Most common STI
Chlamydia
Impact of STI highest in
Heterosexuals under 25
MSM
Black ethnic minorities
Largest STI diagnosis increase in MSM
Syphilis up 20%
Gonorrhoea up 22%
Chlamydia Trachomatis
Obligate intracellular pathogen
Asymptomatic infection common
Serovar
Distinct variation within species of bacteria or virus
Chlamydia Serovars D-K
Most UTIs
Males- urethritis, epididymitis, prostatitis
Females- Cervicitis, PID, Fitz-Hugh Curtis
Neonate- conjunctivitis and pneumonia
Chlamydia Servars L1-3
Lymphogranuloma venerum
–> buboes, proctitis (inflammation of lining of rectum)
Chlamydia trachomatis complications
Reactive arthritis
Infertility
Chlamydia trachomatis treatment
Doxycyline
Azithromycin
Neisseria gonorrhoea- Males
Urethritis Proctitis Sore throat Epididymitis Prostatitis
Neisseria gonorrhoea- Females
Cervicitis
PID
Peri-hepatitis
Septic abortion
Neisseria gonorrhoea- Neonates
Conjunctivitis
Neisseria gonorrhoea- complications
Septic arthritis
Blindness
Infertility
Septicaemia
Neisseria gonorrhoea- management
Ceftriaxone
–> drug resistance increasing
Genital warts
HPV
90% asymptomatic
Multiple sites
Some associated with carcinoma (16,18,31,33)
Increasing incidence ano-genital and oropharyngeal carcinoma
Vaccination
Genital warts management
Topical podophyllotoxon
Imiquimod
Cryotherapy
Herpes Simplex Virus 1 + 2
HSV-1 = Oral HSV-2 = Genital Primary infection Latency Reactivation
Herpes simplex virus 1+2- management
Aciclovir
Famciclovir
Valaciclovir
Syphilis bacteria
Treponema pallidum
Gram negative spirochete bacterium
Treponema pallidum
Primary, secondary, latent, tertiary, congenital
Often asymptomatic in early stages
Diagnosis depends on serology
Syphilis treatment
Penicillin
Doxycycline
Primary Syphilis
Chancre (sore) usually single, painless Dark ground positive Lymphadenopathy Serology may be negative Infectious ++
Secondary Syphilis
Rash Fever Lymphadenopathy Condyloma lata Serology positive Infectious ++
HIV Routine testing
GUM, Ante-natal, TOP, DDU
New registrations in GP and medical admissions in areas where high prevalence
HIV Opportunistic testing of individuals at high risk
STI MSM HIV + partner IDU High prevalence country
HIV Diagnostic testing with indicator clinical conditions
TB/lymphoma
Primary HIV infection
Acute retroviral syndrome
75% patients develop symptoms within 2-6 weeks of infection
Wide differential diagnosis- glandular fever, flu
Increased viral replication
Decreased CD4 count
Time of high risk of transmission
May be HIV antibody negative
HIV antibody
Primary HIV infection may be HIV antibody negative
HIV RNA/p24 antigen positive
HIV antibody can take up to 3 months to become positive
Primary HIV 1 infection Common features
Headache Lymphadenopathy Pharyngitis Nausea Oral/genital ulceration on occasion Rash Myalgia Fever Fatigue Weight loss Night sweats
HIV causing disease
Infects CD4+ cells, macrophages and dendritic cells
Acute (primary) HIV infection leads to massive CD4+ cell loss
Chronic HIV infection associated with on-going CD4+ cell loss, decline in immune function and progressive immunosuppression
HIV-associated disease- Direct HIV effect
Wasting
Diarrhoea
Neurological problems
HIV-associated disease- Opportunistic infections
Viral Fungal Bacterial Mycobacterial Parasitic INFECTIONS
HIV-associated disease- Malignancies
Kaposi’s sarcoma- affects lining of blood vessels, often appears as skin lesions
Lymphoma
Carcinoma cervix
CD4 count >500
Low risk HIV-related disease
CD4 count 350-500
Symptomatic HIV disease possible
CD4 count <200
Risk PCP, gut infections
CD4 count <100
CMV, MAI, crypto, toxo, KS
Aims of antiretroviral therapy
Suppression of HIV replication –>
CD4 count recovery –>
Immune reconstitution –>
Long term reduced risk of morbidity and mortality
Antiretroviral Therapy Principles
HAART= highly active antiretroviral therapy
6 classes of ARV drugs available
Act during viral replication cycle to prevent production of new HIV particles
Combination antiretroviral therapy always
At least 3 drugs from at least two classes –> usually 2 NRTIS + NNRTI or PI
Lifelong treatment
Adherence vital for success –> resistance can develop quickly, and can be transmitted
Antiretroviral therapy Drugs
At least 3 drugs from at least 2 classes
Usually 2 NRTIS + NNRTI or PI
NRTI
Nucleoside Reverse transcriptase inhibitors
Lamivudine
Stops RNA synthesis
NNRTI
Non-nucleoside reverse transcriptase inhibitors
Nevirapine
Stops RNA synthesis
PI
Protease inhibitors
Ritonavir
Stops virus protein being cut up
Types of antiretroviral drugs
Fusion inhibitor Co-receptor antagonist Nucleoside reverse transcriptase inhibitor Non-nucleoside RT inhibitor Integrase inhibitor Protease inhibitor
Short term SEs HAART
Nausea/vomiting/headache Sleep disturbance (efavirenz)
Long term SEs HAART
Lipodystrophy (NRTIs + PIs) Renal dysfunction (tenofovir) Peripheral neuropathy (d4T, AZT, DDI) Lactic acidosis- may be fatal (d4T, DDI)
Problems with HAART
Long + short term side effects
IRIS- paradoxical inflammatory reaction to pathogen
Drug interactions
Complex regimens/polypharmacy
PEP/ PEPSE + PrEP
Indications --> High risk sexual exposure <72 hours --> Needlestick Available via virology/GUM/A+E PrEP- safe and efficacious
HIV management pregnancy
Early HIV screening
ARVT for mother- immediate + continued if low CD4, 2nd trimester + discontinued if high CD4
Elective C section- vaginal delivery possible if undetectable HIV load
ARVT for infant
No breastfeeding
–> Reduced risk of transmission from 25 to less than 1%