GONORRHOEA SYPHILIS TRICHOMONIASIS NSU D O N O VA N O S I S WA RT S B A L A N I T I S

C H A N C R O I D

Diagnosis and Management of STDs

(including HIV infection)

H E PAT I T I S

VA G I N O S I S

H I V / A I D S

B A C T E R I A L

C H L A M Y D I A

Sixth Edition 2005

M O L L U S C U M

H E R P E S CANDIDIASIS PEDICULOSIS SCABIES PID

First published May 1988 Second edition May 1990 Third edition June 1993 Fourth edition August 1996 Fifth edition April 2000 Sixth edition June 2005

All enquiries to: George Nisyrios STD Services, Royal Adelaide Hospital 275 North Terrace Adelaide South Australia 5000

Telephone: (08) 8222 5075 Country callers only: 1800 806 490 Facsimile: (08) 8232 3504 Web site: www.stdservices.on.net

The publisher accepts no responsibility for errors, omissions or inaccuracies contained herein or the consequences of any action taken as a result of information in this publication. These guidelines are no substitute for consultation with a medical practitioner experienced in the managment of conditions described herein. Responsible use of the guidelines requires that the prescriber is familiar with contraindications and precautions relevant to the various pharmaceutical agents recommended herein.

Bulletin No. 1

Diagnosis and Management of STDs

(including HIV infection)

This book, all other publications and education pamphlets can be downloaded from the STD services website at www. stdservices.on.net

June 2005
STD Services Royal Adelaide Hospital

Note to medical practitioners

These guidelines are based on review of current literature, current recommendations of the United States Centers for Disease Control and Prevention, World Health Organization, the British Association for Sexual Health and HIV and local expert opinion. They are written primarily for use by Clinic 275 staff and some flexibility is required in applying them to certain private practice situations. Chapter 1 provides guidance to practitioners on risk assessment and appropriate testing and other sections provide concise information on diagnosis and management of individual diseases. Checklists are provided for use as desktop reminders. Clinic 275 offers a range of additional services: Patients may be referred to Clinic 275 or the practitioner may obtain telephone consultation by contacting a clinic senior medical officer on 8222 5075. A 24 hour emergency consulting service is available by phoning the Royal Adelaide Hospital switchboard on 8222 4000 and asking for the venereologist on call. Ad hoc training at Clinic 275 is available for interested practitioners. Individual arrangements can be made by negotiation with Dr Russell Waddell, clinic manager. A toll free telephone line 1800 806 490 is available for country callers. STD Services (Royal Adelaide Hospital) aims to reduce the impact of STDs in the community by reducing the incidence of disease reducing the duration of infection reducing the complications or anxiety associated with infection decreasing the net cost of managing individual cases.

To facilitate these goals, the service operates a walk-in clinic (no appointment is necessary) at Clinic 275 (275 North Terrace). Opening hours 10.00 am to 4.30 pm Monday, Thursday and Friday, 11.30 am to 6.30 pm Tuesday and Wednesday. A full consultation service is available to all clinicians by contacting the Director, Dr Gavin Hart on 8222 5075 or the clinic manager, Dr Russell Waddell 8222 2509. ii

Contents
Note to medical practitioners ......................................................... ii Checklists Algorithms Chapter 1. Clinical assessment ................................................. 1 Chapter 2. Human Immunodeficiency Virus (HIV) Infection ....... 7 Chapter 3. Gonorrhoea .............................................................. 20 Chapter 4. Syphilis..................................................................... 23 Chapter 5. Genital Herpes ......................................................... 29 Chapter 6. Genital chlamydia trachomatis infection ................. 33 Chapter 7. Non-specific urethritis (NSU) .................................. 35 Chapter 8. Genital warts ........................................................... 38 Chapter 9. Trichomoniasis ......................................................... 41 Chapter 10. Candidiasis............................................................... 43 Chapter 11. Pediculosis pubis .................................................... 46 Chapter 12. Scabies .................................................................... 48 Chapter 13. Molluscum contagiosum ........................................ 50 Chapter 14. Bacterial vaginosis ................................................... 52 Chapter 15. Hepatitis B ............................................................... 54 Chapter 16. Pelvic inflammatory disease .................................. 56 Chapter 17. Balanitis ................................................................... 60 Chapter 18. Other STDs .............................................................. 62 Appendices: 1. Techniques for swab and urine specimen collection .............. 64 2. Notification of syphilis, gonorrhoea, chlamydia, donavanosis, hepatitis B, hepatitis C and HIV infection .............................. 67 3. Case definition of AIDS-defining illnesses used in Australia and USA ...................................................... 73

Checklists

Sexual practices and risk levels for STDs including HIV infection
When counselling patients about safe sex, it is important to remember that STDs such as genital herpes, genital warts, pubic lice (crabs), and scabies are not necessarily prevented by condom use and may be transmitted by close body contact alone. There is negligible risk for activities which do not involve transfer of body fluids, eg kissing, masturbation, massage Oral sex (cunnilingus, fellatio) poses a high risk for transmission of herpes simplex infection but its risk for other STDs is poorly defined Vaginal and anal sex pose a definite risk for all the STDs Condom use reduces the risk of transmission for all STDs

HIV testing and counselling checklist

Take STD history Previous HIV test Explanation of test Determine HIV risk Determine when exposure to risk occurred Check date and result

Rationale for testing (early detection can improve long-term prognosis and reduce risk of transmission) HIV antibody and antigen test Difference between HIV and AIDS 3-month window period from exposure to development of antibodies Advise if repeat test will be necessary Confidentiality issues around HIV testing include appropriate policies within the surgery to protect the patient. Patients should be advised about protecting their own confidentiality by carefully considering and limiting whom they tell Obtain informed consent from patient It is recommended that all HIV results are given in person by medical practitioners

Implications of a negative result

Provides reassurance Provides opportunity to discuss prevention through safe sex If exposure to risk was less than 3 months ago, a repeat test may be indicated

Implications of a confirmed positive result

Discuss the difference between HIV and AIDS Check if there is a trusted support person available Discuss medical follow-up and treatments Support lifestyle changes, eg diet, smoking, rest, safe sex Contact tracing of past sexual partners Arrange another appointment for further counselling or refer to another agency

STD interview checklist

1. Basic pointers Ensure privacy Maintain confidentiality Never make assumptions Maintain a non judgemental attitude Acknowledge personal or patient discomfort Maintain a relaxed body language Use words and terms that the patient understands 2. General History Contact of a STD Past medical history Past STD history Medications Allergies Contraception Last menstrual period Vaccination history Recreational drug use 3. Symptoms and signs Anogenital discharge Dysuria Dyspareunia Pelvic pain Genital/perianal ulcers or lumps Rashes Itching

4. Sexual behaviours/risk markers Regular/casual sexual partner(s) Last sexual contact Gender of partner(s) Any history of male to male sexual contact Type of intercourse oral, vaginal, anal Use of condoms Overseas, interstate sexual contact Use of beats, saunas, internet Injecting drug use Tattoos Blood product exposure (pre 1985 for HIV, pre 1990 for Hepatitis C risk) Needlestick injury

Points on prevention
The following practices will provide some protection from STDs/blood borne diseases. Condoms Recommend the regular use of condoms with a water-based lubricant, eg KY jelly, Wet Stuff Recommend STD check-ups when patients have been exposed to risk Recommend to patients who have recently changed sexual partners that they use condoms for the first 3 months, and then have an STD screen. If the tests are negative (and they are relatively sure that the relationship is monogamous), condoms may be discontinued Communication Encourage communication between people about sexual partners and behaviours Advise injecting drug users of needle exchange programs (Drug & Alcohol Services Council, telephone 1300 131340, can be contacted for information on locations and times) Only new needles, syringes and other injecting equipment should be used. Cleaning and bleaching used equipment does not protect the user against hepatitis C

Check-ups

Clean needles and syringes

Clinical presentation

Suggest that people do not have sex if an STD is suspected until a negative diagnostic test If an STD is diagnosed, suggest no sex until test of cure, or completion of medication

Alternatives

To lower risk, suggest alternatives to penetrative sexual practices when condoms are not available

Chlamydia checklist
Clinical presentation Asymptomatic in at least 50% of individuals Early symptoms may include genital discharge and dysuria More severe signs and symptoms in women may include: menstrual irregularity, pelvic pain, backache, dyspareunia, and mucopurulent cervical discharge Men can develop a mucopurulent urethral discharge and epididymo-orchitis Which patients should be tested A sexual contact of a person with chlamydial infection or another STD If symptomatic Change of sexual partner in previous 2 months More than one sexual partner Patients partner has other sexual partners If patient is under 25 years and there has been unprotected intercourse The chlamydia test PCR on urethral swab or first catch urine in males PCR on endocervical swab or first catch urine in females Chlamydia is an intracellular pathogen, and swabs should aim at collecting columnar-epithelial cells The chlamydia swab should be the last to be performed if it is part of a series of tests The chlamydia swab can be done if a woman is menstruating

Treatment

Azithromycin 1 g orally as a single dose or Doxycycline 200 mg orally daily for 10 days

Patient education Chlamydia infection is a common STD and contact tracing It is a notifiable infection All sexual contacts need to be tested and treated Advise abstinence from sex until 1 week after treatment of self and partner Follow-up Review and check compliance with medication and/or compliance with safe sex guidelines Reinforce prevention and safe sex practices Ensure all sexual contacts have been tested and treated

Male Reproductive System

Female Reproductive System

Algorithms for urethral discharge, vaginal discharge, penile or vulval lesions, and screening asymptomatic patients for syphilis

Algorithm for penile & vulval lesions Inspection

Angiokeratoma Ectopic sebaceous glands Balanitis Benign papillomata Condylomata acuminata Condylomata lata Molluscum contagiosum Pearly penile papules Vitiligo, sebaceous cysts Contact dermatitis Fixed drug eruptions Scabies Eczema Lichen planus Psoriasis Seborrheic dermatitis + + + Genital herpes Syphilis Genital herpes

History + Lesions on other parts of the body

Lesions Vesicular or Ulcerative lesions Serological/microscopic evidence PCR test for herpes History and appearance suggest Appearance suggests malignancy:biopsy

Trauma, non-specific infection Balanitis xerotica obliterans Lichen sclerosus et atrophicus Erythroplasia of Queyrat Squamous cell carcinoma Melanoma, Donovanosis Plasma cell balanitis of Zoon

Patient is Aboriginal - possibly Donovanosis: consult with a specialist Lesion acquired outside Australia (particularly Asia) - possibly chancroid: consult with a specialist

Algorithm for screening asymptomatic patients for syphilis

Syphilis EIA

TPPA and RPR

False-positive Syphilis EIA

Repeat RPR at 4 weeks

RPR titres at 3, 6, 12 months

Clinical assessment

The STD consultation aims to: 1. Define the presenting complaint. 2. Assess sexual and social behaviours for risk factors and risk markers. 3. Screen the patient for sexually transmitted infections and associated conditions. 4. Diagnose and treat infection. 5. Educate the patient on risk modification and offer vaccination. 6. Promote safe sex practices. 7. Limit the spread of STDs in the population and conduct contact tracing. General principles of the sexual consultation include ensuring privacy and maintaining confidentiality between the doctor and patient. It is always best never to make assumptions about the patient or their behaviour and to maintain a non judgemental attitude to patient behaviours. If there is doctor or patient discomfort this can be acknowledged. Maintaining a relaxed body language and using terms that the patient understands and is comfortable with helps rapport development.

History
General history Contact of an STD Past medical and STD history Medications, allergies (emphasise antibiotics) and contraception Last menstrual period Vaccination history Recreational drug use 1

 Symptoms and signs Onset, character, periodicity, duration and relation to sexual intercourse and urination Similarity to previous problems Any STD in sexual partner(s) Anogenital discharge and/or dysuria Dyspareunia and/or pelvic pain Ulcers, lumps, rashes or itching Sexual behaviours/risk markers Any sexual partner(s) and date of last sexual exposure and others in the last 3 months Sex of partner(s) including and history of male to male contact Type of intercourse - oral, vaginal, anal Sex overseas or in high risk areas like beats and saunas Any history of injecting drug use, what drug, how often Any tattoo history or blood product exposure

Examination
This is conducted to assess genital symptoms and as part of asymptomatic assessment. Exposure of abdomen, genitals and thighs is required. Inspect for: rashes, lumps, ulcers, discharge, smell, pubic hair for lice and nits and in most cases the skin of the face, trunk, forearms, palms and the oral mucosa. Palpate: inguinal nodes Men: Inspection of the penis, including meatus, retracted foreskin and perianal area +/- proctoscopy. Palpation of scrotum and expression of any discharge from the urethra. Women: Inspection of external genitalia, perineum and speculum examination of vagina and cervix. Bimanual pelvic examination.

Specimen collection and tests

Men
Urethral swab (1-2 cm inside meatus or of pus) Gram stain Culture and sensitivity on gonorrhoea specific medium Wet prep if trichomonas suspected Chlamydia PCR taken 3-4 cm down urethra not routinely performed unless symptomatic Ulcer swab HSV PCR First catch urine Chlamydia PCR Gonorrhoea PCR if urethral swab not possible in Men who have sex with men Heterosexuals who have had sex outside South Australia or define themselves as Aboriginal If test is positive result must be confirmed by a urethral culture

Men who have sex with men (in addition to the above)
Throat swab Culture and sensitivity on gonorrhoea specific medium Rectal swab Best obtained through direct inspection with proctoscope If proctoscopy unavailable blind swabs are possible Culture and sensitivity on gonorrhoea specific medium Chlamydia PCR

Women
Vaginal wall swab Gram stain for candida and bacterial vaginosis Culture and sensitivity including candida specific medium Vagina posterior fornix Ph Wet prep for trichomonas

 Endocervical swab Culture and sensitivity on gonorrhoea specific medium Chlamydia PCR Pap smear if abnormal cervix or screening PAP due Ulcer swab HSV I, II type specific PCR Rectal swab (if anal sex on history) Best obtained through direct inspection with proctoscope If proctoscopy unavailable blind swabs are possible Culture and sensitivity on gonorrhoea specific medium Chlamydia PCR First void urine Can be tested for Chlamydia by PCR if endocervical swabs not possible

Female sex workers

(in addition to the above)

Throat swab Culture and sensitivity on gonorrhoea specific medium

Blood tests
Hepatitis B serology At first visit Subsequently as determined by risk markers Aboriginal Asian born Men who have sex with men Injecting drug users Sex workers Overseas sex contact Sexual contacts of the above Hepatitis C serology At first visit Subsequently as determined by risk markers Injecting drug users Tattooing Blood product exposure out of Australia 4

 Syphilis serology At first visit When syphilis is suspected on clinical grounds Subsequently as determined by risk markers Aboriginal Men who have sex with men Sex workers Sexual contacts of the above If HIV infection has been diagnosed HIV serology At first visit Subsequently as determined by risk markers Men who have sex with men Injecting drug users Overseas sex contact Sexual contact with a person from overseas Sexual contacts of the above

Diagnosis
History, examination and testing should enable a diagnosis. Algorithms for urethral discharge, vaginal discharge and penile or vulval lesions are included in checklist section. If unsure contact a sexual health physician.

Management
Comprehensive management of sexually transmitted infections has four components.

1. Treatment
Antibiotic therapy or other treatment is provided in accordance with recommendations.

2. Patient education
Patient education should cover the following: Natural history of the disease Sequelae and method of transmission The treatment and side effects Necessity of follow up and investigation and treatment of sexual partners Public health law specific to notifiable diseases Use of condoms and abstinence if required following treatment

3. Contact tracing
Notifiable sexually transmitted infections should be contact traced to allow for timely and appropriate treatment of sexual partners.

4. Follow-up
At least one follow up visit is essential in order to: Assess response and compliance to treatment Assess for side effects of treatment Determine whether sexual intercourse has occurred since treatment Perform investigations to demonstrate cure where appropriate Confirm contact tracing and treatment of sexual partners

Notification
There is a legal requirement for the attending clinician to notify all cases of gonorrhoea, early syphilis, chlamydia, hepatitis B, hepatitis C, HIV and donovanosis to the Department of Health (see Appendix 2)

Human Immunodeficiency Virus (HIV) infection

Risk assessment
Patients presenting for HIV serology should be assessed by a medical officer for STD and HIV risk, which requires taking a detailed sexual and blood exposure history. In addition to routine risk assessment (see Chapter 1), it is useful to determine if the patient has had a previous HIV test, and ask why the patient believes they need a test. Infection with an STD at the time of exposure increases the risk of HIV acquisition. Therefore, all patients at risk of HIV should be advised of the risk of other STDs and be offered testing.

Clinical presentation
Clinical presentations of HIV vary depending on the stage of infection, which includes the following. Acute infection (seroconversion) 50-70% of patients experience a mononucleosis-like illness including fever, lethargy, myalgia, arthralgia, headache, maculopapular rash, lymphadenopathy, splenomegaly 3-6 weeks after infection. Asymptomatic infection Following seroconversion patients may remain asymptomatic for many years.

Symptomatic infection Persistent generalised lymphadenopathy (nodes 1 cm diameter, at 2 extrainguinal sites for 3 months) occurs commonly but is not of prognostic significance. The degree of immune suppression (measured as the CD4 cell count) predisposes to the development of certain illnesses

CD4 Cell Count 150-500/L

Common Clinical Features Oral and vaginal candidiasis, oral hairy leukoplakia, sinusitis, gingivitis, seborrheic dermatitis, psoriasis, warts, molluscum contagiosum, recurrent varicella-zoster and herpes simplex infection, cervical dysplasia, tuberculosis, fever, sweats, weight loss Pneumocystis jiroveci pneumonia, Kaposis sarcoma, oesophageal candidiasis, cerebral toxoplasmosis, lymphoma, HIV dementia, cryptococcal meningitis Cytomegalovirus retinitis, cerebral lymphoma, Mycobacterium avium complex infection

< 150/L

< 50/L

The following table outlines the clinical features of the above infections.

Diagnosis
Pre test counselling should be performed and informed consent obtained prior to testing. HIV testing is performed by a screening ELISA which detects both HIV p24 antigen and HIV antibodies. A positive screening ELISA is confirmed on a Western Blot assay. If the Western Blot is negative, the ELISA result is considered to be a false positive, indicating the patient is not infected with HIV. Repeat testing is only indicated if the patient has been at risk in the three month period prior to the test. If the Western Blot yields an indeterminate result, the patient may have been recently infected with HIV and may be in the process of seroconverting. HIV screening ELISA testing should be repeated at 2 weekly intervals to determine whether the Western Blot assay becomes positive. If the Western Blot is positive, a report is returned with a confirmed positive statement. These patients require specific post test counselling and appropriate medical assessment. Further assessment should be conducted at 3-6 monthly intervals.

Infectious agent Pneumocystis jiroveci

Diagnosis Pneumocystis jiroveci pneumonia

Clinical features Dry cough Dyspnoea Fever Night sweats White mucosal plaques or erythema in oral cavity Dysphagia +/- chest pain Vaginal discharge, erythema, itching Clusters of painful vesicular lesions or shallow ulcers Dermatomal pain Vesicular lesions in dermatomal distribution Cough Fever Weight loss Fatigue Enlarged lymph nodes or spleen Headaches Neurologic abnormalities +/- meningism +/- fever Visual disturbance Diarrhoea Abdominal tenderness Bloating Chronic or recurrent fever Weight loss Fatigue

Candida species

Oral candidiasis (thrush) Oesophageal candidiasis Vaginal candidiasis

Herpes simplex virus (HSV) Varicella zoster virus (VZV)

Oral, genital and anal HSV Shingles/Herpes zoster

Mycobacterium tuberculosis

Pulmonary tuberculosis

Extrapulmonary tuberculosis Cryptococcus neoformans Cryptococcal meningitis

Cytomegalovirus (CMV)

Retinitis Enterocolitis

Mycobacterium avium complex (MAC)

MAC bacteraemia,

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Infectious agent Toxoplasma gondii

Diagnosis Toxoplasma encephalitis

Clinical features Headache Drowsiness Fever Focal neurologic abnormality Seizures Chronic diarrhoea may resolve spontaneously in early HIV infection Right upper quadrant pain Chronic diarrhoea May be asymptomatic

Cryptosporidium

Cryptosporidial enteritis +/- cholangitis

Microsporidia (several organisms)

Microsporidial enteritis +/- cholangitis

Malignancies Kaposis sarcoma

Clinical features Red/purple skin and mucosal lesions Bleeding oral lesions Gastrointestinal obstruction causing nausea/vomiting Pulmonary disease dyspnoea Lymphatic system involvement swelling of extremities Splenomegaly Focal neurologic abnormality Increasing asymmetrical lymphadenopathy Headache Focal neurologic abnormality Post-coital bleeding, intermenstrual bleeding Abnormal Pap smear Mucosal lesion, non-healing Abnormal biopsy

Non-Hodgkins lymphoma

Primary lymphoma brain

Cervical dysplasia/cancer

Anogenital cancer

The case definition of AIDS-defining illnesses used in Australia and the United States is shown in Appendix 3.

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Management
Clinical
Medical history At the first appointment after diagnosis complete assessment includes a full medical and sexual history, including current state of health and systems review. Examination A complete medical examination including: The patients weight and vital signs Lymphadenopathy: cervical, axillary and inguinal Skin lesions or rashes Oral lesions Hepatosplenomegaly Genital, including anorectal, lesions Any neurologic abnormalities Inspection of fundi (in patients with CD4 < 50/L review by an ophthalmologist should be performed 3 to 6 monthly)

12

Investigations The following investigations are conducted: At first visit after diagnosis

Repeat HIV ELISA for confirmation HIV viral load Liver function tests (LFTs), electrolytes, renal function tests Amylase, CK Full blood examination (FBE) CD4, CD8 lymphocyte markers Serologic tests for syphilis Hepatitis A serology Hepatitis B serology Hepatitis C serology HSV type 2, EBV, CMV, toxoplasmosis serology G6PD in case future use of sulphonamides is required

Subsequent routine 3-6 monthly follow up

FBE, CD4/CD8 lymphocyte surface markers, HIV viral load, LFTs, electrolytes, renal function tests. Amylase, CK, lipase, to check for medication side effects if on HAART When the CD4 count falls below 100, regular screening for MAC should be performed (Mycolytic F ) Pap smear should be performed 6-12 monthly, more frequently as CD4 count declines. STD check should be included if relevant symptoms exist or if exposure has occurred.

Antiretroviral therapy
Combination antiretroviral therapy has been demonstrated to significantly increase life expectancy and delay the progression to AIDS in individuals with a CD4 cell count below 500/L. As yet, there are no published data on the effect of combination therapy in individuals with early infection and a normal CD4 cell count. 13

Patients are usually prescribed a minimum of three drugs to include drugs from at least two of the following categories. Treatment recommendations are constantly changing and a detailed description of specific treatment of HIV infection is beyond the scope of these guidelines. Antiretroviral therapy should only be initiated by practitioners experienced in their use. Currently, the main antiretroviral agents for the management of HIV infection in Australia include: Nucleoside analogue reverse transcriptase inhibitors Abacavir (Ziagen) Didanosine (ddI, dideoxyinosine, Videx) Didanosine enteric coated (ddI EC, dideoxyinosine EC, Videx EC) Lamivudine (3TC) Stavudine (d4T, Zerit) Zalcitabine (ddC, dideoxycytidine, Hivid) Combine formulations Abacavir, lamivudine, zidovudine (Tizivir) Lamivudine, zidovudine (Combivir)

Nucleotide analogue reverse transcriptase inhibitors Tenofivir (Viread) Non-nucleoside analogue reverse transcriptase inhibitors Delavirdine (Rescriptor) Efavirenz (Stocrin) Nevirapine (Viramune) Protease inhibitors Atazanavir (Reyataz) Indinavir (Crixivan) Lopinavir (combined formulation with ritonavir, Kaletra) Fosamprenavir (Telzir) Nelfinavir (Viracept) Ritonavir (Norvir) Saquinavir (Invirase hard-gel capsule, Fortovase soft gel capsule) Fusion inhibitors Enfurvirtide (Fuzeon) 14

Management of opportunistic infections

(less likely to occur because of the efficacy of antiretroviral and preventive therapy)
INFECTION Pneumocystis jiroveci Prophylaxis CD4 < 200/L MANAGEMENT

Trimethoprim-sulfamethoxazole (TMP-SMX) 1 DS tablet (160 mg/800 mg) daily or Dapsone 100 mg twice weekly or Pentamidine 300 mg by nebuliser once a month. Nebulised salbutamol may be used as a premedication to reduce bronchospasm. Intravenous therapy If acutely ill, unable to take oral medication, or pO2<60: Trimethoprim 20 mg/kg/day and sulfamethoxazole 75-100 mg/kg/day in 4 divided doses for 21 days or Pentamidine 3 mg/kg once daily plus Hydrocortisone 100 mg iv qid for 7 days Oral therapy TMP-SMX 2 DS tablets tid for 14-21 days or Trimethoprim 200 mg qid and dapsone 100 mg daily for 14-21 days plus Prednisolone 50 mg/day orally for 7-14 days.

Acute infection

Candidiasis Oral (treat until symptoms resolve) Vulvovaginitis Oesophagitis

Fluconazole 200 mg orally daily for 7 days or Nystatin 100,000 unit tablet dissolved in mouth 3-5 times daily or Amphotericin B 10 mg lozenges orally 3-5 times daily See chapter 10 of this book Fluconazole 200 mg orally daily for 2 weeks, then 50-100 mg daily Long term secondary prophylaxis is recommended to prevent relapse.

Cryptococcal meningitis Acute infection

Amphotericin B 0.6-0.8 mg/kg/day iv plus 5-flucytosine 100 mg/kg/day orally qid for 2 weeks followed by Fluconazole 400 mg daily for 6-10 weeks Fluconazole 200 mg once daily There is a 60% recurrence rate if maintenance therapy is not taken.

Maintenance

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INFECTION

MANAGEMENT

Toxoplasma encephalitis Acute Infection Pyrimethamine 200 mg orally as a single dose then 50 mg orally daily plus folinic acid 10 mg orally daily plus sulfadiazine 1 g orally qid for 6 weeks or Pyrimethamine, folinic acid as above plus clindamycin 900 mg iv qid for 3 weeks, then 450 mg orally qid for 3 weeks Maintenance Pyrimethamine, folinic acid plus sulfadiazine 500 mg orally qid or Pyrimethamine, folinic acid, plus clindamycin 300 mg orally qid TMP-SMX 1 DS tablet daily

Prophylaxis Mycobacterium avium complex Treatment

Rifabutin 300 mg orally daily, plus Ethambutol 400 mg orally bd, plus Clarithromycin 500 mg orally bd. The required duration of treatment is uncertain, but should be at least 12 weeks. Indefinite maintenance therapy (with 2 agents) should continue. Azithromycin 1.2 g orally weekly

Prophylaxis CD4 100/L Herpes simplex/zoster Severe Moderate Suppression

Aciclovir 5 mg/kg iv tds for 7 days Valaciclovir 1 g orally tds for 7 days Valaciclovir 500 mg orally bd

Cytomegalovirus retinitis Initial treatment Ganciclovir 5 mg/kg iv bd for 2 weeks or Foscarnet 90 mg/kg iv bd for 2 weeks Maintenance Ganciclovir 10 mg/kg iv 3 days/week or Foscarnet 90 mg/kg iv 5 days/week Anti retroviral therapy with immune reconstitution controls persistent cryptosporidiosis paromomycin 500 mg orally tds until resolution Ceftriaxone 1 g iv daily for 10-14 days followed by Augmentin Duo 850 mg orally bd until resolution

Cryptosporidium enteritis

Bacterial pneumonia

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Prophylactic therapy against opportunistic infections

Primary prophylaxis is given in order to prevent opportunistic infection in an immunosuppressed patient. Trimethoprim-sulfamethoxazole (TMP-SMX, co-trimoxazole) is usually commenced when the CD4 count falls below 200/mL or 20% as prophylaxis against Pneumocystis jiroveci-pneumonia. Valaciclovir is given to immunosuppressed patients with a history of anogenital HSV infection. Secondary prophylaxis is prescribed after an infection has been successfully treated to prevent relapse.

Patient education
Patient education is complex and best performed slowly in stages using a range of resources. Some important considerations include the following: Interpretation of a positive result Nature of HIV and treatment options Method of transmission Need for ongoing medical and psychological care Availability of psychological and social support services and groups NOT to donate blood, semen or other body tissues or organs To use safe sexual practices, ie body fluids should not be exchanged Notify all health workers dealing with the patients ongoing care The patient should not receive any vaccinations without prior discussion with the medical officer involved in the ongoing HIV management. The patient should be assured of confidentiality at all times. As with all STD matters, no information regarding any patient is to be divulged to anyone without the patients written consent. 17

Contact tracing
Contact tracing is required and the patient my be referred to Clinic 275 for this purpose.

Follow-up
The frequency of follow-up visits depends upon the duration of infection and state of disease. The asymptomatic patient with normal CD4 cell count can be seen for assessment and investigations 3-6 monthly. Patients on therapy should be assessed 2-3 monthly. Patients with AIDS need close medical surveillance by their general practitioner in conjunction with the consultant staff of an infectious diseases department at Royal Adelaide Hospital (RAH), Flinders Medical Centre (FMC) or The Queen Elizabeth Hospital (TQEH). Reasons for referral include: Initiation of antiretroviral therapy Prophylactic pentamidine aerosol therapy Onset of a serious opportunistic infection Onset of a secondary malignancy Investigation of persistent symptoms such as diarrhoea with weight loss, pyrexia of unknown origin and neurological symptoms.

Post-exposure prophylaxis (PEP)

Occupational
Provision of PEP is the responsibility of the employer. Staff members should be assessed by the Occupational Health Unit. If prophylaxis is considered appropriate, the Infectious Diseases Unit will manage this. Patients are offered double or triple antiretroviral therapy, depending on the circumstances, for one month.

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Sexual
Non-occupational post-exposure prophylaxis (nPEP) is available at the RAH, TQEH and FMC. STD Services provides nPEP following sexual exposures. Patients requesting nPEP require an STD and HIV risk assessment. This requires taking a detailed sexual and blood exposure history. After counselling, and with informed consent, baseline HIV serology, FBE and LFTs are performed. It is advisable that all patients who are at risk of HIV should be advised of the risk of other STDs and be offered testing for these. Post exposure prophylaxis can be administered up to 72 hours after the exposure. Patients with significant exposures are offered double antiretroviral therapy, eg Combivir, for one month. Starter packs are available in the Clinic and medication is prescribed for one or two weeks at a time. Patients should be advised about safe sexual practices and clean needle programs for injecting drug users. Some patients may require additional psychological support and should be referred to MOSAIC counselling. If the baseline HIV test was positive patients are assessed as per HIV management guidelines (see chapter 2). Patients are monitored closely for side effects of medication and sero-conversion illness. FBE and LFTs are repeated weekly. Check whether medication has been taken in accordance with instructions and whether further sexual activity has occurred since exposure. At the completion of treatment, reinforce safer sexual practices and the need for follow up. Serology at 3 and 6 months after exposure is recommended. Hepatitis B vaccination should be offered to all those at risk (see chapter 15). There is a requirement by the Department of Health to notify the prescribing of anti-retroviral medication for nPEP and the outcome of treatment.

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3
Diagnosis
Confirmed

Gonorrhoea

Presumptive requires confirmation for diagnosis

Gram stain smear - typical intracellular Gram negative diplococci (GNID) PCR first catch urine - positive result

Culture of anogenital or throat swab Typical colonial morphology on selective culture medium, typical Gram stain morphology, positive oxidase reaction confirmed with sugar utilisation, coagglutination or antigonococcal fluorescent antibody testing

Management
Antibiotic treatment
Standard therapy all sites ceftriaxone 250 mg im as one dose diluted in 2ml of 1% lignocaine Observe patient in clinic for 15 minutes after administration Note - there is no readily available oral therapy recommended for routine treatment of gonorrhoea in South Australia

20

Patients with penicillin hypersensitivity Anogenital infection spectinomycin 2 g im as one dose Pharyngeal infection Patients should be referred to Clinic 275. Children weighing less than 45 kg Uncomplicated all sites ceftriaxone 125 mg im as one dose Children with penicillin hypersensitivity Anogenital infection spectinomycin 40 mg/kg im as one dose Pharyngeal infection Patients should be referred to Clinic 275 Children weighing more than 45 kg should receive adult regimens Disseminated gonococcal infection ceftriaxone 1g im or iv daily for 7 days Patients with penicillin hypersensitivity spectinomycin 2 g im 12 hourly for 7 days

Epidemiologic treatment
Epidemiologic treatment refers to treatment with standard regimens, after laboratory tests have been taken, but before confirmatory results are available, on the basis that the benefits of treating outweigh the benefits of not treating.

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The following patients should receive epidemiologic treatment: Those who are contacts of a person with proven gonorrhoea Those from whom an endocervical, urethral or rectal smear show intracellular Gram negative diplococci

Patient education
The following points must be discussed: The importance of immediate testing and treating of all sex partners Abstinence from sex until a test of cure is performed Patient education/provision of literature on gonorrhoea That gonorrhoea is a notifiable disease

Contact tracing
Patients need to be contact traced/referred for contact tracing.

Follow-up
All patients should return 5-10 days after completion of treatment for: Evaluation of symptoms and signs Check reaction to medication Enquiry about sexual activity since treatment Culture from infected sites (test of cure) to include rectal culture from all women with endocervical gonorrhoea Ensure contact tracing has occurred Screen for other STDs and arrange follow up at 3 months for blood borne virus serology and syphilis testing

22

4
Diagnosis
Primary Secondary

Syphilis

Definitive diagnosis involves demonstration of Treponema pallidum by darkfield microscopy in lesions from the anogenital area. There is no merit in performing this test on oral lesions because other treponemes, microscopically indistinguishable from T. pallidum, occur in the mouth. A presumptive diagnosis can be made if a typical ulcer is associated with a consistent history of syphilis in sex partners and/or serologic pattern before or after treatment in the patient.

Typical lesions of secondary syphilis (rash, condylomata, alopecia) and a consistent serologic pattern before and/or after treatment; being a rising RPR titre before treatment (fourfold within 6 months) and a corresponding fall after treatment. In secondary syphilis the RPR titre will usually be 1:8 or greater.

Early latent syphilis

An asymptomatic patient with positive RPR and TPHA and one of the following: Negative serology within the previous 2 years Fourfold increase in RPR titre on subsequent testing Fourfold decline in RPR within 12 months after treatment

23

Late syphilis
Late symptomatic syphilis is suggested when a positive treponemal test (RPR may be negative) occurs in association with typical neurologic or cardiovascular signs. Asymptomatic neurosyphilis is suggested by positive serology and a positive CSF-VDRL. The disease is active if there are 5 or more mononuclear cells/mm3 in the CSF. CSF examination is indicated in the following: Before treatment of any patient with a non-penicillin regimen For patients who do not respond adequately or relapse after therapy For patients with positive serology and signs of neurosyphilis For all HIV positive patients who have syphilis Late latent syphilis is characterised by a positive treponemal test (TPHA or FTA-ABS) and a negative or stable low titre RPR test. This same pattern may be due to adequately treated syphilis or a false positive treponemal test.

Management - early syphilis (less than 2 years duration)

Standard penicillin regimens have been very effective in the treatment of early syphilis. Recently some cases of apparent treatment failure have been documented and the problem is likely to be more severe in patients with impaired immunity, eg HIV infection. It is possible that treatment with benzathine penicillin is less effective than treatment with procaine penicillin. To achieve significant advantages in CSF levels over benzathine penicillin, procaine penicillin dosage should exceed 2 million units daily and probenecid should be administered concurrently.

24

While such large dose regimens of procaine penicillin may offer small theoretical advantages over benzathine penicillin, these regimens have low acceptance among patients and medical practitioners. For these reasons, when a procaine penicillin regimen is employed it should be preceded by an effective dose of benzathine penicillin as a safeguard against premature termination of a course of procaine penicillin.

Treatment
Preferred treatment for all patients particularly Patients with HIV infection Patients at high risk of acquiring HIV infection Patients with recurrent syphilis benzathine penicillin G 1.8 g (2.4 million units) im as one dose followed by procaine penicillin 3 g (3 million units) im daily plus probenecid 500 mg orally 6 hourly for 10 days For situations where compliance with the above regimen is unlikely benzathine penicillin G 1.8 g (2.4 million units) im as one dose For patients who are allergic to penicillin doxycycline 200 mg orally daily for 20 days or tetracycline HCl 500 mg orally 6 hourly for 20 days

Patient education
Warn the patient about the possibility of a Herxheimer reaction and its management. Stress the importance of examining all contacts immediately. The patient should not have sex until treatment is completed and sex partners have been examined (if possible).

25

It is undesirable for the patient (or a sex partner - as appropriate) to become pregnant until a good response to therapy has been demonstrated.

Contact tracing
All patients are to be referred for contact tracing.

Follow-up
4 weeks clinical assessment and sex partner review. 3, 6, 12 months clinical assessment and repeat serology.

Management - late syphilis

Treatment
Late latent syphilis standard therapy benzathine penicillin G 1.8 g (2.4 million units) im as one dose followed by procaine penicillin 3 g (3 million units) im daily plus probenecid 500 mg orally 6 hourly for 20 days or benzathine penicillin G 1.8 g (2.4 million units) im weekly for three weeks For patients allergic to penicillin doxycycline 200 mg orally daily for 30 days or tetracycline HCl 500 mg orally 6 hourly for 30 days Symptomatic late syphilis requires hospitalisation and treatment under consultant supervision.

Patient education
The degree of certainty of the diagnosis, and uncertainty (but generally be optimistic) of the prognosis should be discussed with the patient.

26

Contact tracing
Late syphilis is essentially non-communicable and contact tracing is not indicated.

Follow-up
Repeat serology 3, 6, 12, 24 months after treatment. If CSF has been examined repeat at 3 monthly intervals until the cell count returns to normal.

Syphilis in pregnancy
If congenital syphilis is suspected a specialist should be consulted. All women should have an RPR in the first trimester; women at high-risk, eg Aboriginal women, should have a further test in the third trimester. Women with a positive test should be evaluated rapidly - history, examination, testing of contacts and if unresolved a further RPR (2 weeks after the first test). If active syphilis cannot be reasonably excluded by this process the patient should be treated for early syphilis, as a safeguard against foetal infection. benzathine penicillin G 1.8 g (2.4 million units) im as one dose (ADEC A) For patients allergic to penicillin erythromycin 500 mg orally 6 hourly for 15 days (ADEC A) If the mother is treated with penicillin more than 4 weeks before delivery risk to the infant is minimal and follow-up of the infant involves clinical examination at birth, serology at birth and thereafter 3 monthly until the RPR is negative.

27

If maternal treatment was inadequate, unknown, with drugs other than penicillin, was completed less than 4 weeks before delivery, or if adequate follow-up of the infant cannot be assured, the infant should be treated at birth and have repeat serology 3 monthly until the RPR becomes negative. The CSF should be examined before treatment if there is a substantial risk of congenital syphilis. For asymptomatic infants with normal CSF and for whom follow-up cannot be guaranteed. benzathine penicillin G 50,000 units/kg im as one dose For other infants aqueous procaine penicillin G 50,000 units/kg im daily for 10 days or aqueous crystalline penicillin G 50,000 units/kg iv 12 hourly for 10 days

28

5
Diagnosis
Presumptive
or Evidence of HSV on Pap smear

Genital herpes

Specimen from genital lesion demonstrates typical HSV morphology by electron microscopy

Confirmed
Isolation of herpes simplex virus (HSV) in cell culture or detection of HSV DNA by Nucleic Acid Amplification Test (PCR) in a specimen from the cervix, urethra or a genital or perianal lesion. Ideally, the specimen should be taken within 72 hours of the appearance of a suspicious lesion. Note: HSV serology using EIA is not recommended because of defects in both sensitivity and specificity

Clinical
Typical herpetic genital lesions (pre-emergent paraesthesia, blisters, or multiple, painful shallow ulcers)

Management
Treatment
No treatment is available to eradicate the virus. 29

First episode Antiviral agents reduce viral shedding from lesions, hasten healing and reduce the risk of recurrence while being administered. In the STD clinic valaciclovir is used with the aim of avoiding hospitalisation and/or reducing severe patient distress in acute first episode infection. Standard therapy valaciclovir 500 mg orally 12 hourly for 5 days (ADEC B3) The patient should be reviewed after 5 days for resolution of symptoms. A further 5 days of valaciclovir may be indicated. For HSV proctitis valaciclovir 1000 mg orally 12 hourly for 7 to 10 days (ADEC B3) Recurrent herpes Intermittent therapy Most immunocompetent patients with recurrent disease do not benefit from intermittent antiviral therapy. If indicated, treatment should be instituted during the prodrome or within 2 days of onset of lesions. valaciclovir 500 mg orally 12 hourly for 5 days or famciclovir 125 mg orally 12 hourly for 5 days (ADEC B3) Suppressive therapy In patients with frequent or severe recurrences, daily suppressive therapy reduces the frequency of recurrences, although it does not totally eliminate symptomatic or asymptomatic viral shedding. Suppressive therapy with valaciclovir has also been shown to reduce the risk of transmission to sero-negative partners in monogamous relationships.

30

Standard therapy valaciclovir 500 mg orally daily for a minimum of 6 to 12 months (this dose may be increased to 500 mg twice daily if the patient has recurrences while on suppressive therapy) or famciclovir 250 mg orally 12 hourly for a minimum of 6 to 12 months After 6 to 12 months, medication should be discontinued to allow evaluation of the rate and severity of recurrences.

Adjunct therapy
The primary aim is supportive treatment by keeping lesions as clean and dry as possible while spontaneous healing occurs. This may be achieved by saline bathing (or other cleansing) of the ulcerated area, drying with tissues, application of Betadine paint and/or exposing the ulcers to air or the warmth of a reading light (a fan or hair dryer may be useful) for 10 to 15 minutes several times a day, particularly after urination (for women). Topical lignocaine, antiseptics and zinc creams should not be used. Analgesics by mouth are often useful, particularly at night time. Hospitalisation should be considered for patients who are in obvious distress from the physical effects of their lesions, particularly when pain is aggravated by walking or leads to urinary retention. This pattern occurs mainly in first attacks involving widespread ulceration of the vulval or perineal area.

Patient education
Patient education is often complex. HSV is common with an approximate prevalence of 80-90% for type 1 and 20-30% for type 2. Up to 60-70% of people with HSV type 2 are not aware that they are infected. The risk of acquiring herpes from male to female is about 10% and female to male about 5% per annum in a serodiscordant relationship. The following points should be covered:

31

 The nature of HSV infection including greater severity of initial attack, decreasing frequency and severity of recurrences with time HSV type 1 and 2 infections are common in the community Treatment options Method of transmission Nature of asymptomatic viral shedding during which time transmission may occur Avoidance of sex during outbreaks and optional use of condoms at other times which may decrease transmission For a pregnant woman to inform her treating doctor of her HSV infection

Follow-up
Provide test results False negative results are common and do not exclude herpes in individuals with characteristic clinical signs. Patients with recurrent ulceration where HSV has not been isolated should be reviewed by a sexual health physician Record clinical progress and perceived value of the therapeutic measures used Enquire about any anxieties or further questions the patient may have

32

6
Diagnosis
Treatment
Standard therapy

Genital Chlamydia trachomatis infection

Diagnosis is made on a positive urethral swab or first catch urine in males and on a positive endocervical swab in females for chlamydia PCR. In females without a cervix or in whom swabs cannot be taken, a first catch urine can be tested for chlamydia PCR. Serology is of no value in the diagnosis of genital tract chlamydial infection.

Management

azithromycin 1 g orally as one dose (ADEC B1) Patients allergic to macrolides doxycycline 200 mg orally daily for 10 days (ADEC D)

Epidemiologic treatment
Epidemiologic treatment is given to sexual partners, regardless of age or gender, of persons with proven chlamydia. In all cases, appropriate investigations for chlamydia should be performed before treatment is provided.

33

Patient education
The following points should be covered: Chlamydia is sexually transmitted It is common Infection is asymptomatic in up to 50% of men and 90% of women Re-infection may occur during or after treatment Abstinence from sex until 1 week after patient and partner treatment Chlamydia is a notifiable disease Advise on the side effects of medications

Contact tracing
Contact tracing is required.

Follow-up
Test of cure is not recommended with PCR Check on medication compliance if single dose therapy not used, reaction to medication Evaluate symptoms and signs Enquire about further sexual activity since diagnosis, reinforce prevention and safe sex practices Confirm contact tracing Re test at 3 months for new infection Serological screening for HIV, hepatitis B and syphilis in 3 months

34

7
Treatment

Non-specific urethritis and urethral irritation

Diagnosis
Non-specific urethritis (NSU) is diagnosed in males only, from microscopic examination of a gram stain made from a urethral swab. Diagnosis requires the following: Evidence of urethritis (5 or more polymorphs per high power field) and Absence of gonococci or chlamydia trachomatis. Passage of urine may flush out urethral polymorphs, thus a urethral swab should be taken optimally 4 hours after the last void. NSU may be diagnosed if there is evidence of inflammation even in the absence of symptoms such as urethral discharge or dysuria if there is no other obvious cause for inflammation such as herpes, balanitis or dermatitis.

Management
Antibiotic treatment should not be commenced until urethral swabs have been taken. Standard therapy azithromycin 1 g orally as one dose or doxycycline 200 mg orally daily for 10 days In settings where microscopic examination of a urethral smear is unavailable on site, treatment of presumptive NSU is justified in symptomatic men. 35

Patient education
The following points should be covered: Chlamydia and gonorrhoea test results will be pending at the first visit Abstinence from sex for one week until results are given The nature of the infection It is benign and there is no equivalent in females Symptoms may be slow to resolve despite treatment Note: The significance of ureaplasma is uncertain and its detection does not alter management. Neisseria meningitidis is occasionally identified on urethral culture in asymptomatic men. Its finding is usually incidental and does not require treatment. However, in the presence of symptoms N. meningitidis is assumed to be the cause of urethritis.

Contact tracing
This is only required if chlamydia or gonorrhoea is isolated.

Follow-up
The patient should be clinically reviewed 5 to 10 days after the completion of medication for the following: Review results of gonococcal culture and chlamydia tests Check on medication compliance Evaluate symptoms and signs Check reaction to medication Enquire about sexual activity since treatment If symptoms persist, repeat urethral smear for polymorphs, at least 4 hours after voiding

36

Persistent NSU
In some men, the symptoms of urethritis do not resolve despite compliance with antibiotic therapy and abstinence from sexual activity. In these men, where the urethral smear still shows 5 or more polymorphs per high power field the following treatment regimen is recommended: Standard therapy doxycycline 200 mg orally for 10 days plus metronidazole 400 mg orally 12 hourly for 5 days Alternate therapy roxithromycin 150 mg orally twice daily for 10 days plus metronidazole 400 mg orally 12 hourly for 5 days

Urethral irritation
The diagnosis is made in men with dysuria and/or urethral discharge but no microscopic evidence of urethritis. In settings where microscopy of a urethral smear is not available, this diagnosis cannot be reliably made.

Management
The patient should be reassured that the symptoms are due to a mild irritation and not infection. Possible causes may include trauma, eg vigorous sexual activity or masturbation, or irritants such as alcohol. No antibiotic treatment is required. The symptoms subside in one to two weeks. The patient should be advised to avoid manipulation of the penis (no squeezing or milking of the urethra) and he should abstain from sexual activity and masturbation. Ensure that tests for gonorrhoea and chlamydia (and urinary tract infection if clinically indicated) have been done to exclude these infections. The patient should return for these results in 1 week, and should not have sex until negative gonorrhoea and chlamydia tests are confirmed. 37

8
Diagnosis Management
Treatment
Cryotherapy Podophyllotoxin

Genital warts

Diagnosis is made on clinical grounds. Biopsy may be required for unusual presentations.

The aim of treatment is to remove clinically evident warts. No treatment has been demonstrated to eradicate HPV. All treatment modalities are associated with high recurrence rates. In some cases, genital warts may regress spontaneously.

Liquid nitrogen is applied to visible warts at weekly intervals until resolution.

This is self applied treatment. It is associated with a far lower rate of adverse reactions than treatment with podophyllin. podophyllotoxin 0.5% solution or 0.15% cream topical 12 hourly for 3 days followed by 4 days of no therapy. This cycle may be repeated up to 4 times. A maximum surface area of 4cm2 can be treated (ADEC D). The doctor should demonstrate the proper application technique and identify which warts should be treated.

38

Note: Do not use in pregnancy Do not use on cervical, rectal or urethral warts (because of difficulty in preventing damage to adjacent moist tissues and the potential for systemic absorption) Treat warts in the outer vagina or vestibular area with extreme caution. Only treat small isolated warts and allow to dry, to minimise contact with normal mucosa Never use large volumes by treating extensive or very large warts. When large numbers of warts are present, discuss management with a consultant Imiquimod This is self applied treatment. It is more effective for women than men. imiquimod 5% cream topical for 6-10 hours three times per week on alternate days for up to 16 weeks (ADEC B1).

Referral and investigation

Surgical removal, electrosurgery or laser therapy are used for warts resistant to the foregoing methods, for extensive warts or warts in certain locations, eg rectal warts. Patients with cervical or extensive intravaginal warts should be referred for colposcopy. Urethroscopy is indicated before treating recurrent meatal warts, and proctoscopy before treatment of perianal warts.

Patient education
The following points should be covered: The nature of the infection HPV is very common. Most people will become infected with genital types during their sexual life

39

 Most infected people are asymptomatic with only a very small number developing visible warts The oncogenic types of HPV rarely cause visible genital warts HPV infection is often present in the absence of genital warts and is only of clinical significance if present on the cervix. It is impossible to diagnose subclinical HPV infection clinically Side effects of treatment and their management. If podophyllotoxin has been used, stress the need to return immediately if a severe reaction results from treatment Cryotherapy may cause scarring or pigment changes HPV transmission is thought to be more likely in individuals with clinical warts. Condom use may be recommended until resolution of warts

Follow-up
Clinical assessment at one week, to assess response to therapy, and re-treatment as required. Women with genital warts, or female partners of patients with genital warts should be encouraged to have regular Pap smears.

40

9
Diagnosis Management
Treatment
Standard therapy

Trichomoniasis

Detection of trichomonads in a wet preparation or smear. In males, microscopic examination of centrifuged urine may reveal trichomonads, but this test lacks sensitivity.

metronidazole 400 mg orally 12 hourly for 5 days (ADEC B2) or metronidazole 2 g orally as one dose or tinidazole 2 g orally as one dose (ADEC B2) Alcohol should not be consumed during treatment with metronidazole or tinidazole and for 3 days after treatment.

Patient education
The following points should be discussed: The nature of the infection The need to treat regular sex partners Men are usually asymptomatic and it is rare for trichomonads to be observed Abstinence from sex until the regular partner is treated and cured. If a microbiologic test of cure is unavailable, sexual activity may resume when therapy has been completed and both patient and partner are with out symptoms 41

Contact tracing
Although trichomoniasis is not a notifiable disease contacts should be tested and treated.

Follow-up
One week after completion of therapy for the following: Check that the regular sex partner has been treated (if applicable) Check on compliance for multi-dose regimen Evaluate symptoms and signs Check reaction to medication Enquire about sexual activity since treatment Perform test of cure

42

10
Diagnosis
and

Vulvovaginal Candidiasis

Budding cells or hyphae detected on a KOH preparation or Gram stain. Culture on Sabourauds medium is much more sensitive than smear.

Symptoms and/or signs of vaginitis, eg discharge, vaginal itch or discomfort, external dysuria, vulvovaginal erythema.

Management
Treatment
Treatment is provided only for symptomatic women. Six day regimens are preferred. miconazole 100 mg pessaries or cream 2% intravaginally at night for 6 nights (ADEC A) or clotrimazole 100 mg pessaries or cream 1% intravaginally at night for 6 nights (ADEC A)

Patient education
The following points should be discussed: The nature of the infection The need for adequate hygiene and avoidance of potential irritants 43

 Sexual transmission has negligible significance in the aetiology of vulvovaginal candidiasis. Sex partners do not need to be examined and treated

Follow-up
Required if symptoms do not resolve.

Recurrent candidiasis Clinical features

Identical to acute vulvovaginal candidiasis.

Diagnosis
The occurrence of at least four mycologically proven symptomatic episodes of vaginal candidiasis within 12 months, with the exclusion of other common vaginal pathogens.

Management
Exclude associated factors such as pregnancy, uncontrolled diabetes mellitus, hormone therapy (including oestrogens or corticosteroids), HIV infection and repeated courses of broadspectrum antibiotics. Most sufferers of recurrent candidiasis will already know about avoiding tight-fitting or synthetic underwear, and not using douches or vaginal deodorants.

44

Treatment
Standard therapy clotrimazole 500 mg pessaries intravaginally at night, once weekly for six months or ketoconazole 400 mg orally daily for 5 days after the onset of menses, over a six month period (ADEC B3) (monitor LFTs) or fluconazole 150 mg orally once weekly for six months (ADEC D) or ketoconazole 100 mg orally daily for six months (monitor LFTs) Routine treatment of partners is unlikely to reduce recurrence rates.

45

11
Diagnosis Management
Treatment
Standard therapy

Pediculosis pubis

Observation of pubic lice or nits attached to the hair. The diagnosis is suggested by a history of itching and exposure to lice or observation of crabs by the patient. Pubic lice can also involve eyelashes, eyebrows, beard and body hair. These areas should be examined.

permethrin 1% cream rinse topical from chest to knees washed off after 10 minutes with repeated treatment 1 week later (ADEC B2) Permethrin should be applied to clean and cool skin. The patient should not take a hot bath or shower prior to treatment. Apply to infected and adjacent hairy areas. Nits should be removed with a fine toothed comb. Sex partners should be treated concurrently. Clothing and bed linen contaminated by the patient within the past 2 days should be washed and dried by machine (hot cycle) or dry cleaned. If the eyelashes are infested, white soft paraffin (Lacri-Lube) can be applied to the lashes, and then the eggs removed, twice a day. This treatment should be continued for 7 to 10 days. 46

Patient education
The following points should be discussed: Nature of the infection Stress all the therapeutic features, and the need for concurrent treatment of regular sex partners Non-sexual transmission of crabs is possible, but in almost all instances transmission is the result of prolonged close physical contact Advise that the itch can last for a few days following treatment

Follow-up
Required only if symptoms do not resolve.

47

12
Diagnosis

Scabies

Definitive diagnosis requires microscopic identification of the mites, eggs, larvae or faeces. Clinical diagnosis is made by observing typical lesions on wrists, finger web spaces, axillae, penis or thighs or on eliciting the classic pattern of pruritus (at night, after a hot shower/bath). If associated with exposure to an infected person, the index of suspicion should be high even in the context of non-specific symptoms. Immunosuppressed patients may present with Norwegian scabies. Large numbers of mites are present. The condition may not be pruritic. Extensive crusting may be seen.

Management
Treatment
Standard therapy permethrin 5% cream topical from neck down washed off after at least 8 hours, but not more than 24 hours (ADEC B2) Permethrin should be applied to clean and cool skin. The patient should not take a hot bath or shower prior to treatment. 1% creams and lotions are ineffective against scabies. Pay particular attention to the areas between the fingers and toes, under fingernails and toenails, wrists, armpits, genitals, buttocks and perianal area. It is usually helpful for a second person to assist with the application of cream to areas that are not easily accessible. 48

Reapply cream to the hands if they are washed within 8 hours of treatment. Oral antihistamines can be used to control itching. Immunosuppressed and HIV positive patients These patients may prove resistant to topical therapy. Referral to a Dermatology or Infectious Diseases specialist may be necessary for treatment with systemic ivermectin. Norwegian scabies may also need ivermectin treatment.

Patient education
The following points should be discussed: The nature of the infection The need for concurrent treatment of sex partners and household contacts Non-sexual transmission of scabies is possible, but requires direct and prolonged body contact Clothing and bed linen which may have been contaminated by the patient within the past 2 days should be machine washed and dried (hot cycle) or dry cleaned Pruritus may persist for several weeks after adequate therapy. Systemic antipruritics or topical steroids may be required for alleviation of symptoms Additional weekly treatments are warranted only if live mites can be demonstrated

Follow-up
Follow up is only indicated if symptoms have not resolved.

49

13
Diagnosis Management
Treatment
Cryotherapy

Molluscum contagiosum

Clinical diagnosis is made on the basis of typical hemispherical, smooth, umbilicated, pearly lesions. Lesions are frequently present on the pubis, inner thighs or genitals. In immunocompromised patients lesions may be extensive, larger and atypical in appearance. Molluscum inclusion bodies may be identified by microscopic examination of the stained crushed core of a lesion.

Individual lesions should resolve after a single treatment but it is not unusual for new lesions to appear in the following days or weeks. If the lesions fail to resolve, treatment can be repeated at weekly intervals. Currettage The core of medium or large lesion is removed by slitting the capsule with the edge of a 19 gauge needle. To prevent spread and secondary infection, povidone-iodine (Betadine) should be applied following treatment.

50

Patient education
The following points should be discussed: The nature of the infection as a benign condition The infection is spread by close physical contact. In adults with lesions on or near the genitals it is usually sexually transmitted Advise the patient against scratching which may spread the lesions Cryotherapy may cause scarring and pigment changes

Follow-up
Clinical review 5-10 days after completion of treatment.

51

14
Diagnosis
vaginal fluid pH 4.5

Bacterial vaginosis

Diagnosis requires all of the following criteria homogeneous white vaginal discharge clue cells on wet prep or Gram stain

Management
If candida or trichomonas are present, treat for these conditions and reassess. Treatment is only offered to patients with clinical symptoms or signs, or if intrauterine instrumentation like termination of pregnancy is anticipated and to some pregnant women.

Treatment
Standard therapy metronidazole 400 mg orally 12 hourly for 5 days (ADEC B2) or tinidazole 2 g orally as one dose (ADEC B2) Alcohol should not be consumed during treatment with metronidazole or tinidazole and for 3 days after completion of treatment.

52

For patients intolerant of metronidazole clindamycin cream 2%, 5 g intravaginally at night for 7 days (ADEC A) or econazole 150 mg pessaries intravaginally at night for 3 days (ADEC A)

Patient education
The following points should be discussed: The nature of the condition It is not proven to be sexually transmitted and partners do not need treatment Explain the need to avoid alcohol until 3 days after metronidazole or tinidazole treatment is completed.

Follow-up
Required only if symptoms do not resolve.

53

15
Diagnosis Management

Hepatitis B

Active infection is indicated by the presence of hepatitis B surface antigen (HBsAg) in serum. Acute hepatitis B is diagnosed in patients who are positive for HBsAg and have evidence of disturbed liver function, symptoms and a risk history suggesting recent infection. Repeatedly positive HBsAg over a 6 month period in the absence of acute symptoms or risk history to suggest recent infection indicates a chronic carrier state. A person who has positive hepatitis B surface antibody (HBsAb) and negative HBsAg is immune and should not be further tested for hepatitis B. Positive HBsAb with negative core antibody (HBcAb) is usually indicative of vaccination.

Individuals with active disease, ie HBsAg positive and abnormal liver function tests should be referred to an appropriate specialist. Non-immune sexual and household contacts of hepatitis B infection are candidates for hepatitis B vaccination. Clinic 275 offers vaccination to: Non-immune regular sex partners of patients who have positive HBsAg or Hepatitis B DNA Sex workers Men who have sex with men (past or current)

54

 Injecting drug users (past or current) Indigenous Australians Persons from high prevalence countries Non-immune regular sex partners of the above groups Hepatitis C positive people Vaccination doses are given at 0, 1 and 6 months. This regimen indicates the minimum time between vaccination doses. There is no need to recommence vaccination if there is a delay between doses. Evidence of seroconversion is not sought. Booster doses are not recommended.

Patient education
The following points should be discussed: The nature of the infection Methods of transmission and preventative measures required (taking into account the infective and immune status of the individuals involved) The need to vaccinate sexual and household contacts To minimise alcohol intake Need to vaccinate against Hepatitis A if indicated Hepatitis B infection is a notifiable disease

Contact tracing
Contact tracing is required.

Follow-up
A person with positive HBsAg should be retested in 6 months. A positive test on follow-up indicates a chronic carrier state. If the patient has abnormal liver function tests, refer to an appropriate specialist.

55

16
Diagnosis

Pelvic inflammatory disease (acute salpingitis)

Pelvic inflammatory disease (PID) is usually the result of infection ascending from the endocervix causing endometritis, salpingitis, parametritis, oophoritis, tuboovarian abscess and/or pelvic peritonitis. There is no single historical, physical or lab finding that is both sensitive and specific for the diagnosis of PID.

A combination of clinical and laboratory information is required. Symptoms alone are not a good predictor of PID, and clinical diagnosis alone is difficult. A low threshold for diagnosis should be maintained to prevent sequelae. On examination minimum criteria for diagnosis includes: Cervical and uterine motion tenderness, and Adnexal tenderness These findings may be sufficient for a diagnosis of PID and the commencement of empirical treatment in a woman with a mild presentation, at risk of STDs and in the absence of strong evidence for a competing diagnosis. There should also be one of the following additional criteria suggesting genital tract infection or an inflammatory process. When symptoms are severe, other diagnoses should be considered, and more than one of the following criteria should be present to make a diagnosis of PID:

56

 Temperature > 38 C Abnormal cervical discharge Pelvic abscess or inflammatory complex on bimanual examination Gram stain of the endocervix showing gram negative intracellular diplococci Positive chlamydia test Leucocytosis > 10 x 109 WBC/L Elevated ESR Elevated C-reactive protein The definitive criteria for diagnosing PID include the following: Histopathologic evidence of endometritis on endometrial biopsy Transvaginal sonography or other imaging techniques showing thickened fluid-filled tubes with or without free pelvic fluid or tubo-ovarian complex Laparoscopic abnormalities consistent with PID

Management
Treatment
Objectives of antimicrobial therapy include: Short term - elimination of symptoms and signs of infection and eradication of pathogens Long term - reduction of tubal damage (impossible to evaluate using current data) Treatment is usually initiated empirically before a microbial cause is established. PID is polymicrobial. Neisseria gonorrhoeae and Chlamydia trachomatis are implicated most often but there are a variety of endogenous anaerobic and aerobic bacteria that may also cause PID. 57

Outpatient therapy The following combination regimen should be used. If ongoing parenteral treatment is required, the woman should be hospitalised (see following section) ceftriaxone 250 mg im as one dose plus doxycycline 100 mg orally 12 hourly for 14 days plus metronidazole 400 mg orally 12 hourly for 14 days Indications for hospitalisation Intravenous therapy is recommended for patients with more severe clinical disease such as those with fever, tuboovarian abscess or peritonitis. Other indications for hospitalisation include the following: When surgical emergencies such as appendicitis and ectopic pregnancy cannot be excluded The woman is pregnant Failure to respond to outpatient oral therapy The woman is unable to follow or tolerate an outpatient oral regimen The woman is immunodeficient Removal of IUCD World Health Organisation guidelines state that there is no need for removal of the copper bearing IUCD if the patient wishes to continue using it. If it is to be removed, it should be done so after the commencement of antibiotic treatment. Emergency contraceptive medication can be used to prevent pregnancy. If the infection worsens generally the course would be to remove the IUCD.

58

Sequelae
Complications may occur in spite of adequate treatment. There are uncertainties regarding the effectiveness of antimicrobial therapy in totally eradicating tubal infection, even where cervical infection has been eliminated. Delay in diagnosis and treatment, or inadequate treatment may also increase the rate of complications. Complications include: Infertility Chronic persistent pain Increased incidence of ectopic pregnancy Increased risk of further episodes of PID Tubo-ovarian abscess

Patient education
The following points should be discussed: The nature of the infection It may not be sexually acquired Partners should be tested and treated for sexually transmitted infections Clinical review is required Long term sequelae of PID

Contact tracing
Contact tracing is required if a sexually transmitted infection is identified.

Follow-up
Close follow-up is required to assess for response to treatment and the development of any complications.

59

17
Diagnosis Management
Treatment

Balanitis (and Balano-posthitis)

Diagnosis is made on clinical grounds. Diagnosis may be difficult for the inexperienced because of the diversity of clinical features, which may mimic a variety of conditions.

Although candida and bacteria may be isolated from the inflamed area, medication has a limited role and is best avoided in most cases. The basis of treatment is to keep the foreskin clean and dry. The patient should clean the glans with water 2 to 3 times a day and pat dry. The foreskin should be retracted to expose the glans to the air, a fan or a reading light for 15 minutes. Individuals prone to balanitis should routinely perform this procedure nightly or at least several times a week. The patient should not retract a tight foreskin as paraphimosis is likely to occur. If this procedure is not effective or if the foreskin is tight, circumcision should be considered.

Patient education
The following points should be discussed: The nature of the condition The need for hygiene rather than medications or creams Abstinence from sex during episodes as this may flare the condition 60

 Routine hygiene after sex will help to decrease the chance of developing balanitis The foreskin should always be retracted during urination

Follow-up
Follow-up is required only if symptoms do not resolve.

Foreskin Hygiene
Medication (eg cream or ointment) is rarely necessary, and is usually less effective than hygiene measures for treating balanitis. The aim is to make it difficult for organisms to grow under the foreskin by keeping the glans and the foreskin clean and dry. Once a day, ideally when you have a shower, slide your foreskin back towards your body until the glans is completely uncovered (Figures 1a and 1b). Do not use any force. If there is any resistance or discomfort, check with a doctor. Wash the end of your penis and foreskin thoroughly using warm water only. Alternatively, sorbolene and glycerine cream (available from chemists and supermarkets) may be used as a substitute for soap. After washing, dry the end of the penis and foreskin thoroughly. If convenient, sit with the glans exposed to the air for 10 minutes. More thorough drying can be achieved by using a fan or hair dryer (Figure 2). After drying, replace the foreskin (Figure 3). When you urinate, slide the foreskin back so that urine does not wet the foreskin (Figure 4). After urination, dry the end of the penis and replace the foreskin. If you are prone to developing balanitis a few hours after sex, wash the penis as described above shortly after having sex. Make sure the glans is completely dry before replacing the foreskin.

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18
Chancroid
Diagnosis Treatment
Standard therapy

Other STDs

A cotton or calcium alginate swab taken from the ulcer base should be plated directly onto chocolate agar enriched with 1% isovitalex and containing vancomycin. After incubation in an atmosphere containing 5-10% CO2, colonies appear in 2-4 days (sometimes as late as 7 days). The diagnosis should only be made after consultation with a sexual health physician.

ceftriaxone 250 mg im as one dose (ADEC B1) or azithromycin 1 g orally as one dose (ADEC B1) or erythromycin 500 mg orally 6 hourly for 7 days (ADEC A)

Donovanosis
Diagnosis
Clinical Infection occurs predominantly in Aborigines and occasionally in non-Aborigines who have had sex with Aborigines. Typical granulomatous lesions are beefy red and painless. Laboratory A biopsy specimen is crushed against a slide which is air-dried and stained with Wrights or Giemsas stain. PCR testing is available in specialised laboratories. 62

Treatment
All antibiotics should be taken until lesions heal Standard therapy azithromycin 1 g orally weekly (ADEC B1) or doxycycline 100 mg orally 12 hourly (ADEC D) after failed therapy, or for immunosuppressed patients azithromycin 500 mg orally daily (ADEC B1)

Lymphogranuloma venereum
Diagnosis
The disease is rare in South Australia and diagnosis is difficult. A complement fixation test is sensitive but cross reacts with other chlamydial infections and titres below 1:64 should be interpreted with caution. Chlamydia PCR may be positive from lesions. The diagnosis should only be made after consultation with a sexual health physician.

Treatment
Standard therapy doxycycline 100 mg orally 12 hourly for 21 days (ADEC D) For pregnant or lactating women erythromycin 500 mg orally 6 hourly for 21 days (ADEC A).

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Appendix 1

Techniques for swab and urine specimen collection

Males
Urethral specimens Patients should not pass urine for at least 4 hours prior to specimen collection. Distal urethral swab Performed when Discharge present Urethritis symptoms Confirming a positive urine PCR for gonorrhoea Testing a gonorrhoea contact Test of cure after treatment for gonorrhoea Method Massage the urethra from proximal to distal to present any discharge Using a cotton swab, discharge present at the meatus is smeared on a slide and air dried and then placed on an appropriate transport medium In the absence of a discharge a thin dacron tipped plastic or metal swab is moistened with normal saline and placed 2-3 cm inside the urethra and gently rotated once or twice and removed If no slide is made the lab will prepare one from the swab placed in the transport medium An air dried smear made at the time of specimen collection is of superior quality Gram stain - to assess for Polymorphonuclear leucocyte cell count Presence of gram negative intracellular diplococci Culture for Gonorrhoea 64

Proximal urethral swab Performed when Chlamydia testing required and urine not taken for chlamydia PCR Method a thin dacron tipped plastic or metal swab is moistened with normal saline and placed 3-4 cm inside the urethra and gently rotated once or twice and removed and placed in an empty transport container Rectal specimens Proctoscopy should be performed to inspect for lumps, ulcers, pus, bleeding and specimen collection Swabs are taken for Gonorrhoea culture (plate or transport medium) Chlamydia PCR (dry or moistened cotton tipped swab) Herpes simplex PCR if indicated Pharyngeal specimens Swabs are taken from each tonsillar fossa for Gonorrhoea culture Ulcer specimens Dry or moist cotton tipped swabs taken from the ulcer base can be tested for HSV PCR Swabs are transported in an empty transport container or in viral culture medium First catch urine Should not pass urine for at least 3 hours before the sample collection First 10ml of urine is collected Voiding within 30 minutes prior to sample collection should be considered in interpreting results

Females
Samples are taken during speculum examination. Endoervical specimens A Pap smear is taken first if due or indicated 65

 A cotton tipped swab is inserted into the cervical canal only 0.5 cm and Smeared on a slide and air dried for gram stain Placed in a transport medium for gonorrhoea culture A second cotton tipped swab is inserted 0.5 - 1cm into the cervical canal and kept in place for 10-15 seconds and rotated 1-2 times for Chlamydia PCR testing (place in a empty transport container) Vaginal specimens From the lateral vaginal wall with a cotton tipped swab Smeared on a slide and air dried for gram stain for bacterial vaginosis and candida Placed in a transport medium for gonorrhoea culture and candida culture From the posterior fornix with a cotton tipped swab for pH performed on a pH strip at the time Wet preparation for trichomonas Smear on to a slide and place a drop of normal saline on slide - must be read immediately Rectal specimens These are taken if clinically indicated Samples are collected as described above Pharyngeal specimens These are taken routinely in sex workers Samples are collected as described above Ulcer specimens Dry or moist cotton tipped swabs taken from the ulcer base can be tested for HSV PCR Swabs are transported in an empty transport container or in viral culture medium First catch urine Can be performed if no endocervical swabs are available Sample taken as described above 66

Appendix 2

Notification of syphilis, gonorrhoea, chlamydia, donovanosis, HIV, hepatitis B and hepatitis C infection Notification system
In South Australia there is a dual notification system which collects information from both laboratories and medical practitioners.

Medical notification
There is a legal requirement for the attending clinician to notify all cases of syphilis, gonorrhoea, chlamydia, donovanosis, HIV, hepatitis B and hepatitis C infection.

Laboratory notification
There is a legal requirement for laboratories to notify positive laboratory tests for syphilis, gonorrhoea, chlamydia, donovanosis, HIV, hepatitis B and hepatitis C. STD Services is notified of the patients name, doctors name and phone number. The purpose of this system is to monitor medical notification and to contact the attending doctor rapidly when such notification is not forthcoming. The objectives of notification cannot be achieved by laboratory notification alone.

Gonorrhoea case definition

Isolation of typical gram-negative, oxidase positive diplococci (presumptive Neisseria gonorrhoeae) from a clinical specimen or Demonstration of N. gonorrhoeae in a clinical specimen by detection of nucleic acid by two independant assays or Observation of gram-negative intracellular diplococci in a urethral smear obtained from a male 67

Genital chlamydia case definition

Isolation of Chlamydia trachomatis from a genital specimen or Demonstration of Chlamydia trachomatis in a genital specimen by nucleic acid detection methods or Demonstration of Chlamydia trachomatis in a genital specimen by antigen detection methods or Demonstration of Chlamydia trachomatis in a urine specimen by PCR

Donovanosis case definition

Demonstration of intracellular Donovan bodies on smears or biopsy specimens taken from a lesion or Detection of Calymmatobacterium granulomatis by nucleic acid testing of a specimen taken from a lesion and Clinically compatible illness involving a genital ulceration

Hepatitis B case definition

Demonstration of hepatitis B surface antigen in serum

Hepatitis C case definition

Demonstration of anti-HCV antibodies or Demonstration of HCV RNA by PCR

HIV infection case definition

Demonstration of HIV antibodies by EIA or Western blot positive or Detection of HIV 68

Syphilis case definitions

Terminology Syphilis may be congenital (acquired in utero) or acquired (acquired by sexual or other physical contact with an infected individual). Acquired syphilis may be primary (chancre at site of inoculation), secondary (classical features include fever, lymphadenopathy, symmetrical maculo-papular rash, patchy alopecia, condylomata lata), latent (a quiescent stage with no signs of disease) or tertiary (comprising benign, cardiovascular, neurosyphilis). Syphilis may be symptomatic or asymptomatic. Primary and secondary syphilis are symptomatic. Latent syphilis is asymptomatic. Congenital and tertiary syphilis may be symptomatic or asymptomatic. Syphilis may be described as early or late, which are synonymous with infectious and non-infectious, respectively. Although secondary relapses may occur up to 4 years after infection, most occur within the first year of infection and are rare after the second year. Consequently early syphilis is defined as the first 2 years of infection (and includes primary, secondary and early latent infection). NOTE: Congenital syphilis may be transmitted up to 8 years after a woman becomes infected. Tertiary syphilis usually manifests decades after infection, but neurosyphilis may occur much sooner after infection.

Case definitions Congenital syphilis Proven: Requires identification of T. pallidum by dark field microscopy, fluorescent antibody, or other specific stains in specimens from lesions, autopsy material, placenta or umbilical cord. Other indicators (some or all of which might be used for epidemiological purposes): a reactive serological test for syphilis in a stillborn a reactive VDRL test in CSF of the infant 69

 a reactive serological test for syphilis in an infant with any of the following signs: snuffles, condylomata lata, osteitis, periostitis or osteochondritis, ascites, skin and mucous membrane lesions, hepatitis, hepatomegaly, haemolytic anemia, splenomegaly, nephrosis, nephritis fourfold or greater rise in titre of a nontreponemal test (VDRL/RPR) over a 3-month period a reactive treponemal test or non-treponemal test that does not revert to non-reactive within 6 months Primary syphilis A chancre (typically solitary, indurated and painless) plus demonstration of T. pallidum by darkfield microscopy or fluorescent antibody techniques (not valid for oral lesions as commensal spirochaetes may be indistinguishable from T. pallidum) or serological criteria , such as: seroconversion or increasing titre associated with the lesion or a fourfold rise in reagin titre before therapy or fourfold decline or return to seronegativity within three months of treatment. Secondary syphilis Typical lesions of secondary syphilis plus demonstration of T. pallidum in lesions or reagin titre of 1:16 or greater. Early latent syphilis Absence of signs or symptoms plus a positive treponemal test (TPHA/FTA-ABS) plus documented seroconversion within the previous 2 years or a fourfold rise in reagin titre in the absence of treatment or a fourfold decline in reagin titre following treatment (within 6 months). 70

Late latent syphilis Absence of signs or symptoms plus a positive treponemal test plus lack of a fourfold reagin titre change either before or after treatment. NOTE: In the absence of supporting historical information it is rarely possible to distinguish late latent syphilis from adequately treated syphilis.

Asymptomatic neurosyphilis Cerebrospinal fluid findings of a positive VDRL plus A white cell count exceeding 5/mm3 or total protein exceeding 40 mg/100 ml indicates active neurosyphilis. A negative FTA-ABS in the CSF excludes neurosyphilis. There are many cases where neurosyphilis can be neither confirmed nor excluded. NOTE: The foregoing criteria are not valid during secondary syphilis as 30% of such patients have indicators of neurosyphilis but do not have an outcome differing from those lacking the indicators.

Notification of gonorrhoea, syphilis and chlamydia

Purpose of notification is twofold: to enable epidemiologic analysis for control activities, and to facilitate contact tracing. Clinicians indicate on notification forms whether they wish STD Services to undertake contact tracing or whether they would prefer to investigate the case themselves. Notification forms and reply paid envelopes are sent out from STD Services.

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Notification of HIV Infection

Purpose of HIV notification: to enable surveillance of HIV infection in SA to facilitate contact tracing/partner notification; medical officers notifying the infection can either initiate contact tracing and send relevant information to the HIV epidemiologist or, after consultation with the client, request the HIV epidemiologist to investigate the case Notification forms and reply paid envelopes are sent out from STD Services.

Notification of Hepatitis B Infection

Purpose of HBV notification: to define HBV infection (both acute cases and chronic carriers) in South Australia for epidemiologic analysis to follow up individuals with acute infection Notification forms and reply paid envelopes are sent out from STD Services.

Notification of Hepatitis C Infection

Purpose of HCV notification: to define HCV infection in South Australia for epidemiologic analysis to follow up individuals with recently acquired infection and those whose risk factor was not stated Notification forms and reply paid envelopes are sent out from STD Services.

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Appendix 3

Case definition of AIDS-defining illnesses used in Australia and USA

The AIDS case definition in Australia includes a confirmed diagnosis of HIV-1 infection and one or more of the following AIDS-defining illnesses, diagnosed presumptively or definitively according to the criteria listed below. Candidiasis of the bronchi, trachea or lungs Gross inspection by endoscopy or at autopsy or by microscopy (histology or cytology) on a specimen obtained directly from the tissues affected (including scrapings from the mucosal surface) not from a culture. Candidiasis, oesophageal Definitive diagnosis: As for candidiasis of the bronchi, trachea or lungs. Presumptive diagnosis: 1. recent onset of retrosternal pain on swallowing; and 2. oral candidiasis diagnosed by the gross appearance of white patches or plaques on an erythematous base or by the microscopic appearance of fungal mycelial filaments in an uncultured specimen scraped from the oral mucosa. Cervical cancer, invasive Histological evidence of cancer. Coccidiodomycosis, disseminated or extrapulmonary Microscopy (histology or cytology), culture or detection of antigen in a specimen obtained directly from the affected tissues or a fluid from those tissues. 73

 Cryptococcosis, extrapulmonary Microscopy (histology or cytology), culture or detection of antigen in a specimen obtained directly from the affected tissues or a fluid from those tissues. Cryptosporidiosis, of more than one months duration Microscopy (histology or cytology), culture or detection of antigen in a specimen obtained directly from the affected tissues or a fluid from those tissues. Cytomegalovirus disease, other than liver, spleen or nodes Microscopy (histology or cytology), culture or detection of antigen in a specimen obtained directly from the affected tissues or a fluid from those tissues. Cytomegalovirus retinitis, with loss of vision Definitive diagnosis: As for cytomegalovirus disease, other than liver, spleen or lymph nodes. Presumptive diagnosis: A characteristic appearance on serial ophthalmoscopic examinations, for example discrete patches of retinal whitening with distinct borders, spreading in a centrifugal manner along the paths of blood vessels, progressing over several months, and frequently associated with retinal vasculitis, haemorrhage, and necrosis. Resolution of active disease leaves retinal scarring and atrophy with retinal pigment epithelial mottling. Encephalopathy, HIV related Clinical findings of disabling cognitive or motor dysfunction interfering with occupation or activities of daily living, progressing over weeks to months, in the absence of a concurrent illness or condition other than HIV infection that could explain the findings. Methods to rule out such concurrent illness and conditions must include cerebrospinal fluid examination and either brain imaging (computed tomography or magnetic resonance) or autopsy.

74

 Herpes simplex: chronic ulcer(s) of more than one months duration, bronchitis, pneumonitis or oesophagitis Microscopy (histology or cytology), culture or detection of antigen in a specimen obtained directly from the affected tissues or a fluid from those tissues. Histoplasmosis, disseminated or extrapulmonary Microscopy (histology or cytology), culture or detection of antigen in a specimen obtained directly from the affected tissues or a fluid from those tissues. Isosporiasis, chronic intestinal, of more than one months duration Microscopy (histology or cytology), culture or detection of antigen in a specimen obtained directly from the affected tissues or a fluid from those tissues. Kaposis sarcoma Definitive diagnosis: Microscopy (histology or cytology). Presumptive diagnosis: A characteristic gross appearance of an erythematous or violaceous plaque-like lesion on skin or mucous membrane. (Note: A presumptive diagnosis of Kaposis sarcoma should not be made by clinicians who have only seen few cases). Lymphoma, Burkitts Microscopy (histology or cytology). Lymphoma, immunoblastic Microscopy (histology or cytology). Lymphoma, primary, of brain Microscopy (histology or cytology). Mycobacterium tuberculosis, any site, pulmonary or extrapulmonary Definitive diagnosis: Isolation of Mycobacterium tuberculosis, M. bovis or M. africanum from a clinical specimen

75

Presumptive diagnosis: Demonstration of acid-fast bacilli in a clinical specimen or, when a culture is not available, in a histopathological lesion in a person with signs or symptoms compatible with tuberculosis; or evidence of resolution of disease where treatment with two or more antituberculosis medications have been prescribed and follow-up has been instigated. Mycobacterial disease (other or unidentified species), disseminated or extrapulmonary Definitive diagnosis: Culture. Presumptive diagnosis: Microscopy of a specimen from stool or normally sterile body fluids, or tissue from a site other than lungs, skin or cervical or hilar lymph nodes that shows acid-fast bacilli of a species not identified by culture. Pneumocystis carinii pneumonia Definitive diagnosis: Microscopy (histology or culture). Presumptive diagnosis: 1. a history of dyspnoea on exertion or non-productive cough of recent onset (within the past three months); and 2. chest X-ray evidence of diffuse bilateral interstitial infiltrates or evidence by gallium scan of diffuse bilateral pulmonary disease; and 3. arterial blood gas analysis showing arterial pO2 less than 70 mm Hg, or low respiratory diffusing capacity (less than 80 per cent of predicted values), or an increase in the alveolar-arterial oxygen tension gradient; and 4. no evidence of bacterial pneumonia. Pneumonia, recurrent bacterial Definitive diagnosis: Two or more episodes of acute pneumonia occurring within twelve months. Both episodes must have infection with a pathogen that typically causes pneumonia (other than P. carinii or M. tuberculosis) proven by culture or some other organism-specific diagnostic method and new (not present earlier) radiological evidence of pneumonia.

76

Presumptive diagnosis: Two or more episodes occurring within twelve months of acute pneumonia (new symptoms, signs or Xray evidence not present earlier), based on clinical or radiological evidence. Progressive multifocal leukoencephalopathy Microscopy (histology or cytology). Salmonella septicaemia, recurrent Culture-proven infection with Salmonella species. Toxoplasmosis Definitive diagnosis: Microscopy (histology or cytology). Presumptive diagnosis: Toxoplasmosis of the brain, based on observation of: 1. recent onset of a focal neurological abnormality consistent with intracranial disease or a reduced level of consciousness; and 2. evidence by brain imaging (computed tomography or magnetic resonance imaging) of a lesion having a mass effect or the radiographical appearance of which is enhanced by injection of contrast medium; and 3. serum antibody to Toxoplasma or successful response to therapy for toxoplasmosis. Wasting syndrome due to HIV infection 1. profound involuntary weight loss of more than 10 per cent of baseline body weight; and 2. chronic diarrhoea (at least two loose stools per day for thirty days) or chronic weakness and documented fever (for at least thirty days, intermittent or constant) in the absence of a concurrent illness or condition other than HIV infection, such as tuberculosis, cancer, cryptosporidiosis, or other specific enteritis, that could explain the findings.

77

 Bacterial infection affecting a child less than 13 years of age Laboratory diagnosis of multiple or recurrent bacterial infections (any combination of at least two within two years) of the following types: septicaemia, pneumonia, meningitis, bone or joint infection, abscess of an internal organ or body cavity (excluding otitis media or superficial skin or mucosal abscesses) caused by Haemophilus spp., Streptococcus pneumoniae or other pyogenic bacteria. Lymphoid interstitial pneumonia and/or pulmonary lymphoid hyperplasia affecting a child less than 13 years of age Definitive diagnosis: Microscopy (histology or cytology). Presumptive diagnosis: Lymphoid interstitial pneumonia bilateral, reticulonodular, interstitial pulmonary infiltrates present on chest X-ray for two months or more, with no pathogen identified and no response to antibiotic treatment. Other causes of interstitial infiltrates should be excluded, such as tuberculosis, Pneumocystis carinii pneumonia, cytomegalovirus infection and other viral or parasitic infections.

US Centers for Disease Control (CDC) 1993 classification

Category (A) Asymptomatic, primary HIV, PGL (B) Symptomatic, not (A) or (C) (C) AIDS-defining conditions 78

> 500 A1

CD4 Count 200-500 A2

< 200 A3

B1 C1

B2 C2

B3 C3

Publications of STD Services

Bulletin No. 1 Diagnosis and Management of STDs (including HIV infection) First printed May 1988 Revised May 1990 Revised June 1993 Revised August 1996 Revised April 2000 Reducing the Impact of Sexually Transmitted Diseases including HIV Infection First printed 1988 (Revised 1991) STD Training for Doctors and Medical Students Information Systems for STD Control Programmes Clinic 275 Operations Manual The Epidemiology of Chlamydia and Gonorrhoea Service Evaluation and Staff Management in an STD Clinic

Bulletin No. 2

Bulletin No. 3

Bulletin No. 4

Bulletin No. 5 Bulletin No. 6

Bulletin No. 7

Venereologica: facts and figures from an STD clinic From night clinics to the internet. A History of Sexually Transmitted Diseases in South Australia, 1916-1996 Sexually Transmitted Diseases in SA, 1987-2001 79

Epidemiologic Reports
Produced annually from Report No. 1 - 1987 to No. 16 - 2002 as hardcopies and thereafter No. 17 - 2003 to No. 18 - 2004 electronically.

Quarterly Surveillance Reports

Produced quarterly from No. 1 July-September 1997 to No. 35 January-March 2005

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