Republic of Namibia

Ministry of Health and Social Services

GUIDELINES FOR THE

MANAGEMENT OF
SEXUALLY TRANSMITTED
INFECTIONS

Third Edition, 2023

Directorate: Special Programme
Division: HIV/STI
Email: hivaids@[Link]
Tel: +264 61 203 2858
Fax: +264 61 300539

Inquiries: hivaids@[Link]
 Guidelines for the Management of Sexually Transmitted Infections

FOREWORD

Sexually Transmitted Infections (STIs) continue to be a significant public

health challenge in Namibia, and the burden of these infections contributes
to increased cases of HIV transmission. The updated guidelines have been
developed to provide evidence-based recommendations for the prevention
and management of STIs. They provide a much-needed update to the 2009
guidelines, reflecting the latest scientific evidence and global best practices
in STI prevention and management.

Namibia has been managing STIs using the syndromic management strategy, in line with
the recommendations of the World Health Organization (WHO). This approach has proven
effective within our healthcare system, and the current guideline aims to further enhance
its efficacy. However, recent scientific evidence has indicated that some individuals
may have asymptomatic infections, which cannot be effectively addressed through the
syndromic approach alone. To address this challenge, the updated guideline introduces a
hybrid model that combines syndromic management with aetiological management where
appropriate and possible.

These revised guidelines have been produced based on global etiological data on the
antimicrobial resistance of organisms causing STIs. It is expected that health workers
working at all levels of the healthcare delivery system are familiar with the updated
recommendations so that they use them in a range of situations. These guidelines will be a
helpful planning tool for program coordinators at all levels of the health system.

I am confident that these guidelines will prove to be an invaluable resource for healthcare
professionals working in Namibia and will contribute to reducing the burden of STIs in the
country. I applaud the Namibian Ministry of Health and Social Services and all those who
contributed to the development of these guidelines for their commitment to improving the
health and well-being of the Namibian people.

Hon. Dr. Kalumbi Shangula, MP

Minister

i
Guidelines for the Management of Sexually Transmitted Infections

PREFACE
Sexually transmitted infections (STIs) are a global health threat. The World
Health Organization (WHO) estimates that over 1 million STIs are contracted
every day worldwide. Most infections are asymptomatic. Annually, 374 million
people contract one of the four curable STIs—gonorrhoea, syphilis, chlamydia,
or trichomoniasis. STIs have many complications. Human papillomavirus (HPV) causes
cervical and other anogenital malignancies. HPV is estimated to cause 311 000 cervical
deaths annually in the world. In 2020, there were 604 000 cervical cancer cases and 342
000 deaths. The transmission of STIs from mother to child during pregnancy has been
linked to several negative outcomes, including stillbirth, neonatal mortality, low birth weight,
preterm delivery, sepsis, newborn conjunctivitis, and congenital abnormalities. Gonorrhoea
and chlamydia are the primary causes of pelvic inflammatory disease (PID) and infertility in
women, and all STIs enhance the risk of HIV acquisition. Hepatitis B is estimated to cause
820 000 deaths every year globally, mostly due to cirrhosis and hepatocellular carcinoma.

An unpublished program report found 25 854 vaginal discharge cases and 8 494 PID cases
in Namibian women of all ages in 2021/2022. The same report indicates that 7 349 vaginal
ulcers and 29 787 urethral and vaginal discharges in men and women of all ages. Although
there was antimicrobial resistance (AMR) data obtained from the Namibia Institute of
Pathology (NIP) and Pathcare, the data were not sufficient to give a clear picture of the state
of AMR to STI-causing organisms in Namibia. AMR of STIs, especially in gonorrhoea, has
increased dramatically globally, limiting treatment choices. The Gonococcal AMR Surveillance
Programme (GASP) found high resistance to quinolones, azithromycin, and extended-
spectrum cephalosporins. In 2017–2018, Neisseria gonorrhoeae showed decreasing
susceptibility or resistance to ceftriaxone in 31% of 68 reporting countries, cefixime in 47%
of 51 reporting countries, azithromycin in 84% of 61 reporting countries, and ciprofloxacin in
all 70 countries.

The global rise of AMR, especially in Neisseria gonorrhoeae, and changes in the epidemiology
of STIs, HIV, and STI prevention, diagnosis, and treatment necessitated the revision of the
previous guidelines. The updated guidelines aim to improve STI management, control, and
prevention in Namibia by equipping healthcare workers with the knowledge to provide primary
prevention of STIs to all patients seeking sexual and reproductive health (SRH) services.

Several organizations and individuals contributed to these guidelines. The Ministry of Health
and Social Services (MoHSS) thanks the Directorate of Special Programmes, in particular the
HIV/STI subdivision, the lead consultant, the STI Technical Working Group (TWG), the NIP,
the DREAMS Project funded by PEPFAR/USAID and implemented by Project HOPE Namibia,
I-TECH Namibia, IntraHealth Namibia, CDC, WHO, and USAID for their support.

Mr Ben Nangombe
Executive Director

ii
 Guidelines for the Management of Sexually Transmitted Infections

Table of Contents
Foreword...................................................................................................................................................... i
Preface...........................................................................................................................................................ii
Table of Contents............................................................................................................................... iii
Abbreviations and Acronyms.................................................................................................... v
Summary of Key changes in the New Guidelines....................................................... vi

1. Introduction..........................................................................................................................................1
1.1 Epidemiology and burden of stis....................................................................................................... 1
1.2 Rationale for updating the 2009 sti National Guidelines.............................................................. 2
1.3 Complications of stis........................................................................................................................... 2
1.4 Interaction of hiv and stis.................................................................................................................. 3

2. Comprehensive case management of stis....................................................................5

2.1 Primary prevention of stis................................................................................................................... 5
2.1.1 Social and Behaviour Change communication (sbcc)........................................................ 5
2.1.2 Pre-exposure vaccination........................................................................................................... 5
2.1.3 Male and female condoms......................................................................................................... 5
2.1.4 Voluntary Male Medical Circumcision (vmmc)..................................................................... 5
2.1.5 Pre-exposure prophylaxis for HIV............................................................................................. 5
2.1.6 Post-Exposure Prophylaxis (pep) for HIV and STIs.............................................................. 5
2.1.7 Treatment as prevention............................................................................................................. 5
2.2 Case management of people with stis............................................................................................. 5
2.2.1 Case management of people with asymptomatic stis....................................................... 7
2.2.2. Case management of people with symptomatic syndromic management of stis... 16
2.3 Flowcharts in the management of stis..........................................................................................19

3. Management of sti-associated syndromes.............................................................20

3.1 Urethral discharge syndrome (uds).................................................................................................20
3.2 Vaginal discharge syndrome.............................................................................................................23
3.3 Pelvic inflammatory disease..............................................................................................................29
3.4 Anorectal discharge syndrome (ads)..............................................................................................32
3.5 Genital ulcer disease (gud)...............................................................................................................34

4. Management of stis not presenting with syndromes................................... 38

4.1 Epididymo-orchitis...............................................................................................................................41
4.2 Inguinal Bubo........................................................................................................................................42
4.3 Genital Scabies.....................................................................................................................................43
4.4 Pediculosis Pubis.................................................................................................................................43
4.5 Balanitis/Balanoposthitis...................................................................................................................43
4.6 Screening and Management of Syphilis..........................................................................................44
4.7 Human Papillomavirus (hpv) infection...........................................................................................46

iii
Guidelines for the Management of Sexually Transmitted Infections

4.7.1 Genital Warts...............................................................................................................................46

4.7.2 Hpv and Cervical cancer..........................................................................................................47
4.8 Hepatitis b virus (hbv).......................................................................................................................49

5. Considerations for special populations................................................................50

5.1 Neonatal Conjunctivitis.......................................................................................................................52
5.2 Neonatal Herpes...................................................................................................................................52
5.3 Syphilis in pregnancy...........................................................................................................................54
5.4 Congenital Syphilis...............................................................................................................................55
5.5 Stis in Children and Adolescents.....................................................................................................55
5.6 Preventing Stisin case of Sexual Assault.......................................................................................56

6. Surveillance, research needs, and practical considerations........... 58

6.1 Surveillance and Research needs.....................................................................................................58
6.2 Monitoring and Evaluation of STI programs...................................................................................59
6.3 Minimum requirements for sti management in a Healthcare facility......................................61

7. Bibliography...................................................................................................................................... 63

8. Annexes.................................................................................................................................................. 65
8.1 Annex 1: Specimen collection procedures for sti testing...........................................................65
8.2 Annex 2: Common STI syndromes and their causes and Recommended treatment........... 67
8.3 Annex 3: Main sti pathogens, and treatment-paediatric doses................................................68
8.4 Annex 4: Oral desensitisation procedure for patients with proven allergy to Penicillin......... 69
8.5 Annex 5: Photographs of Sexually Transmitted Infections.........................................................70
8.6 Annex 6: Acknowledgement List.......................................................................................................72

iv
 Guidelines for the Management of Sexually Transmitted Infections

ABBREVIATIONS AND ACRONYMS

ADS Anorectal Discharge Syndrome TPHA Treponema Pallidum

AIDS Acquired Immunodeficiency Hemagglutination Assay
Syndrome UDS Urethral Discharge Syndrome
AMR Antimicrobial Resistance VDS Vaginal Discharge Syndrome
ART Antiretroviral Therapy VMMC Voluntary Medical Male Circumcision
BD Twice a day VVC Vulvovaginal candidiasis
BV Bacterial Vaginosis WLHIV Women living with HIV
CNS Central Nervous System
CS Congenital Syphilis
CSF Cerebrospinal Fluid
CT Chlamydia Trachomatis
DNA Deoxyribonucleic Acid
EPT Expedited Partner Treatment
GUD Genital Ulcer Disease
HBV Hepatitis B Virus
HIV Human Immunodeficiency Virus
HIVST HIV Self-Testing
HPV Human papilloma Virus
HSV-1 Herpes Simplex Virus type 1
HSV-2 Herpes Simplex Virus type 2
HTS HIV Testing Services
IM Intramuscular
IV Intravenous
MCS Microscopy, culture, and Sensitivity
MG Mycoplasma genitalium
MoHSS Ministry of Health and Social Services
MSM Men who have sex with men
MU Mega Units
NG Neisseria Gonorrhoeae
PCR Polymerase Chain Reaction
PEP Post-exposure prophylaxis
PID Pelvic Inflammatory Disease
PLHIV People Living with HIV
PrEP Pre-exposure Prophylaxis
PoC Point of Care
QID Four times a day
RNA Ribonucleic Acid
RPR Rapid Plasma Reagin
SBCC Social and Behaviour Change
Communication
SRH Sexual and Reproductive Health
STAT Take immediately
TDS Three times a day

v
Guidelines for the Management of Sexually Transmitted Infections

SUMMARY OF KEY CHANGES IN THE

NEW GUIDELINES
Syndrome/condition Old Guidelines New Guidelines
Urethral Discharge Cefixime 400mg PO, STAT OR Ceftriaxone 1g IM single dose AND
Syndrome Ceftriaxone 250mg IM STAT, Doxycycline*100mg PO, BD for 7 days.
AND Alternative to ceftriaxone is cefixime
Azithromycin 1g PO, STAT, 800mg PO, STAT.
AND Metronidazole 2g PO, STAT *Azithromycin 1g PO, STAT to be used in
doxycycline allergy.
Metronidazole 2g PO, STAT to be given
if persistent/recurrent symptoms
Vaginal Discharge Patient not sexually active in the Patient not at high risk of endocervical
Syndrome last 3 months and has no other risk infection caused by N. gonorrhoeae
factors for STIs: and/or C. trachomatis or speculum
Metronidazole 2g PO, STAT AND examination not showing signs of
Clotrimazole vaginal pessary 500mg cervicitis:
inserted immediately as a single dose Metronidazole 400mg PO, BD for 7
PLUS Clotrimazole vaginal cream days AND Clotrimazole vaginal pessary
locally BD for 7 days. 500mg inserted immediately as a single
Patient sexually active and has other dose PLUS Clotrimazole vaginal cream
risk factors for STIs: locally BD for 7 days.
Cefixime 400mg PO, STAT OR Patient at high risk of endocervical
Ceftriaxone 250mg IM, STAT AND infection caused by N. gonorrhoeae
Azithromycin 1g PO, STAT, AND and/or C. trachomatis or speculum
Metronidazole 2g PO, STAT AND examination showing signs of
Clotrimazole vaginal pessary 500mg cervicitis:
inserted immediately as a single dose Ceftriaxone 1g IM single dose AND
PLUS Clotrimazole vaginal cream Doxycycline*100mg PO, BD for 7 days
locally BD for 7 days (Maximum 2 AND Metronidazole 400mg PO, BD
weeks). for 7 days AND Clotrimazole vaginal
pessary 500mg inserted immediately as
a single dose PLUS Clotrimazole vaginal
cream locally BD for 7 days (Maximum
2 weeks).
Pelvic Inflammatory Ceftriaxone 250mg IM single dose AND Ceftriaxone 1g IM single dose AND
Disease (PID) Doxycycline*100mg PO, BD for 14 days Doxycycline*100mg PO, BD for 14 days
AND Metronidazole 400mg PO, BD for AND Metronidazole 400mg PO, BD for
7 days 14 days
Alternative to doxycycline is In Doxycycline allergy use Erythromycin
Azithromycin 1g PO, weekly for 2 500mg PO, QID for 14 days OR
weeks Azithromycin 1g PO, weekly for 2 weeks.
Alternative to ceftriaxone is Cefixime
800mg PO, STAT.
Anorectal Discharge Not included Ceftriaxone 1g IM single dose AND
Syndrome Doxycycline*100mg PO, BD for 7 days.
Add Acyclovir 400mg PO, TDS for 10
days if there is a painful ulcer.
Alternative to Ceftriaxone is Cefixime
800mg PO, STAT.

vi
 Guidelines for the Management of Sexually Transmitted Infections

Genital Ulcer Treatment of patients with vesicles or Treatment of patients with vesicles or
Disease blisters only: blisters only:
Acyclovir 400mg PO, TDS for 7 days Acyclovir 400mg PO, TDS for 10 days
Treatment of patient with ulcer Treatment of patient with ulcer and
Benzathine Penicillin 2.4 MU IM, STAT, partner
PLUS Acyclovir 400mg PO, TDS for 7 Benzathine Penicillin 2.4 MU IM, STAT,
days PLUS Azithromycin 1g PO, STAT. PLUS Acyclovir 400mg PO, TDS for 10
Doxycycline could replace Azithromycin days PLUS Azithromycin 1g PO, STAT.
for partner for 7 days Doxycycline 100mg PO, BD OR
Erythromycin 500mg PO, QID for 14
days can replace Benzathine Penicillin
Treatment of recurrent vesicles
Acyclovir 800mg PO, TDS for 5 days
Suppressive therapy for herpes simplex
Acyclovir 400mg PO, BD for 6-12
months
Epididymo-orchitis Ceftriaxone 250mg IM single dose Ceftriaxone 1g IM single dose AND
AND Azithromycin 1g PO, weekly for 2 Doxycycline 100mg PO, BD for 14 days
weeks OR Doxycycline 100mg PO, BD Add amoxicillin-clavulanic acid
for 14 days 875/125mg PO, BD for 7 days if patient
above 35 years old.
Alternative to Doxycycline is
Erythromycin 500mg PO, QID for 14
days.
Other changes Old Guidelines New Guidelines
Syphilis in RPR done at first antenatal visit RPR done at first antenatal visit and
pregnancy repeated at 34 weeks or first contact
after 34 weeks for those who tested
negative before 20 weeks of pregnancy.
Patient Review On stipulated days following initiation Only if there is no improvement
of treatment.
Partner Patient Referral Patient referral and expedited partner
management treatment where this is feasible.
Primary prevention Not mentioned 200mg Doxycycline after unprotected
of STIs anal sex (within 24 hours and no later
than 72 hours) for high-risk populations
to prevent chlamydia and syphilis.
Screening of Not mentioned Asymptomatic pregnant women, AGYW,
asymptomatic high-risk populations, PLHIV, and people
special populations in correctional facilities and other closed
settings should be screened for certain
STIs at stipulated intervals.
Aetiological Not mentioned Use diagnostic testing, including PoC
diagnosis of VDS testing before treating the patient.

vii
Guidelines for the Management of Sexually Transmitted Infections

1. INTRODUCTION
1.1 EPIDEMIOLOGY AND BURDEN OF STIs

Sexually transmitted infections (STIs) are a major public health issue that affects people’s quality of life
and results in significant morbidity and mortality globally. Pregnant women, adolescent girls, and young
women (AGYW), persons living with HIV (PLHIV), and key and vulnerable groups are disproportionately
affected by STIs. According to the World Health Organization (WHO), there are a total of 374 million new
infections of the four curable STIs- chlamydia, gonorrhoea, syphilis, and trichomoniasis cases reported
every year and STIs including HIV and viral hepatitis account for 2.3 million deaths per year worldwide.
The prevalence of some viral STIs is similarly high, with an estimated 417 million people infected with
herpes simplex virus type 2 (HSV-2), and about 291 million women harbour human papillomavirus
(HPV) at any time. The burden of STIs is greatest in resource-limited countries and the WHO African
region reported the highest numbers of new cases of gonorrhoea and trichomoniasis among women
and men.

When left undiagnosed and untreated, STIs can result in serious complications and sequelae, such as
pelvic inflammatory disease (PID), infertility, ectopic pregnancy, miscarriage, foetal loss, and congenital
infections and cancer. The mental effects of STIs include stigma, shame, and loss of self-worth. STIs
have also been associated with fears of relationship disruption and gender-based violence, thus
undermining effective partner notification.

In Namibia, STIs are reported by symptomatic syndromes and there is no fine age and sex
disaggregation of data. According to the 2021/2022 program report, urethral discharge syndrome
(34%) is the most common reported syndrome, followed by vaginal discharge (30%), other STIs (17%),
Pelvic Inflammatory Disease (10%), and genital ulcer disease (8%). The HIV prevalence among adults
(ages 15-49 years) in Namibia was 12.4% (Men: 8.4%; Female: 15.1%) nationally (Spectrum 2022).
Although there was antimicrobial resistance (AMR) data obtained from the Namibia Institute of
Pathology (NIP) and Pathcare, the data were not sufficient to give a clear picture of the state of AMR
to STI-causing organisms in Namibia. Most HIV infections are transmitted through unprotected sexual
contact. The presence of STIs and having more than one sexual partner are the two most important
factors contributing to the horizontal spread of the virus. Conventional STIs and HIV infection share
similar risk factors and several studies have demonstrated the synergy of the two conditions hence
strengthening STI prevention and control programmes is critical.

Preventing and controlling STIs are considered to be integral parts of comprehensive sexual and
reproductive health (SRH) services and the main method of reducing the impact of STIs is through
effective case identification and management. Most low-to-middle-income countries (LMICs) offer
a syndromic approach to STIs as low-cost, high-quality point-of-care diagnostic tests are not easily
available. However, this approach misses all asymptomatic infections and has suboptimal diagnostic
accuracy, particularly for vaginal discharge syndromes, leading to undertreatment, overtreatment, or
inadequate treatment of patients. Hence, Namibia will employ a syndromic approach together with
the phased introduction of targeted diagnostic testing including point-of-care testing, where resources
permit, to improve case-finding and infection management.

1
 Guidelines for the Management of Sexually Transmitted Infections

1.2 RATIONALE FOR UPDATING THE 2009 STI NATIONAL GUIDELINES

Changes in the global epidemiology of STIs and progress in prevention, diagnosis, and treatment


of STIs and HIV

The global rise in AMR, especially in Neisseria gonorrhoeae necessitates effective treatment
protocols that consider local AMR patterns.
To align the STI national guidelines with the latest WHO and other international organisations’
treatment guidelines.

1) Improved STI control and prevention in Namibia by equipping healthcare workers

with the knowledge to provide primary prevention of STIs to all patients seeking
SRH services.
The revision 2) Rapid, simple, accurate, and cost-effective treatment of patients with STIs and
of the their partners; and appropriate education and provision of combination prevention
guidelines interventions.
will result in: 3) Standardised training and supervision of healthcare providers.
4) Delayed development of AMR.
5) Improved surveillance of STIs.
6) Improved rational drug procurement for the treatment of STIs.
7) Improved linkages to HIV/AIDS prevention, treatment, and care services.

1.3 COMPLICATIONS of STIs

Failure to diagnose and treat STIs in the early stages may result in serious complications. Most
complications are preventable if the STIs are diagnosed and treated early. The most serious health
consequences of STIs, other than HIV/AIDS, tend to occur in women and newborn children. Measures
to prevent mother-to-child transmission of STIs have been judged among the most cost-effective
measures for preventing neonatal morbidity.

COMPLICATIONS COMPLICATIONS COMPLICATIONS OF PSYCHOSOCIAL

IN WOMEN IN MEN MOTHER-TO-CHILD COMPLICATIONS
TRANSMISSION
• Cervical cancer • Urethral stricture • Congenital syphilis • Stigma, shame, and
• PID with resulting and infertility where • Gonococcal infection loss of self-worth
infertility treatment is delayed. of the conjunctiva - a • Fears of relationship
• Chronic lower • HPV-associated anal potentially blinding disruption and
abdominal pain cancer and penile condition, gender-based
• Ectopic pregnancy cancer • Chlamydial violence, thus
and related maternal pneumonia undermining effective
mortality (PID • Perinatal hepatitis B partner notification
increases the risk of infection
ectopic pregnancy by • Sepsis
10-fold) • Low-birth weight and
• Miscarriages prematurity
• Stillbirths • Neonatal death
• Pelvic abscess
• Sepsis

2
Guidelines for the Management of Sexually Transmitted Infections

1.4 INTERACTION OF HIV AND STIs

STIs and HIV Transmission: HIV is a unique STI that is greatly affected by other concomitant “classical”
bacterial and viral STIs that cause genital ulcers and/or mucosal inflammation. STIs also serve as a
marker for risky sexual behaviours. STIs increase the infectiousness of people living with HIV (PLHIV) by
increasing the viral concentration in the genital tract, and by increasing the potential for HIV acquisition
in people at risk for HIV. In addition, some STIs can increase blood HIV concentration and promote the
progression of the disease.

Both ulcerative and non-ulcerative STIs are associated with a several-fold increased risk of
transmitting or acquiring HIV. Infections causing genital ulcers are associated with the highest risk
of HIV transmission. In addition to curable ulcer-causing STIs (such as syphilis and chancroid), highly
prevalent HSV-2 infections substantially increase vulnerability to transmitting and acquiring HIV. Non-
ulcerative STIs, such as gonorrhoea, chlamydia, and trichomoniasis, have been shown to increase HIV
transmission through the genital shedding of HIV.

STIs and HIV in the era of antiretroviral treatment (ART) and Pre-exposure prophylaxis (PrEP): Over
the past decade, the evidence proving that people living with HIV who have undetectable plasma HIV
RNA do not transmit HIV (U=U) and the demonstration that pre-exposure prophylaxis (PrEP) protects
individuals against the sexual acquisition of HIV has altered the dynamics of HIV-STIs epidemiologic
synergy. In the current era, individuals who are adherent to antiretroviral medication, whether for
treatment or prevention, can expect to engage in condomless intercourse without either acquiring HIV
or transmitting the virus to others. The HIV prevention benefits of ART and PrEP are not altered by
concomitant or acquired STIs.

Effects of untreated HIV on STIs: The clinical features of various types of STIs are influenced by co-
infection with HIV in the absence of ART.

STI POSSIBLE ATYPICAL EFFECT OF UNTREATED HIV

MANIFESTATIONS IN UNTREATED INFECTION ON STI TREATMENT
HIV INFECTION
Syphilis •R
 apid progress to neurosyphilis •F
 ailure following a single injection
•M
 ultiple, painful, or atypical lesions of of Benzathine penicillin is increased
● primary syphilis among patients with primary syphilis
Chancroid •M
 ore extensive or multiple lesions • Increased rates of treatment failure
•A
 ccompanied systemic especially when single-dose therapies
●
manifestations such as fever and are given
●
chills.
• Nonreactive
 chancroid with no bubo
formation
HSV •R
 ecurrent or persistent genital ulcers • Severe
 genital herpes may require
(often multiple and extensive) treatment of primary episodes or
●
•E
 xtra-genital or perianal ulceration suppression of recurrence with
acyclovir.
Vulvovaginal •R
 ecurrent disease • Topical
 antifungal drugs are less
Candidiasis (VVC) effective and hence oral drugs like
ketoconazole may be indicated
NOTE: Conventional STI and HIV infection share similar risk factors; conventional STI facilitates the acquisition
and transmission of HIV infection; and effective STI control can help prevent HIV epidemics

3
 Guidelines for the Management of Sexually Transmitted Infections

2. COMPREHENSIVE CASE MANAGEMENT

OF STIs

1) 
Accurate risk assessment and education and counselling of persons at risk
Prevention regarding ways to avoid STIs through changes in sexual behaviours and the use of
and control recommended prevention services.
of STIs are 2) Pre-exposure vaccination for vaccine preventable STIs such as HPV and HBV.
based on the 3) Identification of persons with an asymptomatic infection and persons with
following symptoms associated with an STI.
five major 4) Effective diagnosis, treatment, counselling, and follow-up of persons who are
strategies: infected with an STI.
5) Evaluation, treatment, and counselling of sex partners of persons who are infected
with an STI.

2.1 PRIMARY PREVENTION OF STIs

Primary Prevention of STIs includes the following measures:

2.1.1 Social and Behaviour Change Communication (SBCC)

Social and behaviour change communication goes beneath the surface to address the causes of the
behaviours as well as the social structures that drive the epidemic and the factors that increase risk
and vulnerability. These include:

• Comprehensive sexuality education.

• STI and HIV pre-test information and post-test counselling.
• Safer sex/risk-reduction counselling including correct and consistent use of condoms with
lubricants, and if necessary, discussion around barriers to safe sex, and a reduction in the number
of sexual partners.
• Abstinence from oral, vaginal, or anal sex.
• Education and counselling that is tailored to the needs of the target population, including
adolescents and other high-risk populations.

Refer to the MoHSS guidelines on integrated SBCC strategy for further information.

2.1.2 Pre-exposure vaccination

Pre-exposure vaccination is one of the most effective methods for preventing transmission of HPV and
hepatitis B virus (HBV), both of which can be sexually transmitted.

2.1.3 Male and Female Condoms

Condoms offer one of the most effective methods of protection against STIs, including HIV, when used
correctly and consistently. Female condoms are effective and safe but are not as widely used as male
condoms. Healthcare providers should work with individuals to identify the type of condom (male,
female, or both) that works well for their situations.

4
Guidelines for the Management of Sexually Transmitted Infections

2.1.4 Voluntary Male Medical Circumcision (VMMC)

VMMC reduces the risk of heterosexually acquired HIV infection in men by approximately 60% and
provides some protection against other STIs, such as herpes and HPV.

2.1.5 Pre-exposure prophylaxis for HIV

Comprehensive clinical practice guidelines are available for providers in prescribing PrEP to reduce the
risk of HIV infection (refer to ART guidelines). PrEP has demonstrated safety and efficacy.

2.1.6 Post-exposure prophylaxis (PEP) for HIV and STIs

Guidelines for using PEP aimed at preventing HIV as a result of sexual exposure are available (refer to
ART guidelines). Sexually active persons who frequently use PEP should be counselled on PrEP after
completing their PEP course and testing negative for HIV.

PEP for cases of rape: refer to section 5.6.

STI PEP for high-risk populations

200mg doxycycline after unprotected anal sex (within 24 hours and no later than 72 hours) for some
high-risk populations (MSM and transwomen) to prevent chlamydia and syphilis.

2.1.7 Treatment as Prevention

Patients living with HIV taking ART who maintain an undetectable viral load demonstrated no risk of
transmitting HIV to their HIV-negative sex partners (U=U).

2.2 CASE MANAGEMENT OF PEOPLE WITH STIs

Three approaches to the management of STIs are:

• Aetiological: - where one collects specimens for laboratory identification of causative agents
before treatment.
• Clinical: - where one depends on own experience and knowledge to make a diagnosis and provide
treatment based on signs and symptoms of the patient, and
• Syndromic: - where the identified 5 syndromes (urethral discharge, vaginal discharge, anorectal
discharge, genital ulcer disease and PID) rely on systematic reviews of symptoms and signs.
Syndromic management treats the patient to cover the majority of organisms that may cause
those syndromes. Syndromic management relies on flow charts which are the standard of care
when laboratory diagnosis is not available.

2.2.1 Case Management of People with Asymptomatic STIs

Diagnostic screening of asymptomatic individuals can identify those patients that would remain
untreated using a syndromic approach. It is estimated that only 11% - 33% of Chlamydia trachomatis
infections in men, and 6% - 17% in women, become symptomatic; estimates for symptomatic Neisseria
gonorrhoeae infection are 45% - 85% in men and 14% - 35% in women. Another benefit of diagnostic
STI screening over symptom-based screening is improved antimicrobial stewardship and optimisation
of partner management.

Recommendations for screening asymptomatic individuals should consider the STI prevalence,
sexual behaviour, disease severity and sequelae, health impact, and cost. Based on these criteria,
recommendations have been made for the screening of certain subpopulations as part of routine
comprehensive SRH services, subject to the availability of resources.

5
 Guidelines for the Management of Sexually Transmitted Infections

Screening of asymptomatic STIs relies on etiological diagnosis of STIs. Nucleic acid amplification
testing (NAAT) is very sensitive and specific and can usually be done on non-invasive samples such as
urine but often takes 3–4 hours to complete (or even up to several days depending on the laboratory),
is expensive, and is usually based in a laboratory rather than at a health facility where people present
with STI symptoms.

Although ideal, it remains a challenge for healthcare providers in resource-limited settings. It constrains
their time and resources, increases costs for the patients, and reduces their access to treatment. Due to
the time needed for the result of the laboratory test, some individuals may be infected and contagious
without knowing. Retention in care to come back and get the results and the treatment if any is also
a challenge. Near point-of-care tests based on molecular technology can be performed during the
clinic visit for the same-visit test results for gonorrhoea and chlamydial infections. These tests can
be strategically used when available to reduce the above challenges and ensure treatment at the first
point of contact with people with STIs.

Population group Suggested screening frequency for CT/NG, syphilis, and HBV
Pregnant women • CT/NG and syphilis: at the first antenatal visit, and 34 weeks or first
contact after 34 weeks if the first syphilis test was done before 20
●
weeks of pregnancy.
•H
 BV: at the first antenatal visit and while the woman is admitted for
delivery
Adolescent girls and young •C
 T/NG and syphilis: at least annually based on risk assessment*
women •H
 BV: at first encounter based on risk assessment*

High-risk populations, including •C

 T/NG and syphilis: every 6 months
those on PrEP •H
 BV: at first encounter

People in correctional facilities •C

 T/NG and syphilis: Upon intake and every 6 months thereafter
and other closed settings •H
 BV: upon intake

People living with HIV •C

 T/NG and syphilis: screen at first HIV evaluation when initiating
● ART, and at least annually thereafter.
•H
 BV: at baseline

*An AGYW is at increased risk of STIs if she is sexually active and has one or more of the following risk
factors: a sex partner has an STI, a new sexual partner in the three months preceding the current visit, had
more than one sex partner in the three months preceding the current visit, engaged in transactional sex,
or sex under the influence of drugs.

6
Guidelines for the Management of Sexually Transmitted Infections

2.2.2. Case Management of People with Symptomatic Syndromic Management of STIs

A number of different sexually transmissible pathogens produce a common pattern of STI symptoms
and signs. A syndrome is simply a group of the symptoms of which a patient complains and the
signs observed during examination. Syndromic case management and appropriate evaluation of STI
includes at least the following:

• History taking, including medical and sexual history.

• Physical examination, particularly of the anogenital area.
• Establishment of the correct syndromic diagnosis.
• Effective treatment at the first point of care of the patient.
• Provision of health education and counselling about infection and risk reduction.
• HIV testing services (HTS).
• Promotion and/or provision of:
- Condoms (male or female) and lubricants.
- PrEP.
- Other preventive interventions, such as vaccination against
Hepatitis B, vaccines against HPV, where appropriate, and VMMC.
• Partner notification and management.
• Clinic follow-up where appropriate.
• Referral for complicated cases.
• Laboratory investigations for persistent or recurrent symptoms.

Syndromic management is an evidence-based approach that relies on systematic reviews

conducted to identify the syndromes and produces flowcharts to allow best practices. Effective case
management consists not only of antimicrobial therapy to obtain a cure and reduce infectiousness but
also of comprehensive assessment and care of the person’s reproductive health and that of their sex
partners. For adolescents, the approach must be appropriate and user-friendly so that the provision
of STI services at primary healthcare outlets can be regarded as accessible and non-judgemental by
these vulnerable people at a critical stage in their development – a view they may carry with them into
adulthood.

[Link] History taking and assessing STI and HIV risk

History taking and physical examination are the foundation of accurate diagnosis and treatment in the
syndromic management of STIs. The aims of history taking, and examination are to:

• Make an accurate and efficient Syndromic STI diagnosis.

• Establish the patient’s risks of transmitting or contracting STI.
• Find out about partners who may also have been infected.

It is important to note that to obtain a thorough history, the provider needs to gain the client’s trust.
This is particularly challenging with STIs clients because of the nature of the disease. Some clients will
not be comfortable talking about sex while others may withhold information to protect the identity of
their partners. To overcome such problems, the healthcare provider needs to work hard at establishing
rapport with the client. Privacy, respect, and confidentiality are essential during history taking and
examination. When asking questions, healthcare providers should:

7
 Guidelines for the Management of Sexually Transmitted Infections

• Keep questions free of moral judgment.

• Use terms and words that are easily understood.
• Request permission to ask personal questions or to examine the patient.
• Use closed and open-ended questions appropriately.
• Recognise and use verbal skills effectively to gather useful information. e.g. facilitation,
directing, summarising, empathy, and reassurance.
• Integrate history-taking of common health risk factors with sexual history risk factors.

Below are some guiding questions that providers should use to obtain a thorough history
from a client:
Medical History
General • Has the patient ever been treated for an STI
• Age in the past?
• Sex • Where possible, document the number
• Marital status of episodes and treatment received to
• Presenting complaint (s): assess whether this is a new syndrome or
duration of illness persistence/recurrence.
• Has the patient ever had an HIV test?
• Is the patient HIV-positive? If so, is s/he
currently on ART?
• Is the patient HIV-negative? If so, is s/he
currently on PrEP?
• Is there any history of other serious or
chronic illnesses?
• Is the patient misusing alcohol or drugs?
• Is the patient using any medication at
present (please list)?
• Has he /she received antibiotics for any
condition in the last 4 weeks (list)?
• Does he/she have any known drug allergies?
• Is there any history of weight loss, fevers,
or cough?
• For male clients ask:
➢ - 
When did you last pass urine
(discharge may not be visible and
microbiology unlikely to be positive if
urine passed within the past 4 hours).
➢ - Are you circumcised?

8
Guidelines for the Management of Sexually Transmitted Infections

Sexual History
The 5 “Ps” may be a useful way to remember the major aspects of sexual history.

1 Partners
• Are you sexually active?
• Do you have sex with men, women, or both?
• In the past 3 months, how many partners have you had sex with?
• In the past 12 months, how many partners have you had sex with?
• Is it possible that any of your sex partners in the past 12 months had sex with someone else while
they were still in a sexual relationship with you?
• Do your partner(s) currently have other sex partners?

2 Practices: ask specific questions about the kinds of sex the client has had over the last
12 months
To understand your risk for STIs, I need to understand the type of sex you have had recently.
• Do you have genital sex (penis in the vagina)?
• Anal sex (penis in the anus)?
• Oral sex (mouth on penis, vagina, or anus)?
- Are you a top and/or bottom (for men who have sex with men), and/or versatile?
 Do you meet your partners online or through apps?
 Have you or any of your partner(s) used drugs?
 Have you exchanged sex for basic needs (money, food, housing, drugs, etc.)?
 Is there anything else about your sexual practices that I need to know about?

3 Protection from STIs

• Do you and your partner(s) discuss STI prevention?
• If you use prevention tools, what methods do you use?
(For example, external or internal condoms— also known as male or female condoms—dental
dams, etc.).
• How often do you use this/these method(s)?
- Frequencies: sometimes, almost all the time, all the time.
• Have you received HPV and/or hepatitis B shots?
• Are you aware of PrEP, a medicine that can prevent HIV? Have you ever used it or considered
using it?

4 Past History of STIs

• Have you ever been tested for STIs and HIV? Would you like to be tested?
• Have you been diagnosed with an STI in the past? When? Did you get treatment?
• Have you had any symptoms that keep coming back?
• Has your current partner or any former partners ever been diagnosed or treated for
an STI or have complained of any problems with sores on their genitals, pain when
passing urine, or discharge? Were you treated or seen with the same STI(s)? Do
you know your partner(s) HIV status?
• Have you ever been screened for cervical cancer? If so, what was the result? Did
it show?

9
 Guidelines for the Management of Sexually Transmitted Infections

5 Pregnancy intention
• When did your last menstrual period start? If unknown and the patient is not using
contraceptive methods, perform a pregnancy test.
• Are your periods irregular and/or unusually heavy?
• Do you have children? If so, how many?
• Do you think you would like to have (more) children at some point? If yes, when do
you think that might be?
• How important is it for you to prevent pregnancy (until then)?
• Are you or your partner using contraception or practising any form of birth
control? Would you like to talk about ways to prevent pregnancy? Do you need any
information on birth control?

Specific questions relating to the presenting STI syndrome

1. Urethral Discharge Syndrome:

• Describe the discharge (colour, presence of blood).
• Pain on passing urine or a burning sensation within the penile urethra (this indicates urethritis).
• Suprapubic/abdominal or loin pain (this suggests a UTI).

One area in which risk assessment can be useful for a man is when he presents with dysuria
without a urethral discharge. The risk assessment may be considered to be positive for an STI if
the man has had unprotected sex within the last 21 days, to allow for the incubation period of both
NG and CT.

2. Vaginal Discharge Syndrome:

Usually, women who present to a healthcare facility with a vaginal discharge do so when they
perceive it as being unusual for them (such as the quantity, thickness, change in colour, or smell).
The majority will have either bacterial vaginosis or T. vaginalis infections as well as candidiasis.
Thus, during history-taking, risk assessment of a woman with abnormal vaginal discharge requires
a good sexual history to estimate her risk of endocervical infection with N. gonorrhoeae and/or C.
trachomatis. In the published literature, clinical observations that have consistently been found to
be associated with endocervical infection are:

• the presence of cervical mucopurulent discharge (speculum examination).

• cervical erosions or cervical friability (speculum examination); and
• bleeding between menses or during sexual intercourse.

The risk assessment needs to consider these parameters together with some demographic and
behavioural risk factors frequently associated with endocervical infection, and the risk may be
considered positive for STIs if the following criteria are met:
• if the client’s sex partner has an STI, for example, a urethral discharge or genital ulcers, OR
• if the answer is yes to two or more of the following, and she is sexually active:
○ - younger than 25 years of age (some studies have found 21 years as significant).
○ - she has had a new sexual partner in the three months preceding the current visit: or
○ - she has had more than one sex partner in the three months preceding the current visit.

Positive responses to the risk assessment increase the likelihood that the client has an STI. In
that situation, encouraging and discussing partner treatment with the same regimen as the index
client, even if it is not certain that the client has an STI, is therefore prudent, while recognising that

10
Guidelines for the Management of Sexually Transmitted Infections

the commonest cause of vaginal discharge, bacterial vaginosis, is not considered to be sexually
transmitted and neither is Candida albicans.

3. Genital Ulcer Disease

• Did the ulcer start with tingling or blister or
• Have you ever had this before?
• Painful or painless? Single or multiple?
• Any rashes or other symptoms (fevers, chills, etc)?

4. Scrotal swelling
• Sudden onset? (suggests torsion).
• On and off? (Suggests a hernia).
• History of trauma?
• Symptoms of UDS?
• Cough/fever/systemic?

5. Inguinal bubo
• History of being preceded by an ulcer?
• Cough/weight loss/night sweats?

[Link] Physical examination

Conducting the examination

A. General approach to the examination

• Inform the client what the examination will entail and obtain verbal assent or
consent.
• Prepare the patient for examination by describing what is to be done in advance.
• Make sure your patient is comfortable.
• Use the language the patient can understand to describe the physical findings.
• Any examination of the anogenital area should preferably be conducted in the
presence of a chaperone. A male healthcare provider should ideally have a female
chaperone in attendance, and vice versa, at all times unless this is not feasible
because of staff capacity.
• Examine in a private, well-lit room.
• Ask the patient to lie down on a couch and expose the genital area from the
umbilicus to the knee level. Where a couch is not available, the male patient may
be examined in a standing position, but this should be avoided when necessary.
• Cover the patient with a modesty blanket or a draw sheet and expose the part of
the body to be examined when ready.
• Wash hands before the examination and put on clean gloves with each patient.
Palpation must be done gently to ensure that, if there are any tender areas, they are
not pressed in a way that hurts unintentionally.
- General inspection to ensure other conditions are captured:
- Inspect inside the mouth for signs of oral thrush, oral sores, or other lesions.
- Inspect the skin over the abdomen for rashes and any obvious swellings.
- Check the pubic area for evidence of other STIs, such as pubic lice and nits, scabies, sores,
and enlarged inguinal lymph nodes.
- check for any skin rashes on the palms of the hands and soles of the feet.

11
 Guidelines for the Management of Sexually Transmitted Infections

- check the thighs and buttocks for rashes.

- check the area around the anus for discharge, rashes, and warts.
- check the groin for swellings and sores.
- check the external genitalia and take note of any discharge and other lesions.
- check for patchy hair loss.

B. Male examination
• Check the external genitals – penis and scrotum – and note any discharge and
other lesions, such as ulcers and warts.
• Palpation must be done gently to ensure that, if there are any tender areas, they
are not pressed in a way that hurts unintentionally. This will enable the healthcare
provider to identify the following:
- palpating the inguinal region (groin), axillae, submandibular areas, and neck looking for
enlarged lymph nodes and buboes.
- palpate the scrotum, feeling for the testis, epididymis, and spermatic cord on each side, and
note any signs of discomfort suggestive of tenderness.
- examine the penis, noting any rashes, warts, or sores.
- ask the person to pull back the foreskin, if present, and look at the glans penis and urethral
meatus for discharge or any other lesions.
- palpate any genital ulcers for tenderness and induration and look for phimosis and
paraphimosis.
- examining the glans penis and urethral meatus for discharge or any other lesions. If no
obvious discharge is present, ask the patient to milk the urethra gently from the base towards
the urethral meatus to determine any discharge.
• Ask the patient to bend the knees towards the chest to expose the perineum,
buttocks, and anal region.
• If the patient is examined in the standing position, ask the patient to turn his back to
you and bend over, spreading his buttocks slightly, and the anus is then examined
for ulcers, warts, rashes, or discharge.

C. Female examination
• Examination of a woman during menstruation is not contraindicated, and testing
for STIs, such as N. gonorrhoeae and C. trachomatis can be performed if the woman
gives consent. Urine samples, vaginal swabs, and blood tests can all be collected
for STI tests during menstruation.
Abdominal examination: The abdomen must be palpated gently, watching the face
for any indication of areas of tenderness and feeling for any masses and swellings,
including pregnancy. In women with lower abdominal pain or vaginal discharge,
focus the examination on the pelvis to assess for signs of PID (see the section on
PID)
Pelvic examination: Ask the patient to bend her knees towards the chest and then
separate them and the following should continue to be observed:
- Inspect the vulva, perineum (between the vagina in front, the buttocks behind, and the medial
sides of the thighs on both sides), and the perianal skin for rashes, sores, warts, and swelling.
- Inspect between the labia and the urethral opening for any obvious lesions or discharge and
any vaginal discharge. Note the colour, smell, and type of vaginal discharge.
- Two fingers should be inserted into the vagina and a bimanual examination carried out with

12
Ministry of Health and Social Services

one hand on the pelvic area of the abdomen and the other inside the vagina, feeling for masses
and tenderness and checking for cervical motion tenderness by moving the cervix gently from
side to side to elicit uterine and/or adnexal tenderness.
- A speculum examination should be performed next to visualise the cervix and vaginal mucosa.

D. How to perform a speculum examination

• A speculum examination is often performed alongside a bimanual examination
as part of a good practice gynaecological workup, especially for women with
anogenital symptoms. In preparation for performing a speculum examination, the
following steps should be taken.
- Before the examination, inform the patient about the procedure and reassure the patient that
the procedure should not be painful but if the patient is uncomfortable or experiences pain,
the procedure will be discontinued.
- Ask the patient to empty the bladder to make the examination more comfortable.
- Inform the patient to remove the underwear and lie on the examination couch and provide her
with a sheet to cover herself.
- Provide privacy for the patient to undress.
- Have all the equipment needed laid out and ready on a trolley, such as a speculum, warm
water, gloves, swabs, and a waste disposal bin?
- Metal speculum must be sterilized before use, and plastic specula must not be reused.
- Prepare the light source and test it before beginning the procedure.
- Maintain privacy throughout the procedure.

The procedure should be done as follows:

- Wet the speculum with clean warm water before inserting it.
- Insert the first finger of the gloved hand in the opening of the woman’s vagina (some clinicians
use the tip of the speculum instead of a finger for this step). As the finger is put in, it is gently
pushed down on the muscle surrounding the vagina, and then the speculum is inserted slowly
while asking the woman to relax her muscles.
- On the other hand, the speculum is held with the speculum blades together between the index
and middle fingers and turned sideways as the speculum is slipped into the vagina while
taking care not to press on the urethra or clitoris because these areas are very sensitive.
- When the speculum is halfway in, it is turned so the handle is facing downward. (Note: some
examination couches do not have enough room to insert the speculum with the handle down
– in this case, it is turned up).
- The blades of the speculum are then gently opened a little while searching for the cervix.
- The speculum is then moved around slowly and gently until the cervix can be seen between
the blades – at this point, the screw (or otherwise lock on the speculum) can be tightened so
it will stay in place.
- The cervix should look pink, round, and smooth. There may be small yellowish cysts, areas of
redness around the opening of the cervix (cervical os), or a clear mucoid discharge – these
are normal findings.
- Look for signs of cervical infection by checking for yellowish discharge or easy bleeding when
the cervix is touched with a swab and any abnormal growths or sores.
- Note whether the cervical os is open or closed and whether there is any discharge or bleeding.
- If there is blood in the vagina, look for any biological tissue coming from the cervix, which
could be signs of induced abortion or miscarriage.
- If necessary, perform endocervical swabs, swabs from the posterior fourchette of the vagina

13
 Guidelines for the Management of Sexually Transmitted Infections

– as well as referring to a medical officer for a biopsy.

- To remove the speculum, it should first be gently pulled out until the blades are clear of the
cervix. Then the blades are brought together but not completely closed to avoid pinching the
vaginal wall and gently pulled out, turning the speculum gently to look at the walls of the
vagina.
- The healthcare provider should give feedback on the findings of the examination.
- Remember that if a patient has extensive, painful genital ulcers, it may not be possible to
perform a speculum examination.
- Refer patients with suspicious growths or bleeding lesions for gynaecological assessment.

E. Anoscopy examination
An anoscope is an instrument used for visualising the anus and the lowest portion of the rectum. It can
be used to identify abnormalities, such as haemorrhoids, inflammation, and tumours in this part of the
gastrointestinal tract. Anoscopy can be performed within a healthcare facility if sufficient training has
been undertaken and equipment is available. No special preparations are needed, such as emptying
the bowels or topical anaesthetic. Caution is needed among patients who have undergone recent anal
surgery or are known to have anal fissures. In preparation for performing an anoscopy, the following
steps should be taken.
• The patient should be informed about the procedure.
• The patient should be informed that the procedure is painless, but pressure similar
to that of a bowel movement may be felt.
• The anoscope should have been properly sterilised before use.
• All the secondary equipment needed should be laid out ready on a trolley, such as a
lubricant, gloves, light source, and cotton swabs, preferably with large tips.

The procedure should be carried out as follows:

• Ask the patient to lie down on the left lateral position.
• Separate the buttocks or ask the patient or an assistant to help and examine the
perianal area for warts, haemorrhoids, or polyp prolapses.
• Perform a digital rectal examination with a lubricated, gloved index finger, taking
note of sphincter tone and any prostate abnormalities.
• Remove the finger and change the glove to a new one.
• Lubricate the anoscope and insert it into the anus gently and, pointing the anoscope
towards the umbilicus, advance it completely into the anus or as far as the patient
can tolerate it.
• Remove the obturator of the anoscope to examine the anal mucosa, removing any
faecal matter with a swab.
• Check for blood, mucus, pus, or haemorrhoidal tissue.
• Gently remove the anoscope when done and observe the sides of the anal canal
in the process.
• The provider should give feedback on the examination findings.

[Link] Targeted Diagnostic testing, including PoC for the management of VDS
The aetiology of VDS is more diverse than UDS. In addition to NG, CT, and TV infections, Bacterial
Vaginosis (BV) and VVC are important conditions to consider. The occurrence of BV and VVC might not
be related to sexual activity and may present in combination with an STI or as a stand-alone condition.
Hence, the pooled diagnostic accuracy of VDS case management for CT/NG is low, resulting in high
numbers of overtreatment and missed treatment. Hence, Namibia will employ a syndromic approach

14
Guidelines for the Management of Sexually Transmitted Infections

together with the phased introduction of diagnostic testing including PoC testing for CT/NG, syphilis,
and Hepatitis B, subject to the availability of resources.

[Link] Health promotion package for Patients with STIs and their partner(s)
Consultation for an STI is a unique opportunity to provide education and risk reduction counselling
on the prevention of HIV and STIs to people most at risk of infections. Education encourages patient
behaviour change and is an integral part of STI case management. It must be an interactive process that
involves assessing what your patient already knows about STIs and then building on that knowledge.
The main issues to discuss with a patient with STI are:

• What STIs, including HIV, are and how they are transmitted and acquired.
• What STI the patient has, its implications and treatment, and the importance of complying
with treatment as well as abstaining from further sexual intercourse until treatment has been
completed and the infection has been controlled or cured
• The risk for acquiring and transmitting HIV infection.
• Encourage combination prevention interventions including condom use, PrEP, PEP, VMMC, and
HIV treatment as prevention.
• Methods of lowering risk of acquiring STIs and HIV, including abstinence/delaying sexual activity
among youth, being faithful to one partner, and use of male and/or female condoms.
• The need to change sexual behaviour; encouraging choices to change behaviour; discussing
barriers that the patient perceives to changing behaviour, and what changes the patient can and
will make in their sexual behaviour.
• Importance of prompt care seeking for symptoms at appropriate medical sites.
• Talk about partners, and the importance of treating partners and emphasising that not treating
partner(s) will lead to reinfection.
• Confirm the three essential decisions (to complete their treatment, to change any risky sexual
behaviour, and to see that their sexual partners are treated).
• Screening for other infections should be offered, especially for HIV infection and syphilis.

The health promotion approach can be summarised using the 7Cs:

● • Counselling and education, including risk reduction and HIV testing.
● • Condom and water-based lubricant promotion, provision, and demonstration
to reduce the risk of STIs and HIV.
● • Compliance/adherence to treatment.
● • Contact treatment/ partner management.
● • Confidentiality.
● • Circumcision promotion for eligible men.
● • Cervical cancer screening for eligible women.

Patients who are found not to have an STI should also be offered health education on the prevention
of STIs.

Condom promotion and distribution

All patients should understand that STIs are preventable and that prevention may be achieved by
abstaining from sexual activity, by having sex with an uninfected lifelong mutually faithful partner, or
by using condoms correctly during every sexual act. Therefore, condom promotion and distribution are
critical components of effective STI case management. The STI consultation provides an opportunity

15
 Guidelines for the Management of Sexually Transmitted Infections

to promote and supply condoms, as the patient should be more receptive to understanding their
usefulness in decreasing their future exposure to STI/HIV. Condom promotion should include:

• Advice about using condoms (i.e., providing basic information about condoms as well as a
dialogue with each client to identify and address potential barriers to condom use).
• Demonstrating the correct use, including partner negotiation skills for condom use, and
• Providing male and female condoms to the patient and advice on further condom supply.

HIV Testing Services (HTS)

HIV testing is recommended for all patients with STIs who are not already known to have HIV infection.
Testing should be routine at the time of the STI evaluation, regardless of whether the patient reports
any specific behavioural risks for HIV. Testing for HIV should be performed at the time of STI diagnosis
and treatment if not performed at the initial STI evaluation and screening. The 5 Cs of consent,
confidentiality, counselling, correct test results, and connection to HIV prevention, treatment, and care
should apply in providing HTS. Secondary distribution of HIV self-testing (HIVST) kits by patients with
STI to their sexual partners can be considered.

[Link] Follow-up and Referrals for Patients with STI

People diagnosed with STIs should be provided with same day treatment and, if any diagnostic tests
are to be carried out, they should not, ideally, delay treatment. This would ensure an immediate break
in the chain of transmission and prevent STI-related complications and long-term sequelae of STIs.
Giving treatment during the same visit reduces infectiousness and onward transmission. If effective
medicines are given and any test results are available on the same visit, then follow-up may be restricted
only to those with persistent symptoms after a stipulated period. This will reduce costs for both the
patient and the healthcare system. Follow-up may be specifically requested in certain conditions, such
as a woman being treated for acute PID as an outpatient or a neonate with ophthalmia neonatorum to
ensure that the treatment has been effective, since delays in cure may result in severe consequences
such as infertility and loss of eyesight, respectively. If the STI has not resolved when treatment ends,
the healthcare provider will need to determine whether this resulted from poor compliance, or the
patient has a persistent infection because of AMR or has been reinfected.

Some patients might need a referral to another level of care. The healthcare provider at the first point
of care should then determine whether the referral should be made to clinicians who have extensive
specialised training or experience in diagnosing, treating, and following up complex STI cases or to
a facility with laboratory-based tests to exclude AMR or to any other specialist centre. For example,
someone with an abnormality in the anorectal area may need to be referred to a colorectal surgeon or
oncologist, and someone with a testicular problem to a urologist. Healthcare providers need to have
information on referral channels at their disposal for complex genitourinary symptoms they feel unable
to handle.

[Link] Notification and Management of Sexual Partner(s)

Notification and management of sexual partner(s) are some of the most important components of STI
case management. Failure to treat an infected partner with an STI will invariably lead to reinfection,
hence partner management is the only way of breaking the cycle of transmission and preventing the
development of potential STI complications. Many STIs, such as gonococcal infection, chlamydial
infections, syphilis, and HIV, may be asymptomatic, and people may not be aware that they are
infected. Thus, partner notification can be one way to detect and treat asymptomatic individuals. Some

16
Guidelines for the Management of Sexually Transmitted Infections

reproductive tract infections are not sexually transmitted, such as the bacteria responsible for bacterial
vaginosis among women with vaginal discharge. Although C. albicans can be sexually transmitted, it
is not classified as an STI. The sex partners of people with candidiasis do not need treatment unless
they exhibit symptoms. Partner notification, therefore, needs to be approached with caution for women
with vaginal discharge since they may not have a sexually transmitted pathogen. This is one of the
reasons for the introduction of targeted PoC testing or near PoC testing with a focus on VDS to guide
appropriate partner notification and treatment.

Partner notification also offers an opportunity to provide focused STI/HIV education and HTS including
HIV self-testing (HIVST) to individuals who are by definition at high risk of infection. There is good
evidence that partner notification is an effective means of detecting untreated STIs.

Effective management cannot be achieved without partner notification and treatment.

Principles of partner management

Partner notification should be conducted in such a way that all information remains confidential. The
process should be voluntary and non-coercive. The healthcare provider is also required to show respect
and a non-judgmental attitude. Management of sexual partners is based on knowledge of the index
patient’s diagnosis. The strategy selected for the treatment of partner(s) will depend on several factors,
which include: the risk of infection, the seriousness of the disease, the ability or willingness of the
sexual partner (s) to seek timely treatment, risk of intimate partner violence (IPV), the availability of
effective treatment, and the likelihood of spread if epidemiological treatment is not given. The following
strategies can help with the treatment of partners:

• Partner(s) treatment at the health facility: this is the preferred modality for partner management
and includes the provision of the same treatment as the patient even if the partner(s) have no
sign of STI.
• Expedited Partner Treatment (EPT): this modality should only be used if the sex partners of
persons with STIs (particularly chlamydia or gonorrhoea) are unable or unlikely to seek timely
treatment from a healthcare facility. It involves the provision of medications or prescriptions to
the patient. Because EPT must be an oral regimen and current gonorrhoea treatment involves an
injection, EPT should be reserved for partners unlikely to access timely treatment. All sex partners
from the previous 60 days or the most recent sex partners if the patient has not had sex during
the 60 days before the diagnosis can be offered EPT. Distribution of HIVST together with EPT can
be considered.
• In addition to the STI being treated, the partner should also be assessed for other STIs and offered
HTS including HIVST.

Two approaches to partner management

A. Passive contact tracing (Also known as patient referral)

In passive contact tracing it is the patient who takes responsibility for contacting partners and asking
them to come for treatment. An infected patient is encouraged to notify partner(s) of their possible
infection without the direct involvement of healthcare providers. News of STI can be especially
damaging when a patient or partner hears of their partner’s infidelity for the first time. Such events
might lead to marital breakdown, divorce, verbal or physical abuse, loss of home or livelihood, or
even ostracism from the social group. Because of these and other reasons, many patients might feel
unwilling or unable to discuss the STI with partners, so the service provider aims to help the patient
decide what to do. An index patient might approach partner(s) in several ways:

17
 Guidelines for the Management of Sexually Transmitted Infections

• By directly explaining the STI infection and the need for treatment.
• By accompanying a partner to the healthcare facility.
• By giving each partner a card asking him or her to attend the centre.

The success of patient referral is dependent on the index patient and the partner’s motivation and the
quality and appropriateness of counselling received by the index patient. Moreover, its success depends
on the skills of the service provider: what you say to the patient, how you say it, and, equally important,
how you listen to the patient and respond to what he or she says. The service provider needs to:

• Explain that all the patient’s partners need to be treated so that the patient is not reinfected, and
his/her partners don’t suffer the consequences of untreated STI.
• Remind the patient how to avoid re-infection (abstain, be monogamous, use condoms, get all
partners treated).
• Help the patient learn how to communicate with partners.
• Give referral slip to the client to give to partner(s) so that they can come for treatment as well.

STI PARTNER NOTIFICATION REFERRAL SLIP

REFERRAL SLIP REFERRAL SLIP

Serial Number Serial Number

Date of Issue: Date of Issue:

Issuing health facility: Issuing health facility:

Diagnostic code (VDS, GUD, UDS, LAP, ADS) Diagnostic code (VDS, GUD, UDS, LAP, ADS)
Other specify: ………………………………….…………………………………. Other specify: ………………………………….………………………………….

Name and contact details of Index Patient: Name and contact details of Partner:

Name and contact details of Partner: Please come to the nearest health facility and bring this slip with you

NOTE:
The above card is in two parts. Once the details are recorded, the card is cut in two and the right side
is given to the patient to pass on to the partner(s). The left side is retained for centre records. In case
of more than one partner issue separate cards. Partners will leave the slip at the clinic where they get
treatment so that the partner’s treatment is recorded.

B. Active contact tracing (Also known as provider referral)

This is where a member of the health team contacts the partner(s) of a patient with an STI. Provider
referral can be expensive and can be perceived as a threat to patient confidentiality if the patient is not
informed in advance that this might occur.

For further information refer to the Standard Operating Procedure (SOP) for Implementation of Partner
Notification System for STIs.

18
Guidelines for the Management of Sexually Transmitted Infections

2.3 FLOWCHARTS IN THE MANAGEMENT OF STIs

The flowcharts were designed to help healthcare providers make rational decisions regarding the
clinical management of each STI syndrome. For each syndrome, a clinical algorithm is developed and
is to be followed when managing STIs. An algorithm is a decision and an action tree. It is like a map that
guides the healthcare provider in a series of decisions and actions. Each decision or action is enclosed
in a box, with one or two routes leading to another box, containing another decision or action. For all
the syndromes, offer a health promotion package.

Upon learning a patient’s symptoms, the healthcare provider turns to the relevant flowchart and works
through the decisions and actions it suggests.

Benefits of using flowcharts

• They can be used at any time in all types of healthcare facilities.
• They suggest clear decisions.

Three steps flowcharts

Each flowchart is made up of these three steps.
• The clinical problem: is what the patient complains of, that is, the patient’s presenting symptom.
• The decision that needs to be taken. This is the box, which requires further information, which you
find out by taking a history or examining the patient.
• The action that needs to be carried out. Each of the exit paths leads to an action box. This is the
box that instructs the service provider on what action to take.

19
 Guidelines for the Management of Sexually Transmitted Infections

3. M
 ANAGEMENT OF STI-ASSOCIATED
SYNDROMES

3.1 URETHRAL DISCHARGE SYNDROME (UDS)

Definition
Urethral discharge is the presence of a secretion from the anterior urethra. Characteristically, it presents
with a urethral discharge with or without dysuria (pain on urination). Occasionally, dysuria or itching
at the tip of the urethra may be the only symptom. Complications of UDS include epididymitis, scrotal
swelling, and urethral strictures.

Aetiology
The most common causes of urethral discharge syndrome are:
• Neisseria gonorrhoeae
• Chlamydia trachomatis

Other causes of urethral discharge and dysuria are Trichomonas vaginalis, Mycoplasma genitalium,
herpes simplex, Ureaplasma urealyticum, Neisseria meningitidis, and rarely genitourinary TB.

Urethritis in men is nearly always due to STIs. This should not be confused with other signs and
symptoms of UTI such as suprapubic pain, and flank pain which are usually not due to STIs.

Examination
On general examination, check for rashes on hands or feet, which may indicate the presence of other
STIs. On genitourinary examination check for discharge from the urethral meatus and genital lesions.
In uncircumcised men, secretions from the folds of the foreskin (smegma) may appear to come from
the meatus. If no discharge is visible, it may be necessary to milk the urethra. Start at the base of the
penis, and gently apply pressure toward the meatus. This should usually be performed by the patient.
Refer to Annex 5 for photos of urethral discharge syndrome.

20
Guidelines for the Management of Sexually Transmitted Infections

Algorithm for Urethral Discharge Syndrome

Patient presenting with urethral

discharge and/or dysuria

Take a history and examine.

Ask patient to milk urethra if
necessary

Discharge
confirmed?
YES NO

Treat for NG and CT. Offer health At STI risk

education on prevention of STIs and risk assessment
rule out presence of other STIs by
doing HIV test and RPR

Review patient in 7 days if there is No risk

no improvement. identified

•Investigate for UTI

No follow-up visits •Offer health education
needed. Check on prevention of STIs.
Symptoms YES •Investigate for STIs
for completion of
resolved? (HIV test and RPR)
partner notification
•Review after 7 days if
symptoms persist
NO

Possibility of Refer to medical officer for AMR

reinfection/poor testing, other investigations, and further
NO
treatment compliance management, including treatment of
ruled out? TV and MG

YES

Retreat for NG and CT

21
 Guidelines for the Management of Sexually Transmitted Infections

Recommended syndromic treatment of Urethral Discharge Syndrome

Syndrome Preferred options (Treat for N. Alternative (Treat for N. gonorrhoeae
gonorrhoeae and C. trachomatis) and C. trachomatis)

Ceftriaxone** 1g IM single dose Cefixime** 800mg PO, STAT

PLUS PLUS
Doxycycline* 100mg PO, BD for 7 Doxycycline* 100mg PO, BD for 7 days
days OR
UDS
Cefixime** 800mg PO, STAT
PLUS
Erythromycin 500mg, PO QID for 7 days
OR
Ceftriaxone 1g IM single dose
PLUS
Erythromycin 500mg, PO QID for 7 days
For persisting/recurrent infection (Add treatment for T. vaginalis)
UDS Metronidazole 2g PO, STAT Metronidazole 400mg PO, BD for 7 days
*When a patient is allergic to Doxycycline, use Azithromycin 1g PO, STAT
**If a patient is allergic to cephalosporins, REFER/CONSULT medical doctor.
Review patient in 7 days if there is no improvement
Laboratory Diagnosis
Patients with persistent symptoms after treatment should have specimens collected for etiological
confirmations. E.g., urethral discharge/secretion or swab in a semi-solid transport media for MCS
AND /OR urine 5 to 10 ml (for N. gonorrhoeae and C. trachomatis PCR).

22
Guidelines for the Management of Sexually Transmitted Infections

3.2 VAGINAL DISCHARGE SYNDROME

Definition
Women usually have a physiological vaginal discharge which is usually white or clear and non-offensive.
It can vary during the menstrual cycle, pregnancy, lactation, use of hormonal contraceptives, and some
other medications, and is commonly increased during sexual arousal. In these situations, women can
usually be reassured that the increase in quantity is normal and does not require treatment.

A spontaneous complaint of abnormal vaginal discharge (in terms of quantity, colour, or odour) is most
commonly a result of a vaginal infection. It may in some cases be caused by mucopurulent STI-related
cervicitis, infection within the uterus, or cervical cancer.

Aetiology
• The main step here is to differentiate through speculum examination whether there is cervicitis
(cervical origin of the discharge) or not (vaginal origin of the discharge).
• The three most common causes of the vaginal origin of the discharge are bacterial vaginosis (BV)
and infection with T. vaginalis and C. albicans.
• BV is not an STI, and it occurs when the normal acidic vaginal flora is depleted and overtaken by
anaerobic and other bacteria. This may occur spontaneously – particularly around the time of the
menstrual period but is also commonly triggered by washing inside the vagina with substances
other than water (thereby causing depletion of lactobacilli). Although it is not sexually transmitted
it is often triggered by sexual activity; it is more common in women who have frequent partner
changes and may occur with sexual activity with a new partner. It is also commoner in women
who have an IUD in situ and those who insert herbs or other foreign bodies into the vagina.
• Candidiasis is not usually sexually transmitted. It can occur spontaneously but occurs commonly
in patients with the following conditions: pregnancy, immunosuppression including HIV, use of
antibiotics, diabetes, use of systemic steroids, and sometimes hormonal medications e.g., oral
contraceptives.
• Among post-pubertal women, N. gonorrhoeae and C. trachomatis infect the endocervix rather
than the vagina, and they, therefore, may not present with vaginal discharge.
• Cervicitis is a common complication of genital herpes simplex and is sometimes caused by
mechanical or chemical trauma and sometimes HPV infection.

Symptoms and signs

• Candida is associated with vulval or vaginal itching or sometimes burning. An examination
may reveal redness and inflammation, there may be an odourless ‘cottage cheese’ like white
discharge. The skin may be irritated/scratched and there may be adherent white plaques on the
vaginal epithelium.
• BV is associated with a ‘fishy smelling’ greyish-white discharge of variable amounts. There is not
typically, any inflammation.
• Trichomoniasis is often asymptomatic. Where symptoms occur, they include profuse yellowish-
green frothy discharge, vulval itching, and staining of underwear. Vaginal and vulval epithelium
may be inflamed and the cervix may also be red and irritated (’strawberry cervix’).
• Where cervicitis is symptomatic, symptoms may include vaginal discharge, pain and/or bleeding
on penetrative intercourse, bleeding at times other than during a period (intermenstrual bleeding)
and can lead to PID (refer to section 3.3). Speculum examination reveals mucopurulent discharge
at the cervical opening, a red or inflamed cervix, and there may be easily induced bleeding of the
cervical mucosa on examination. Refer to Annex 5 for photos of mucopurulent cervicitis.

23
 Guidelines for the Management of Sexually Transmitted Infections

• Persistent vaginal discharge despite repeated courses of antibiotics may indicate cervical
cancer.
• The clinical detection of cervical infection is difficult because a large proportion of women with
gonococcal or chlamydial cervical infection remain asymptomatic.

Examination
All female patients with VDS must be fully examined, including speculum visualisation of the cervix.
The pelvic examination includes documentation of guarding, rebound tenderness, cervical motion
tenderness, and the absence of these signs. Evidence of cervicitis is an indication for treatment of
STIs regardless of the history obtained. Where there are other abnormal appearances of the cervix, the
patient should always be referred to the next level.

24
Guidelines for the Management of Sexually Transmitted Infections

Algorithm for Vaginal Discharge Syndrome using the Syndromic approach

Patient complains of abnormal

vaginal discharge

Take medical and sexual history to assess

for likely exposure to STIs

Refer if other conditions

Perform clinical exam and bimanual digital identified or consult
exam of the vagina other algorithms based
on other signs and
symptoms

Speculum NOT available or

Speculum available and acceptable
NOT acceptable

Vaginal discharge
Perform speculum exam present on genital
exam
YES
NO

Evidence of Woman at high

YES Treat NG and CT YES
cervicitis risk of STI

PLUS

NO NO
Treat for BV and TV; Also treat for
candidiasis if curd-like discharge and/or
vaginal itchiness

PLUS

Offer health education on prevetion of STIs and rule out other STIs. Offer HIV test and RPR

NOTE: if woman complains of recurrent or persistent discharge refer to a centre with laboratory
capacity

25
 Guidelines for the Management of Sexually Transmitted Infections

Algorithm for Vaginal Discharge Management using the Aetiological approach

Patient complains of abnormal vaginal discharge

Refer if other
Take medical and sexual Perform clinical exam and conditions identified
history to assess for likely bimanual digital exam of or consult other
exposure to STIs the vagina algorithms based
on other signs and
symptoms

Molecular assays or rapid point of care test for NG and CT

available for all patients

Conduct test for NG and CT

Refer to syndromic
approach and
revise treatment Results available
NO same day?
according to test
results when
available YES

YES Test Positive NO

Treat NG and/or CT based

on test results

PLUS

Treat for BV and TV if abnormal vaginal discharge present or according to microscopy examination or
molecular assay for TV); treat for candidiasis if curd-like discharge and/or vaginal itchiness

PLUS

Offer HIV test and RPR, and other preventive services

26
Guidelines for the Management of Sexually Transmitted Infections

Recommended treatment of Vaginal Discharge Syndrome

Syndrome Infections Preferred options Alternatives Options for
covered pregnant women
or during
breastfeeding
NOTE:
Metronidazole
should ideally be
avoided in the
first trimester
Patient not at high risk of endocervical infection caused by N. gonorrhoeae and/or C.
trachomatis or speculum examination not showing signs of cervicitis (Treat for Bacterial
vaginosis, T. vaginalis, and vaginal candidiasis)
BV Metronidazole Metronidazole 2g Metronidazole
400mg PO, BD for PO, STAT 200mg PO, TDS
TV
7 days for 7 days
VDS Vaginal Clotrimazole Fluconazole Clotrimazole
candidiasis* vaginal pessary 200mg PO, STAT vaginal pessary
500 mg inserted 500 mg inserted
Immediately as a Immediately as a
single dose single dose
PLUS PLUS
Clotrimazole Clotrimazole
vaginal cream vaginal cream
locally bd for 7 locally bd for 7
days days
Patients at high risk of endocervical infection caused by N. gonorrhoeae and/or C. trachomatis
or speculum examination showing signs of cervicitis (Treat for N. gonorrhoeae, C. trachomatis
Bacterial vaginosis, T. vaginalis, and vaginal candidiasis)
NG Ceftriaxone** 1g Cefixime** Ceftriaxone** 1g
IM, single dose 800mg PO, STAT IM, STAT
OR
Cefixime 800 mg
PO, STAT
CT Doxycycline Azithromycin 1g Erythromycin
100mg PO, BD for PO, STAT 500mg PO, QID
7 days OR for 7 days
VDS
Erythromycin OR
500mg PO, QID Azithromycin 1g
for 7 days PO, STAT
TV Metronidazole Metronidazole 2g Metronidazole
400mg PO, BD for PO, STAT 200mg PO, TDS
7 days for 7 days

Vaginal Clotrimazole Fluconazole Clotrimazole

candidiasis* vaginal pessary 200mg PO, STAT vaginal pessary
500 mg inserted 500 mg inserted
Immediately as a Immediately as a
single dose single dose
PLUS PLUS
Clotrimazole Clotrimazole
vaginal cream vaginal cream
locally bd for 7 locally bd for 7
days days

27
 Guidelines for the Management of Sexually Transmitted Infections

*Treat for vaginal candidiasis if there is vulval oedema/curd-like discharge, erythema (looks red), or
excoriations
** If a patient is allergic to cephalosporins, REFER/CONSULT medical doctor.
NOTE: Review the patient after 7 days if no improvement or earlier if the condition gets worse.
• Patients taking metronidazole should be cautioned to avoid alcohol until more than 24 hrs.
after completing the course.
• Criteria for the risk of endocervical infection include having a sex partner with an STI and
any 2 of the following:
a) Age less than 25 years (b) Having had a new sex partner within 3 months of the current
visit (c) Having had more than one sex partner within 3 months of the current visit
TAKE BLOOD FOR RPR FOR ALL WOMEN PRESENTING WITH VDS
Laboratory diagnoses
Vaginal swab and endo-cervical swab in semi-solid transport media MCS AND /OR urine 5 to 10 ml
(for N. gonorrhoeae and C. trachomatis PCR).
Specimen collection method: 1st; insert the speculum in the vagina, Swab the cervical os clean
of vaginal secretions, then insert a swab into the endo-cervical canal and rotate the swab once or
twice.

Complications of cervicitis and vaginitis

• PID
• Chronic pelvic pain
• Infertility
• Premature rupture of membrane
• Pre-term labour
• Dyspareunia

28
Guidelines for the Management of Sexually Transmitted Infections

3.3 PELVIC INFLAMMATORY DISEASE

Definition
Lower abdominal pain may be due to a variety of serious conditions, including pelvic inflammatory
disease (PID). PID comprises a spectrum of inflammatory disorders of the upper female genital tract,
including any combination of endometritis, salpingitis, oophoritis, tubo-ovarian abscess, and pelvic
peritonitis.

Aetiology
Causative agents of pelvic inflammatory disease include N. gonorrhoeae and C. trachomatis.
Facultative gram-negative rods and Mycoplasma genitalium have also been implicated. Since
differentiating between these clinically is impossible and precise microbiological diagnosis is difficult,
the treatment regimens must be effective against this broad range of pathogens. The occurrence of
vaginal discharge may precede PID.

Symptoms and signs

Acute PID is difficult to diagnose because of the considerable variation in symptoms and signs
associated with this condition. Women with PID often have subtle or nonspecific symptoms or are
asymptomatic. Delay in diagnosis and treatment probably contributes to inflammatory sequelae in the
upper genital tract.

Bilateral lower abdominal or pelvic pain is the most common clinical complaint. The presentation
may range from abrupt and fulminant to a sub-acute form with mild symptoms often described as
dull abdominal pain. Patients often complain of irregular or heavy menstrual bleeding. The presence
of vaginal discharge, pain during intercourse or urination, and lower abdominal pain are some of the
symptoms of PID. The signs indicative of PID are adnexal tenderness and cervical excitation tenderness.

Examination
The common findings on physical examination include abdominal tenderness and cervical/adnexal
motion tenderness. Fever, guarding, and rebound tenderness may be observed in severe cases.

Many patients with PID improve with antibiotics alone and the fever usually subsides in less than
72 hours. However, failure to improve within 72 hours after antibiotic treatment indicates failure of
medical treatment and the patient should be referred for further evaluation.

29
 Guidelines for the Management of Sexually Transmitted Infections

Algorithm for Pelvic Inflammatory disease

Patient complains of
lower abdominal pain
with or without vaginal
discharge

Take history, LMP (including gynaecological

and sexual history).
Examine the abdomen and the genitalia.
Do pregnancy test.

Presence of any of
the following
• Missed/overdue period Pain on moving
• Recent delivery/abortion/ the cervix (cervical
miscarriage excitation tenderness)
• Abdominal guarding NO or
and/or rebound Lower abdominal
• Tenderness, Fever tenderness with or
YES • Abnormal vaginal bleeding without Fever
• Abdominal mass

YES NO
• Put up an IV line
• Resuscitate if necessary
• Check pregnancy test result
and Hb Treat for PID.
Condition Patient to return Any other
• Refer to medical doctor NO
Improved. after 3 days. illness.
• immediately for further
investigations and
management
YES YES

Complete the treatment.

Offer the health
Manage
education on the
appropriately
prevention of STIs and
rule out other STIs. Offer
HIV test and RPR

30
Guidelines for the Management of Sexually Transmitted Infections

Recommended syndromic treatment of Pelvic Inflammatory Disease for patient and partner
Syndrome Preferred options (Treat for N. Alternative (Treat for N. gonorrhoeae,
gonorrhoeae, C. trachomatis, and C. trachomatis, and anaerobes)
anaerobes)
Ceftriaxone** 1g IM single dose Cefixime** 800mg PO, STAT
PLUS PLUS
Doxycycline* 100mg PO, BD for 14 Doxycycline* 100mg PO, BD for 14
days days
PLUS PLUS
Metronidazole 400mg PO, BD for Metronidazole 400mg PO, BD for 14
14 days days
OR
PID Cefixime** 800mg PO, STAT
PLUS
Erythromycin 500mg, PO QID for 14
days
PLUS
Metronidazole 400mg PO, BD for 14
days
OR
Ceftriaxone** 1g IM single dose
PLUS
Erythromycin 500mg, PO QID for 14
days
PLUS
Metronidazole 400mg PO, BD for 14
days
* When a patient is allergic to Doxycycline, use Azithromycin 1g PO, once weekly for 2 weeks
** If a patient is allergic to cephalosporins, REFER/CONSULT medical doctor.
Review patient after 3 days
Laboratory diagnosis
• Patients with persistent symptoms after treatment should have specimens collected for
etiological confirmations. E.g., vaginal discharge/secretion or swab in a semi-solid transport
media for MCS AND urine 5 to 10 ml (for N. gonorrhoeae and C. trachomatis PCR).
• Specimen collection method: First insert the speculum in the vagina, swab the cervical os clean
of vaginal secretions, then insert the swab into the endo-cervical canal and rotate the swab once
or twice.

31
 Guidelines for the Management of Sexually Transmitted Infections

3.4 ANORECTAL DISCHARGE SYNDROME (ADS)

Anorectal symptoms and anorectal STIs are prevalent among men who have sex with men (MSM),
female sex workers, transgender people, and heterosexual women who engage in anal sexual
intercourse. High-risk sexual behaviour associated with anorectal infections includes receptive anal sex,
oro-anal contact (anilingus or rimming), fisting (inserting a hand into the rectum or vagina), fingering
(touching another’s genitals or anus using fingers or digital-vaginal penetration), nudging (unprotected
penile-anal external contact without penetration), dipping (partly inserting or briefly inserting the penis
into the anus without a condom, followed by immediate withdrawal) and sharing sex toys.

Aetiology
Anal infections are usually caused by N. gonorrhoeae, C. trachomatis, T. pallidum, and HSV. Other
organisms that can rarely cause anal infection include Shigella, Campylobacter, Salmonella,
cytomegalovirus, and amoebiasis.

Symptoms and signs

Anorectal infections may be associated with anorectal pain, itching, discharge, bleeding, the sensation
of rectal fullness, tenesmus, constipation, and mucus streaking of stools. MSM, male and female sex
workers, transgender people, and women who have receptive anal intercourse with men with STIs, can
also present with asymptomatic anorectal infections. An examination for anal infections includes an
external examination of the anus to observe a discharge, ulcers, or external warts. Refer to Annex 5 for
photos of anorectal discharge.

Algorithm for Anorectal Discharge syndrome

Person with symptom of anorectal discharge

and reports receptive anal sex

Take history and do physical examination.

Perform genital and peri-anal inspection and anoscopy
(if anoscope is available) or digital exam if acceptable

Anorectal discharge Refer to medical officer for other

present? investigations if discharge is not related
to STIs

YES NO

• Treat for NG and CT

Refer to medical
• If there is a painful ulcer treat for HSV
officer for other
investigations if
Review after 7 days if symptoms persist. If symptoms
discharge is not
persist with good adherence, refer to medical officer for
related to STIs
AMR testing, and further management

32
Guidelines for the Management of Sexually Transmitted Infections

Recommended syndromic treatment of Anorectal Discharge Syndrome

Syndrome Preferred options (Treat for N. Alternative (Treat for N. gonorrhoeae
gonorrhoeae and C. trachomatis) and C. trachomatis)
Ceftriaxone* 1g IM single dose Cefixime* 800mg PO, STAT
PLUS PLUS
Doxycycline 100mg PO, BD for 7 Doxycycline 100mg PO, BD for 7 days
days OR
Cefixime* 800mg PO, STAT
ADS PLUS
Erythromycin 500mg, PO QID for 14
days
OR
Ceftriaxone* 1g IM single dose PLUS
Erythromycin 500mg, PO QID for 14
days
* If a patient is allergic to cephalosporins, REFER/CONSULT a medical doctor.
If there is a painful ulcer, treat for Herpes Simplex Virus by adding Acyclovir 400mg PO, TDS for 10
days, PLUS take blood for RPR.
Review after 7 days if there is no improvement.
Laboratory Diagnosis
Anorectal swab: The swab should be inserted 3-4 cm into the anus and rotated gently for about
10-30 seconds.

33
 Guidelines for the Management of Sexually Transmitted Infections

3.5 Genital ulcer disease (gud)

Definition
A genital ulcer is a loss of continuity of the skin of the genitalia. The ulcer may be painful or painless,
single, or multiple, and frequently associated with enlarged inguinal lymph nodes. Refer to annex 5 for
photos of genital ulcer disease.

Aetiology
The relative prevalence of causative organisms for genital ulcer disease (gud) varies considerably in
different parts of the world. The commonest causes of genital ulcers globally are herpes infection and
syphilis. Other causes can include chlamydia trachomatis serovars l1–l3 (lymphogranuloma venereum)
and hemophilus ducreyi (chancroid), depending on the local epidemiology.

Symptoms and signs

Herpes simplex infection

Herpes simplex may appear as a cluster of vesicular lesions on the genital area, which then develops
into multiple, shallow, and painful ulcers. First-episode infections are often associated with systemic
and local symptoms of fever, headache, malaise, and myalgia, usually in the first 3-4 days. Locally, there
may be pain, itching, dysuria, vaginal or urethral discharge, and tender inguinal lymphadenopathy. The
lesions may start as papules (pimples) or vesicles (blisters), which spread rapidly over the genital area.
The lesions may last up to 15-20 days until crusting and/or healing.

Among both men and women, a cluster of vesico-pustular or ulcerative lesions is observed on the
external genitalia (penis, urethral meatus, scrotum, pubic area, and vulva). Multiple small vesicular
lesions may coalesce into large ulcers. Most people with hsv-2 infection present at later stages of
ulceration and hardly show the typical vesicles of early hsv-2 manifestation. Refer to annex 5 for
photos of genital herpes.

Syphilis
Primary syphilis is characterized by an ulcer (syphilitic chancre) at the site of infection that develops
after an incubation period of about three weeks from sexual contact but can range from nine to 90
days. The ulcers are usually single lesions and painless. The person with syphilis may miss them if they
occur in concealed areas, such as the cervix or the pharynx. If not treated, the ulcer will heal without
scarring after some 2–10 weeks.

Secondary syphilis presents with signs of disseminated syphilis, about 3–6 weeks after infection, but
this can be as long as six months. The manifestations may include any of the following:
• A generalized maculopapular rash that is usually asymptomatic or mildly itchy and may also be
seen on the palms and plantar surfaces of feet.
• Patchy alopecia.
• Generalized lymphadenopathy.
• Condylomata lata – hypertrophic lesions resembling flat warts in moist areas, such as the labia
and perineum and the folds of the foreskin.
• Painless shallow ulcers of the oral or genital mucous membranes (mucous patches).
If not treated at this stage, syphilis enters latency which might be followed by the tertiary stage of syphilis.

Latent syphilis has no clinical manifestations, but the individual is infectious to the sex partner(s) and
there is a high risk of transmission to the fetus during pregnancy.

34
Guidelines for the Management of Sexually Transmitted Infections

Tertiary syphilis usually occurs 10-30 years after the infection began. Most people with untreated
syphilis do not develop tertiary syphilis. However, when it occurs, it affects multiple organ systems
such as the cardiovascular system and the nervous system.

Chancroid
Lesions of chancroid begin as an erythematous papule within hours to days of sexual exposure and the
papule evolves into a pustule that breaks down and becomes a painful ulcer. Among men, the ulcers
are usually on the penis (foreskin, shaft, and sometimes on the glans), and as many as 50% develop
unilateral or bilateral painful inguinal lymph nodes. Large, painful, fluctuant lymph nodes (buboes) may
also occur. If not treated, buboes may suppurate and form fistulae or ulcers.

In women, ulcers of chancroid are on the vulva, and anal ulcers from autoinoculation may also occur.
Ulcers among women may be asymptomatic, especially when they are internal. Women do not
frequently present with inguinal adenopathy.

Other genital ulcer diseases

Donovanosis (granuloma inguinale) and lymphogranuloma venereum (lgv) also cause genital ulcers.
Donovanosis is caused by the intracellular bacterium called klebsiella granulomatis (formerly known as
campylobacter granulomatis). It begins as nodules under the skin that group and form usually painless
well-defined ‘beefy’ red lesions. Although lgv begins with a small painless ulcer, it is rarely noticed by
the patient and lasts for only one or two days. The characteristic lesion of lgv is a tender inguinal bubo
that may leak pus. This is the main reason why people seek treatment.

35
 Guidelines for the Management of Sexually Transmitted Infections

Algorithm for genital ulcer disease

Patient complains of a genital sore

or blisters with or without pain

Take history and examine (including

speculum examination for females)

Characterise the
lesion(s)?

Painful cluster of vesicles or Ulcer present on genitalia

blisters present on genitalia

Offer the health promotion package • Treat for syphilis, Chancroid and HSV
• Treat for HSV • Advise to abstain until healed,
• Advise to abstain until healed, • Offer partner treatment
• Offer partner treatment • Review patient after 7days if
• Review patient after 7days if there is no there is no improvement
improvement

Continue
treatment.
Offer health
Improvement at
education on YES
follow up?
prevention
of STIs and
rule out other NO
STIs. Offer
HIV test and
Poor compliance
RPR
or super imposed
infection

Continue treatment REFER to medical doctor for AMR

Check for completion of partner YES NO testing, other investigations, and
notification and treatment further management

36
Guidelines for the Management of Sexually Transmitted Infections

Recommended treatment for Genital Ulcer Disease

Syndrome Preferred options Alternatives Options for pregnant
women or during
breastfeeding
Treatment for patients with vesicles or blisters only for the first time (Treat for Herpes Simplex
Virus only)
GUD Acyclovir* 400mg PO, None Use Acyclovir only
TDS for 10 days when the benefit
outweighs the risk. The
dosage is the same as
in non-pregnancy.
Genital ulcers treatment (Patient 1st episode AND partner) (Treat for syphilis, Chancroid, and
Herpes Simplex Virus)
GUD Benzathine Doxycycline 100mg Benzathine
Penicillin**2.4 MU IM, PO, BD for 14 days Penicillin**2.4 MU IM,
STAT PLUS STAT
PLUS Acyclovir 400mg PO, PLUS
Acyclovir* 400mg PO, TDS for 10 days Acyclovir* 400mg PO,
TDS for 10 days OR TDS for 10 days
PLUS Erythromycin 500mg PLUS
Azithromycin 1g PO, PO, QID for 14 days Azithromycin 1g PO,
STAT PLUS STAT
Acyclovir* 400mg PO, OR
TDS for 10 days Erythromycin 500mg
PO, QID for 14 days
PLUS
Acyclovir* 400mg PO,
TDS for 10 days
Treatment of recurrent vesicles
GUD Acyclovir 800mg PO, Acyclovir 400mg PO, Acyclovir 800mg PO,
BD for 5 days TDS for 5 days BD for 5 days
Suppressive therapy for Herpes simplex
GUD Acyclovir 400 mg PO, None Acyclovir 400 mg PO,
BD for 6 to 12 months BD for 6 to 12 months
* For patients with advanced HIV, Acyclovir should be given at the same dose until lesions have
cleared.
**If pregnant and allergic to penicillin, the patient should be desensitised using the oral method
as recommended by the Centers for Disease Control and Prevention. Refer to Annexure 4. This
should be done in a hospital setting.
NOTE:
1. Caesarean section is advised where primary herpes is contracted in the third trimester of
pregnancy, but it is not indicated in recurrence.
2. Treatment of recurrence may be restricted to Acyclovir if the patient reports no sexual contact
in the previous 3 months, and an individual with recurrent vesicular ulcers in the same sites and
with a recent history (<3 months) of syphilis treatment.
RPR monitoring to be done.
3. Suppressive therapy should be proposed in patients with recurrent ulcers that are too frequent
(such as 4-6 episodes or more a year) or with severe symptoms or causing distress.
4. REFER patients who have not improved after 7 days of first episode treatment but have good
adherence to treatment to the medical officer for Antimicrobial Resistance testing.

37
 Guidelines for the Management of Sexually Transmitted Infections

4. M
 ANAGEMENT OF STIs NOT
PRESENTING WITH SYNDROMES

4.1 EPIDIDYMO-ORCHITIS

Definition
Epididymo-orchitis is caused by inflammation of the epididymis and/or testicle and is usually
accompanied by pain, oedema, and sometimes urethral discharge and dysuria. Refer to Annex 5 for
photos of Epididymo-orchitis.

Aetiology
The causes can vary depending on the age of the patient. The swelling is likely to be caused by
N. gonorrhoeae, C. trachomatis, M. genitalium, and gram-negative organisms.

Other non-sexually transmitted infectious causes of scrotal swelling include brucellosis, tuberculosis
(TB), and mumps. However, these conditions produce systemic disease and may be associated with
additional findings.

Note: It is important to exclude other causes of scrotal swelling like testicular torsion, trauma, and
incarcerated inguinal hernia as they require urgent referral for proper surgical evaluation and treatment. If
in doubt, refer the patient to the next level of care.

38
Guidelines for the Management of Sexually Transmitted Infections

Sexually active patient complains of

scrotal swelling or pain, and/or pain on
urination

Take history and examine.

Rule out inguinal hernia

Is swelling or Treat for UDS and refer

tenderness NO to medical doctor if
confirmed? not sure

YES

Presence of:
• Sudden onset of scrotal
swelling
• Rotated & elevated testes
• Hydrocele
• History of trauma
• Non-STI reason for
YES
swelling/pain NO

TREAT FOR
EPIDIDYMO- ORCHITIS:
Resuscitate and/or refer In men older than
to medical doctor for Condition 35 years and MSM
NO
further investigations and improved? regardless of age treat
management for anaerobes
YES

Complete treatment.
Offer health education on prevention
of STIs and rule out other STIs.
Offer HIV test and RPR

39
 Guidelines for the Management of Sexually Transmitted Infections

Algorithm for Epididymo-orchitis

Recommended treatment of Epididymo-orchitis
Condition Preferred options (N. Alternative (N. gonorrhoeae and
gonorrhoeae and C. trachomatis) C. trachomatis)
Ceftriaxone 1g IM single dose Cefixime 800mg PO, STAT
Epididymo-orchitis PLUS PLUS
Doxycycline 100mg PO, BD for 7 Doxycycline 100mg PO, BD for 7
days days
OR
Cefixime 800mg PO, STAT
PLUS
Erythromycin 500mg, PO QID for
14 days
OR
Ceftriaxone 1g IM single dose
PLUS
Erythromycin 500mg, PO QID for
14 days
NOTE:
1. Bed rest, scrotal support, and analgesia are essential parts of the management
2. In men older than 35 years and MSM regardless of age, add amoxicillin-clavulanic acid 875/125
mg BD for 7 days to cover for anaerobes.
3. REFER to the urologist via the usual referral pathway if there is no improvement.
Laboratory diagnosis
Diagnosis is confirmed by culture of urethral discharge. A urine sample can also be used for both C.
trachomatis and N. gonorrhoeae or both via PCR. PCR for M. genitalium too.

Complications
Complications include atrophy of the testis, testicular abscess,
infertility, and rarely, gangrene.

40
Guidelines for the Management of Sexually Transmitted Infections

4.2 INGUINAL BUBO

Definition
Inguinal and femoral buboes are localised, enlargements of the lymph nodes in the groin area (can be
uni- or bilateral), which are painful and may be fluctuant and are a result of STIs. Refer to Annex 5 for
photos of inguinal bubo.

Aetiology
They are frequently associated with:
• LGV (mostly found in MSM)
• H. ducreyi (chancroid)
• Klebsiella granulomatis, previously known as C. granulomatis.

Non-sexually transmitted local and systemic infections e.g. infections of the lower limb or and in particular
TB can also cause swelling of inguinal lymph nodes but this is not considered to be inguinal bubo.

T. pallidum, herpes simplex, and other causes of a genital ulcer may also be associated with inguinal
lymphadenopathy, but these are managed as per GUD protocol.

Algorithm for Inguinal Bubo

Patient complaining of hot painful

inguinal swelling

Take history and examine. Exclude hernia or

femoral aneurysm

Inguinal bubo
and/or genital NO Offer health education on
ulcer present prevention of STIs
YES

Ulcer
YES Follow genital ulcer flow
present

NO

Treat for LGV, H. ducreyi, and K. granulomatis

If bubo is flactuant, aspirate pus and repeat every 72 hours if necessary.
Ask patient to return in 7 days if symptoms persist

Poor
Condition NO compliance to
improved? therapy?
YES NO YES

Continue treatment, offer Refer to medical Offer health promotion

health education on the doctor for AMR testing, package and repeat
prevention of STIs, and rule other investigations, therapy
out other STIs. Offer HIV and management
test and RPR

41
 Guidelines for the Management of Sexually Transmitted Infections

Recommended treatment for inguinal bubo (Treat for Chancroid and K. granulomatis)
Azithromycin 1g PO, once a week for 3 weeks OR Doxycycline 100mg PO, BD for 3 weeks
NOTE: Fluctuant lymph nodes should be aspirated through healthy skin. Incision and drainage or
excision of nodes may delay healing and should not be attempted.
REFER to the medical officer for AMR testing if there is no improvement.
Laboratory diagnosis
Genital ulcer swab; Aspiration of the bubo for culture and testing AAFB; Tissue biopsy where
K. granulomatis is suspected

Complications
• Phimosis
• Urethral stricture
• Urethral Fistula
• Ulcers
• Genital lymphoedema and damage to pelvic organs

4.3 GENITAL SCABIES

Definition
An infestation of the skin caused by the mite Sarcoptes scabiei which burrows the skin, causing lesions
where the female rests and lays eggs.

Aetiology
It is caused by the mite Sarcoptes scabiei and it is transmitted by close contact with an infested case,
either sexual or non-sexual.

Symptoms and signs Laboratory Diagnosis Treatment

Common symptom is itching. Microscopy. Recommended treatment:
Erythematous papules and burrow ink. test. Benzyl benzoate emulsion
burrows. adhesive plaster test. (BBE)
Can be complicated by Polymerase chain reaction- Dosage:
secondary infection. based test. Adults and children > 6 years:
usually remain symptom-free apply a thin layer over the
for 2-6 weeks. whole body, omitting the head
Diagnosed through physical and neck. Wash off after 24h.
examination. Alternative:
Permethrin 5% Cream.
Apply from the neck to the toes
for 8 -14 hours.
NOTE:
1. For children < 6 years
and pregnant women, use
permethrin 5% cream.
2. Clothing or bed linens used
by the patient in the two
days before the start of the
treatment should be washed
and dried well.
3. Counselling, compliance,
contact tracing, and condom
use should be advised.

42
Guidelines for the Management of Sexually Transmitted Infections

4.4 PEDICULOSIS PUBIS

Definition
An infestation of the skin caused by the pubic louse (Phthirus pubis) which produces itching around
the pubic and peri-anal area, and occasional eyelashes.

Aetiology
It is caused by the Phthirus pubis lice, and it is transmitted by close contact with an infested case,
either sexual or non-sexual.

Diagnosis Treatment
•P  hysical examination: The parasite is visible Recommended treatment:
to the naked eye. Benzyl benzoate 25%, lotion applied to the
• The mature lice are brown or bluish-grey and entire body from the neck down nightly for two
approximately the size of pinheads. nights. Patients may bath before re-applying
• The main symptom is itching which is usually Benzyl benzoate 25% lotion and should bath 24
severe. hours after the final application.
• The parasite can spread to the thighs, chest, Alternative:
axillae, and even the eyelids. Permethrin cream 1% for 8 hours.
• Scratching of skin punctures may result in NOTE: The above preparation should be
secondary infection. liberally rubbed into the affected areas.
• Dead lice and nits are then removed with
a fine-toothed comb. Shaving is usually
● unnecessary. The procedure should be
● repeated after 7 days.
• Clothing or bed linen used by the patient
in the two days before the start of the
treatment should be washed and dried
well.

4.5 BALANITIS/BALANOPOSTHITIS

Definition
This condition is characterised by soreness and itchiness of the glans usually with an inability to
retract the foreskin. If the origin is an infection, it can include infection with Candida albicans or
mixed bacteria. This condition is NOT an STI and is often encountered in the setting of poor hygiene
and/or diabetes mellitus. It can also be due to inflammatory skin diseases which require referral to a
dermatologist.

Symptoms and signs Recommended treatment

• It presents with pruritus and soreness and • Clotrimazole cream BD for 7 days.
there may be cracks on the foreskin. • Wash daily and advise the retraction of the
• Genital ulceration and urethral discharge foreskin when bathing. If the prepuce is not
should be sought and treated. retractable, refer the patient for possible
● VMMC.
● NOTE: Diabetes should be excluded by doing
Blood Glucose Test or urine test for glycosuria.

43
 Guidelines for the Management of Sexually Transmitted Infections

4.6 SCREENING AND MANAGEMENT OF SYPHILIS

Definition
Syphilis is an infectious venereal disease caused by the spirochete Treponema pallidum. Syphilis can be
acquired or congenital. Acquired syphilis can be divided into two major groups: early and late syphilis.
Early syphilis comprises the primary stage, secondary stage, and early latent stage (of less than two
years duration).

Transmission
Treponema pallidum bacteria is transmitted by sexual contact with infectious lesions, from mother to
foetus in utero, via blood product transfusion, and occasionally through breaks in the skin that come
into contact with infectious lesions.

Laboratory Diagnosis
• RPR, and TPHA if RPR is positive. The sample should be collected in a red-top tube (clotted) or a
serum separator tube (SST, yellow-top tube with gel).
• If available: Treponema pallidum enzyme-linked immunoassay (ELISA), Treponema pallidum
particle agglutination (TPPA) assay, Fluorescent Treponemal Antibody (FTA) assay, and Rapid
treponemal antibody test (TPAb).
• Cerebrospinal fluid venereal disease research laboratory test (CSF-VDRL) is regarded as the gold
standard for the diagnosis of neurosyphilis; a reactive result, in the absence of contaminating blood,
confirms a neurosyphilis diagnosis. A nonreactive CSF-VDRL does NOT rule out neurosyphilis.
• CSF-RPR testing SHOULD NOT be used in the evaluation of possible neurosyphilis.
• Microscopy – syphilitic treponemes can be observed from lesions of secondary syphilis, such as
condylomata lata and mucous patches.
• Molecular detection – T. pallidum can be detected by molecular methods from lesions of
secondary syphilis.

Low positive RPR titres (<1:8) should be confirmed with FTA or TPHA to rule out biological false
positives.

NOTE:
1. Both RPR and TPHA might be negative in early infection (first 4 weeks after infection). If there is a
high suspicion of syphilis, the tests (RPR & TPHA) should be repeated at 4 and 12 weeks.
2. For pregnant women, screening tests should be done at the first Antenatal Care visit, and 34 weeks or
first contact after 34 weeks in women who would have been screened before 20 weeks of pregnancy.

44
Guidelines for the Management of Sexually Transmitted Infections

Treatment of syphilis at different stages

Stage Clinical presentation Treatment

Primary syphilis Presence of syphilitic chancre Recommended regimen:
(painless ulcer) often with regional Note: Ulcers may be difficult to find in
lymphadenopathy (incubation 10- women or MSM
90 days). Alternative regimen
Note: Ulcers may be difficult to find Doxycycline 100mg PO, BD for 14 days.
in women or MSM OR
Erythromycin 500mg PO, QID for 14 days.
Secondary Fever, papulosquamous rash, Recommended regimen:
syphilis which includes the palms of the Benzathine penicillin 2.4 MU IM, STAT.
hands and soles of feet. Alternative regimen:
Presents 6 weeks to 6 months after Doxycycline 100mg PO, BD for 14 days.
infection. OR
Erythromycin 500mg PO, QID for 14 days
Early Latent No clinical manifestation. Less than Recommended regimen:
syphilis 2 years in duration. Benzathine penicillin 2.4 MU IM, STAT.
Alternative regimen
Doxycycline 100mg PO, BD for 14 days.
OR
Erythromycin 500mg PO, QID for 14 days
Late Latent No clinical evidence of treponemal Benzathine penicillin 2.4 MU IM, given
syphilis infection. More than 2 years weekly for 3 weeks.
duration.
Neurosyphilis Can present as: Benzylpenicillin G 18 - 24 MU IV per day
• Cranial nerve dysfunction administered as 3-4 MU every 4 hours for
• Meningitis 14 days.
• Stroke
• Acute or chronic altered mental * Refer to the specialist using the usual
status referral pathway for management
• Loss of vibration senses
• cognitive dysfunction
Early Syphilis in Same as primary Syphilis above Recommended regimen:
pregnancy Benzathine penicillin 2.4 MU IM, STAT.
Alternative regimen:
Ceftriaxone 1g IM, OD for 8-10 days
OR
Erythromycin 500mg PO, QID for 14 days
OR
Azithromycin 2g PO, STAT.
NOTE: Penicillin desensitisation should be
attempted first before offering alternative
regimens in pregnant women with
penicillin allergy
Late syphilis in Same as secondary Syphilis above. Recommended regimen:
pregnancy Benzathine penicillin 2.4 MU IM, given
weekly for 3 weeks.
Alternative regimen
Erythromycin 500mg PO, QID for 30 days
NOTE: Penicillin desensitisation should be
attempted first before offering alternative
regimens in pregnant women with
penicillin allergy

45
 Guidelines for the Management of Sexually Transmitted Infections

Note:
1. Although erythromycin is used to treat pregnant women, it does not cross the placental barrier
completely and the foetus is not treated. The newborn infant, therefore, needs treatment soon after
delivery.

Complications
• Miscarriage and stillbirths in pregnancy.
• Cardiovascular complications; dilated aneurysm of the ascending aorta, narrowing of the coronary
aorta, or aortic valvular insufficiency.
• CNS complications: dementia, psychosis, and meningovascular neurosyphilis.

4.7 HUMAN PAPILLOMAVIRUS (HPV) INFECTION

4.7.1 Genital Warts

Definition
Genital warts are raised skin-coloured growth with a cauliflower-like surface on the genitalia, per-anal
area, or urethra. Refer to Annex 5 for photos of genital warts.

Aetiology
Approximately 150 types of HPV have been identified, and at least 40 of them affect the genital area.
HPV types 6 and 11 are associated with genital warts. The HPV types that cause genital warts are not
associated with cancer. HPV types 16 and 18 cause the majority of cervical, penile, valvular, vaginal,
anal, and oropharyngeal cancers and precancers.

Symptoms and signs Recommended treatment

•G  enital warts may not cause symptoms and • Podophyllin resin 15%-25% to be applied
can regress naturally. on warts, avoiding normal tissue. Wash
● thoroughly 1-4 hours after application.
• Diagnosis is done through physical Treatment should be repeated at weekly
examination. intervals.
●
• Genital warts may be flat or papillary in shape • Referral of patients with widespread invasive,
or extensive among patients who have a meatal, or cervical warts is necessary for
concomitant infection with HIV. cryotherapy or surgical removal.
●
• It is also important to exclude secondary Note:
syphilis as the lesions can be confused with 1. The primary goal for the treatment of genital
condylomata lata. warts is to eliminate the symptoms caused by
● visible warts.
2. Eradication of the virus and elimination of
infectivity is difficult to achieve.
3. All female patients presenting with genital
warts should have a Pap smear done and
follow cervical cancer guidelines.
4. Podophyllin is not recommended in
pregnancy. Cryotherapy and surgical removal
should be used.
5. Caesarean section delivery is indicated for
women with extensive anogenital warts.

46
Guidelines for the Management of Sexually Transmitted Infections

4.7.2 HPV and Cervical Cancer

Globally, cervical cancer is the fourth most frequent cancer among women. The distribution of cervical
cancer cases globally is disproportionately lower among high-income countries (HICs) compared
to LMICs because of the high coverage of organised screening services and adequate treatment
of precancerous lesions. Organised screening services in HICs have shifted in many places to HPV
screening rather than Papanicolaou (Pap) smear screening. In 2020, 604 000 new cases of cervical
cancer and 342 000 deaths were reported globally. Ninety percent of the deaths were in LMICs. 177
000 of the new cases and 77 000 deaths were in Africa. Sub-Saharan Africa (SSA) has the highest
rates of cervical cancer in the whole world. The cervical cancer burden in SSA is worsened by the
high prevalence of HIV in the region, early onset of sexual intercourse, a high rate of unprotected sex
and sexually transmitted infections, and insufficient sexual and reproductive health education among
young girls and women.

Close to 100% of all cervical cancer cases are attributable to HPV. HPV types 16 and 18 cause at least
70% of all cervical cancers globally while types 31, 33, 45, 52, and 58 cause a further 20% of the cases.
Persistent infection with high-risk HPV accounts for more than 99% of cervical cancer globally. HPV is
the most common viral sexual infection of the reproductive tract globally. It is estimated that over 70%
of sexually active men and women will be infected with HPV in their lifetime. The period from exposure
to HPV infection to the development of cancer is approximately 15-20 years. The immune system plays
an important role in the regression or progression of HPV infection to cervical cancer. Women living
with HIV (WLHIV), including those on treatment with antiretroviral therapy, are six times more likely to
develop cervical cancer compared to those without HIV. Untreated HIV infection reduces the time it
takes for HPV infection to develop into cervical cancer to 5-10 years.
The key determinants of HPV infection for both men and women are related to sexual behaviour and
include young age at sexual initiation, a high number of sexual partners, and having partners with
multiple partners. High-risk HPV infection is most common in young women, with a peak prevalence as
high as 25–30% in women under 25 years of age. In most sites, prevalence decreases sharply with age.
As it usually takes 10–20 years for precursor lesions caused by HPV to develop into invasive cancer,
most cervical cancers can be prevented by early detection and treatment of precancerous lesions.

Studies are showing a relationship between HPV and other cancers. The attributable risk (AR) for
penile cancer due to HPV 16 and 18 is 40% while it is 52% for anal cancer among women, 42% for
HPV 16 in anal cancer among men, and 46% for HPV 16 and 18 in vulvar and vaginal cancer. Due to
this relationship, all women and men presenting in STI clinics will need to be offered an anogenital
examination to make sure they do not have these other HPV-related cancers.

Key points
• Cervical cancer is one of the leading causes of cancer death in women in developing countries.
• The primary underlying cause of cervical cancer is infection with HPV, a very common virus that
is sexually transmitted.
• Most HPV infections resolve spontaneously; those that persist may lead to the development of
precancer and cancer if untreated.
• It usually takes 10 to 20 years for precursor lesions caused by HPV to develop into invasive
cervical cancer.
• Effective interventions against cervical cancer exist, including screening for, and treatment of,
precancer and invasive cancer.
• An estimated 92% of women in LMICs have never been screened for cervical cancer.

47
 Guidelines for the Management of Sexually Transmitted Infections

• Over 90% of women newly diagnosed with cervical cancer live in LMICs, and most are diagnosed
when they have advanced disease.
• The cure rate for invasive cervical cancer is closely related to the stage of disease at diagnosis
and the availability of treatment. If left untreated, cervical cancer is almost always fatal.
• Because of its complexity, cervical cancer control requires a team effort and communication
between healthcare providers at all levels of the healthcare system.

Prevention of Cervical cancer

For the prevention of cervical cancer in Namibia, refer to the National Cervical Cancer Prevention
Guidelines. A summary of the prevention measures is below.
• Regular screening of women of childbearing age, including WLHIV.
• Prioritise HPV vaccination for girls between 9-14 years. They should receive at least one dose, and
where two doses are given, they should be 6-12 months apart.

Frequency of Cervical cancer screening

HIV STATUS AGE VIA testing frequency PAPSMEAR testing frequency
Positive 20-49 years 3 years Screen until 3 consecutive
negative tests, then screen
every 3 years.
Negative 25-49 years 5 years Every 3 years.
Positive > 50 years Not indicated for post- Every 3 years.
menopausal women
Negative > 50 years Not indicated for post- Stop after at least one
menopausal women negative screening result in
the past 3 years.

Note: Where HPV DNA screening is available, it should be performed every 5-10 years in the general
population and 3-5 years among WLHIV

The four components of Cervical cancer control

Within a national cancer control programme, there are four basic components of cervical cancer control:
• primary prevention: i.e. actions to avoid exposure to the principal cause of a disease, which is HPV
infection, and HPV vaccination.
• early detection, through increased awareness and organised screening programmes.
• diagnosis and treatment.
• palliative care for advanced disease.

4.8 HEPATITIS B VIRUS (HBV)

Definition
A vaccine-preventable infection of the liver caused by the Hepatitis B virus. Approximately 5% of
patients with HBV infection become chronically infected, and 25% of these develop Chronic Active
Hepatitis which can progress to cirrhosis and hepatocellular carcinoma.

Transmission
Hepatitis B infection is transmitted via sexual contact, vertically, parenterally (e.g. blood transfusion), or
through the use of contaminated needles.

48
Guidelines for the Management of Sexually Transmitted Infections

Laboratory diagnosis and monitoring

Diagnosis Monitoring tests
•P  atients may be symptomatic or If available:
asymptomatic. Symptoms include malaise, • FBC
nausea, vomiting, and fatigue. • HBc-IgG and HBc-IgM for recent or latent •
• HBsAg infection
• LFTs • HBeAg
• Ultrasound scan of the abdomen • Hep B viral load
• Computed tomography (CT) scanning of the • Hep D if treatment is required.
abdomen.

Management
The goal of management is to prevent disease progression to cirrhosis, liver failure, or hepatocellular
carcinoma. In Namibia, patients with HBV-HIV co-infection receive antiretrovirals that are also active
against HBV, namely tenofovir and lamivudine/emtricitabine as part of their ART regimen.

Prevention
A Hepatitis B vaccine is available in Namibia as part of the Expanded Programme on Immunisation.
HBV-exposed babies should also receive the HBV immunoglobulin with their 1st HBV vaccine dose.
The vaccine is also recommended for those at risk of occupational exposure. Other groups for
consideration are close contacts of known HBsAg-positive patients as well as HBsAg-negative PLWH.

49
 Guidelines for the Management of Sexually Transmitted Infections

5. CONSIDERATIONS FOR SPECIAL

POPULATIONS

5.1 NEONATAL CONJUNCTIVITIS

Definition
The neonate may develop an infection of the eyes during birth as a result of genital infection of the
mother with N. gonorrhoea or C. trachomatis. It is also referred to as ophthalmia neonatorum.

Aetiology
It is caused by STIs such as:
• N. gonorrhoeae
• C. trachomatis

Other common causes include staphylococcus aureus, streptococcus pneumonia, Haemophilus species,
and pseudomonas species.

Symptoms and signs

The clinical features include periorbital swelling, redness of the eyes with sticky eyelids, and purulent
discharge from the eyes. Thus, a high index of suspicion and the institution of appropriate management
is essential when these clinical findings occur in the neonatal period.

Complications
Unless properly treated it can lead to blindness.

Prevention of Ophthalmia Neonatorum

Gonococcal ophthalmia neonatorum is preventable with timely eye prophylaxis. The infant’s eyes
should be carefully cleaned immediately after birth.

The application of chloramphenicol 1% ointment (alternatively tetracycline 1%) to the eyes of all
infants at the time of delivery is strongly recommended as a prophylactic measure. However, ocular
prophylaxis provides poor protection against C. trachomatis conjunctivitis. Infants born to mothers
with gonococcal infection should receive additional treatment.

50
Guidelines for the Management of Sexually Transmitted Infections

Algorithm for Neonatal conjunctivitis syndrome

Neonate with eye discharge or

eyelid oedema

Take history and

examine

Reassure mother and advise to

Are eyelids swollen return if necessary. Offer health
with purulent NO education on prevention of STIs
discharge? and rule out other STIs.
Offer HIV test and RPR
YES

Sticky eye(s) without Mild purulent discharge without Abundant purulent discharge and/or
purulent discharge swollen eyelids and no corneal swollen eyelids and or corneal hazziness
haziness
YES YES YES

Cleanse eyes with clean cloth, cotton wool or swab, taking care not to touch or injure the eye

Treat baby for: Treat baby for: Treat baby for:

• NG and CT • NG and CT • NG and CT
REFER to medical doctor REFER to medical doctor for
for further management further management

IMPROVED Review daily Mother and Father

Treat as VDS or UDS

Finalise treatment - Reassure mother. Offer health education on prevention of

STIs and rule out other STIs. Offer HIV test and RPR

Urgent Referral to medical doctor:

• All neonates with abundant purulent discharge and/or swollen eyelids and/or corneal
haziness Neonates unresponsive to treatment within 2 days

Recommended Treatment for Neonatal Conjunctivitis Syndrome

Ceftriaxone 50mg/kg body weight (maximum 125mg) IM, STAT PLUS
Erythromycin 50mg/kg PO, QID for 14 days
PLUS, OFFER COUNSELLING FOR HIV TESTING. TAKE BLOOD FOR RPR/VDRL

51
 Guidelines for the Management of Sexually Transmitted Infections

5.2 NEONATAL HERPES

Definition
Neonatal herpes may occur after the birth of a neonate from a mother with active herpes genitalis. In
addition to severe skin disease, the neonate may develop aseptic meningitis or encephalitis and it is
frequently fatal. Suspected neonatal herpes should be admitted to the hospital and managed as an
emergency.

Recommended treatment for Neonatal Herpes

Acyclovir 10 mg /Kg IV three times daily for 14 days for localized mucosal or dermal infections.
Acyclovir 20 mg /Kg IV three times daily for 21 days for disseminated infections.
Counsel the mother regarding herpes.
Screen for HIV, Syphilis, and other STIs.

5.3 SYPHILIS IN PREGNANCY

Pregnant women should be routinely screened serologically for syphilis early in pregnancy. Adverse
pregnancy outcomes such as miscarriage or stillbirth, congenital syphilis in the newborn, and
progression of latent syphilis in the mother have anticipated complications if the mother is left untreated
for syphilis. Thus, the RPR test should be routinely done on pregnant women in their first trimester, at
the first antenatal visit, and at 34 weeks or first contact after 34 weeks in women screened before 20
weeks of pregnancy, and treatment should be instituted if the RPR test shows strong reactivity. Weak
reactivity should warrant specific serological tests (TPHA or FTA) before a decision to treat is made.

For the recommended treatment of syphilis in pregnancy, refer to section 4.7 and the algorithm on
syphilis in pregnancy.

52
Guidelines for the Management of Sexually Transmitted Infections

Algorithm of Syphilis in pregnancy

Routine screening for syphilis in

pregnant women

Take history and conduct physical examination

Take blood for RPR test (if scheduled for syphilis screening)*, for HIV test
(if due for testing), and for other ANC routines

Syphillis test/RPR
Any STI syndrome?
positive

Treat for syphilis. In case of

Use appropriate penicillin allergy, refer to hospital for
flowchart, manage desensitisation.
appropriately

Treat Asymptomatic newborns

Symptomatic newborn of of mothers with positive syphilis
mothers with positive syphilis test if mother was not treated,
test during pregnancy: OR if mother received < 3 doses
REFER to medical doctor for of Benzathine penicillin, OR if
congenital syphilis management. mother delivers within 4 weeks of
commencing treatment.

Follow up 3 months after last injection to confirm 4 fold reduction in RPR titres, provided
the initial titre was > 1:8. If the initial titre was < 1:8 further reduction may not occur

*Screen for syphilis in all pregnant women at first antenatal visit. Repeat test at 34 weeks of
gestation (or first contact thereafter) in women who tested negative before 20 weeks gestation

53
 Guidelines for the Management of Sexually Transmitted Infections

5.4 CONGENITAL SYPHILIS

Infection of the foetus could occur in utero resulting in either stillborn or complications happening
at birth, such as neonatal death. Many infants could be born without symptoms but develop clinical
findings compatible with congenital syphilis in the course of their lives. All syphilis-exposed infants
should receive treatment and be managed and monitored as follows:

• Infants born to inadequately treated mothers should receive treatment for congenital syphilis (CS)
and have an RPR test with titre at delivery as well as at six months post-treatment to evaluate
treatment response.
• Infants born to adequately treated mothers with no sign of maternal reinfection do not require
treatment or follow-up RPR titres, but they should be evaluated for clinical signs suggestive of CS
at delivery. If such clinical signs are identified these infants should receive testing, recommended
treatment, and follow-up.
• Any previously undiagnosed and untreated infant ≥6 months of age who has a reactive RPR
titre should be considered a case of CS and receive treatment according to the recommended
treatment.

Recommended treatment for congenital syphilis

Early congenital syphilis (confirmed or • Aqueous crystalline penicillin G
presumptive disease) (Benzylpenicillin) 50,000 units/kg body weight/
dose, IV every 12 hours during the first 7 days
of life and every 8 hours thereafter for 3 days.
• Alternative: Procaine Penicillin 50,000 units/kg
body weight/dose IM, OD for 10 days.
Late congenital syphilis (2 or more years) • Aqueous crystalline penicillin G
(Benzylpenicillin) 50,000 units/kg IV, QID for 10
days
Note: CSF should be examined with VDRL to exclude the involvement of the CNS

54
Guidelines for the Management of Sexually Transmitted Infections

Algorithm for Congenital Syphilis

Maternal reactive RPR and

treponemal test

Appropriate Treatment inadequate or not

treatment prior adequately documented in
to or during pregnancy (no treatment, non-
pregnancy penicillin treatment or inadequate
penicillin dose

At least 3 or 4
fold fall in Inadequate fall
maternal RPR in maternal
titers RPR titers
Full evaluation
for congenital syphilis
including long
bones and CSF
Infant Infant RPR Infant RPR 4
RPR non- reactive fold higher than
reactive and infant maternal or infant
asymptomatic symptomatic

Patient Signs and

asymptomatic, symptoms of
CSF & long congenital
bones normal syphilis
1. No further diagnostic evaluation
or treatment required.
2. Clinical and serological follow-up
until 15 to 18 months of age Treat for congenital syphilis

55
 Guidelines for the Management of Sexually Transmitted Infections

5.5 STIs IN CHILDREN AND ADOLESCENTS

Chlamydial vaginitis acquired perinatally could manifest up to the age of three years. However, in some
cases, it may be related to sexual abuse. In addition, bacterial vaginitis has been diagnosed in children
who have been abused, but its presence alone does not prove sexual abuse. Genital warts can be
acquired congenitally and are not specific indicators of abuse unless supported by other evidence.

STIs in adolescents place them at a higher risk of acquiring HIV. This is because the same biological
and social factors that increase vulnerability to STIs also increase vulnerability to HIV infection.

Biological factors
• A mucosal tear during a sexual act.
• Underdeveloped vaginal epithelium, which could be easily infected by aetiologies of STI.

Social factors
•M
 ultiple sexual partners
•S
 ex work
•P
 oor health-seeking behaviour
•P
 oor self-esteem
•L
 ack of youth-friendly services

The following key issues are useful to remember during the management of STIs in adolescents.
Adolescents may have limited access to health care and may not seek care adequately. Therefore,
arrangements should be made to ensure compliance and future follow-up. Partner notification and
management are often difficult, thus risk of reinfection exists. Pregnancy should be considered, and
screening is pertinent in adolescent females.

56
Guidelines for the Management of Sexually Transmitted Infections

5.6 PREVENTING STIs IN CASE OF SEXUAL ASSAULT

In line with national guidelines for ART for the provision of post-exposure prophylaxis (PEP) for survivors
of sexual violence, STI prophylaxis is important. The following should be done.

Female Male
Test Pregnancy test HIV test
HIV test HBsAg
HBsAg RPR test
RPR test
Prophylaxis Emergency contraceptives Hepatitis B Prophylaxis-Hepatitis
Hepatitis B Prophylaxis-Hepatitis B immunoglobulin and hepatitis B
B immunoglobulin and hepatitis B vaccination should be done as soon as
vaccination should be done as soon as possible if the survivor is not already
possible if the survivor is not already immune, and no later than 21 days after
immune, and no later than 21 days after the incident. If the results of the HBsAb
the incident. If the results of the HBsAb test are non-reactive, vaccinate at 0, 1,
test are non-reactive, vaccinate at 0, 1, and 3-6 months.
and 3-6 months. HIV PEP
HIV PEP Anti-tetanus vaccine
Anti-tetanus vaccine
Recommended: Ceftriaxone 1g IM, STAT
Recommended: Ceftriaxone 1g IM, OR
STAT Alternative: Cefixime 800 mg PO, STAT
OR PLUS
Alternative: Cefixime 800 mg PO, STAT Doxycycline 100mg PO, BD
PLUS for 7 days.
Doxycycline 100mg PO, BD for 7 days OR
OR Erythromycin 500mg PO,
Erythromycin 500mg PO, QID QID for 7 days
for 7 days in pregnant women.
PLUS
Metronidazole 400mg PO, BD for 7 days

The client should also be given PEP for HIV in line with the national guidelines (See the National
Guidelines for ART).

The occurrence of STIs in children except for neonatal infections and congenital syphilis invariably
indicates sexual abuse. Healthcare providers should contact child protection services for comprehensive
management (Also refer to Clinical Care for Survivors of Sexual Abuse in Namibia).

The occurrence of STIs in children and adolescents is caused by similar pathogens as in adults and
thus similar management principles should be followed. However, some medications used in adults
may not be appropriate for children. Annex 3 shows the paediatric doses of drugs commonly used to
treat STIs in children.

57
 Guidelines for the Management of Sexually Transmitted Infections

6. S
 URVEILLANCE, RESEARCH NEEDS,
AND PRACTICAL CONSIDERATIONS
6.1 SURVEILLANCE AND RESEARCH NEEDS

For surveillance purposes, the most useful STI syndrome is male urethral discharge. Curable, bacterial
STIs (e.g.: gonorrhoea, chlamydia) with acute onset and short duration serve as the best tool for
assessing STI incidence and prevalence and as a proxy for measuring the impact of STI/HIV prevention
and control programs. The other syndromes are either not necessarily recently acquired (ex: genital
ulcer) or may not be transmitted sexually (e.g.: vaginal discharge). However, recording and reporting
them is important from the point of view of the management of health services.

STIs generally reflect risk behaviour in the relatively recent past better than HIV prevalence data,
because curable STIs are usually of relatively short duration. An increase in safe behaviour may
therefore be reflected much more quickly in lower STI rates than it is in lower HIV rates. It should be
borne in mind, however, that lower STI rates may reflect improvements in the quality and coverage of
treatment as well as changes in risky behaviour. For these reasons, good STI incidence and prevalence
data can contribute significantly to tracking trends in risky sex and potential exposure to HIV infection
and monitoring the success of measures aimed at promoting safer sex.

Uses of data from STI surveillance systems

• To assess the burden of STIs, by providing an indicator of the minimum incidence of recently
acquired infections.
• To monitor trends in the incidence of recently acquired infections if health-seeking behaviour is
stable and consistent.
• To provide information necessary for the management of patients and their sex partners.
• To provide data necessary for planning and managing health services.
• To provide data for advocacy and resource mobilisation and programme planning, targeting,
monitoring, and evaluation.

Challenges in STI surveillance

•D
 ifficulty in conducting robust surveillance when laboratory testing is not available to detect
STIs and understand the causes of STI syndromes.
•T
 he asymptomatic nature of many STIs results in a significant burden of infections
being missed due to a lack of diagnostic testing and limited linking of laboratory data to
epidemiological data in many settings.

Anticipated responses
•O
 ngoing STI surveillance at the country level, therefore, needs to be strengthened. The few
available data should be used as stepping stones to improve surveillance by using the gaps for
planning and programming to obtain more robust data. This should be done continuously and
not only periodically.
•S
 ince the syndromic approach is being used in the country, Namibia should keep on top of
the causes of the STI syndromes emerging by regularly conducting aetiological studies from
sentinel sites using molecular assays, linked to other programmes, if necessary.
•S
 TI surveillance should be an integral part of the syndromic approach, linked with periodic
assessment of the AMR of key pathogens.

58
Guidelines for the Management of Sexually Transmitted Infections

• The complications of STIs are another component that adds to the disease burden, and routine
STI surveillance should incorporate monitoring of STI complications within STI management
reporting systems.
• STI surveillance in key populations remains fundamental since the STI prevalence in these
populations remains a significant contributor to the STI epidemic. For this, the collaboration of
NGOs should be sought and strengthened to harness these stakeholders as sources of data.
Regular systematic STI surveillance and screening for STIs among key populations would be
more relevant than occasional surveillance in providing information for effective interventions.
• Capacity-building is required for STI surveillance and monitoring. This requires strengthening
laboratories by investing in human resources for laboratories and fostering the availability of and
access to affordable STI diagnostic tests.
• Advocating for funding is essential for developing alternative approaches for managing people
with STIs by using rapid PoC diagnostic tests.
• For syphilis, since there is routine maternal screening and trend estimation at the country level,
modelling should be used more systematically and frequently to establish maternal syphilis trend
estimates, together with the WHO congenital syphilis estimation tool to estimate the incidence
of congenital syphilis as a basis for validating the elimination of mother-to-child transmission.
These elements can be strengthened and scaled up, linked with STI workshops that are often
conducted by UNAIDS for regional HIV estimation.

6.2 MONITORING AND EVALUATION OF STI PROGRAMS

Without clear objectives and targets, monitoring and evaluation will be difficult, and in some cases
impossible. Some objectives are so broad that it can be difficult to measure their achievement. Good
objectives should be specific, measurable, achievable, reasonable, and time-bound, and contribute to
attaining the overall goals of the program.

Monitoring of STI programs

Program monitoring tracks progress in program performance by establishing that project inputs,
activities, and outputs have occurred. Program monitoring also identifies possible problem areas that
may require more in-depth evaluation. Components of STI programs that can be monitored include:
• Infrastructure and management information system (MIS)
- Appropriate data management system: record-keeping and reporting system.
- Availability of appropriately trained staff.
- Adequate equipment and space.
• Confidentiality practices
- Adequate premises for the protection of privacy and confidentiality.
- Issues of consent.
• Provision and delivery of services (including the readiness of the healthcare facility and the
quality of services)
- Adequate essential drugs and diagnostics for STI aetiologies in the community.
- Appropriate and available treatment guidelines or standards and adherence to them.
- Clinical care.
- Laboratory testing.
- Access to services by the target audience.
- Availability of condoms and water-based lubricants.
- Availability of equipment to demonstrate correct condom use.
• The utilisation of services

59
 Guidelines for the Management of Sexually Transmitted Infections

- Accessible and acceptable services for high-risk populations.

- Demography of population benefiting from services.
- Client satisfaction.
- Referrals.
- Partner notification.
• Human resources and capacity
- Staff training.
- Communication issues.
• Management and supervision
- Training, support, and staff development.
- Supervision tools.
- Staff performance.
- Budgeting and planning.
• Primary prevention activities
- Behaviour changes communication activities to increase knowledge and awareness.
- Referrals that promote STI services.
- Counselling.
- Availability of educational material.
• The community component of the intervention
- Policy.
- Community partnership.
- Networking and collaboration.
- Involvement of opinion leaders.

Evaluation of STI programs

Evaluation of STI programs should ideally follow the following steps:
• Engaging stakeholders
• Describing the program
• Focusing the evaluation
• Gathering credible evidence and justifying conclusions
• Ensuring the use of the results and sharing lessons learned

Engaging stakeholders
Stakeholders for an evaluation are the individuals or organisations who are actively involved in its
implementation or who have an interest in its findings. Genuine consultation with them should take
place through all accessible channels, including meetings, emails, and conference calls. Stakeholders
ought to additionally consist of those who might potentially impact adjustments that emerge from
evaluations. They should be in a position to support the evaluation and its findings in addition to
serving as its guide and providing technical and other recommendations. Engaging stakeholders
is essential to ensure the usage of an evaluation. Although defined as the first step within the
framework, engagement can benefit all other steps. Stakeholders can assist in defining a program,
ranking evaluation methodologies and questions, interpreting results, and outlining the most effective
distribution channels for the results.

Describing the program

Program descriptions that are clear serve as clear road maps for evaluation. It is much simpler to
determine what could be measured or documented and where future research may be most necessary
when the targeted outputs, results, contextual effects, and relationships underpinning a program or

60
Guidelines for the Management of Sexually Transmitted Infections

intervention are clarified. Systems diagrams, theories of change, and logic models can all be used to
describe a program in a way that reveals its intended logic. The preferences and requirements of the
tool’s users should be taken into consideration. There are various stages at which descriptions can be
constructed. For instance, an STI program might have a description for the whole program and then
have nested descriptions that provide more specific information about each segment, like the service
work done by partners or the techniques used for policymaking. STI programs typically have similar
short-term outcomes, such as increased STI screening and treatment, and similar long-term results,
such as decreased STI prevalence and incidence.

Focusing the evaluation

Evaluations need to be narrowly targeted to be effective and practical. Like other programs, STI
programs are complicated, and even with limitless resources, it would be impossible to analyse
every aspect of them equally well throughout the range of evaluation issues that programs could be
interested in. As a result, it is important to choose carefully where to concentrate evaluation efforts.
Choosing which component of a program to analyse is the first step in the process of narrowing and
defining the focus of an evaluation. Budgetary, political, scientific, and other factors are all considered
when making this decision.

Gathering credible evidence and justifying conclusions

Once an evaluation plan is made, the goal is then to gather the evidence. The emphasis in evaluation
is on credible evidence. For program decisions to be informed by credible evidence, a balance must
be struck between the practicality of data collection and analysis and the value of that evidence. To
maintain credibility, the evaluation uses scientific techniques for data collecting and analysis. Evidence
can be both quantitative and qualitative, and it may use a variety of data sources and methodologies.
The process of selecting and using important indicators dominates evaluation work. By definition,
strong indicators have high credibility and scientific merit, as well as clear meaning. STI programs
must use indicators that are adapted to their context while collaborating to identify measures that are
strongest and have broad application. Indicators that can be used in STI programs include those that
measure the reduction in STI risk, improvement in STI services, reduction in contextual constraints,
and the prevalence of STIs in certain population groups, such as syphilis among pregnant women.

Ensuring the use of the results and sharing lessons learned

In some respects, the effectiveness of an evaluation can be judged by how effectively the results were
put to use. The actions taken before ought to lead to this. If relevant stakeholders understand the
program and the evaluation, if the focus of the evaluation is important, and if the evidence gathered
and analysis conducted is credible, then the results have a high chance of being actionable and used to
inform the program. Use of results could lead to the expansion of a strategy, adjustments to a strategy,
or discontinuation of a strategy.

61
 Guidelines for the Management of Sexually Transmitted Infections

6.3 MINIMUM REQUIREMENTS FOR STI MANAGEMENT IN A HEALTHCARE FACILITY

Management of STIs is an integral part of the whole management of patient care in all healthcare
facilities in Namibia. Although STI treatment is already integrated into the training of healthcare
workers, emphasis should be placed on the detection of STI cases at every point of contact.

The following aspects are essential for the proper management of STIs in healthcare facilities:
• Out-Patient healthcare providers trained in syndromic management of STIs.
• Availability of reporting forms
- Partner referral cards
- Summary form
- Statistics
• Availability of the following equipment and supplies:
- examination lights
- Speculums
- Punch biopsy forceps
- Gloves
- Examination couch
- STI medicine and Family Planning commodities
- Female and male Condoms Models: Pelvic and Penile models.

62
Guidelines for the Management of Sexually Transmitted Infections

7. BIBLIOGRAPHY

Ballard R, Htun Y, Fehler G, Neilsen G. The Diagnosis and Management of Sexually Transmitted
Infections in Southern Africa. 3rd ed. Johannesburg. South African Institute for Medical Research.
2000.

Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018:
GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer
J Clin. 2018; 68(6):394-424.

Carter MW. Program Evaluation for Sexually Transmitted Disease Programs: In Support
of Effective Interventions. Sex Transm Dis. 2016; 43(2 Suppl 1): S11-17. [Link]
org/10.1097%2FOLQ.0000000000000281

Centres for Disease Control and Prevention. Sexually Transmitted Infections Guidelines, 2021.
Morb Mortal Wkly Rep. 2021; 70(4):1-187. [Link]
[Link]

Centres for Disease Control and Prevention. Fast Facts on Global Hepatitis B. 2022. Available at: https://
[Link]/globalhealth/immunization/diseases/hepatitis-b/data/[Link].

Dzinamarira T, Moyo E, Dzobo M, Mbunge E, Murewanhema E. Cervical cancer in sub-Saharan Africa:

an urgent call for improving accessibility and use of preventive services. Int J Gynecol Cancer. 2022.
Available at: [Link]

Handfield HH. Color Atlas & Synopsis of Sexually Transmitted Diseases. 3rd ed. New York. McGraw Hill
Medical. 2011.

James C, Harfouche M, Welton NJ, Turner KM, Abu-Raddad LJ, Gottlieb SL, et al. Herpes simplex virus:
global infection prevalence and incidence estimates, 2016. Bull World Health Organ. 2020; 98(5):315-
329.

MoHSS. Guidelines for the Management of Sexually Transmitted Infections using the Syndromic
Approach. 2nd ed. Windhoek. 2009.

MoHSS. National Cervical Cancer Prevention Guidelines. Windhoek. 2018.

MoHSS. National Guidelines: Antenatal Care for a Positive Pregnancy Experience. Windhoek. 2020.

MoHSS. National Guidelines for Antiretroviral Therapy Pocket Guide 2021. Windhoek. 2021.

MoHSS. Namibia Standard Treatment Guidelines. Windhoek. 2021.

Mullick S, Watson-Jones D, Beksinska M, Mabey D. Sexually transmitted infections in pregnancy:

Prevalence, impact on pregnancy outcomes, and approach to treatment in developing countries. Sex
Transm Infect. 2005; 81:294-302.
Murewanhema G, Moyo E, Mhango M, Chitungo I, Moyo P, Musuka G, Dzobo M, Dzinamarira T. Abnormal

63
 Guidelines for the Management of Sexually Transmitted Infections

vaginal discharge among women of reproductive age in sub-Saharan Africa: the need for a paradigm
shift from syndromic approach to specific pathogen identification and directed treatment. Int J Infect
Dis Regions. 2022; 5:165-168. Available at: [Link]

Passmore J, Jaspan H, Masson L. Genital inflammation, immune activation, and risk of sexual HIV
acquisition. Curr Opin HIV AIDS. 2016; 11(2):156-162.

Peters RP, Garrett N, Chandiwana N, Kularatne R, Brink AJ, Cohen K, et al. Southern African HIV Clinicians
Society 2022 guideline for the management of sexually transmitted infections: Moving towards best
practice. S Afr J HIV Med. 2022; 23(1).1450. [Link] v23i1.1450

Tsevat D, Wiesenfeld H, Parks C, Peipert J. Sexually transmitted diseases, and infertility. Am J Obstet
Gynecol. 2017; 216(1):1-9.

Unemo M, Lahra MM, Escher M, Eremin S, Cole MJ, Galarza P, et al., 2021. WHO global antimicrobial
resistance surveillance for Neisseria Gonorrhoeae 2017–18: a retrospective observational study.
Lancet Microbe. 2021; 2: e627-e636.

World Health Organization. Report on global sexually transmitted infection surveillance 2018. 2018.
Available at: [Link]

World Health Organization. Global Guidance on Criteria and Processes for Validation: Elimination of
Mother-to-Child Transmission of HIV, Syphilis, and Hepatitis B Virus. 2021. Available at: [Link]
[Link]/publications/i/item/9789240039360

World Health Organization. Guidelines for the management of symptomatic sexually transmitted sexually
transmitted infections. 2021. Available at: [Link]

World Health Organization. Sexually transmitted infections (STIs). 2022. Available at: [Link]
int/news-room/fact-sheets/detail/sexually-transmitted-infections-(stis)#:~:text=More%20than%20
1%20million%20sexually,%2C%20gonorrhoea%2C%20syphilis%20and%20trichomoniasis.

World Health Organization. Cervical Cancer. 2022. Available at: [Link]

sheets/detail/cervical-cancer#:~:text=Key%20facts,%2Dincome%20countries%20.

64
Guidelines for the Management of Sexually Transmitted Infections

8. ANNEXES
8.1 ANNEX 1: SPECIMEN COLLECTION PROCEDURES FOR STI TESTING

Specimens Collection procedure

Urethral swab Gently insert the swab 3-4cm in urethral, rotate slowly and withdraw gently.
Vaginal swab Insert the swab into the vagina and rotate the swab
Endocervical swab 1. Wipe the cervix clean of vaginal secretions and mucus.
2. Insert the swab into the cervix os.
3. Rotate the swab and obtain exudate from the endocervical gland.
4. If no exudate, insert swab into the endocervical canal and rotate the
swab
Rectal swab 1. Insert the swab past the anal sphincter.
2. Move from side to side, allow 10-30s for absorption and withdraw.
3. If the swab is contaminated with faeces, use a new swab for
recollection.
Ulcer swab Moisten the swab with saline and collect the specimen by rubbing the base
of the lesion
Urine Collect 5-10 mL of urine in a sterile container

8.2 ANNEX 2: COMMON STI SYNDROMES AND THEIR CAUSES AND RECOMMENDED
TREATMENT

STI CAUSAL PATHOGEN PREFERRED TREATMENT ALTERNATIVE

SYNDROME TREATMENT
Urethral Neisseria gonorrhoeae Ceftriaxone 1g IM, single Cefixime 800mg PO,
discharge dose STAT
Chlamydia trachomatis Doxycycline 100 mg PO, BD Azithromycin 1 g PO,
for 7 days STAT (In doxycycline
allergy)
Genital ulcer HSV-2 (Herpes) Acyclovir 400mg PO, TDS
for 10 days
Treponema pallidum Benzathine Penicillin* 2.4 Doxycycline 100mg
(Syphilis) MU IM, single dose PO, BD for 14 days
Chlamydia trachomatis L1, Doxycycline 100mg PO, BD
L2, L3 (LGV) for 21 days
Haemophilus ducreyi Doxycycline 100mg PO, BD Azithromycin 1g PO,
(Chancroid) for 10 days STAT
Klebsiella granulomatis Azithromycin 1g PO, STAT Specialist input is
needed if not resolved

65
 Guidelines for the Management of Sexually Transmitted Infections

STI CAUSAL PATHOGEN PREFERRED TREATMENT ALTERNATIVE

SYNDROME TREATMENT
Vaginal Neisseria gonorrhoeae Ceftriaxone 1 g IM, single Cefixime 800 mg PO,
discharge dose STAT
Chlamydia trachomatis Doxycycline 100 mg PO, BD Azithromycin 1g PO,
for 7 days STAT
Trichomonas vaginalis Metronidazole 400 mg PO,
BD for 7 days.
Candida species If vulval oedema/curd-like
(candidiasis or “thrush”) discharge, erythema, or
excoriations present, add:
Clotrimazole vaginal
pessary 500mg stat
inserted or 100mg BD for
3 days inserted or 200mg
at night for 3 days PLUS
Clotrimazole vaginal cream
BD x 7 days.
Pelvic Neisseria gonorrhoeae Ceftriaxone 1g IM, single Cefixime 800mg PO,
Inflammatory Chlamydia trachomatis dose STAT
Disease Doxycycline 100 mg PO, BD Erythromycin 500mg
for 14 days PO, QID for 14 days
Trichomonas vaginalis Metronidazole 400mg PO,
BD for 7 days
Candida species If vulval oedema/curd-like
(candidiasis or “thrush”) discharge, erythema, or
excoriations present, add:
Clotrimazole vaginal
pessary 500mg stat
inserted or 100mg BD for
3 days inserted or 200mg
at night for 3 days PLUS
Clotrimazole vaginal cream
bd for 7 days.
Anorectal Neisseria gonorrhoeae Ceftriaxone 1g IM single Cefixime 800mg PO,
discharge dose STAT.
Chlamydia trachomatis Doxycycline 100 mg PO, BD Azithromycin 1gm
for 14 days PO, 2 doses at weekly
interval.
Herpes simplex Acyclovir 400mg PO, TDS
for 10 days
Treponema pallidum Benzathine Penicillin**2.4 Doxycycline 100 mg
MU IM, single dose PO, BD for 14 days
Epididymo- Neisseria gonorrhoeae Ceftriaxone 1g IM single Cefixime 800mg PO,
orchitis dose STAT.
Chlamydia trachomatis Doxycycline 100 mg PO, BD Azithromycin 1g PO
for 14 days 2 doses at weekly
intervals.
Mycoplasma genitalium Amoxicillin/clavulanic Acid
875/125 mg BD for 10 days

66
Guidelines for the Management of Sexually Transmitted Infections

STI CAUSAL PATHOGEN PREFERRED TREATMENT ALTERNATIVE

SYNDROME TREATMENT
Inguinal bubo Chlamydia trachomatis Doxycycline 100 mg PO, BD Azithromycin 1g PO,
for 14 days 2 doses at weekly
intervals
Haemophilus ducreyi Doxycycline 100mg PO, BD Azithromycin 1g PO,
(Chancroid) for 10 days 2 doses at weekly
intervals
Neonatal Neisseria gonorrhoeae Neonate
conjunctivitis AND Chlamydia Irrigate eyes.
trachomatis Ceftriaxone 50mg/kg body
weight IM as a single dose
to a maximum of 125mg
AND Erythromycin 50mg/
kg per day PO, QID for 14
days
Mother
Ceftriaxone 1g IM, single
dose OR Cefixime 800mg
PO, STAT AND Azithromycin
1g oral single dose
Father
Ceftriaxone 1g IM, single
dose OR Cefixime 800mg
PO, STAT AND Doxycycline
100mg PO, BD for 7 days

8.3 ANNEX 3: MAIN STI PATHOGENS, AND TREATMENT-PAEDIATRIC DOSES

Pathogen Treatment
Bacterial infections
Neisseria gonorrhoeae Ceftriaxone 20-50mgs IM single dose
Chlamydia trachomatis Azithromycin [1 year and over]
8-11kgs: 62.5mg 12hrly
12-19kgs:125mgs 12hrly
20-29kgs: 187mgs 12hrly
30-49kgs: 250mgs 12hrly 7 days
Chlamydia trachomatis (strains L1-L3) Azithromycin, 20mg/kg (maximum 1g), orally, in
a single dose.
Treponema pallidum Benzathine Penicillin 600,000-1.2 Mega units IM
50,000units/KG IMI]
Erythromycin 50 mg/kg, 6 hrly, in divided
doses,14 days
Procaine Penicillin G 150,000 IU/kg, IM 12 hourly
14 days
Erythromycin 50 mg/kg, 6 hrly, in divided doses,
30 days
Haemophilus ducreyi Ceftriaxone 20-50mgs IM single dose
Azithromycin, 20mg/kg (maximum 1g), orally, in
a single dose.

67
 Guidelines for the Management of Sexually Transmitted Infections

Pathogen Treatment
Klebsiella granulomatis (formerly Erythromycin 50 mg/kg, 6 hrly, in divided doses,
Calymmatobacterium granulomatis) 14 days
Azithromycin [1 year and over]
8-11kgs; 62.5mg 12hrly
12-19kgs;125mgs 12hrly
20-29kgs;187mgs 12hrly
30-49kgs; 250mgs 12hrly
Until the lesions get epithelialized, may take
weeks
Mycoplasma genitalium Azithromycin, 20mg/kg (maximum 1g), orally, in
a single dose.
Trichomonas vaginalis Metronidazole, 15mg/kg per day orally in three
divided doses x 7 days (above 45kgs give 2g,
orally in a single dose)
Candida albicans Fluconazole 200mg single oral dose
Nystatin vag. Pessaries [100.000 units] daily, 14
days Clotrimazole vag. Pessaries 200mgs nocte,
3 days Clotrimazole vag. Tablet 500mg nocte
[single dose] Miconazole vag. Cream bd x 7 days
Please note: Nystatin and Miconazole, pediatric
doses not specified
Parasitic infestations
Phthirus pubis Benzyl Benzoate emulsion [ BB cream], 25%
emulsion
1% Gamma benzene hexachloride
Crotamiton 10% ointment
Sarcoptes scabiei Benzyl Benzoate emulsion [ BB cream], 25%
emulsion 1% Gamma benzene hexachloride
Crotamiton 10% ointment
Viral infections
Human immunodeficiency virus (HIV) Appropriate ART
Herpes simplex virus type 2 (HSV-2) Initial episode:
2yrs and older
Acyclovir 200mgs 5 hrly, 10 days
Under 2 yrs.
Acyclovir 100mgs 5hrly, 10 days
Subsequent episodes; above treatment for 5
days Suppressive therapy:
Over 2yrs
Acyclovir 200 mg 12 hrly daily
Under 2yrs
Acyclovir 100mgs 12 hrly
maximum 1 year
Protozoal infections
Trichomonas vaginalis Metronidazole 7mg/kg, 8 hrly, 7 days

68
Guidelines for the Management of Sexually Transmitted Infections

8.4 ANNEX 4: ORAL DESENSITISATION PROCEDURE FOR PATIENTS WITH PROVEN

ALLERGY TO PENICILLIN

ORAL DESENSITISATION PROTOCOL

Dose Penicillin V Amount (ml) Amount (units) Cumulative dose
suspension (units)
(units/ml)
1 1 000 0.1 100 100
2 1 000 0.2 200 300
3 1 000 0.4 400 700
4 1 000 0.8 800 1 500
5 1 000 1.6 1 600 3 100
6 1 000 3.2 3 200 6 300
7 1 000 6.4 6 400 12 700
8 10 000 1.2 12 000 24 700
9 10 000 2.4 24 000 48 700
10 10 000 4.8 48 000 96 700
11 80 000 1.0 80 000 176 700
12 80 000 2.0 160 000 336 700
13 80 000 4.0 320 000 656 700
14 80 000 8.0 640 000 1 296 700

Note:
• Observation period: 30 minutes before parenteral administration of penicillin.
• Interval between doses: 15 minutes
• The specific amount of medicine is diluted in approximately 30 minutes of water and then given
orally.

(Adapted from the New England Journal of Medicine 1985; 312:1229-32. As cited by Ballard et al., 2000)

69
 Guidelines for the Management of Sexually Transmitted Infections

8.5 ANNEX 5: PHOTOGRAPHS OF SEXUALLY TRANSMITTED INFECTIONS

a) Genital ulcer disease b) Herpes Simplex Infection

c) Genital ulcer disease d) Urethral Discharge syndrome

e) Vaginal discharge syndrome f) Inguinal bubo

70
Guidelines for the Management of Sexually Transmitted Infections

g) Genital ulcer disease h) Anal discharge syndrome

i) Epididymo-orchitis j) Genital wart

k) Mucopurulent cervicitis l) Vulvovaginal candidiasis

71
 Guidelines for the Management of Sexually Transmitted Infections

8.6 ANNEX 6: ACKNOWLEDGEMENT LIST]

The MoHSS would like to thank the following individuals who supported the revision of these guidelines:

LEAD REVIEWERS
CONSULTANT LEAD REVIEWER: Dr. Enos Moyo, Public Health/HIV Specialist; Health Economist
MoHSS LEAD REVIEWER: Dr. Bikinesi L, DSP, MoHSS

TECHNICAL WORKING GROUP (TWG) MEMBERS

1. Dr. Abeje Z, USAID Namibia
2. Ms. Agabus J, Oshikuku, MoHSS
3. Dr. Amutenya V, Namibia Institute of Pathology
4. Ms. Benjamin A, NHTC
5. Dr. Bilah I, I-TECH Namibia
6. Dr. Melese E, Project HOPE Namibia
7. Ms. Iitula A, Oshakati, MoHSS
8. Ms. Jatileni N, DSP, MoHSS
9. Ms. Jod ZT, IntraHealth Namibia
10. Ms Johannes T, Pharmaceutical Services, MoHSS
11. Dr. Kakubu MM, Khomas region, MoHSS
12. Dr. Kamangu J, DSP, MoHSS
13. Ms. Katjiukua C, PHC, MoHSS
14. Dr. Kawana M, DSP, MoHSS
15. Ms. Kosmas K, Outjo, MoHSS
16. Dr. Lumbala F, Omaheke region, MoHSS
17. Dr. Mangwana H, Project HOPE Namibia
18. Dr. Manhando K, Erongo region, MoHSS
19. Ms. Mateus N, DSP, MoHSS
20. Ms. Mbome C, Namibia Institute of Pathology
21. Ms. Nalupe M, DSP, MoHSS
22. Mr. Natanael S, DSP, MoHSS
23. Ms. Ndeikemona L, PHC, MoHSS
24. Dr. Ndhlovu S, IntraHealth Namibia
25. Ms. Sheehama S, Walvis Bay, MoHSS
26. Ms. Shilomboleni M, IntraHealth Namibia
27. Ms Shilongo S, Namibia Institute of Pathology
28. Dr. Sithole E, CDC Namibia
29. Mr. Wolkeba S, DSP, MoHSS

EXTERNAL REVIEWERS
1. Dr. Katjitae I, Specialist Physician
2. Dr. Tagwira VJ, Specialist Obstetrician and Gynaecologist

WORLD HEALTH ORGANIZATION

1. Dr. Sirak H, WHO Namibia
2. Dr. Maatouk I, STI Technical Officer, WHO Headquarters

72
Guidelines for the Management of Sexually Transmitted Infections

NOTES

73