A brief introduction to

Sexually Transmitted Infections

NESRINE RIZK MD
MED 1
MARCH 2023
 Worldwide epidemiology
Increasing trends worldwide
Different epidemics based on characteristics of the population
More than 1 million sexually transmitted infections (STIs) are acquired every
day worldwide.
Each year, there are an estimated 357 million new infections with 1 of 4 STIs:
chlamydia, gonorrhea, syphilis and trichomoniasis.
Adolescents: more than half new cases

[Link]
 Worldwide Burden of STI’s
Transmission and prevalence are influenced by social and economic factors

The burden of STI’s varies greatly from region to region, and from community
to community. Where STI’s are common, so are their complications.

STI’s such as syphilis, gonorrhoea and chancroid spread more rapidly in places
where communities are disrupted, migrant labor is common and commercial
sex networks are active.

Sexually transmitted and other reproductive tract infections

A guide to essential practice. [Link]
Comprehensive sexual and reproductive health
Call for a comprehensive holistic approach
STIs have a profound impact on sexual and reproductive health worldwide
◦ Drug resistance is a major threat worldwide.

Integrating reproductive health services and sexual health services with preventative measures
Reaching adolescents is crucial especially in countries with young populations
Pathogens Transmitted Sexually
•HIV
•Ureaplasma urealyticum
•Hepatitis B Virus
•Mycoplasma genitalium
•CMV, EBV
•Haemophilus ducreyi (Chancroid)
•Human Papilloma Virus (HPV)
•Chlamydia trachomatis L1, L2, L3
•Treponema pallidum (Syphilis) (Lymphogranuloma venereum)
•HHV-8, Kaposi’s Sarcoma Herpes Virus •Klebsiella granulomatis (Granuloma
(KSHV) inguinale)
•Herpes Simplex Virus (HSV) •Trichomonas vaginalis
•Neisseria gonorrhoeae •Scabies, Pediculosis pubis
•Chlamydia trachomatis
Sexually Transmitted Pathogens
wide group of pathogens
◦ viruses
◦ bacteria
◦ parasites
biologically different
common transmission mode
common risk factors
often multiple infections at the same time
often asymptomatic infection
 Overview of Complications of
Sexually Transmitted Diseases
Upper Genital *PID/Infertility

STD’s
*Ectopic Pregnancy
Tract Infection
*Chronic Pelvic Pain

• Wide variety of Systemic Infection *Low Fetal Birthweight

pathogens can be *Congenital Infection
transmitted
sexually
*Cervical and Anal Cancer
• Often transmit
more efficiently
male→female than
*HIV Transmission
female→male
 HIV and AIDS
TREATMENT IS PREVENTION

ART/keeps improving
single drug regimen
less side effects
HIV PREVENTION
•PrEP: pre-exposure prophylaxis
•PEP: post exposure prophylaxis
•PMTC: prevention of mother to child transmission
•Barrier protection/condoms
Hepatitis B virus
 Hepatitis B virus
Around 50% of transmission is through sexual contact

Structure of the HBV

 Hepatitis B virus
Usually a chronic infection with risk of reactivation
especially with immune suppressive therapy
Vaccine available and protective at around 80-100%
◦ response to vaccine is age dependent . declines with age

Treatment:
◦ Available
◦ Tablets
◦ Lifelong
 Hepatitis C virus

Hepatitis C is a virus that can be transmitted through

blood-to-blood contact.
◦ This can happen through sharing needles or other injection
drug use equipment, getting a tattoo or piercing with
unsterilized equipment, or having a blood transfusion.
◦ While rare, hepatitis C can also be transmitted through
sexual contact or from mother to baby during
childbirth.
 Hepatitis C virus

Recent advances in treatment options have made curing

hepatitis C easier.
With new medications that are highly effective, patients
can now expect to achieve a cure rate of up to 98%.
These new treatments have fewer side effects and a
shorter duration compared to traditional treatments,
making them more accessible and convenient for
patients.
Human Papilloma Virus

• Most common sexually transmitted

infection worldwide
• Different strains of the HPV virus
• genital warts
• cervical cancer types 16 and 18
• Multiple sexual partners: increases
likelihood of acquisition and
infection
• Smoking associated with persistence

• Vaccines available
 Human Papilloma Virus

HPV VACCINE
HPV types 16 and 18: 70% of all cervical cancers
HPV types 31, 33, 45, 52, and 58 = 20% of cervical cancer
HPV types 6 and 11 : 90 % of anogenital warts
AVAILABLE VACCINES
◦ Quadrivalent HPV vaccine (Gardasil) targets HPV types 6, 11, 16, and 18
◦ 9-valent vaccine (Gardasil 9) targets HPV types (6, 11, 16, and 18) and types 31, 33, 45, 52, 58
◦ Bivalent vaccine (Cervarix) targets HPV types 16 and 18

◦ EFFICACY
◦ 97% effectiveness in naïve population
◦ Australia is on track to elimination of cervical cancer
[Link]
Michaela T Hall et al. The projected timeframe until cervical cancer elimination in Australia: a modelling study, The Lancet Public Health, Volume 4,
Issue 1, 2019,Pages e19-e27
 Herpes Simplex Viruses

Oropharyngeal disease Genital herpes

A-Primary infection
Primary genital herpes can be severe
Pharyngitis and tonsillitis and may last ~3 weeks
Gingivostomatitis Lesions are very painful and are
associated with fever
B-Recurrence
Recurrence of genital herpes is common
Herpes labialis (cold sore/fever blister) and is usually mild (fewer vesicles, lasts
~ 10 days)
 Herpes Simplex Viruses

Treatment
Treatment CDC guidelines (2015)
Primary infection:
◦ Acyclovir: 400 mg three times daily or 200 mg five times daily
◦ Valacyclovir: 1000 mg twice daily
Chronic suppressive therapy:
◦ Acyclovir 400 mg twice daily
◦ Valacyclovir 500 mg once daily or 1000 mg once daily
Chlamydia
Chlamydia: Epidemiology
Most common bacterial STI
Many cases asymptomatic
◦ In the USA 10% of adolescent girls infected
◦ Up to 85% of infected women are asymptomatic

Clinical Presentation
◦ Mucopurulent cervicitis/vaginal discharge
◦ Dysuria
◦ Lower abdominal pain
◦ Urethritis, salpingitis, and proctitis

Treatment
first-line agents include doxycycline and azithromycin
 Gonorrhea

Clinical aspects
•Frequently asymptomatic
Infection of the
• Vaginal discharge
◦ Urethra
• Abnormal uterine ◦ Endocervix
bleeding
◦ Upper genital tract
• Dysuria ◦ Pharynx
• Mucopurulent cervicitis ◦ Rectum
• Lower abdominal pain
 Gonorrhea

Treatment Considerations
Concern worldwide about increasing resistance to cephalosporins
FQ resistance is wide spread
Single-agent therapy with ceftriaxone is the preferred regimen
for treatment of gonococcal infections.

Presumptive treatment of chlamydia if not excluded by testing.

CDC recommendations to use doxycycline (100 mg orally twice
daily for seven days)
 SYPHILIS

Humans are the only natural host

Treponema pallidum
Syphillis – transmitted by:
◦ sexual contact
◦ congenitally
 SYPHILIS
Clinical Presentation
Primary / Infectious / Early Syphilis Stage
Primary Phase
Primary chancre
◦ Begins as papule, usually in the genital area
◦ Appears 9-90 days after exposure
◦ Heals with scarring in 3-6 weeks and 75% of patients show no further symptoms
Secondary Phase
◦ occurs 6 weeks – 6 months after chancre
◦ Systemic symptoms: fever, malaise, generalized lymphadenopathy, and patchy
alopecia
◦ Maculo-papular rash usually on palms and soles
Syphilitic Rash

Credit: Dr. Gavin Hart and CDC

Credit: Connie Celum and Walter Stamn
and Seattle STD/HIV Prevention Training Center
 SYPHILIS
Clinical Presentation (continued)
Secondary / Latent Stage:
Positive serology
• Rapid Plasma Reagin (RPR)
• Venereal Disease Research Lab (VDRL)
Patients are asymptomatic and not infectious after first year, but may
relapse
• 1/3 will convert to sero-negative status
• 1/3 will stay sero-positive but asymptomatic
• 1/3 will develop tertiary syphilis
 SYPHILIS
Clinical Presentation (continued)
Tertiary Stage:
Cardiovascular: Aortic valve disease, aneurysms
Neurological: Meningitis, encephalitis, tabes dorsalis, dementia
Gumma formation: Deep cutaneous granulomatous pockets
Orthopedic: Charcot’s joints, osteomyelitis
Renal: Membranous Glomerulonephritis
 SYPHILIS
Treatment Considerations
Primary/ secondary/ latent stage: Benzathine penicillin
Neurosyphilis: Penicillin G
Jarisch-Herxheimer reaction may occur
De-sensitization of pregnant women
 Trichomonas vaginalis

Signs and symptoms:

Clinical Presentation
•Vulvar irritation
•Dysuria
•Dyspareunia
•Pale yellow, malodorous - gray/green
frothy discharge
•Strawberry cervix, inflamed and friable
Treatment Considerations

For HIV-infected women: same treatment as non-HIV infected women

Metronidazole or Tinidazole

Sex partners have to be treated

Lice and Scabies
The approach to the Patient
with an STI
A Guide to Taking a Sexual History
The Five P’s
•Partners
• Gender(s), Number (three months, lifetime)

•Practices
• Types of sex: anal, vaginal, oral

•Protection from STIs

• Condom use

• Prevention of pregnancy
• Contraception

•Past history of STIs

Partner Management
•Essential for success therapeutic plan
•Expedited treatment
•Patient may need help disclosing to partner
STI Prevention: Clinician’s Role
Risk reduction counseling
Assess risk and test accordingly
Sex education
Effective sex education can reduce likelihood of having
unsafe sex
it does not reduce the likelihood of having sex
Prevention of STI’s
1. Condom use
◦ Abstinence
2. Vaccination
◦ HPV
◦ Hepatitis B
3. Circumcision
4. Diagnosing and treating STI’s
5. Referring partners for treatment
6. PrEP and PEP for HIV prevention
Providing Culturally Competent Care

Language and literacy level

 Cultural and social background and its impact on her
 Understanding of health, illness, and the female anatomy
 Comfort with discussing sexual health issues
 Comfort and previous experience with STI screening or testing
 History of sexual abuse and/or domestic violence may cause
anxiety and exam refusal
Conclusion or beginning! 38

STI screening and treatment should be a primary intervention and a standard

of care in all health care settings.
Adapt interventions to age, culture, gender, sex orientation, socio-economic…
Integrate care!