HIV and STIs

Question 1

HIV Transmission

Answer 1

Bodily fluids: blood, breast milk, semen, vaginal fluids
Blood: needle stick, contaminated surgical equipment
Sex = biggest mode of transmission
MTCT (Mother to child transmission)

Question 2

Trends of HIV epidemiology

Answer 2

initially lots of people dying & lots of cases then peak 1990s/early 2000s then started to drop off due to effectiveness of treatment etc. (but on a graph number of people living with hiv going up (because people are living – not dying). Number of cases decreasing (partly because viral load is decreasing due to treatment so less infectious (U=U etc.))

Question 3

Scale of HIV
(How many new cases, how many total, how many deaths)
worldwide

Answer 3

1.5 million new infections 2021
38.4 million people living with HIV 2021
650,000 AIDS related deaths 2021

Question 4

Globally where are the most cases

Answer 4

Eastern & Southern Africa
Western & Central Africa
Southern Asia

Question 5

Stages of HIV epidemic

Answer 5

Nascent: <5% Prevalence in all risk groups
Concentrated: >5% prevalence in one or more risk group
Generalised >5% prevalence in general population

Question 6

What does who is most likely to be infected depend on

Answer 6

Where you are in the world and what stage the pandemic is in that area
E.g. in areas where epidemic is nascent or concentrated –> highest prevalence is in risk groups. Whereas in areas where HIV is endemic: more of the burden is in the heterosexual community

Question 7

High risk groups for HIV

Answer 7

Sex workers
IVDU
Migrants from endemic countries
MSM
Clients of sex workers
Transgender women

Question 8

Where do HIV cases come from UK (historically and now)

Answer 8

Initially cases were imported.
Now roughly 50% imported & 50% home grown

Question 9

What percentages of cases are in high risk groups in Europe compared to E&S Africa

Answer 9

Europe: 99% infections in high risk groups
Eastern & Southern Africa: 25% in high risk groups - most cases in general population

Question 10

What stage of the HIV Epidemic is the UK in

Answer 10

Concentrated phase

Question 11

What is the UK prevalence of HIV
(& rough african)

Answer 11

UK: 0.2%
Some African Countries: 20%

Question 12

Goals of HIV testing services

Answer 12

• Provide a high quality service for identifying HIV
• HIV treatment
• HIV Care
• HIV Support
• Prevent Transmission (PMTCT - prevention of mother to child transmission; VMMC - voluntary medical male circumcision; PrEP; PEP

Aim to close the gap and get people on ART asap

Need to identify high risk groups e.g. TB patients

Question 13

5 Cs of WHO HIV Testing Services

Answer 13

Consent (for testing, treatment etc. - don’t force people)
Confidentiality
Counselling (psychological trauma, often get diagnosed with multiple diseases at once e.g. TB & HIV)
Correct test results
Connection /linkage to prevention, care & treatment - no point testing if not going to treat

Question 14

What is the new focus to address the HIV testing gap

Answer 14

Emphasis on quality, efficiency, yield & linkage
o Improving quality to prevent misdiagnosis
o Getting testing out into communities
o Supporting better linkage
o Better focus and appropriate targeting.

Question 15

Common reasons for HIV misdiagnosis

Answer 15

Clerical/technical errors (mislabelling, poor records etc.)
User error (of tests)
Cross reactivity (antibodies from intercurrent infection, late stage AIDS etc.)
Incorrect/suboptimal testing strategy
Poor management & supervision

Question 16

How to test for HIV

Answer 16

combination of rapid diagnostic tests (RDTs) and/or enzyme immunoassays which, when used together, achieve at least a 99% positive predictive value.

Question 17

How many HIV tests to do in lower burden countries

Answer 17

Lower burden = <5% prevalence
3 consecutive reactive tests

Question 18

How many HIV tests to do in high burden countries

Answer 18

High burden = >5% prevalence
2 consecutive reactive tests

Question 19

How to get testing out into communities

Answer 19

Rapid diagnostic tests (finger prick)
Lay testers & task shifting
Self testing
Home, mobile & outreach testing (moonlight testing, schools, workplaces, religious facilities etc.)
Rapid tests in shopping centres etc.
Occupational health
Screening for pregnant women

Question 20

HIV Testing: linkage to care and prevention

Answer 20

Don’t just test: if positive counselling & linkage to treatment
If negative: link to prevention services - condoms etc.

Question 21

Who are the key populations to target for HIV testing

Answer 21

o Pregnant women
o Couples & partners
o Men
o Infants, children, adolescents
o TB
o Sex workers
o IVDU
o MSM
o Transgender people

Question 22

How else to target key populations HIV testing

Answer 22

HIV partner services: couples/contacts testing & counselling
Facility based HIV testing services – entry via HIV and ART services – test for TB. And entry via TB services – test for HIV etc.
(&STI, Hepatitis, Antenatal)

Question 23

How to address HIV (generally)

Answer 23

Regular STI testing (STIs all augment each other)
Education - condoms, awareness etc.
PrEP & PEP
Address stigma
Outreach programmes for risk groups

Question 24

Should a HIV positive mother breast feed

Answer 24

Risk of transmission from mother to child while breast feeding.
But in many LMICs the risks of not breast feeding are really high: malnutrition, immune system etc.
Best practice: treat mother with ARTs so U=U and baby safe for breastfeeding

Question 25

Can HIV be transmitted on saliva

Answer 25

No/very low. Don't need to worry about contaminated utensils etc.

Question 26

Strategies for preventing HIV transmission

Answer 26

- PrEP - Blood supply screening - Condoms - Education/behaviour modification - Clean syringes - Treatment/prevention of drug/alcohol abuse - Microbicides - STI treatment - Medical male circumcision - Treatment as prevention - HIV testing/counselling - PMTCT

Question 27

Most effective --> least effective HIV prevention strategies

Answer 27

ART PrEP VMMC STI treatment Microbicide HIV vaccine

Question 28

Issues with condoms

Answer 28

Only work if used properly - before any sexual contact Need to challenge cultural norms: "doesn't feel as good with a condom etc." (and can be difficult to get condoms)

Question 29

Other risk factors for HIV

Answer 29

Sexual violence

Question 30

Why does circumcision work

Answer 30

*By removing foreskin, circumcision reduces the ability of HIV to penetrate due to keratinization of the inner aspect of the remaining foreskin. * The inner part of the foreskin contains many Langherhans cells, that are prime targets for HIV. Some of these are removed with the foreskin. * Ulcers, characteristic of some STI’s that can facilitate HIV transmission, often occur on the foreskin. By removing the foreskin, the likelihood of acquiring these infections is reduced. * The foreskin may suffer abrasions or inflammation during sex that could facilitate the passage of HIV.

Question 31

How to prevent HIV transmission through IVDU/syringes

Answer 31

Needle & syringe programmes Drug dependency treatment - in particular opioid substitution therapy Close compulsory drug detention & rehab centres Management of TB & viral hep Clean syringes Discourage needle sharing

Question 32

How to reduce MTCT of HIV

Answer 32

Comprehensive antenatal HIV screening & appropriate ART HIV retesting during 3rd trimester Encourage breastfeeding

Question 33

What are the 'rules' of ART

Answer 33

3 drugs - minimises risk of resistance Start early Adherence - if don't = resistance issues & not U=U AE & interactions CD4 & VL response Timely 2nd line treatment options

Question 34

What makes ART delivery challenging

Answer 34

It is human resource driven - countries with a shortage of HCPs struggle Price of ART can also be prohibitive

Question 35

HIV & TB

Answer 35

1/3 of AIDS deaths were due to TB in 2018 HIV makes TB worse and vice versa & makes you more likely to get it Higher risk of drug resistance

Question 36

How to prevent comorbidity in HIV

Answer 36

- All chronic diseases of age are more common in HIV (especially now as living longer) - Management of comorbidities is usually the same - But diagnostic overshadowing: HCPs attribute all symptoms of a HIV positive patient to their HIV and don’t investigate – so other conditions are underdiagnosed and undertreated. - Drug to drug interactions can also be an issue.

Question 37

Summary Exam Q: how to mitigate the impact of HIV

Answer 37

(Would need to go into more detail, but main points): - Preventing advanced disease (Robust HIV testing services) - Preventing transmission (Multifaceted approach) - Preventing advanced disease (ART access and delivery) - Preventing opportunistic disease (Screening) - Preventing co-morbidity (Integrated NCD diagnosis and management)

Question 38

What STIs have recently been emerging

Answer 38

Mpox Shigella sonnei (MSM) Neisseria meningitidis Ebola virus Zika virus

Question 39

List 13 common STIs

Answer 39

Chlamydia Gonorrhoea Syphilis Trichomonas Vaginalis (TV) Mycoplasma Genitalium Chancroid Donovanosis HSV (cold sores) HPV Hep A,B,C HIV

Question 40

Why are STIs increasing

Answer 40

People are no longer so scared of HIV so don't bother with condoms - because HIV treatment has been so successful

Question 41

How many STIs acquired daily worldwide

Answer 41

> 1 million (most asymptomatic)

Question 42

What are the top 4 most common STIs

Answer 42

Chlamydia, Gonorrhoea, Syphilis, Trich (all curable) (these are the only curable?)

Question 43

Prevalence of genital HSV 1 infection

Answer 43

>500 million people aged 15-49 globally

Question 44

What % of 4 main curable STIs are in developing countries

Answer 44

75-85%

Question 45

Relationship between STIs and HIV

Answer 45

Facilitiates HIV transmission Contributes to high HIV prevalence

Question 46

Impact of STIs

Answer 46

Huge impact on reproductive and child health (and ultimately total physical health)

Question 47

What helps drive the STI epidemic

Answer 47

- Poor sexual education - Lack of access (to testing, treatment etc.) - Poverty/social deprivation - Migration & displacement – wars, labour, natural disasters - Rapid urbanisation with the sociocultural changes that come with that (husband moves to city etc  casual sex outside of relationship) - Economic and political instability  war - Early sexual debut - Multiple and concurrent partners - Absence of visible symptoms - Unprotected sex - Substance misuse – leads to increased risk taking - High prevalence of antimicrobial resistance for some pathogens (e.g. gonorrhoea superbug a few years ago) - Lack of public awareness - Lack of training of health workers - Long-standing widespread stigma. - Sex tourism. - Religion – shame etc.

Question 48

Why are adolescents/young adults particularly at risk of STIs

Answer 48

- more likely to have multiple sexual partners - may have difficulty using barrier protection - may be more likely to have higher risk partners & take higher risk behaviours - may have less access to STI care

Question 49

Reasons for low access to STI care in some young people

Answer 49

- Lack of awareness - Non disclosure of sexual activity (don't want to tell parents etc.) - fear of being found out by parents - Restrictive policies of clinics (needing parental accompanyment etc.) - Lack of money to pay for care

Question 50

% asymptomatic chlamydia

Answer 50

70% women 50% men Asymptomatic cases help drive the epidemic

Question 51

Universal risk factors for STIs

Answer 51

several partners frequent partner change unprotected sex

Question 52

Consequences of poor sexual health

Answer 52

Poor reproductive & maternal health (infertility, PID, ectopics) MTCT Anogenital cancers (HPV) Transmission of HIV HepB

Question 53

Consequences of MTCT of STIs

Answer 53

Eye infections (Chlamydia & gonorrhoea) can cause blindness Sepsis Stillbirth Low birth weight neonatal death Prematurity Congenital deformities (congenital syphilis)

Question 54

How much does an untreated STI increase risk of acquiring & transmitting HIV

Answer 54

Up to 10 times increased risk

Question 55

STI trend in UK today

Answer 55

Diagnosis of STIs on the increase Highest among young people, some minority ethnic groups & MSM Recent rise in >45s

Question 56

Why has there been a rise in STIs in >45s UK

Answer 56

Online dating – increasing access to different pools of people STIs such as syphilis weren’t an issue when currenet >45s were younger – so lack of knowledge/awareness – not taking preventative steps

Question 57

Which vulnerable groups & why do STIs disproportionately effect

Answer 57

Young people Minority ethnic groups Those effected by poverty & social exclusion IVDU Sex workers & their contacts MSM Big role of culture/religion/stigma – young people not being able to buy condoms etc.

Question 58

Primary prevention of STIs

Answer 58

Counselling & behavioural interventions & education Barrier methods Interventions targeted at high risk groups Immunisation (Trials ongoing for pre/post EP Abx for STIs (not HIV)

Question 59

What dont condoms protect against

Answer 59

STIs that cause extra genital ulcers (syphilis or genital herpes) or HPV

Question 60

What STIs can be immunised against

Answer 60

Hep A (not routine except for high risk e.g. MSM for STIs) Hep B (MSM, Sex workers and their contacts, IVDU & contacts, people from high risk areas & their contacts (Africa, Asia, Far East, Eastern Europe) HPV MPox

Question 61

Primary prevention of HIV

Answer 61

PrEP PEP TasP (treatment as prevention) PMTCT Male circumcision Tenofovir gel

Question 62

How to take PrEP

Answer 62

take before exposure reduces risk of being infected if exposed Can be taken on an event basis or daily

Question 63

How to take PEP

Answer 63

Short course of HIV meds taken within 72 hours of possible exposure Continued for 28 days

Question 64

What is TasP

Answer 64

Treatment as Prevention (for HIV) Start treatment asap after diagnosis to ensure viral load remains undetectable U=U

Question 65

How to do PMTCT

Answer 65

all pregnant women offered STI screening at antenatal booking. All HIV positive pregnant women are treated with HIV medication as soon as possible to ensure viral load is undetectable at the time of delivery and therefore reduce the risk of infection.

Question 66

Who does male circumcision help

Answer 66

Reduces risk of female to male transmission (by up to 60%) and provides protection against some other STIs e.g. HSV & HPV

Question 67

Does Tenofovir gel work?

Answer 67

when used as a vaginal microbicide, has had mixed results in terms of the ability to prevent HIV acquisition, but has shown some effectiveness against HSV-2

Question 68

Purpose of secondary prevention

Answer 68

to identify & detect disease in its earliest stages before it becomes noticable

Question 69

Secondary prevention for STIs

Answer 69

STI Screening HIV testing (universal testing: sexual health clinics, antenatal clinics, GP practices where prevalence >2%, sometimes ICU/AE) Integrating STI services into existing services (reproductive health, for new GP registrants) National screening programmes e.g. o National Chlamydia Screening Programme

Question 70

tertiary prevention of STIs

Answer 70

prompt and effective treatment (to cure disease, to prevent & limit complications/sequale, to prevent transmission) Single dose regiments if possible to aid treatment compliance

Question 71

What is a syndromic approach to STI treatment When & why is it useful

Answer 71

Treatment based on constellation of clinical signs and symptoms – rather than actual diagnosis Used in resource poor settings Pragmatic: doesn't require lab facilities, patients are treated at time of visit so not lost to follow up, all major pathogens are treated - avoiding missed treatment due to false negatives

Question 72

How to prevent reinfection of STIs

Answer 72

o Abstinence until completion of treatment o Identification and treatment of all sexual contacts (as far as is possible)

Question 73

Aims/objectives of STI surveillance

Answer 73

Integral part of STI control programmes Must be actively conducted, be purposeful and result in PH action. AIMS: o To obtain information on the burden of STIs in the population o To determine and describe the demographic and geographical distribution of STIs o To compare the situation and trends in different demographic and geographical situations

Question 74

Components of STI surveillance

Answer 74

STI case reporting (etiologic or syndromic) STI Prevalence assessment & monitoring (sentinel surveillance) Specific activities (lab assessment of AMR, validation of syndromic management, required reporting e.g. resistant gonorrhoea. Other: special surveys/studies e.g. behavioural surveillance

Question 75

Examples of STI surveillance programmes UK

Answer 75

GRASP (gonoccocal AMR) Enhanced Laboratory Surveilllance for Infectious Syphilis Programme HARS: HIV and AIDS reporting system Voluntary lab reporting PHE reference lab - syphilis

Question 76

What does HARS (HIV and AIDS Reporting System) aim to do

Answer 76

 reduce the reporting burden for reporting sites  increase the efficiency of HIV surveillance  enhance standard HIV surveillance outputs  produce quality of care indicators  directly support commissioning services

Question 77

Objectives of STI surveillance

Answer 77

o Estimate the STD problem's magnitude; define needed resources, raise awareness and gather support o Measure frequency, distribution and antimicrobial sensitivity; define and monitor procedures o Monitor trends, reinforce political support, monitor and improve the existing programs

Question 78

STI control in resource poor settings

Answer 78

- promotion of safe sex & primary prevention - Condom programming (promotion, supply & distribution) - Promotion of healthcare seeking behaviour - integration of STI prevention & care into other programmes (primary care, antenatal etc.) - comprehensive STI case management (syndromic approach) - specific services for high risk populations - prevention & care of congenital syphilis & conjunctivitis (often not thought about, mum not swabbed etc.) - Early detection of symptomatic and asymptomatic infections

Question 79

Why do STI control programmes often fail in developing countries

Answer 79

o Low priority for policy makers & planners for resources because perceived to result from discreditable behaviour o Failure to recognise the magnitude of problem o Failure to associate diseases with serious complications o Control efforts concentrated on symptomatic patients (usually men) and failing to identify asymptomatic individuals (commonly women) until complications develop o Lack of simple screening tests for cervical infections that could be used to screen women attending family planning, antenatal, or maternal and child health clinics o Service delivery through specialised STI healthcare facilities which provide inadequate coverage and tend to confer stigma o Treatment strategies focused on unrealistic requirements for definitive diagnosis rather than on practical decision making o Ineffective low cost antibiotics continuing to be used for reasons of economy o Little emphasis on educational and other efforts to prevent infection occurring in the first place, especially among adolescents in and out of school o Absence of authoritative guidance on a rational, practical, and well-defined package of activities for prevention and care programmes o Lack of attention to structural issues which impact STI transmission (poverty, literacy, conflict, repression of homosexuality and prostitution, societal attitudes to marginalised communities)