smears
Trichomoniasis
1.
2.
3.
4.
Pregnant woman <25 years)
Pregnant woman <25 years)
Cliffe SJ et al. Chlamydia in the Pacific Region, the Silent Epidemic. Sex Trans Dis 35(9):801-6, 2008
Gold J. Republic of Palau: Second generation HIV and STI surveillance surveys 2005 - 2006 final report. PRHP, 2008.
Fonua L et al. Second generation HIV surveillance in antenatal clinic attendees and youth, Tonga. 2008
Fotinatos N et al. Trichomonas vaginalis in Vanuatu Aust J Rural Health 16(1): 23–7, 2008.
Prevalence in Pacific
Condition
Prevalence
Islands
Comments
Genital
chlamydiosis
18%
Pregnant women (SGS)
11-17%
29%
12.8%
(40%
FJ,KB,SM,SI,
TO,VT1
Palau2
Fiji1
Tonga 20083
Samoa1
Hepatitis B
10%
11.8%
Palau
Tonga3
Pregnant women (SGS)
Gonorrhoea
1.7%
Pregnant women (SGS)
1.2%
(5.9%
FJ,KB,SM,SI,
TO,VT1
Tonga 20083
Samoa1
25.3%
•14.7%
•43.4%
Vanuatu4
•Vila
•Ambae
Women having pap smears
Trichomoniasis
1.
2.
3.
4.
Pregnant woman <25 years)
Pregnant woman <25 years)
Cliffe SJ et al. Chlamydia in the Pacific Region, the Silent Epidemic. Sex Trans Dis 35(9):801-6, 2008
Gold J. Republic of Palau: Second generation HIV and STI surveillance surveys 2005 - 2006 final report. PRHP, 2008.
Fonua L et al. Second generation HIV surveillance in antenatal clinic attendees and youth, Tonga. 2008
Fotinatos N et al. Trichomonas vaginalis in Vanuatu Aust J Rural Health 16(1): 23–7, 2008.
Prevalence in Pacific
Condition
Prevalence
Islands
Comments
Genital
chlamydiosis
18%
Pregnant women (SGS)
11-17%
29%
12.8%
(40%
FJ,KB,SM,SI,
TO,VT1
Palau2
Fiji1
Tonga 20083
Samoa1
Hepatitis B
10%
11.8%
Palau
Tonga3
Pregnant women (SGS)
Gonorrhoea
1.7%
Pregnant women (SGS)
1.2%
(5.9%
FJ,KB,SM,SI,
TO,VT1
Tonga 20083
Samoa1
25.3%
•14.7%
•43.4%
Vanuatu4
•Vila
•Ambae
Women having pap smears
Trichomoniasis
1.
2.
3.
4.
Pregnant woman <25 years)
Pregnant woman <25 years)
Cliffe SJ et al. Chlamydia in the Pacific Region, the Silent Epidemic. Sex Trans Dis 35(9):801-6, 2008
Gold J. Republic of Palau: Second generation HIV and STI surveillance surveys 2005 - 2006 final report. PRHP, 2008.
Fonua L et al. Second generation HIV surveillance in antenatal clinic attendees and youth, Tonga. 2008
Fotinatos N et al. Trichomonas vaginalis in Vanuatu Aust J Rural Health 16(1): 23–7, 2008.
Prevalence in Pacific
Condition
Prevalence
Islands
Comments
Genital
chlamydiosis
18%
Pregnant women (SGS)
11-17%
29%
12.8%
(40%
FJ,KB,SM,SI,
TO,VT1
Palau2
Fiji1
Tonga 20083
Samoa1
Hepatitis B
10%
11.8%
Palau
Tonga3
Pregnant women (SGS)
Gonorrhoea
1.7%
Pregnant women (SGS)
1.2%
(5.9%
FJ,KB,SM,SI,
TO,VT1
Tonga 20083
Samoa1
25.3%
•14.7%
•43.4%
Vanuatu4
•Vila
•Ambae
Women having pap smears
Trichomoniasis
1.
2.
3.
4.
Pregnant woman <25 years)
Pregnant woman <25 years)
Cliffe SJ et al. Chlamydia in the Pacific Region, the Silent Epidemic. Sex Trans Dis 35(9):801-6, 2008
Gold J. Republic of Palau: Second generation HIV and STI surveillance surveys 2005 - 2006 final report. PRHP, 2008.
Fonua L et al. Second generation HIV surveillance in antenatal clinic attendees and youth, Tonga. 2008
Fotinatos N et al. Trichomonas vaginalis in Vanuatu Aust J Rural Health 16(1): 23–7, 2008.
Prevalence in Pacific
Condition
Prevalence
Islands
Comments
Genital
chlamydiosis
18%
Pregnant women (SGS)
11-17%
29%
12.8%
(40%
FJ,KB,SM,SI,
TO,VT1
Palau2
Fiji1
Tonga 20083
Samoa1
Hepatitis B
10%
11.8%
Palau2
Tonga3
Pregnant women (SGS)
Gonorrhoea
1.7%
Pregnant women (SGS)
1.2%
(5.9%
FJ,KB,SM,SI,
TO,VT1
Tonga 20083
Samoa1
25.3%
•14.7%
•43.4%
Vanuatu4
•Vila
•Ambae
Women having pap smears
Trichomoniasis
1.
2.
3.
4.
Pregnant woman <25 years)
Pregnant woman <25 years)
Cliffe SJ et al. Chlamydia in the Pacific Region, the Silent Epidemic. Sex Trans Dis 35(9):801-6, 2008
Gold J. Republic of Palau: Second generation HIV and STI surveillance surveys 2005 - 2006 final report. PRHP, 2008.
Fonua L et al. Second generation HIV surveillance in antenatal clinic attendees and youth, Tonga. 2008
Fotinatos N et al. Trichomonas vaginalis in Vanuatu Aust J Rural Health 16(1): 23–7, 2008.
Prevalence in Pacific
Condition
Prevalence
Islands
Comments
Genital
chlamydiosis
18%
Pregnant women (SGS)
11-17%
29%
12.8%
(40%
FJ,KB,SM,SI,
TO,VT1
Palau2
Fiji1
Tonga 20083
Samoa1
Hepatitis B
10%
11.8%
Palau2
Tonga3
Pregnant women (SGS)
Gonorrhoea
1.7%
Pregnant women (SGS)
1.2%
(5.9%
FJ,KB,SM,SI,
TO,VT1
Tonga 20083
Samoa1
25.3%
•14.7%
•43.4%
Vanuatu4
•Vila
•Ambae
Women having pap smears
Trichomoniasis
1.
2.
3.
4.
Pregnant woman <25 years)
Pregnant woman <25 years)
Cliffe SJ et al. Chlamydia in the Pacific Region, the Silent Epidemic. Sex Trans Dis 35(9):801-6, 2008
Gold J. Republic of Palau: Second generation HIV and STI surveillance surveys 2005 - 2006 final report. PRHP, 2008.
Fonua L et al. Second generation HIV surveillance in antenatal clinic attendees and youth, Tonga. 2008
Fotinatos N et al. Trichomonas vaginalis in Vanuatu Aust J Rural Health 16(1): 23–7, 2008.
Prevalence in Pacific
Condition
Prevalence
Islands
Comments
Genital
chlamydiosis
18%
Pregnant women (SGS)
11-17%
29%
12.8%
(40%
FJ,KB,SM,SI,
TO,VT1
Palau2
Fiji1
Tonga 20083
Samoa1
Hepatitis B
10%
11.8%
Palau
Tonga3
Pregnant women (SGS)
Gonorrhoea
1.7%
Pregnant women (SGS)
1.2%
(5.9%
FJ,KB,SM,SI,
TO,VT1
Tonga 20083
Samoa1
25.3%
•14.7%
•43.4%
Vanuatu4
•Vila
•Ambae
Women having pap smears
Trichomoniasis
1.
2.
3.
4.
Pregnant woman <25 years)
Pregnant woman <25 years)
Cliffe SJ et al. Chlamydia in the Pacific Region, the Silent Epidemic. Sex Trans Dis 35(9):801-6, 2008
Gold J. Republic of Palau: Second generation HIV and STI surveillance surveys 2005 - 2006 final report. PRHP, 2008.
Fonua L et al. Second generation HIV surveillance in antenatal clinic attendees and youth, Tonga. 2008
Fotinatos N et al. Trichomonas vaginalis in Vanuatu Aust J Rural Health 16(1): 23–7, 2008.
Prevalence in Pacific
Condition
Prevalence
Islands
Comments
Genital
chlamydiosis
18%
Pregnant women (SGS)
11-17%
29%
12.8%
(40%
FJ,KB,SM,SI,
TO,VT1
Palau2
Fiji1
Tonga 20083
Samoa1
Hepatitis B
10%
11.8%
Palau
Tonga3
Pregnant women (SGS)
Gonorrhoea
1.7%
Pregnant women (SGS)
1.2%
(5.9%
FJ,KB,SM,SI,
TO,VT1
Tonga 20083
Samoa1
25.3%
•14.7%
•43.4%
Vanuatu4
•Vila
•Ambae
Women having pap smears
Trichomoniasis
1.
2.
3.
4.
Pregnant woman <25 years)
Pregnant woman <25 years)
Cliffe SJ et al. Chlamydia in the Pacific Region, the Silent Epidemic. Sex Trans Dis 35(9):801-6, 2008
Gold J. Republic of Palau: Second generation HIV and STI surveillance surveys 2005 - 2006 final report. PRHP, 2008.
Fonua L et al. Second generation HIV surveillance in antenatal clinic attendees and youth, Tonga. 2008
Fotinatos N et al. Trichomonas vaginalis in Vanuatu Aust J Rural Health 16(1): 23–7, 2008.
Prevalence in Pacific
Condition
Prevalence
Islands
Comments
Genital
chlamydiosis
18%
Pregnant women (SGS)
11-17%
29%
12.8%
(40%
FJ,KB,SM,SI,
TO,VT1
Palau2
Fiji1
Tonga 20083
Samoa1
Hepatitis B
10%
11.8%
Palau
Tonga3
Pregnant women (SGS)
Gonorrhoea
1.7%
Pregnant women (SGS)
1.2%
(5.9%
FJ,KB,SM,SI,
TO,VT1
Tonga 20083
Samoa1
25.3%
•14.7%
•43.4%
Vanuatu4
•Vila
•Ambae
Women having pap smears
Trichomoniasis
1.
2.
3.
4.
Pregnant woman <25 years)
Pregnant woman <25 years)
Cliffe SJ et al. Chlamydia in the Pacific Region, the Silent Epidemic. Sex Trans Dis 35(9):801-6, 2008
Gold J. Republic of Palau: Second generation HIV and STI surveillance surveys 2005 - 2006 final report. PRHP, 2008.
Fonua L et al. Second generation HIV surveillance in antenatal clinic attendees and youth, Tonga. 2008
Fotinatos N et al. Trichomonas vaginalis in Vanuatu Aust J Rural Health 16(1): 23–7, 2008.
Prevalence in Pacific
Condition
Prevalence
Islands
Comments
Genital
chlamydiosis
18%
Pregnant women (SGS)
11-17%
29%
12.8%
(40%
FJ,KB,SM,SI,
TO,VT1
Palau2
Fiji1
Tonga 20083
Samoa1
Hepatitis B
10%
11.8%
Palau
Tonga3
Pregnant women (SGS)
Gonorrhoea
1.7%
Pregnant women (SGS)
1.2%
(5.9%
FJ,KB,SM,SI,
TO,VT1
Tonga 20083
Samoa1
25.3%
•14.7%
•43.4%
Vanuatu4
•Vila
•Ambae
Women having pap smears
Trichomoniasis
1.
2.
3.
4.
Pregnant woman <25 years)
Pregnant woman <25 years)
Cliffe SJ et al. Chlamydia in the Pacific Region, the Silent Epidemic. Sex Trans Dis 35(9):801-6, 2008
Gold J. Republic of Palau: Second generation HIV and STI surveillance surveys 2005 - 2006 final report. PRHP, 2008.
Fonua L et al. Second generation HIV surveillance in antenatal clinic attendees and youth, Tonga. 2008
Fotinatos N et al. Trichomonas vaginalis in Vanuatu Aust J Rural Health 16(1): 23–7, 2008.
Prevalence in Pacific
Condition
Prevalence
Islands
Comments
Genital
chlamydiosis
18%
Pregnant women (SGS)
11-17%
29%
12.8%
(40%
FJ,KB,SM,SI,
TO,VT1
Palau2
Fiji1
Tonga 20083
Samoa1
Hepatitis B
10%
11.8%
Palau
Tonga3
Pregnant women (SGS)
Gonorrhoea
1.7%
Pregnant women (SGS)
1.2%
(5.9%
FJ,KB,SM,SI,
TO,VT1
Tonga 20083
Samoa1
25.3%
•14.7%
•43.4%
Vanuatu4
•Vila
•Ambae
Women having pap smears
Trichomoniasis
1.
2.
3.
4.
Pregnant woman <25 years)
Pregnant woman <25 years)
Cliffe SJ et al. Chlamydia in the Pacific Region, the Silent Epidemic. Sex Trans Dis 35(9):801-6, 2008
Gold J. Republic of Palau: Second generation HIV and STI surveillance surveys 2005 - 2006 final report. PRHP, 2008.
Fonua L et al. Second generation HIV surveillance in antenatal clinic attendees and youth, Tonga. 2008
Fotinatos N et al. Trichomonas vaginalis in Vanuatu Aust J Rural Health 16(1): 23–7, 2008.
Most significant?
1.
2.
3.
4.
5.
6.
7.
8.
Human papilloma virus infection
Syphilis
Genital herpes
Genital chlamydiosis
HIV
Gonorrhoea
Hepatitis B
Trichomoniasis
47%
22%
9%
9%
7
8
6%
3%
3%
0%
1
2
3
4
5
6
Significance
In relation to the health of the
population of a country or territory in
general ...
... or of particular populations
Determined by a range of factors:
Prevalence
Severity of acute symptomatology
Transmissibility – preventability
Curability
Long term consequences or complications
Human Papilloma Virus
Non-enveloped DNA virus
Replicates exclusively in epithelial
cells
Transmitted by skin to skin contact
with microabrasions
Enters cell and modifies cell cycle to
maxmise further transmissibility
Naturally cleared in months to years
Median duration of infection 8
months, 9% persistent after 2
years1
Persistence related to:
Infection with multiple types
Infection with high risk types 1.
Ho GY et al. Natural history of cervicovaginal papilloma virus
infection in young women. N Engl J Med 338(7):423-8, 1998
HPV associated disease
>100 genetically related types
Different types adapted for different skin areas
Types 16 & 18 (and others) strongly associated with
cervical carcinoma
Types 6 & 11 (and others) associated with visible
anogenital warts
Some types also associated with anal, penile and oral
cancers
Islands’ experience of cancer of cervix and anogenital
warts
HPV: genital warts
Genital warts: diagnosis
Genital warts: treatment
Lots of different approaches – nothing is
perfect!
Most treatment is cosmetic not curative
Very high recurrence rates
Imiquimod cream (Aldara®)
Induces local immune response
5% cream applied 3x/week for up to 16 wks
Response is delayed
Lower recurrence rate
Contraindicated in pregnancy
Expensive!
First line treatment in your centre?
Podophylotoxin
Diathermy
Cryotherapy
Imiquimod
Surgical excision
Nothing
Something else
20%
17%
17%
17%
17%
10%
py
Im
iq
ui
Su
m
rg
od
ic a
le
xc
is i
on
No
th
So
in
m
g
et
hi
ng
el
se
he
ra
rm
Cr
yo
t
th
e
Di
a
hy
l
ot
ox
i
n
y
3%
Po
do
p
1.
2.
3.
4.
5.
6.
7.
My favourite treatment
HPV: Cervical cancer
HPV: Cervical cancer
Population
Period
Incidence/100,000
French polynesian women
1990-1995
23.21
Hawai’ian Indigenous &
Asian women
1973-96
6.42
Hawai’ian white women
1973-96
6.92
US white women
1973-96
6.32
Global estimate
2002
16
1. Gleize L et al. Cancer registry of French Polynesia: Results for the 1990±1995 period among native and immigrant population. European
Journal of Epidemiology 16: 661-7, 2000.
2. Frish M, Goodman MT. Human Papillomavirus-Associated Carcinomas in Hawaii and the Mainland U.S. Cancer 88(6):1464-9, 2000.
3. GLOBOCAN database.
HPV: Cervical cancer
Population
Period
Incidence/100,000
French polynesian women
1990-1995
23.21
Hawai’ian Indigenous &
Asian women
1973-96
6.42
Hawai’ian white women
1973-96
6.92
US white women
1973-96
6.32
Global estimate
2002
16
1. Gleize L et al. Cancer registry of French Polynesia: Results for the 1990±1995 period among native and immigrant population. European
Journal of Epidemiology 16: 661-7, 2000.
2. Frish M, Goodman MT. Human Papillomavirus-Associated Carcinomas in Hawaii and the Mainland U.S. Cancer 88(6):1464-9, 2000.
3. GLOBOCAN database.
HPV: Cervical cancer
Population
Period
Incidence/100,000
French polynesian women
1990-1995
23.21
Hawai’ian Indigenous &
Asian women
1973-96
6.42
Hawai’ian white women
1973-96
6.92
US white women
1973-96
6.32
Global estimate
2002
16
Importance of screening programs
Potential impact of HPV vaccines
Islands experience with Ca cervix, screening
programs and HPV vaccines (Gardasil, Cervarix)
1. Gleize L et al. Cancer registry of French Polynesia: Results for the 1990±1995 period among native and immigrant population. European
Journal of Epidemiology 16: 661-7, 2000.
2. Frish M, Goodman MT. Human Papillomavirus-Associated Carcinomas in Hawaii and the Mainland U.S. Cancer 88(6):1464-9, 2000.
3. GLOBOCAN database.
Genital herpes
Caused by two types of DNA
viruses herpes simplex 1 & 2
(HSV 1 & 2 = HHV 1 & 2)
Other herpesviruses that cause
human diseases :
HHV3 (Varicella zoster)
Chickenpox/shingles
HHV4 (Ebstein-Barr virus)
infectious mononucleosis
HHV5 (Cytomegalovirus)
HHV6 & 7 (Roseola infantum)
HHV8 (Kaposi’s sarcoma)
Genital herpes
HSV spread by skin to skin or mucosa to
mucosa contact with friction
Primary infection at site of entry then
lifelong infection of sensory dorsal
ganglia supplying infected skin/mucosa
‘Originally’
HSV1 – oral ‘cold sores’
HSV2 – genital herpes
Now primary HSV1 is common cause of genital
herpes in developed countries
Genital herpes
1 – 26 days (usually 6 – 8 days) after
first acquisition – primary infection
Complications of primary infection
include urinary retention, aseptic
meningitis and rarely transverse
myelitis
First clinical episode is not always
primary infection
Genital herpes
Clinical course of episode
Prodromal tingling  vesicles 
ulcers  crusts  healing
All takes 5 – 7 days but active HSV
infection is the first 48 hours – after
that it is just healing
Need to treat episode within first 48
hours or not worth it (except in
people with HIV)
Genital herpes
Genital herpes & HIV
Relative risk of acquiring HIV based on HSV2 serology,
adjusted for age and sexual behavior
Freeman EE et al. Herpes simplex virus 2 infection increases HIV acquisition in men and women:
systematic review and meta-analysis of longitudinal studies. AIDS 20(1) :73–83, 2006
Genital herpes & HIV
HSV ulcers often coalesce and persist
in people with HIV
Genital herpes treatment
Setting
Drug
Duration
First episode
aciclovir 200mg 5x/day
valaciclovir 500mg – 1g 2x/day
famciclovir 250mg 3x/day
5 – 10 days
Episodic therapy
for recurrent
disease
(patient initiated)
aciclovir 200mg 5x/day
valaciclovir 500mg 2x/day
famciclovir 125mg 2x/day
5 days
3 days
5 days
Continuous
suppressive
therapy
aciclovir 400mg 2x/day
valaciclovir 500mg – 1g daily
famciclovir 250mg 2x/day
All safe and effective for
long term use – but
expensive!
Genital herpes treatment
Setting
Drug
Duration
First episode
aciclovir 200mg 5x/day
valaciclovir 500mg – 1g 2x/day
famciclovir 250mg 3x/day
5 – 10 days
Episodic therapy
for recurrent
disease
(patient initiated)
aciclovir 200mg 5x/day
valaciclovir 500mg 2x/day
famciclovir 125mg 2x/day
5 days
3 days
5 days
Continuous
suppressive
therapy
aciclovir 400mg 2x/day
valaciclovir 500mg – 1g daily
famciclovir 250mg 2x/day
All safe and effective for
long term use – but
expensive!
Genital herpes treatment
Setting
Drug
Duration
First episode
aciclovir 200mg 5x/day
valaciclovir 500mg – 1g 2x/day
famciclovir 250mg 3x/day
5 – 10 days
Episodic therapy
for recurrent
disease
(patient initiated)
aciclovir 200mg 5x/day
valaciclovir 500mg 2x/day
famciclovir 125mg 2x/day
5 days
3 days
5 days
Continuous
suppressive
therapy
aciclovir 400mg 2x/day
valaciclovir 500mg – 1g daily
famciclovir 250mg 2x/day
All safe and effective for
long term use – but
expensive!
Some evidence of survival benefit in people with
HIV who have HSV if HSV treated
Continuous suppressive therapy certainly
worthwhile if symptomatic
Take a break!
Syphilis
Caused by a spirochaete
(spiral bacterium):
Treponema pallidum
Transmitted by skin to skin
or mucous membrane
contact with abrasion
Four classical stages:
Primary
Secondary
Latent
Tertiary
Early syphilis is not always
classical
Primary syphilis
9 – 90 days after exposure
Appearance of chancre at site of
exposure
Usually single, painless, indurated,
sharply defined edges
Can often be missed (if not penile!)
Disappears in 3 to 6 weeks if not
treated
Chancres
Secondary syphilis
6 weeks to 6 months after primary
infection
In ~1/3rd chancre will still be present
Fever, malaise, headache, myalgia
Rash in 80-90%
Classically dark pink macules
‘The great mimic’
Can affect palms and soles
Transient or can last weeks
Secondary syphilis
Secondary syphilis
Mouth ulcers – multiple
Can coalesce  ‘snail track’ ulcers
Rash on scalp can cause hair loss
Genital lesions – condylomata lata
Rarely neurological complications:
Aseptic meningitis
Cranial nerve palsies
More common in people with HIV
Rarely glomerulonephritis, hepatitis
Secondary syphilis
Secondary syphilis
Latent syphilis
Asymptomatic
Now divided into:
Early latent:
Six months to 2 years (1 year in USA)
Still considered ‘infectious syphilis’
Late latent:
> 2 years (1 year in USA) and asymptomatic
Condsidered ‘late syphilis’
Can still be transmitted from mother to child
Tertiary syphilis
Four to 30+ years from primary
infection
Approximately 1/3rd of patients
untreated
Gummatous (‘benign’)
Cardiovascular
Neurosyphilis
Tertiary syphilis
Diagnosis of syphilis
Dark ground illumination of fluid from
chancre
T. pallidum PCR from chancre fluid
Serological testing:
Non-treponemal tests:
VDRL (Venereal Disease Research Laboratories)
RPR (Rapid Plasma Reagin)
Treponemal specific tests:
T. Pallidum haemagglutination assay (TPHA)
Flourescent treponenal Ab absorbtion (FTA-ABS)
Treponemal IgG immunoassays
Syphilis serology
Non-specific tests (RPR or VDRL) are either
reactive or non-reactive ...
But can measure level of reactivity through
dilution
Useful for monitoring response to treatment
1:1 = Reactive with 1:1 dilution (half & half)
but non-reactive at 1:2 dilution (1/3 to 2/3)
1:64 = Still reactive when serum diluted 1:64
– ie very high reactivity level
RPR or VDRL can be falsely positive but
seldom >1:4, TP specific test will differentiate
Dilution
1
1
Reactive
titre = 1:1
2
1
Non-reactive
Dilution
4
Reactive
1
titre = 1:4
8
1
Non-reactive
Syphilis serology
RPR/VDRL
RPR/VDRL titre
TPHA
Active infection
+
>1:8
+
Latent syphilis
+
Often <1:4
+
False positive
+
Usually <1:4
-
Successful treatment
+ or -
2 titres decrease
(e.g. from 1:16 to 1:4)
+
Syphilis serology
RPR/VDRL
RPR/VDRL titre
TPHA
Active infection
+
>1:8
+
Latent syphilis
+
Often <1:4
+
False positive
+
Usually <1:4
-
Successful treatment
+ or -
2 titres decrease
(e.g. from 1:16 to 1:4)
+
Syphilis serology
RPR/VDRL
RPR/VDRL titre
TPHA
Active infection
+
>1:8
+
Latent syphilis
+
Often <1:4
+
False positive
+
Usually <1:4
-
Successful treatment
+ or -
2 titres decrease
(e.g. from 1:16 to 1:4)
+
Syphilis serology
RPR/VDRL
RPR/VDRL titre
TPHA
Active infection
+
>1:8
+
Latent syphilis
+
Often <1:4
+
False positive
+
Usually <1:4
-
Successful treatment
+ or -
2 titres decrease
(e.g. from 1:16 to 1:4)
+
Congenital syphilis
Occurs when woman with secondary or
early latent becomes pregnant or woman
has secondary syphilis during pregnancy
40% stillborn
40-70% of survivors infected (in utero),
of whom 12% will die in infancy
Liver, spleen and bony abnormalities
Hutchison’s triad: deafness, Hutchinson’s
teeth, interstitial keratitis
Congenital syphilis
Syphilis treatment
Stage
First choices
Penicillin allergy
Early:
Primary
Secondary
Early latent
• benzathine penicillin 2.4
million units IM stat1
• procaine penicillin 0.6
million units IM daily
x 10 days
• doxycycline 100mg
2x/day x 14 days
• [azithromycin 500mg
daily x 10 days]2
Late latent
‘Benign’ tertiary
Cardiovascular
• benzathine penicillin 2.4
million units IM weekly
x 3 weeks
• procaine penicillin 0.6
million units IM daily
x 21 days
• doxycycline 100mg
2x/day x 28 days
• ceftriaxone 500mg IM
daily x 14 days
Neurosyphilis
• 2 – 4 million units
aqueous benzylpenicillin
IV four hourly
x 10 – 14 days
• Doxycycline 200mg
2x/day x 28 – 30 days
• ceftriaxone 1 – 2g IM
daily x 14 days
1. ? Use weekly for 3 weeks in people with HIV
2. Azithromycin resistant treponemes are emerging – may no longer be appropriate
Syphilis treatment
Stage
First choices
Penicillin allergy
Early:
Primary
Secondary
Early latent
• benzathine penicillin 2.4
million units IM stat1
• procaine penicillin 0.6
million units IM daily
x 10 days
• doxycycline 100mg
2x/day x 14 days
• [azithromycin 500mg
daily x 10 days]2
Late latent
‘Benign’ tertiary
Cardiovascular
• benzathine penicillin 2.4
million units IM weekly
x 3 weeks
• procaine penicillin 0.6
million units IM daily
x 21 days
• doxycycline 100mg
2x/day x 28 days
• ceftriaxone 500mg IM
daily x 14 days
Neurosyphilis
• 2 – 4 million units
aqueous benzylpenicillin
IV four hourly
x 10 – 14 days
• Doxycycline 200mg
2x/day x 28 – 30 days
• ceftriaxone 1 – 2g IM
daily x 14 days
1. ? Use weekly for 3 weeks in people with HIV
2. Azithromycin resistant treponemes are emerging – may no longer be appropriate
Syphilis treatment
Stage
First choices
Penicillin allergy
Early:
Primary
Secondary
Early latent
• benzathine penicillin 2.4
million units IM stat1
• procaine penicillin 0.6
million units IM daily
x 10 days
• doxycycline 100mg
2x/day x 14 days
• [azithromycin 500mg
daily x 10 days]2
Late latent
‘Benign’ tertiary
Cardiovascular
• benzathine penicillin 2.4
million units IM weekly
x 3 weeks
• procaine penicillin 0.6
million units IM daily
x 21 days
• doxycycline 100mg
2x/day x 28 days
• ceftriaxone 500mg IM
daily x 14 days
Neurosyphilis
• 2 – 4 million units
aqueous benzylpenicillin
IV four hourly
x 10 – 14 days
• Doxycycline 200mg
2x/day x 28 – 30 days
• ceftriaxone 1 – 2g IM
daily x 14 days
1. ? Use weekly for 3 weeks in people with HIV
2. Azithromycin resistant treponemes are emerging – may no longer be appropriate
Chlamydia trachomatis
Gram-negative bacterium
Obligate intracellular pathogen
Cannot survive or replicate outside of cells
Formally classified as rickettsia
Causes genital infection and eye disease
(trachoma)
Transmitted by fluid (and cell) transfer
during vaginal, anal and oral sex
Asymptomatic in ~75% of genitally
infected females and ~50% of genitally
infected males
Chlamydia trachomatis
Chlamydia: complications
Pelvic inflamatory disease
(~40% of untreated women)
Female Infertility
Early spontaneous abortion
Premature labour
Neonatal eye disease
Epididymitis
Male infertility
Islands experience of complications?
Chlamydia diagnosis
Rapid tests are insensitive and have little
value in asymptomatic screening
Nucleic acid testing on swabs or first
pass urine is ‘gold standard’
Stand displacement assay (BD Probetec)
now available in multiple Pacific Island
under Global Fund project – islands
experience so far?
Chlamydia treatment
Setting
First line
Alternatives
Uncomplicated
infection in males
or females
• azithromycin 1g stat
• doxycycline 100mg
2x/day x 7 days
• erythromycin base 500 mg 4x/day x
7days
• erythromycin ethylsuccinate 800 mg
4x/day x 7days
• amoxycillin 500 mg 3x/day x 7days
• ofloxacin 300 mg 2x/day x 7days
• tetracycline 500 mg 4x/day x 7days
Pelvic inflamatory
disease
• azithromycin 1g stat
AND
• doxycycline 100mg
2x/day x 14 days
AND
• metronidazole 400mg
2x/day x 14 days
• Add ceftriaxone 250mg IM stat if
gonorrhoea cannot be excluded
Pregnancy
• erythromycin base 500
mg 4x/day x 7days
• erythromycin
ethylsuccinate 800 mg
4x/day x 7days
• amoxycillin 500 mg
3x/day x 7days
• Doxycycline, tetracycline and
orfloxacin are contraindicated in
pregnancy
• Azithromycin has not been shown to
be efficaceous in pregnancy
• Erythromycin estolate is not safe in
preganacy (hepatotoxicity)
Chlamydia treatment
Setting
First line
Alternatives
Uncomplicated
infection in males
or females
• azithromycin 1g stat
• doxycycline 100mg
2x/day x 7 days
• erythromycin base 500 mg 4x/day x
7days
• erythromycin ethylsuccinate 800 mg
4x/day x 7days
• amoxycillin 500 mg 3x/day x 7days
• ofloxacin 300 mg 2x/day x 7days
• tetracycline 500 mg 4x/day x 7days
Pelvic inflamatory
disease
• azithromycin 1g stat
AND
• doxycycline 100mg
2x/day x 14 days
AND
• metronidazole 400mg
2x/day x 14 days
• Add ceftriaxone 250mg IM stat if
gonorrhoea cannot be excluded
Pregnancy
• erythromycin base 500
mg 4x/day x 7days
• erythromycin
ethylsuccinate 800 mg
4x/day x 7days
• amoxycillin 500 mg
3x/day x 7days
• Doxycycline, tetracycline and
orfloxacin are contraindicated in
pregnancy
• Azithromycin has not been shown to
be efficaceous in pregnancy
• Erythromycin estolate is not safe in
preganacy (hepatotoxicity)
Chlamydia treatment
Setting
First line
Alternatives
Uncomplicated
infection in males
or females
• azithromycin 1g stat
• doxycycline 100mg
2x/day x 7 days
• erythromycin base 500 mg 4x/day x
7days
• erythromycin ethylsuccinate 800 mg
4x/day x 7days
• amoxycillin 500 mg 3x/day x 7days
• ofloxacin 300 mg 2x/day x 7days
• tetracycline 500 mg 4x/day x 7days
Pelvic inflamatory
disease
• azithromycin 1g stat
AND
• doxycycline 100mg
2x/day x 14 days
AND
• metronidazole 400mg
2x/day x 14 days
• Add ceftriaxone 250mg IM stat if
gonorrhoea cannot be excluded
Pregnancy
• erythromycin base 500
mg 4x/day x 7days
• erythromycin
ethylsuccinate 800 mg
4x/day x 7days
• amoxycillin 500 mg
3x/day x 7days
• Doxycycline, tetracycline and
orfloxacin are contraindicated in
pregnancy
• Azithromycin has not been shown to
be efficaceous in pregnancy
• Erythromycin estolate is not safe in
preganacy (hepatotoxicity)
Chlamydia treatment
Setting
First line
Alternatives
Uncomplicated
infection in males
or females
• azithromycin 1g stat
• doxycycline 100mg
2x/day x 7 days
• erythromycin base 500 mg 4x/day x
7days
• erythromycin ethylsuccinate 800 mg
4x/day x 7days
• amoxycillin 500 mg 3x/day x 7days
• ofloxacin 300 mg 2x/day x 7days
• tetracycline 500 mg 4x/day x 7days
Pelvic inflamatory
disease
• azithromycin 1g stat
AND
• doxycycline 100mg
2x/day x 14 days
AND
• metronidazole 400mg
2x/day x 14 days
• Add ceftriaxone 250mg IM stat if
gonorrhoea cannot be excluded
Pregnancy
• erythromycin base 500
mg 4x/day x 7days
• erythromycin
ethylsuccinate 800 mg
4x/day x 7days
• amoxycillin 500 mg
3x/day x 7days
• Doxycycline, tetracycline and
orfloxacin are contraindicated in
pregnancy
• Azithromycin has not been shown to
be efficaceous in pregnancy
• Erythromycin estolate is not safe in
preganacy (hepatotoxicity)
Chlamydia treatment
Setting
First line
Alternatives
Uncomplicated
infection in males
or females
• azithromycin 1g stat
• doxycycline 100mg
2x/day x 7 days
• erythromycin base 500 mg 4x/day x
7days
• erythromycin ethylsuccinate 800 mg
4x/day x 7days
• amoxycillin 500 mg 3x/day x 7days
• ofloxacin 300 mg 2x/day x 7days
• tetracycline 500 mg 4x/day x 7days
Pelvic inflamatory
disease
• azithromycin 1g stat
AND
• doxycycline 100mg
2x/day x 14 days
AND
• metronidazole 400mg
2x/day x 14 days
• Add ceftriaxone 250mg IM stat if
gonorrhoea cannot be excluded
Pregnancy
• erythromycin base 500
mg 4x/day x 7days
• erythromycin
ethylsuccinate 800 mg
4x/day x 7days
• amoxycillin 500 mg
3x/day x 7days
• Doxycycline, tetracycline and
orfloxacin are contraindicated in
pregnancy
• Azithromycin has not been shown to
be efficaceous in pregnancy
• Erythromycin estolate is not safe in
preganacy (hepatotoxicity)
Chlamydia treatment
Setting
First line
Alternatives
Uncomplicated
infection in males
or females
• azithromycin 1g stat
• doxycycline 100mg
2x/day x 7 days
• erythromycin base 500 mg 4x/day x
7days
• erythromycin ethylsuccinate 800 mg
4x/day x 7days
• amoxycillin 500 mg 3x/day x 7days
• ofloxacin 300 mg 2x/day x 7days
• tetracycline 500 mg 4x/day x 7days
Pelvic inflamatory
disease
• azithromycin 1g stat
AND
• doxycycline 100mg
2x/day x 14 days
AND
• metronidazole 400mg
2x/day x 14 days
• Add ceftriaxone 250mg IM stat if
gonorrhoea cannot be excluded
Pregnancy
• erythromycin base 500
mg 4x/day x 7days
• erythromycin
ethylsuccinate 800 mg
4x/day x 7days
• amoxycillin 500 mg
3x/day x 7days
• Doxycycline, tetracycline and
orfloxacin are contraindicated in
pregnancy
• Azithromycin has not been shown to
be efficaceous in pregnancy
• Erythromycin estolate (Ilosone) is not
safe in preganacy (hepatotoxicity)
Gonorrhoea
http://www.spc.int/hiv/osshhm/
Hepatitis B
DNA virus
Body fluid transmission
Transmissibility varies
with viral load
HBeAg positivity = highly transmissible
Transmitted from mother to child at time
of delivery:
20% if HBeAg negative
90% if HBeAg positive
Hepatitis B
~10% prevalence in most Pacific Islands
= ‘endemic’
If acquired at birth 95% develop lifelong
infection
If acquired later 70-95% clear infection
and develop immunity
If lifelong infection, 40% will die from
cirrhosis or liver cancer
Islands experience with HBV and
immunisation
Trichomoniasis
Caused by protozoan
Trichomonas vaginalis
At least 50% asymptomatic
Causes vaginitis in women
Causes urethritis in men (rarely)
Yellowish ‘fishy’ discharge
‘Strawberry cervix’
Trichomoniasis
Diagnosed on wet mount of vaginal
discharge:
see moving organisms
must be done straight away
2 – 3 x increase in risk of HIV
acquisition1
Treated with metronidazole or
tinidazole
1. Sorvillo F. Trichomonas vaginalis, HIV, and African-Americans. Emerging Infectious Diseases 7(6):927-32, 2001
Most significant?
1.
2.
3.
4.
5.
6.
7.
8.
Human papilloma virus infection
Syphilis
Genital herpes
Genital chlamydiosis
HIV
Gonorrhoea
Hepatitis B
Trichomoniasis
23%
20%
10%
20%
13%
10%
3%
1
2
3
4
5
0%
6
7
8
Questions?
Case study - Anna
20 year old woman presents in early in
her first pregnancy (LMP 8 weeks ago)
Lives with her husband of two years and
his family
Monogamous
Husband is a seafarer – currently away
PH: ?infectious mono 18 months ago
Urine ßHCG positive
Nausea and breast tenderness – no other
symptoms
Never had a pap-smear
Further management
1. Work out her dates
and book her
delivery
2. Organise an
ultrasound
3. Do a speculum
examination
4. Do some blood
tests
5. Something else
42%
31%
23%
4%
0%
1
2
3
4
5
Case study - Anna
Further management
1. Swab for MC&S
2. First pass urine for
chlamydia &
gonorrhoea
3. Treat with
clotrimazole
(Canesten®)
4. Do a wet mount of
vaginal discharge
5. Something else
56%
24%
16%
4%
0%
1
2
3
4
5
Gram stain microscopy
Wet mount
Blood tests
1.
2.
3.
4.
5.
Haemoglobin
HBsAg
RPR
HIV Ab
All of the above
93%
0%
1
4%
2
0%
3
4%
4
5
Case study - Anna
Chlamydia NA positive
Gonorrhoea NA positive
HBsAg –ve, HBsAb +ve, HBcAb+ve
What does this mean?
RPR reactive 1:16
What does this mean?
TPHA reactive
No history of syphilis symptoms
No old sera available
HIV rapid test (Abbott Determine)
reactive
Anna:Management
Counselling & support +++++
Chlamydia:
Amoxycillin 500mg 3x/day for 7 days
Gonorrhoea:
ceftriaxone 250mg IM stat
Trichomoniasis:
metronidazole 400mg 2x/day for 7 days at
start of second trimester (14 weeks)
Anna:Management
Syphilis:
Benzathine pencillin 2.4 million units IM weekly
for 3 weeks
HIV:
Confirmatory testing ASAP
Careful counselling in meantime
If confirmed, initiate antiretroviral therapy at start
of second trimester (14 weeks)
Testing and ‘management’ of husband
Papsmear once trichomonas and
gonorrhoea effectively treated.
Criteria
effective
ART
Questionsfor
and
further discussion
6. A local partnership between public health
services, clinical services and community
organisations exists to ensure a continuum of
care and support for people taking treatment,
including support for ART adherence
7. A core multidisciplinary HIV care team has
received appropriate training
8. Diagnostic services available to perform HIV
antibody tests and essential routine tests to
monitor for drug toxicity
9. An adequate patient record system exists