‫ميحرلا نمحرلا هللا مسب‬

SEXUAL TRANSMITTED INFECTIONS

STIs
HIV, AIDS, and Other Sexually Transmitted Infections

Presented by:
Dr. Ahmed Awadelkreem
MBBS – Omdurman Islamic University
MSc. Family Medcine - Alzaeim Alazhary University
Registrar of Family Medicine - SMSB

June 2023
 OBJECTIVES
1. Know the common risks and modes of transmission of human
immunodeficiency virus (HIV )/ acquired immunodeficiency syndrome AIDS.

2. Be aware of common presentations of persons infected with HIV.

3. List the most common sexually transmitted infections (STIs).

4. Describe common treatment regimens for STIs.

CASE SCENARIO
 Case 45

A 39-year-old homeless man presents to the emergency department (ED) with a

nonproductive cough & subjective fever. He says that his illness has been
worsening over the past 2 weeks, originally starting with dyspnea on exertion
and now he is short of breath at rest. On questioning, he tells you that he lives in
a homeless shelter when he can, but he frequently sleeps on the streets. He has
used IV drugs (primarily heroin) "on and off" and has been sexually promiscuous
with both men and women without barrier protection for many years. He denies
any significant medical history, and only gets medical care when he comes to
the ED for an illness or injury. On review of systems, he complains of chronic
fatigue, weight loss, and diarrhea.
 On examination
He is a thin, disheveled man appearing much older than his stated age. His
temperature is 100.4°F (38.0°(), his blood pressure is 100/50 mm Hg, his pulse
is 105 beats/min, and his respiratory rate is 24 breaths/min. His initial oxygen
saturation is 89% on room air, which comes up to 94% on 4 L of oxygen by
nasal cannula. Significant findings on examination include dry mucous
membranes, a tachycardic but regular cardiac rhythm, a soft & non tender
abdomen, and generally wasted-appearing extremities. His pulmonary
examination is significant for tachypnea and fine crackles bilaterally, but there are
no visible signs of cyanosis on extremities. His chest x-ray reveals diffuse,
bilateral, interstitial infiltrates that look like "ground glass:'
 On examination
 What is the most likely cause of this patient's current pulmonary
complaints?

 What underlying illnesses does this patient most likely has?

 What diagnostic testing and treatment should be started?

 Summary
A 39-year-old, homeless, IV drug abuser is seen with fever, cough, dyspnea, &
fatigue. He is found to be tachypneic, febrile, and hypoxemic. His chest x-ray
reveals bilateral interstitial infiltrates.
• Most likely cause of current illness; Pneumocystis jiroveci (formerly known as
Pneumocystis carinii) pneumonia.
• Most probable underlying illness; AIDS.
• Recommended current testing and treatment; Complete blood count (CBC ),
serum electrolytes, arterial blood gas; HIV enzyme-linked immunosorbent assay
with confirmatory Western blot; CD4/CD8 cell count; HIV RNA assay; sputum
culture for P jiroveci and acidfast bacilli; urine culture for Chlamydia & Neisseria
gonorrheae; serum rapid plasma reagin (RPR ); start treatment with oral
trimethoprim-sulfamethoxazole (TMP-SMX); and consider starting highly active
antiretroviral therapy (HAART) with appropriate case management including
intensive drug abuse treatment, counseling, and social work.
APPROACH TO:

HIV, AIDS, & OTHER SEXUALLY

TRANSMITTED INFECTIONS
 DEFINITIONS

• ACQUIRED IMMUNODEFICIENCY SYNDROME: The advanced stage of

the HIV infection, in which opportunistic infections occur with specific
criteria for its designation.
• HUMAN IMMUNODEFICIENCY VIRUS: A retrovirus that infects the
helper T cells of the immune system, which are defined by the
presence of the cell-signaling protein CD4, and causes a decline in
both their number and their effectiveness.
CLINICAL APPROACH
 HIV/AIDS
Epidemiology
• As of 2013, over 35 million people in the world are living with HIV infection
and/or AIDS. Over 1.5 million people died of AIDS-related illnesses worldwide
in 2013, with a disproportionate share of the deaths occurring in sub-Saharan
Africa.
• HIV disease is caused by the human retroviruses, HIV-1 and HIV-2. HIV-1 is
more common worldwide, whereas HIV-2 has been reported in western Africa,
Europe, South America, and Canada.
• As of 2011, 1.2 million people in the United States were estimated to be
infected with HIV, with approximately 25% of persons unaware of their
infection. The highest prevalence of HIV occurs in men who have sex with
other men and in IV drug users, although the occurrence in heterosexual
sexual contact is increasing. African Americans are disproportionately affected
with infection, both in total numbers of cases and in development of new
infections.
 Transmission
HIV is transmitted from person to person through contact with infected blood &
body fluids. Sexual contact is the most common mechanism of transmission &,
while anal intercourse has the highest rate of transmission, HIV can be acquired
through vaginal and oral intercourse as well. Heterosexual transmission of HIV
now accounts for 27% of new infection and 86% of cases in infected women.
The risk of HIV transmission is also increased by the presence of genital or anal
lesions caused by other sexually transmitted diseases, such as gonorrhea,
syphilis, and genital herpes.
 Transmission
The risk of transmission can be reduced by the proper and consistent use of
latex condoms (either male or female condoms). Because HIV can pass through
lambskin condoms, these are not recommended. Male circumcision has also
been shown to decrease the rate of HIV transmission. Due to the large amount
of undiagnosed HIV infections, the Centers for Disease Control and Prevention
(CDC) expanded screening recommendations, which are summarized in
Table45-1. Sharing needles by IV drug users is the third most common source of
transmission of HIV behind male-to-male and heterosexual transmission.
Vertical transmission from an infected woman to her baby has been found to
occur during pregnancy, during the process of delivery of a baby, and rarely from
breast-feeding.
 Transmission cont..
Blood and blood-product transfusions have been linked to infection, although the
routine screening of donor blood for HIV now makes this an extremely rare
event. Health-care workers have been infected with HIV through accidental
punctures with needles or by infected blood entering through open skin wounds
or mucous membranes. The risk of transmission to health-care workers is low
and is related to the viral load of the patient, the amount of blood to which the
worker is exposed, and the depth of the inoculum. Post exposure risk of
developing HIV infection can be reduced by immediate and careful cleaning of
the exposure/ puncture site along with post exposure prophylactic (PEP)
treatment with antiretroviral therapy started within 72 hours after exposure.
Regimens for PEP include two to three antiretroviral medications taken for 28
days.
 Clinical Course of HIV Infection
Following initial exposure to HIV, some patients will complain of nonspecific
symptoms, such as low-grade fever, fatigue, sore throat, or myalgias. This illness
typically occurs 6 to 8 weeks following the infection and is commonly self-limited.
The primary infection is also known as acute seroconversion syndrome, as the
symptoms are thought to be related to the development of antibodies to the
virus. Following the resolution of the primary infection symptoms (if any occur),
there is a period of clinical latency. During this time, most infected persons are
asymptomatic, although some may develop lymphadenopathy. This period can
last from 6 months to up to 10 years following the transmission of the virus.
However, while the patient is asymptomatic during this period, a relentless
decline in helper and suppressor T-cell number and immune function usually
occurs in the untreated patient, with the result that many patients initially present
with profound immunodeficiency and opportunistic infections.
Clinical Categorization of HIV/AIDS Infections
• The CDC defines four clinical stages for adults aged greater than or equal to
13.
• Stage 1: No AIDS-defining illness and either CD4 cell count greater than or
equal to 500 cells/ µL or percentage of total lymphocytes greater than 29
• Stage 2: No AIDS-defining illness and either CD4 cell count of 200 to 499
cells/ µL or percentage between 14 and 28
• Stage 3: (AIDS) CD4 cell count less than or equal to 200 cells/ µL or
percentage less than 14 and documentation of AIDS-defining condition (Tables
45-2 and 45-3)
• Stage 4: Unknown laboratory parameters with an AIDS-defining condition
• For classification purposes, a patient's HIV is defined by the highest clinical
stage in which the patient has ever qualified.
Diagnostic Evaluation
The standard screening test for HIV infection is the detection of HIV antibodies
using the enzyme-linked immunosorbent assay (ELISA). Samples that are
repeatedly positive on ELISA testing must be confirmed by Western blot testing,
an electrophoresis assay that detects antibodies to HIV antigens of specific
molecular weights. When HIV is diagnosed, a complete history and physical
examination should be performed. Emphasis should be placed on identifying
possible mechanisms of exposure, comorbid conditions, presence of STis,
determining the presence of AIDS-defining conditions, reducing risky behaviors,
and assisting with coping strategies. HIV infection is reportable to local health
authorities, but partner notification laws vary by state, so it is important to know
both local and state regulations.
Diagnostic Evaluation cont ..

Before instituting therapy, laboratory testing should include HIV genotype testing
to identify strains that may be resistant to therapy. A quantitative assay of HIV
RNA levels (viral load) can help to assess disease activity. CD4 and CDS
lymphocyte counts and viral load should be measured at baseline and every 3 to
6 months thereafter to monitor for disease staging, progression, and the risk of
complications and opportunistic infections. A CBC, comprehensive metabolic
panel, and urinalysis should be performed at baseline and periodically thereafter
to monitor for complications of HIV and of the medications that are used in
treatment. Serology for toxoplasmosis and cytomegalovirus should also be
obtained to identify organisms at risk for reactivation following
immunosuppression.
Diagnostic Evaluation cont ..

Screening for other sexually transmitted diseases (syphilis, hepatitis B and C, N

gonorrhea, Chlamydia trachomatis, herpes simplex) should be performed initially
and repeated, if needed, because of any ongoing risks identified. Hepatitis A and
B vaccination should be offered to those who lack immunity. A purified protein
derivative (PPD) test should be done, and if initially negative, repeated annually.
However, a PPD may be falsely negative if the patient is very
immunosuppressed or very ill. If positive, a chest x-ray and Quantiferon Gold test
should be performed for confirmation of potential active tuberculosis disease.
Women should have regular Papanicolaou (Pap) smears and human
papillomavirus (HPV) testing to evaluate for cervical dysplasia or cancer.
 Late Disease
HIV and its comorbid opportunistic infections can affect every organ system in
the body. Some infections, such as tuberculosis and pneumococcal pneumonia,
also affect healthy people but are greatly increased in incidence and severity in
the presence of HIV disease. Many mildly pathologic organisms, such as
Candida species, cause unusual, severe infections in parts of the body, such as
the esophagus and lungs, which they would rarely if ever affect without
coinfection with HIV. Moreover, some AIDS-defining conditions, such as Kaposi
sarcoma, can occur in persons with normal T-cell counts while other infections,
such as cytomegalovirus retinitis and cryptococcal meningitis, are only seen in
the presence of extreme immunodeficiency and very low T-cell counts.
Late Disease cont ..
Many cancers are common in HIV-positive people, some of which, such as
cervical carcinoma, are found in the non-HIV infected population while others,
such as primary central nervous system (CNS) lymphoma, are extremely rare
outside of persons infected with HIV. Moreover, HIV infection damages the body
directly and leads to such conditions as HIV related dementia and HIV-
associated nephropathy. Without antiretroviral therapy, AIDS is a universally fatal
disease.
Treatment
Treatment Because of the complexity of treatment regimens and frequently
changing treatment guidelines, patients with HIV I AIDS should be referred, in
almost all cases, to a physician with expertise in treating these conditions,
including an infectious disease specialist. In general, HAART, the combination of
several antiretroviral drugs aimed at controlling the viral load of HIV and
preventing HIV from multiplying, is used in patients who have AIDS (by
laboratory or clinical criteria), who have symptoms of disease, or who are
pregnant (to reduce the risk of vertical transmission).
Treatment cont..
Updated guidelines on HIV I AIDS treatment and monitoring can be obtained by
going to http://www.aidsinfo.nih.gov. Prophylactic treatments to reduce the risk of
infection are also important in immunosuppressed patients. HIV patients should
receive annual attenuated influenza vaccination and should be offered
pneumococcal vaccination (preferably before the CD4 count falls to less than
200 cells/µL). Live virus vaccines are contraindicated in both HIV patients, if CD4
counts are less than 200, and their close (household) contacts. Prophylaxis
against P jiroveci pneumonia should be instituted using TMP-SMX when the
CD4 count falls to less than 200 cells/ µLor if there is a history of oropharyngeal
candidiasis. Mycobacterium avium-intracellulare complex prophylaxis, using
azithromycin or clarithromycin, is recommended if the CD4 count falls to less
than 50 cells/ µL.
 OTHER SEXUALLY
TRANSMITTED INFECTIONS
 Chlamydia
Infection with C trachomatis is the most frequently reported sexually transmitted
infection in the United States. Chlamydia can be passed from person to person
by vaginal, anal, or oral intercourse. Infections are frequently asymptomatic,
making screening necessary to identification. The United States Preventive
Services Task Force (USPSTF) recommends screening for Chlamydia in all
sexually active women age 24 or younger and in older women who are at
increased risk for infection. Risk factors for infection include having multiple
sexual partners, young age, history of other STI, and non-Hispanic Black race.
The risk of transmission can be reduced by the proper use of latex condoms
with every sexual encounter.
Chlamydia cont..
Untreated Chlamydia infections in women can lead to ascending infections (ie,
pelvic inflammatory disease [PIO]), with an increased risk of ectopic pregnancy
or infertility. Chlamydia can also cause cervicitis in women and epididymitis in
men. It can cause urethritis and pharyngitis in men and women. Testing for
Chlamydia can be performed by collecting samples directly from the cervix,
pharynx, or urethra, or by C trachomatis nucleic acid amplification testing of
properly collected urine samples. Patients diagnosed with Chlamydia and their
sexual partner(s) should be treated to reduce the risk of complications and to
prevent further spread of the disease. Common treatment regimens for
uncomplicated infection include azithromycin 1 g single dose PO or doxycycline
100 mg PO twice a day for a week. Doxycycline should not be used in a
pregnant woman.
Gonorrhea
Gonorrhea is the common name for infection caused by N gonorrhoeae. This
may also pass from person to person by vaginal, oral, or anal intercourse.
Gonorrhea frequently leads to symptoms and signs of urethral infection in men,
including dysuria and penile discharge. In women, the infection may be
asymptomatic until complications, such as PIO, occur. Because of this, the
USPSTF recommends routinely screening sexually active women age 24 and
less and older women at risk for gonorrhea. Testing for gonorrhea is performed
similarly to, and usually in tandem with, testing for Chlamydia by sampling the
cervix, urethra, anus, or pharynx or collecting urine for N gonorrhoeae nucleic
acid amplification. Because of frequent coinfection, persons with gonorrhea
should also routinely be treated for Chlamydia. The recommended treatment for
gonorrhea is ceftriaxone 250 mg IM X 1 dose (along with treatment for
Chlamydia as described earlier).
Syphilis
Syphilis is the manifestation of infection by the spirochete Treponema pallidum.
Syphilis infections may be symptomatic or asymptomatic (latent). Symptomatic
syphilis is often divided into three stages based on the symptom and length of
time from exposure.
• Primary: Characterized by a painless ulcer, or chancre, at the site of infection
(usually on the genitalia)
• Secondary: Characterized by skin rash, neurologic symptoms, or
ophthalmologic abnormalities
• Tertiary: Characterized by cardiac or granulomatous lesions (gummas)
Commonly, syphilis is diagnosed on serologic testing of an asymptomatic
person and this is called latent syphilis.
Syphilis cont..
If latent syphilis can be diagnosed within a year of infection, it is known as "early
latent;" all other latent syphilis is either "late latent" or "latent syphilis of unknown
duration:' Syphilis can be diagnosed either by direct identification of the
Treponema spirochete or by serologic testing. Spirochetes can be identified by
dark-field microscopy of tissue or exudate from a chancre. Serologic testing can
be either a nontreponemal test, such as the RPR or Venereal Disease Research
Laboratory (VDRL) test or a treponemal test, such as the fluorescent treponemal
antibody absorbed (FTA-ABS) test. In general, initial screening is done with the
RPR or VDRL test and confirmation testing done with the FTA-ABS. Screening
for syphilis is recommended for all pregnant women in order to lower the risk of
congenital syphilis. Screening should be performed for anyone with another STI
or otherwise at high risk for infection. Penicillin G is the recommended treatment
for syphilis in all stages. The dosage, preparation used, and length of treatment
will vary based on the stage of the disease. For penicillin-allergic patients,
doxycycline, tetracycline, or ceftriaxone may be used as alternatives.
Herpes
Genital herpes is a viral infection caused by herpes simplex virus (HSV) type 1
or type 2. Most cases of recurrent genital herpes are caused by HSV-2.
Clinically, HSV causes painful vesicles or ulcers. However, most persons
infected with HSV-2 have not been clinically diagnosed because of the presence
of mild or unrecognized infection. These persons may shed virus and therefore
may transmit the infection to others while being asymptomatic. HSV infections
may be diagnosed by culture or polymerase chain reaction (PCR) testing of
samples from clinically evident lesions. Serologic antibody testing to both HSY-1
and HSY-2 is also available, although both false positive and false negative and
cross-reactivity may occur..
Herpes cont..
Testing positive for HSY-1 alone can also be difficult to interpret, as this is a
common nonsexually transmitted infection of childhood. Antiviral therapy is
available for HSY infections. Treatment can be used both for the acute
management of symptomatic outbreaks and for suppression to reduce the
frequency of outbreak or the risk of viral transmission to an uninfected partner.
Pregnant women with a history of HSY should be placed on suppressive
therapy late in pregnancy to reduce the risk of symptomatic outbreak or viral
shedding at the time of delivery, so as to reduce the risk of neonatal herpes in
the newborn. Women with clinically evident genital herpes at the time of delivery
should be offered cesarean deliverya
Trichomoniasis
Trichomoniasis, or"trich;' is a very common, curable sexually transmitted
infection caused by the protozoan Trichomonas vaginalis. This infection is
asymptomatic in approximately 70% of those infected. Symptomatic women
may have vaginal itching, burning, or discharge. On examination, the physician
may see a "frothy" discharge and the characteristic erythematous "strawberry"
cervix. Symptomatic men may have urethral itching, burning, or discharge. The
diagnosis of trichomoniasis can be made by the direct visualization of the motile,
flagellated trichomonads and many white blood cells on a wet mount of vaginal
or penile discharge. Trich can be treated with a single, 2-g dose of oral
metronidazole for the identified patient and sexual partner(s). Tinidazole is an
alternative treatment.
HPV
HPY infection is the most common sexually transmitted infection. It can be
passed during anal, vaginal, or oral intercourse or by skin to skin contact during
sexual activity. There are many strains of HPY and the manifestation of the
infection, if any, is related to the specific viral strain, the site of infection and host
factors. Most infections with HPV are asymptomatic and cleared by the body's
immune system. HPY infections can lead to genital warts, cervical cancer in
women, penile cancer in men, and anal or oropharyngeal cancers in both.
Because of the ubiquity of the virus and the health risks related to exposure,
vaccination against HPY is recommended routinely for both adolescent girls and
boys. HPY vaccination has been shown to reduce the incidence of genital warts
and of cervical cancer.
 COMPREHENSION QUESTIONS
A 42-year-old woman who is known to be HIV positive is found to have a CD4
count of 125 cells/ mm3 and is taking HAART. She has not experienced any
AIDS-defining illness. She continues to use IV heroin and abuse alcohol on a
daily basis. She does not regularly take her antiretroviral medication and is often
lost to follow-up. Which of the following treatments is most appropriate at this
time?
1. Initiate fluconazole for candidiasis prophylaxis.
2. Initiate antiviral treatment for herpes zoster prophylaxis.
3. Initiate TMP-SMX for P jiroveci pneumonia prophylaxis.
4. Initiate clarithromycin for M avium-intracellulare complex prophylaxis.
COMPREHENSION QUESTIONS cont..
A 25-year-old previously healthy man presents to the emergency room after
experiencing a generalized tonic-clonic seizure that lasted 30 seconds. He has
been experiencing headaches over the past 6 months but no other associated
symptoms. His mother states that she witnessed him to have two previous
seizures. The patient has a history of being sexually promiscuous and using IV
illicit drugs. The result of his last HIV test is unknown. On neurologic
examination, he is noted to have increased tone on the right and decreased right
arm swing when walking. The remainder of his neurologic examination is
unremarkable. A computed tomography (CT) scan of the head with contrast
reveals that he has a ring-enhancing lesion measuring 15-mm over the left
motor strip region and a 12-mm ring-enhancing lesion in the left basal ganglia.
Which of the following would be an AIDS-defining condition in this patient?
A. Glioblastoma multiforme
B. Subarachnoid hemorrhage
C. Herpes zoster encephalitis
D. Listeriosis with brain abscess E. Primary brain lymphoma
COMPREHENSION QUESTIONS cont..
A 22-year-old woman tests positive for gonorrhea from routine screening during
a well-woman examination. She was asymptomatic at the time of the testing.
She has no known drug allergies. Which of the following treatments would be
recommended for her?
1. Penicillin G 1.2 million units IM x 1
2. Ceftriaxone 250 mg IM X 1
3. Ciprofloxacin 250 mg PO X 1 dose
4. Ceftriaxone 250 mg IM X 1 and azithromycin 1 g PO X 1
COMPREHENSION QUESTIONS cont..
A 45-year-old man has STI screening done at a screening fair at a local free
clinic. He has never been tested for STis before and is completely
asymptomatic. He tests negative for HIV, gonorrhea, and Chlamydia but is
notified that he has a positive RPR. What is the next appropriate step for him?
A. Treatment with penicillin G
B. FTA-ABS testing
C. Notification of his STI to the local health department
D. Repeat his STI panel as this is likely a false-positive test
 ANSWERS
45.1 C. With this level of cell count, the patient should continue antiretroviral
therapy and start P jiroveci pneumonia prophylaxis. The level is not yet low
enough to recommend M avium-intracellulare complex prophylaxis.
45.2 D. Primary brain lymphoma is an AIDS-defining condition. Glioblastoma
multiforme and subarachnoid hemorrhage may present with these symptoms,
but are not AIDS-defining conditions. Listeriosis and herpes zoster encephalitis
can be associated with HIV, but are not AIDS-defining conditions.
45.3 D. Patients who test positive for gonorrhea should be treated for both
gonorrhea and Chlamydia. Ceftriaxone 250 mg IM is the appropriate treatment
for gonorrhea and azithromycin is the appropriate treatment for Chlamydia. Her
sexual partner( s) should also be offered treatment.
45.4 B. He has tested positive on his initial screening test for syphilis with a
nontreponemal test. A confirmatory test with a treponemal test should be
performed prior to making the diagnosis or implementing treatment. If he is
confirmed as positive, he should then be treated with penicillin and notification
should be made to the health department.