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STI Management Training Guide

FHI 360 is a nonprofit organization that collaborates with the Egyptian Ministry of Health and Population and USAID to improve the management of sexually transmitted infections (STIs) in Egypt. The Training Manual for the Management of STIs includes comprehensive guidelines and training materials aimed at enhancing the skills of healthcare providers in detecting and treating STIs. The manual covers various topics, including the current STI situation, communication skills, case management approaches, and syndromic management of specific STIs.

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0% found this document useful (0 votes)

7 views146 pages

STI Management Training Guide

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diriba

We take content rights seriously. If you suspect this is your content, claim it here.

Available Formats

Download as PDF, TXT or read online on Scribd

You are on page 1/ 146

In July 2011, FHI became FHI 360.

FHI 360 is a nonprofit human development organization dedicated to improving lives in lasting ways by
advancing integrated, locally driven solutions. Our staff includes experts in health, education, nutrition,
environment, economic development, civil society, gender, youth, research and technology – creating a
unique mix of capabilities to address today’s interrelated development challenges. FHI 360 serves more
than 60 countries, all 50 U.S. states and all U.S. territories.

Visit us at www.fhi360.org.
Ministry of Health and Population
National AIDS Program
Arab Republic of Egypt

Training Manual
for the Management
of Sexually Transmitted Infections
Development of this manual was a fully collaborative effort
with the Egyptian Ministry of Health and Population
(MOHP), Family Health International (FHI) and the United
States Agency for International Development (USAID).
These activities were funded by the USAID through FHI’s
Implementing AIDS Prevention and Care (IMPACT) Project,
Cooperative Agreement HRN-A-00-97-00017-00.The views
expressed in this manual do not necessarily reflect the
views of USAID.

© 2006 Ministry of Health and Population

(MOHP) and Family Health International (FHI). All
rights reserved. This document may be freely
reviewed, quoted, reproduced or translated, in full
or in part, provided the source is acknowledged.
This manual may not be sold or used in
conjunction with commercial purposes.
Developed by:
Dr. Cherif Soliman, Family Health International

Reviewed by:
Dr. Adel Botros - Cairo Skin and STI Hospital
Dr. Doaa Oraby - Family Health International
Ms. Dina Khaled - Family Health International
Dr. Abdel Salam El Sherbiny - Consultant
Introduction

The Egyptian Ministry of Health and Population (MOHP) has made

tremendous strides in upgrading services for the detection and treatment
of sexually transmitted infections (STIs). This Training Manual, in
conjunction with the National Guidelines for the Management of Sexually
Transmitted Infections, form a comprehensive package for the
standardized implementation of STIs services nationwide.

This manual serves as the basis for training programs designed for
enhancing the skills of service providers on the detection and treatment of
STIs. The manual consists of two components. Firstly, Facilitator’s
Guidelines, which includes a description of the Training Manual, outlines
of the sessions, recommended instructions on the training format and
sample forms, including agendas and evaluation forms. The second
section of the manual includes the training slides, both printed and
electronic versions.

Together, these materials facilitate the training of trainers, thereby

contributing to the creation of a cadre of services providers versed in
standardized protocols for the detection and treatment of STIs.

Special gratitude is due to Family Health International (FHI) and the

United States Agency for International Development (USAID), for their
support in upgrading STI services in Egypt, including the development of
this Training Manual, the National Guidelines for the Management of
Sexually Transmitted Infections, and the establishment of the Pilot STI
Clinics in Cairo and Alexandria.

Special thanks are also due to the staff of the National AIDS Program and
the Department of Dermatology and STIs at the Cairo Skin and STI
Hospital (El Hod El Marsoud), for their on-going contribution to these
activities.

I look forward to the success of these activities in maintaining the good

health of all Egyptians.

Dr. Nasr El Sayed

First Undersecretary
Ministry of Health and Population
Table of Contents

Page
Facilitator's Guidelines 1

Training Slides

• The STIs Situation 10

• Facts about STIs 20

• RTIs/STIs/HIV 34

• Steps of the Comprehensive Management 51

of STIs

• Communication Skills 66

• Health Education Messages: The 4Cs 78

• Approaches for STIs Case Management 98

• Syndromic Management of STIs

o Urethral Discharge in Men 113

o Genital Ulcer 129

o Inguinal Swelling (Bubo) 160

o Scrotal Swelling and Pain 168

o Vaginal Discharge 176

o Lower Abdominal Pain in Women 201

o Neonatal Conjunctivitis 213

o Other STIs 218

• STIs Data 226

Appendices

• A- Sample of workshop agenda 233

• B- Samples of pre and post test questionnaires 236

• C- Course evaluation form 241

• D- Data collection instruments 243

References 250
STIs Training Manual

1. Components of the STIs Training Manual

The complete training manual includes one set of each of the

following:

• Facilitator’s guidelines

• Printed version of training slides

• CD of training slides

• National guidelines for the management of sexually transmitted

infections

National guidelines for the management of sexually transmitted

infections should be distributed for participants by the end of the
training. Participants’ handouts can be readily drawn from any section
of the manual and the related CD that is designed to stand on its own
to the extent that it can be used as a self-teaching manual. The
course is designed to ensure that a critical body of information is
transferred to the trainers and that a consistently high standard of
training is maintained.

The following additional training aids are also included in the training
manual as appendices:

• Sample of workshop agenda

• Samples of pre-and post-test questionnaire

• Course evaluation form

• Data collection instruments

Other training aids required for the training course include:

• Flip-charts and marking pens

• Data Show

• Penis models and latex condoms to demonstrate correct

condom use

1
2. Training Sessions

The training manual contains materials for training sessions that can be
selected from and adapted to the needs of different audiences.
Following is the brief description of the contents of the training
sessions.

Session 1: Introduction to the Workshop sets the tone of the

workshop, clarifies the objectives, addresses participants' expectations
and establishes ground rules. This session will include the following:
• To conduct the pre-test
• To introduce facilitators and participants to the workshop and to
each other
• To review the workshop agenda
• To establish ground rules for the workshop

Session 2: The STIs Situation describes the current STI situation in

the world and in Egypt.

Session 3: Facts about STIs should cover the following:

• To identify how STIs are transmitted and the factors that
influence transmission
• To sensitize to the serious complications which some STIs
can cause

Session 4: RTIs/STIs/HIV sensitizes participants to understand

the relation between HIV, STIs and other RTIs and the importance of
STI control in the era of AIDS. It points out that individuals who
suffer from STIs are a particular important target group for
preventive behavioral interventions as well as curative ones.

Session 5: Steps of the Comprehensive Management of STIs

teaches the meaning of comprehensive case management including
diagnosis, treatment, patient education, condom demonstration, and
partner management. It also introduces the concept of STI risk
assessment. This session should include materials to accustom the
participants with every step involved in STI case management.

2
Session 6: Communication Skills helps participants become more
aware of the importance of establishing a non-judgmental and
trusting rapport with their patients. It initiates the process of “attitude
restructuring” and introduces effective communication skills. This
session should include the following:

• To recognize the major barriers to an effective communication

related to STIs

• To develop more effective communication skills

Session 7: Health Education Messages (The 4Cs) familiarizes

participants with the basic health education messages and gives them
an opportunity to practice their communication skills. While
facilitating this session the following things should be accomplished:

• To make the participants familiar with the following four basic

health education messages:
- Compliance to treatment
- Counseling/education
- Condom use; demonstration of correct use
- Contact tracing and treatment

Session 8: Approaches for Case Management of STIs gives the

rationale for the syndromic approach and sets the foundation for
sessions on the management of specific syndromes. This session
should include the following:

• To compare between different approaches to STIs diagnosis

• To present the rationale for the syndromic approach

• To clarify some problems regarding laboratory investigations

• To classify the main causative agents by their clinical

syndromes

• To describe general guidelines on the use of flow-charts

Sessions 9-16: STIs Syndromes familiarizes participants with

syndromic flow-charts for seven STI syndromes: Urethral Discharge
in Men; Genital Ulcer; Inguinal Swelling (bubo); Scrotal Swelling

3
and Pain; Vaginal Discharge; Lower Abdominal Pain in Women;
Neonatal conjunctivitis; and other STIs including Molluscum
Contagiosum, Scabies, Condyloma Accuminata and Pediculosis Pubis.
Each session includes:
• Background information on common etiologies and
complications
• The corresponding syndromic flow-chart
• Therapeutic recommendations
• Clinical slides
• Case studies
Treatment recommendations are based on the experience from
different service facilities and the availability of drugs for the STI case
management that are included in flow-charts and their explanations.

Session 17: STIs Data discusses the importance of routine

collection of data, data management, record keeping and reporting.

Session 18: Closing session concludes the training and should

include:
• Post-test questionnaire
• Course evaluation
• Closing

Sessions for practicing clinical skills: these should be undertaken

after completing the theoretical component of the training. The
following should be included in these sessions:
• To practice the correct use of syndromic approach to STI case
management under the guidance of the trainer at specialized
clinics
• To learn and practice how to collect specimen for basic
laboratory diagnosis in case of vaginal discharge. These
sessions will deal with the following laboratory tests related to
STI screening:
- Gram stain smear
- Saline wet mount
- KOH and pH testing

4
3. Recommended Training Format and Strategies

Methodologies to be used during training session include:

• Presentations
• Interactive discussions
• Slides demonstrating clinical cases
• Case studies
• Group work, and
• Practical demonstration

The manual contains materials for variety of training sessions that

you can select from depending on the participant requirements and
the duration of the training workshop. The estimated time required
will depend on the background of the participants and their specific
requirements. The materials needed are indicated at the top of the
"facilitator’s guidelines”. A sample agenda for a five-day workshop for
the Physicians is included in (Appendix-A). You are strongly advised
to pre-test the sessions with your intended audience before finalizing
your training schedule.

As a general rule, didactic presentations are minimized and

interactive/participatory sessions are maximized.

For most of the sessions, Power Point Slides will be used for two
reasons: (1) with slides the lights stay on and participants are less
likely to doze off; (2) slides are easier to update and add to during a
workshop. During the sessions on different syndromes, Clinical
slides and Case Studies will be used as additional support. The
Flow-Charts for Syndromic Case Management of STIs and
Explanations for Use are designed for the service providers and
these can be used as wall charts or pocket charts.

Participants in general tend to be more eager to learn about the latest

therapeutic recommendations and are less inclined toward the
preventive aspects of the training. Keeping this in mind, we advise
that the sessions be strategically scheduled in such a way as to
optimize participation in these less popular sessions. Awarding a
certificate of attendance only to those who attended all the sessions is
another incentive as participants often appreciate these certificates
that they can frame and exhibit at their clinics.

5
4. Introduction to the Workshop

Objectives
• To introduce the facilitators and participants to the workshop
and to each other
• To review the workshop agenda
• To establish ground rules for the workshop

Materials and Supplies

• Power point slides and data show

• Flip-charts and marking pens

• Participants Handouts
- List of facilitators & participants
- Workshop agenda
- Ground rules

Group Introductions
• Name
• Current occupation/position
• Experience with STIs/AIDS
• One expectation for the workshop

Everyone should receive the workshop agenda along with the list of
facilitators. A list of the participants should also be given to all the
workshop participants. These introductions allow participants to
establish their roles in the group, and for you to assess the
experience and backgrounds of the participants.

Begin the session by introducing yourself. Let other facilitators/

resource persons introduce themselves. Then give each participant
the opportunity to introduce him/herself. Each person should say a
little about his/her background (current position, experience
with STIs/HIV/AIDS) and to present one expectation he/she has
for the workshop. Make note of the individual expectations on a flip-
chart as they are reported so that you can let participants know early
if they have expectations that will be met during this workshop.

6
Workshop Agenda

Session 1: Introduction to the Workshop

Pre-test questionnaire

Session 2: The STIs Situation

Session 3: Facts about STIs

Session 4: RTIs/STIs/HIV

Session 5: Steps of the Comprehensive Management of STIs

Session 6: Communication Skills

Session 7: Health Education Messages: The 4Cs

Session 8: Approaches for STIs Case Management

Session 9: Urethral Discharge in Men

Session 10: Genital Ulcer

Session 11: Inguinal Swelling (Bubo)

Session 12: Scrotal Swelling and Pain

Session 13: Vaginal Discharge

Session 14: Lower Abdominal Pain in Women

Session 15: Neonatal Conjunctivitis

Session 16: Other STIs

Session 17: STIs Data

Session 18: Post-test questionnaire

Course Evaluation
Closing

7
Practical sessions of clinical skills

Distribute and go over the workshop agenda (fill in appropriate dates

and times or prepare your own agenda). This is a good time to let
participants know if they have expectations that will not be met in the
workshop. Acknowledge that the following topics are not within the
scope of the workshop: HIV pre and post-test counseling, clinical
management of HIV positive individuals or AIDS patients, laboratory
diagnosis of STIs etc...

Ground rules of the workshop

• Confidentiality

• Each is entitled to his/her own opinion (No judgments of what

others say)

• Explain that although the format of the workshop includes a

number of short didactic presentations, it will emphasize
interactive sessions that will require their full and active
participation.

In order for the group to operate smoothly it is important to have a

set of agreed upon rules that are observed during the entire
workshop. This will enhance the trust you develop with the
participants and among the participants themselves. Explain each rule
as follows:
• Confidentiality: it is important to stress confidentiality to
establish an environment where participants can talk
honestly and openly.

• Each is entitled to his/her opinions: let participants know

that all opinions are equally valid and valued, even if
more people hold an opposing opinion.

Inform the participants that they should ask questions if something is

not clear, including words and instructions given during the exercises.

8
5. Evaluation

During the training, evaluation of trained individuals will be through:

• Questions and answers

• Quick feedback

• Practical exercises

Also the training manual includes two types of evaluation forms:

(1) Pre-/post-test questionnaire (Appendix-B) which is administered

before and after the workshop to measure changes in participants'
knowledge and attitudes.

(2) Course evaluation form (Appendix-C) which is administered at

the end of the workshop so that participants can rate the quality
and usefulness of the course contents and materials, and make
any comments or suggestions on how the course might be
improved.

It is suggested that:
- All evaluation exercises are conducted anonymously;
- All written comments/suggestions in the course evaluation be
shared with all the participants for further feedback and
discussion;
- Results of the pre and post-tests questionnaire (proportion of
correct answers for each question before and after the training)
be available before the end of the workshop (this can be
completed while the course evaluation comments are being
reviewed) so that any areas of weakness or confusion can be
identified and remedied on the spot.

Finally, the true outcome of the training could only be assessed by

evaluating its impact on participants' STI management practices. This
is not an easy undertaking but can be accomplished through
supervision/monitoring and or follow-up surveys.

9
TRAINING SLIDES
The STIs Situation
Global Incidence of Curable STIs
340 million new cases occurred in 1999, ages 15-49
200

non-
non-ulcerative
150
Millions ulcerative

100

0
Trichomoniasis Chlamydia Gonorrhea Syphilis Chancroid
Source: WHO, 2005

----------------------------------------------------------------------------------------------------------------

10
How Accurate are STIs Figures?
There is an underestimate of STIs in the general population

• Asymptomatic patients
– 70% of women and 30% of men with chlamydia
– 80% of women and 10% of men with gonorrhea

• In developing countries, despite that STIs are notifiable:

– Many patients do not seek treatment (auto-medication…)
– Treatment is done by non-professionals
– Difficulty accessing STIs clinics
– Weak reporting system
– Inefficient surveillance system

----------------------------------------------------------------------------------------------------------------

11
STIs in the Developing World

• Lack of reliable STIs data

• High incidence and prevalence in some populations
• High rate of complications and sequelae
• Serious problem of antibiotic resistance
• Dramatic interaction with HIV infection
• Major impact of socio-economic factors
• Control programs, inadequate or non-existent

----------------------------------------------------------------------------------------------------------------

12
STIs in Egypt

• Information about STIs is quite limited

• Reviewing of the available data confirms their presence

• The conservative environment created by cultural, religious and

social values helps maintain the low rates of STIs

• Several trials for the introduction of syndromic approach for the

management of STIs

----------------------------------------------------------------------------------------------------------------

13
STIs Services in Egypt
• Private versus Governmental
– STIs clinics
– Dermatology
– OB/GYN
– ANC
– Urology
– PHC
• Auto medication
• Pharmacists
• Others

----------------------------------------------------------------------------------------------------------------

14
Results of STIs Studies in Egypt

A few reliable studies were conducted,

But should be interpreted with methodological concerns

• RTIs/STIs are present

• Higher rates among high-risk populations
• Most prevalent: Trichomonas, Chlamydia, Gonorrhea, Human
Papilloma virus, Herpes
• Less prevalent: Syphilis and other ulcerative STIs

----------------------------------------------------------------------------------------------------------------

15
Evaluation of Selected Reproductive
Health Infections in Various
Egyptian Population Groups in
Greater Cairo
Cairo, 1998 - 2000

STIs Prevalence by Group

Prostitutes MSM Drug users ANC FP

(n=52) (n=80) (n=150) (n=604) (n=108)
% % % % %

Syphilis (TPHA) 5.8 7.5 1.3 0.0 0.0

Gonorrhea 7.7 8.8 2.7 2.0 2.8

Chlamydia 7.7 8.8 2.7 1.3 2.8

Trichomoniasis 19.2 1.3 0.7 0.7 2.8

Any STI 36.5 23.8 5.3 4.0 8.3

Source: El Sayed N., et al., 2002

----------------------------------------------------------------------------------------------------------------

16
Current MOHP Efforts to Standardize
Quality RTIs/STIs Activities
MOHP with FHI technical assistance and USAID funding
Combination of Curative and Preventive Care

• National HIV/STIs Surveillance Plan

• National Guidelines for the Management of STIs
• STIs Training Manual
• Establishment of Pilot STIs Clinics:
– Cairo Skin and STIs Hosp. (El Hod El Marsoud)
– Alexandria Skin and STIs Clinic (Mina El Basal)

----------------------------------------------------------------------------------------------------------------

17
National Guidelines
for the Management of STIs

WHO Standard Flow Charts adapted to

the local context :

• Etiologic profiles
• Antibiotic resistance patterns
• Availability of examination facilities
• Availability of laboratory support
• Availability of drugs

----------------------------------------------------------------------------------------------------------------

18
MOHP Central Laboratories

Referral Laboratories

• Departments: bacteriology and virology

• Sophisticated techniques and qualified personnel
• Gold Standard tests: PCR, LCR
• Research, Quality control ….
• Not for daily screening for RTIs/STIs

----------------------------------------------------------------------------------------------------------------

19
Facts about STIs
Modes of STIs Transmission
• Unprotected penetrative sexual intercourse
(vaginal or anal): all STIs

• Mother-to-child:
– During pregnancy: HIV – Syphilis
– At delivery: HIV – Gonorrhoea – Chlamydia – Herpes
– After birth (lactation): HIV

• Transfusion or other contact with blood (Syphilis – HIV)

• Close contact: Scabies, molluscum contagiosum ……

----------------------------------------------------------------------------------------------------------------

20
Global HIV Infections
by Mode of Exposure

80
70
60
% of global 50
40
infections
30
20
10
0
bl

he
oo

al
d

th
T

ca
mode of exposure

re
----------------------------------------------------------------------------------------------------------------

----------------------------------------------------------------------------------------------------------------

21
STIs/HIV Transmission
Dynamics at the Population Level

C o re B rid g e G en eral
g ro u p s g ro u p s P o p u latio n

----------------------------------------------------------------------------------------------------------------

22
MYTH: “Condoms are not effective
against HIV/STIs”
• Condoms are effective at protecting against HIV/STIs
when used consistently and correctly.

• When used correctly, condoms rarely break

(2% of the time in the US).

• When condoms do break, it is generally due to incorrect

use, and not because of poor quality.

• HIV/STIs cannot pass through intact latex condoms.

----------------------------------------------------------------------------------------------------------------

23
STIs and Condom Use Rates in
Female Sex Workers in Thailand
250.00 100

Condom use rates %

90
STIs (thousands)

200.00 80
70
150.00 60
50

100.00 40
30
50.00 20
10
0.00 0
1987 1988 1989 1990 1991 1992 1993

Source: Hannenberg, R, et al., 1994

----------------------------------------------------------------------------------------------------------------

24
MYTH: “Only high risk groups are
at risk for the disease”

• That is simply not true

• It is not who you are that puts you at risk, it's what you do

“HIV/AIDS/STIs do not discriminate”

----------------------------------------------------------------------------------------------------------------

25
MYTH: “Sexually transmitted infections
are often transmitted non-sexually”

STIs include:
»Chlamydial infection
»Trichomoniasis

“STIs are Sexually transmitted”

----------------------------------------------------------------------------------------------------------------

26
MYTH: “High-Risk Behaviors are not
common in our community”

“High-Risk Behaviors do exist in our community”

----------------------------------------------------------------------------------------------------------------

27
Women at Risk
Low status may limit ability to
negotiate safer sex, obtain
information and receive health care

Ray Witlin / World Bank

Vaginal surface is larger and more
vulnerable to infection than penis
Female adolescents are more
vulnerable to STIs due to cervical
ectopy
STIs are often asymptomatic in
women and go untreated

----------------------------------------------------------------------------------------------------------------

28
Socio-Economic Factors
Facilitating Transmission of Infections
• Social mobility
• Stigma and denial
• Political and social instability
• Cultural factors
• Poverty
– Early marriage
– Delay in getting STIs treatment
– Non-compliance to treatment
• Drug abuse

----------------------------------------------------------------------------------------------------------------

29
Behaviors Likely to Increase
the Risk of Getting an STI

• Having more than one partner

• Frequent partner change

• Having sex with casual partners

• Having sex with those known to have many partners

----------------------------------------------------------------------------------------------------------------

30
Cultural Issues

• Providers are often embarrassed to talk about STIs

• Counseling is rarely done
• Partners are often not treated, nor counseled
• Condoms are not promoted, nor demonstrated

Results:
– Failure to follow safe sex practices, such as using
condoms
– Failure to bring in sexual partners for treatment

----------------------------------------------------------------------------------------------------------------

31
Complications of Untreated STIs
• HIV infection
• Spontaneous abortion
• Chronic abdominal pain or infertility in women
• Sepsis, ectopic pregnancy, cervical cancer and death
• Blinding eye infections
• Pneumonia in infants
• Newborn congenital malformation
• Urethral stricture in men
• Infertility in men
• Social consequences: beating and divorce

----------------------------------------------------------------------------------------------------------------

32
Complications of Untreated STIs (cont.)

• 55-85% of women with PID may become infertile

• PID increases the risk of ectopic pregnancy by 7-10 folds

• 10-30% of men with gonorrhea develop epididymitis

• 20-40% of the epididymitis cases become infertile

• Neonatal conjunctivitis may cause permanent damage of

vision of 1-6% of the affected infants

----------------------------------------------------------------------------------------------------------------

33
Steps in the
Comprehensive
Management of STI Cases
The 7 Steps of the Comprehensive
Case Management of STIs
Step 1 : Take history
Step 2 : Conduct physical examination
Step 3 : Provide curative or palliative therapy
Step 4 : Provide health education messages
(the 4 Cs)
Step 5 : Demonstrate and provide condoms as
appropriate
Step 6 : Offer treatment for partner
Step 7 : Schedule clinical follow-up as
appropriate

----------------------------------------------------------------------------------------------------------------

51
Step 1 : Take a History

• Obtain reason for consultation (infection, fear of

infection…)
• Reassure patient that absolute confidentiality will be
maintained
• Find out what symptoms and signs if any prompted the
visit
• Conduct a behavioral risk assessment
• Obtain information on drug allergies & current
medications

----------------------------------------------------------------------------------------------------------------

52
History Taking

History taking will consist of the following:

• Personal history
• Present illness
• Medical history
• Sexual history

----------------------------------------------------------------------------------------------------------------

53
History Taking: Personal History

This should include the following:

– Age
– Marital status
– Number of children
– Locality
– Education
– Employment
– For women: if lactating or pregnant

----------------------------------------------------------------------------------------------------------------

54
History Taking: Present Illness
• Ask the patient about the presenting complaint and duration

• You may concentrate on a specific STI syndrome

• You may ask related questions such as:

– Scrotal swelling: ask about the history of trauma
– Lower abdominal pain: ask about missed period; recent
delivery/abortion; vaginal discharge/bleeding
– Genital ulcer: recurrent vesicular painful lesions
– Vaginal discharge: risk assessment

----------------------------------------------------------------------------------------------------------------

55
History Taking: Medical History

While taking medical history ask about the following:

• History of past STIs

• Other illness

• Medications taken

• Drug allergy

----------------------------------------------------------------------------------------------------------------

56
History Taking: Sexual History

Ask specific questions for:

– Risk assessment
– Currently active sexually
– Sex partner(s) in the last six months
– Condom use in the last six months
– Condom use in the last time had sex

Appropriate counseling is based on assessing risk

and barriers to change patients sexual behavior

----------------------------------------------------------------------------------------------------------------

57
Step 2 : Conduct Physical
Examination: Male Patients
• Ask the patient to stand up and lower his pants/trousers, so that
he is undressed from chest down to knees
• Inspect while the patient is standing up or laying down
• Palpate the inguinal region for enlarged lymph nodes and buboes
• Palpate the scrotum, feeling for testis - epididymis - spermatic
cord
• Examine the penis, noting any rashes or ulcers, then ask the
patient to retract the foreskin and examine
• If no obvious urethral discharge, ask the patient to milk the urethra
• Record the findings

----------------------------------------------------------------------------------------------------------------

58
Step 2 : Conduct Physical
Examination: Female Patients
• Ask the patient to remove her clothing from the chest down, and
then lie on the coach
• Use a sheet to cover the parts of the body you are not examining
• Ask the patient to bend knees and separate her legs, then
examine the vulva, anus and perineum
• Inspect external genitalia for irritation and ulcers
• Palpate the inguinal region for enlarged lymph nodes and buboes
• Palpate the abdomen (superficial and deep) for pelvic masses
and tenderness

----------------------------------------------------------------------------------------------------------------

59
Step 2 : Conduct Physical
Examination: Female Patients
• Conduct a speculum examination (visualization of the
cervix):
– Swab the cervix with a clean gauze and wait for 1-2
minutes to watch cervical discharge, friability as well as
ulcers
– While withdrawing the speculum watch the vaginal
epithelium for discharge and ulcers
• Conduct a bimanual examination and note for cervical
motion tenderness
• Record the findings

----------------------------------------------------------------------------------------------------------------

60
Step 3 : Provide Curative or
Palliative Therapy
“Do not substitute drugs and doses that are
recommended in the National Guidelines for the
Management of STIs”

• Ineffective or sub-therapeutic treatment:

– loosing the confidence of your patient
– spread of the infection
– emergence of drug resistance

----------------------------------------------------------------------------------------------------------------

61
Step 4 : Provide Health Education
Messages (the 4 Cs)

----------------------------------------------------------------------------------------------------------------

62
Step 5 : Demonstrate and Provide
Condoms as Appropriate

----------------------------------------------------------------------------------------------------------------

63
Step 6 : Offer Treatment for Partner
• Partner notification and treatment is especially important
for female partners
- women are frequently asymptomatic
- women are unaware of their infection

• Consider providing the patient with additional treatment

for the partner.

----------------------------------------------------------------------------------------------------------------

64
Step 7 : Schedule Clinical
Follow-up as Appropriate
• Patients are advised to return if symptoms persist
• Follow-up is most important for patients with genital ulcer disease, pelvic
inflammatory disease and scrotal swelling & pain;

Urethral Discharge in Men : 1 week

Genital Ulcer: 1 week
Vaginal Discharge: return if symptoms persist
Lower Abdominal Pain: 3 days
Scrotal Swelling and Pain: 1 week
Inguinal Swelling (Bubo): 1 week
Neonatal Conjunctivitis: 3 days

----------------------------------------------------------------------------------------------------------------

65
Communication Skills
Ways to Establish Good
Rapport with a Client/Patient

• Verbal skills: the way we talk to the

client/patient and ask questions

• Non-verbal skills: how we behave towards

the patient

----------------------------------------------------------------------------------------------------------------

66
Examples of Behaviors that Can
Make a Patient Feel Uncomfortable
• Not greeting or looking at the client
• Not giving your full attention (reading or looking impatiently at
your watch)
• Sitting while the client stands
• Being judgmental and showing disapproval (using a harsh
tone of voice, unpleasant facial expressions)
• Not respecting issues of privacy and confidentiality (allowing
your conversation to be overheard by others)

----------------------------------------------------------------------------------------------------------------

67
Examples of Behaviors
of an Uncomfortable Patient
• Does not answer

• Will not tell the truth

• Will not share important information with you

• Will not remember what you tell him/her

• Does not trust you

• Does not come back

----------------------------------------------------------------------------------------------------------------

68
Opinions, Attitudes and Beliefs

Values Clarification

----------------------------------------------------------------------------------------------------------------

69
Possible Statements
1. AIDS is a punishment for sinful acts
2. A person who is carrying a condom is prepared to have sex
and is therefore a “loose” and “immoral”
3. Most men have more than one sexual partner in their
lifetime
4. A man would be offended if his doctor suggested that he
should use a condom when he engages in casual sex
5. A man would be offended if his wife suggested that he uses
a condom
6. In the family, prevention of pregnancy and disease are
a woman's responsibilities

----------------------------------------------------------------------------------------------------------------

70
Sexual Words

• Providers should become familiar and comfortable with the

local terms people use

• To communicate more effectively with clients and not to

become personally disgusted or embarrassed when they are
used

----------------------------------------------------------------------------------------------------------------

71
List of Sexual Words
1. STI 9. VD
2. Gonorrhea 10. Syphilis
3. Condom 11. Penis
4. Ejaculation 12. Testicles
5. Anus 13. Buttocks
6. Vagina 14. Breast
7. Masturbation 15. Vaginal Intercourse
8. Anal Intercourse 16. Oral Sex

----------------------------------------------------------------------------------------------------------------

72
Major Barriers for Communication

• A judgmental attitude that stems from differences in values,

opinions and beliefs

• Issues of privacy and confidentiality

• A discomfort discussing sexual matters

----------------------------------------------------------------------------------------------------------------

73
Communicating WELL

• Welcome your clients

• Encourage your clients to talk

• Look at your clients

• Listen to your clients

----------------------------------------------------------------------------------------------------------------

74
Use of Encouragers
[S for statement, R for response]

S: “I have pain and white stuff from down there”

R: “Can you tell me more about it?” or
“How long have you had this problem? ”

S: “I didn't come sooner because I had no transport”

R: A simple nod is appropriate, or
“Yes, finding transportation can be difficult and expensive”

S: “I know I shouldn't fool around with many ladies, but it is

hard not to”
R: “I'm glad that you are aware that your behavior is not
safe. What precautions do you take ?”

----------------------------------------------------------------------------------------------------------------

75
Use of Encouragers (cont.)
[S for statement, R for response]

S: “I don't know how to use condoms”

R: “Many people don't. I will be glad to teach you”

S: “My husband will beat me if I tell him I have this disease”

R: An empathic nod or “hmm” or
“How can I help you?”

S: “I have to go with many men so I have money for my children”

R: “Being a single parent must be very hard on you” or
“If you must engage in such activities to support your family,
are you taking any precautions to protect your health?”

----------------------------------------------------------------------------------------------------------------

76
Main Points for
Effective Communication
• Ensure privacy for the patient so that your conversation
cannot be overheard and the examination is not seen by
others
• Respect the opinions, attitudes and beliefs of the patient even
if they are different from your own values (try not to be
judgmental)
• Use a vocabulary that is at once clear and acceptable to both
you and your patient
• Welcome, encourage, look at and listen to your patient

----------------------------------------------------------------------------------------------------------------

77
Health Education Messages
The 4Cs
The Four Basic Health Education
Messages ( the 4 Cs)

1. Compliance with treatment

2. Counseling/Education

3. Condoms use; demonstration of correct use

4. Contact Tracing and Treatment

----------------------------------------------------------------------------------------------------------------

78
The First C:
Compliance with Treatment

Advise the patient to :

– take all the drugs as directed even if the
symptoms resolve

– abstain from sex until the treatment is

completed, the infection is cured and partner
has been treated

– Return for a follow up

----------------------------------------------------------------------------------------------------------------

79
Reasons for Non-compliance
with Drug Treatment
• Patient does not understand the instructions

• Treatment schedule is too complicated

• Drugs are too expensive: patients may not want to purchase the
full treatment or may save some for ‘next time’

• Symptoms have resolved so patient stops treatment

• Unpleasant side effects

----------------------------------------------------------------------------------------------------------------

80
Ways to Improve
Compliance with Treatment
• Give instructions in a way that the patient can understand

• Ask the patient to repeat the instructions

• Write down all details and give it to the patient

• Use symbols for the patients who cannot read

• Explain that it is important to complete the treatment even after the

symptoms have gone

• Discuss potential compliance problems such as multi-drug schedules,

drug cost and side effects

----------------------------------------------------------------------------------------------------------------

81
The Second C:
Counseling/Education
Messages tailored for each patient :
• how the disease was contracted (sex with an infected
partner)
• potential complications if not treated early and effectively
• mode of transmission of STIs, including HIV/AIDS
• STIs augment the risk of HIV transmission
• information about safer sex practices
- Abstinence
- Being faithful,
- Condom use; consistently and correctly

----------------------------------------------------------------------------------------------------------------

82
Counseling and Education

• offer referrals for VCT for HIV and for syphilis serology
• advise for follow-up visit and for the need to treat sexual
partners
• assess the patient’s risk factors with careful sympathetic
questions
• help the patient decide to change his or her sexual behavior
in order to avoid further infection
“It is not quite enough to have the patient agree to chose
the safer sexual behavior”

----------------------------------------------------------------------------------------------------------------

83
The Third C:
Condoms use: (Demonstration of Correct Use)

• Explain how to prevent future STIs including HIV infection

(ABC)
• Demonstrate correct condom use as appropriate
• Dispense condoms as appropriate

----------------------------------------------------------------------------------------------------------------

84
Advantages of Condom Use

• Prevents STIs including HIV/AIDS

• Prevents unwanted pregnancy
• Slows down ejaculation and thereby prolongs pleasure
• Feels more secure
• Shows caring about partner
• Saves the cost and embarrassment of seeking treatment
• Can add erotism to foreplay

----------------------------------------------------------------------------------------------------------------

85
Disadvantages of Condom Use
• Slows ejaculation
• Prevents wanted pregnancy
• May be less enjoyable
• Hard to discuss subject with partner
• Can interrupt love-making
• Can cause vaginal irritation
• May require additional lubricant
• Requires advance planning
• Can tear or slip off
• Costs money
• Few men are allergic to latex

----------------------------------------------------------------------------------------------------------------

86
Steps for Use of Male Condom
• DO NOT use condoms which are dry, dirty, brittle, discolored,
sticky, melted, damaged or past their expiration date
• Carefully open the package. DO NOT use your teeth or sharp
object
• DO NOT unroll the condom before putting it on
• If not circumcised, pull the foreskin back
• Squeeze the air out at the tip of the condom
• Continue to squeeze while unrolling the condom directly onto the
hard penis till it covers all of the penis
• Always put on condoms before penetration

----------------------------------------------------------------------------------------------------------------

87
Steps for Use of Male Condom
• DO NOT use grease, oils, lotions or vaseline to make the condoms
slippery (condom might break)
• Use glycerin or other water based lubricants if desired
• After ejaculation, hold the rim of the condom and pull the penis out
(before it gets soft)
• Slide the condom off without spilling the semen
• Tie and wrap the condom (in paper, if available) and throw it in a
dustbin
• DO NOT reuse condoms
• Store a supply of fresh condoms in a cool, dry place

----------------------------------------------------------------------------------------------------------------

88
Reasons for Non Compliance
with Condom Use
• Dislike of condoms
• Problems of condom accessibility, availability or
affordability
• Difficulty raising the subject of condom use in a
relationship or negotiating its use
• Unfamiliarity with the condom and its use

----------------------------------------------------------------------------------------------------------------

89
Ways to Increase Condom Use

• Educate the patient about the advantages of condom

use
• Ensure that a patient is familiar with the appearance,
the texture and the correct use of a condom
• Educate the patient about where to obtain quality
condoms
• Make helpful suggestions on how the patient can
negotiate its use in a way that is appropriate for a
particular relationship

----------------------------------------------------------------------------------------------------------------

90
The Fourth C:
Contact Tracing and Treatment
Educate the patient about :
The importance of notifying recent sexual contact even if he/she
is asymptomatic and encouraging them to get treatment

----------------------------------------------------------------------------------------------------------------

91
Partner Notification

Patient referral (notification done by the patient)

Possible ways of partner management

- Providing additional treatment for the partner
- Encouraging partners to come to the clinic to receive
treatment

----------------------------------------------------------------------------------------------------------------

92
Ways to Improve Partner
Notification & Treatment

• Explain ‘ping pong’ infections: the patient may get re-

infected by his/her untreated partner (who is frequently
asymptomatic).

• Warn the male patient that his female partner may

develop serious complications if untreated including
infertility. If she is pregnant she may pass the infection
to her child.

----------------------------------------------------------------------------------------------------------------

93
Priority Groups for Partner Notification

Wife or female sexual partners of male STIs patients

- frequently asymptomatic
- unaware of their infection
- potential complications are serious

----------------------------------------------------------------------------------------------------------------

94
Treating Partners
For All Syndromes:
“Partners should receive treatment even if they are asymptomatic”

Except for :
- Vaginal discharge (Vaginitis)
- Anaerobic infections

Bacterial vaginosis
Candidiasis are not sexually transmitted
Anaerobic infections

N.B. Mother and her sexual partner should be treated

in case of Neonatal conjunctivitis

----------------------------------------------------------------------------------------------------------------

95
Practicing the 4 Cs: Case Study 1

A 27 years old man presents to you with a thick purulent

discharge from his penis.
He tells you that normally he only goes with his wife but a
couple of nights ago his friends took him drinking and they
ended up with women.

----------------------------------------------------------------------------------------------------------------

96
Practicing the 4 Cs: Case Study 2

A single 20 years old sex worker comes to you with a vaginal

discharge.
After examination, you prescribe the following medications :
ciprofloxacin 500 mg in a single dose, doxycycline 100 mg twice
daily for seven days, metronidazole 2 g in a single dose,
clotrimazole 200 mg vaginal pessary each night for 3 nights.

----------------------------------------------------------------------------------------------------------------

97
Approaches for STIs
Case Management
Approaches for Diagnosis and Treatment

z Three approaches:
− laboratory-based (etiologic)
− clinical without laboratory support
− syndromic management

z All approaches work only if infected person:

− has symptoms
− seeks health care
− receives proper treatment

----------------------------------------------------------------------------------------------------------------

98
Laboratory-Based Approach
Laboratory tests used to identify infectious agent

z Most precise method

z Requires substantial resources
z Treatment usually delayed
z False Results
¾ Syphilis: window period , false results

¾ Chlamydia & Chancroid

¾ Gonorrhea: not sensitive in females

¾ Trichomonas (hot climate)

“Often low sensitive laboratory techniques are used”

----------------------------------------------------------------------------------------------------------------

99
Clinical Approach
without Laboratory Support
Depends on signs and symptoms

z Based on clinical judgment

z Least reliable method
z Single STI is typically identified and treated
z Examples:
¾ Masked by other treatment

¾ Chancre and Chancroid

¾ Gonorrhea and Chlamydia

¾ Vaginitis and cervicitis

“Moreover non experts are using clinical approach”

----------------------------------------------------------------------------------------------------------------

100
Syndromic Approach
“Based on the recognition of syndromes and treatment which deals
with the majority of likely causative agents”

z Clients treated for all major causes of syndrome

z Algorithms should be adapted to local prevalence of STIs

z Can be used where laboratory services are unavailable

z Accuracy improves when supplemented with simple

laboratory tests and minimal clinical signs
(Enhanced Syndromic Approach)

----------------------------------------------------------------------------------------------------------------

101
One or Multiple Pathogens for Each Syndrome

----------------------------------------------------------------------------------------------------------------

102
Advantages of the Syndromic Approach

• Reduces probability of incorrect clinical diagnosis

• Specialized equipment unnecessary
• Clinical protocols are standardized
• Uniformity in collecting data
• Can be used by any level of health care providers
• Diagnosis and treatment can be provided at first visit
• In many cases, referral is not needed

“First visit may be the last visit”

----------------------------------------------------------------------------------------------------------------

103
Disadvantages of the Syndromic
Approach

• Undue exposure to potential side effects of drugs due to

over treatment

• Health care providers feel uncomforted not to use his/her

clinical experience

• Algorithms not equally accurate

----------------------------------------------------------------------------------------------------------------

104
Syndromic Approach: Accuracy

Syndrome Accuracy of algorithm

Genital ulcer
Syndrome AccuracyGood
of algorithm
Urethral discharge
Genital ulcer
Lower abdominal
Urethral dischargepain Good
Moderate
Vaginal discharge (vaginitis)
Lower abdominal pain
Moderate
Vaginal discharge
Vaginal discharge (cervicitis)
(vaginitis) Poor
Poor
“Accuracy varies with each syndrome”

----------------------------------------------------------------------------------------------------------------

105
One Algorithm does not Fit All Settings
• Clinical setting
• Disease prevalence:
» High sensitivity approach is preferred in high
prevalence
» High specificity approach is preferred in low
prevalence
• Level of clinical/ laboratory evaluation
• Available resources

----------------------------------------------------------------------------------------------------------------

106
Proper Implementation
of Appropriate Algorithm

• Training : theoretical and practical on field

• Successful model
• Adequate Support
• Data and drugs
• Adapted to context
• Monitoring and supervision
• Promotion
• Complete package

----------------------------------------------------------------------------------------------------------------

107
Possible Laboratory Tests
and Syndromic Approach

• Bed side Lab tests for woman with vaginal discharge

• Site Lab tests for Syphilis serology, confirmation of

diagnosis, resistant cases

• Referral Lab tests for Syphilis serology, confirmation of

diagnosis, resistant cases, research studies, validation of
protocols, antibiotic sensitivity…

----------------------------------------------------------------------------------------------------------------

108
Syndrome Management
Studies in Women

• RTIs (not necessarily STIs) are prevalent

• Symptoms of vaginal discharge is not a prediction of
Gonorrhea or Chlamydial infection - rather Bacterial
vaginosis and Trichomoniasis
• Majority of women with Gonorrhea or Chlamydial cervical
infection will not have symptoms

----------------------------------------------------------------------------------------------------------------

109
Syndrome Management
Studies in Women

• Diagnostic accuracy of laboratory screening tools for

Gonorrhea or Chlamydial infection is poor
• Even “Gold standard” tests underestimate prevalence
• Application of simple risk assessments appear feasible
and acceptable in general clinic settings
• Clinical skills of providers influence the performance of
decision model

----------------------------------------------------------------------------------------------------------------

110
Selection of Approaches

• Symptomatic:
– Enhanced syndromic approach

• Asymptomatic: ( Mainly women)

– Syphilis serology screening at ANC
– Partner treatment
– Surveillance

----------------------------------------------------------------------------------------------------------------

111
Possible Approaches
for High Risk Groups

• Proper outreach
• Targeted treatment protocols
• Selective presumptive treatment for asymptomatic high
risk females
• Periodic screening for Syphilis
• STI services for men and clients of CSWs
• Prepackage therapy for drug stores/pharmacies

----------------------------------------------------------------------------------------------------------------

112

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