sti

1. Common Sexually Transmitted
Diseases (STDs) and
HIV-Infected Women
October 2007

2. 2
This slide set was developed by members of the Cervical
Cancer Screening Subgroup of the AETC Women's Health
and Wellness Workgroup:
 Laura Armas, MD; Texas/Oklahoma AETC
 Kathy Hendricks, RN, MSN; François-Xavier Bagnoud Center
 Supriya Modey, MBBS, MPH; AETC National Resource Center
 Andrea Norberg, MS, RN; AETC National Resource Center
 Peter Oates, RN, MSN, ACRN, NP-C; François-Xavier Bagnoud Center
 Jamie Steiger, MPH; AETC National Resource Center
Other subgroup members and contributors include:
 Abigail Davis, MS, ANP, WHNP; Mountain Plains AETC
 Lori DeLorenzo, MSN, RN; Organizational Ideas
 Rebecca Fry, MSN, APN; François-Xavier Bagnoud Center
 Pamela Rothpletz-Puglia, EdD, RD; François-Xavier Bagnoud Center
 Jacki Witt, JD, MSN, WHNP; Clinical Training Center for Family Planning
2

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Learning Objectives
1. Identify the five most common STDs affecting
HIV-infected women
2. Discuss clinical presentations associated with
the five common STDs
3. Recall methods for diagnosing the five common
STDs

4. 4
Common STDs in HIV-Infected Women
1. Herpes Simplex Virus (HSV)
2. Syphilis
3. Chlamydia
4. Gonorrhea
5. Trichomoniasis

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Herpes Simplex Virus (HSV)

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HSV: Clinical Presentation
Primary Infection
 Prodrome phase:
Tingling/itching of skin
 Appearance of painful
vesicles in clusters on an
erythematous base
 Vesicles ulcerate then
crust over and heal
within 7-14 days
 Viral shedding continues
for up to 2-3 weeks
Recurrent Disease
 After primary infection,
virus migrates to sacral
ganglion and lies
dormant
 Reactivation occurs
due to various triggers
 Reoccurrence is usually
milder and shorter in
duration

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Herpes Simplex in Women with AIDS
Credit: Jean R. Anderson, MD

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HSV: Diagnosis
 Clinical presentation
 Viral culture
 Tzanck smear/Giemsa smear
 Skin biopsy

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HSV: Treatment Considerations
 Antivirals
 Lesions may be bathed in mild soap and water
 Sitz baths may provide some relief
 Sex partners may benefit from evaluation and
counseling
 Transmission is possible when lesions not present
due to viral shedding

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Syphilis

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Syphilis: Clinical Presentation
Primary / Infectious / Early Syphilis Stage:
Primary Phase
 Primary chancre
 Begins as papule and erodes into painless ulcer with
a hard edge and clean base
 Usually in the genital area
 Appears 9-90 days after exposure
 Can be solitary or multiple (eg. kissing lesions)
 Heals with scarring in 3-6 weeks and 75% of patients
show no further symptoms

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Primary Chancre
Primary
Chancre
Credit: Centers for Disease Control and Prevention (CDC)

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Syphilis: Clinical Presentation (continued)
Primary / Infectious / Early Syphilis Stage:
Secondary Phase
 Occurs 6 weeks – 6 months after chancre
 Lasts several weeks
 Accompanied with fever, malaise, generalized
lymphadenopathy, and patchy alopecia
 Maculo-papular rash usually on palms and soles
 Condyloma lata on perianal or vulval areas
 Possible mild hepatosplenomegaly

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Syphilitic Rash
Credit: Dr. Gavin Hart and CDC
Credit: Connie Celum and Walter Stamn
and Seattle STD/HIV Prevention Training Center

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Condyloma lata
Credit: CDC
Condyloma
lata

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Syphilis: Clinical Presentation (continued)
Secondary / Latent Stage:
 Positive serology
 Rapid Plasma Reagin (RPR)
 Venereal Disease Research Lab (VDRL)
 Patients are asymptomatic and not infectious
after first year, but may relapse
 One-third will convert to sero-negative status
 One-third will stay sero-positive but asymptomatic
 One-third will develop tertiary syphilis

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Syphilis: Clinical Presentation (continued)
Tertiary Stage:
 Cardiovascular: Aortic valve disease, aneurysms
 Neurological: Meningitis, encephalitis, tabes
dorsalis, dementia
 Gumma formation: Deep cutaneous
granulomatous pockets
 Orthopedic: Charcot’s joints, osteomyelitis
 Renal: Membranous Glomerulonephritis

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Syphilis: Diagnosis
Requires demonstration of:
 Organisms on microscopy using dark field
 Positive serology on blood or cerebrospinal
fluid (CSF)
Non-Specific Treponemal Tests:
1. Venereal Disease Research Laboratory
(VDRL)
2. Rapid Plasma Reagin (RPR)

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Syphilis: Diagnosis (continued)
 Positive serology on blood or CSF
 Specific Treponemal Test:
1. Fluorescent Treponemal Antibody Absorption
(FTA-ABS)
2. Microhemagglutination-Treponema pallidum (MHA-TP)
 Organism may not be cultured but diagnosis cannot
be determined by clinical findings only

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Syphilis: Treatment Considerations
 Primary/ secondary/ latent stage: Benzathine
penicillin
 Neurosyphilis: Penicillin G
 Ask about penicillin allergy before treatment
 Jarisch-Herxheimer reaction may occur

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Chlamydia

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Chlamydia: Clinical Presentation
 Mucopurulent cervicitis/vaginal discharge
 Dysuria
 Lower abdominal pain
 Urethritis, salpingitis, and proctitis
 Post coital bleeding – friable cervix
Key Considerations:
 50% of females are asymptomatic
 Sterile pyuria with urinary tract symptoms should
trigger you to think chlamydia

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Cervicitis
Credit: University of Washington and
Seattle STD/HIV Prevention Training Center

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Chlamydia: Diagnosis
 Chlamydia culture
 New tests include:
 Direct immunofluorescence assays (DFA)
 Enzyme immunoassay (EIA)

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Chlamydia: Treatment Considerations
 Antibiotics
 Azithromycin
 Evaluate and treat sexual partners
 Avoid sex for seven days after completion of
treatment

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Gonorrhea

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N. gonorrhoeae-gram negative
diplococci
Diplococci
Credit: Negusse Ocbamichael and Seattle STD/HIV Prevention Training Center

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Gonorrhea: Clinical Presentation
Areas of Infection
 Urethra
 Endocervix
 Upper genital tract
 Pharynx
 Rectum
Signs and Symptoms
 Frequently asymptomatic
 Vaginal discharge
 Abnormal uterine bleeding
 Dysuria
 Mucopurulent cervicitis
 Lower abdominal pain

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Gonorrhea: Diagnosis
 Clinical exam
 Cervical culture
 Polymerase chain reaction (PCR) or ligase
chain reaction (LCR)
 Gram stain–polymorphonucleocytes with
gram negative intracellular diplococci

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Gonococcal Isolate Surveillance Project (GISP) — Percent
of Neisseria gonorrhoeae isolates with resistance or
intermediate resistance to ciprofloxacin, 1990–2005
Percent
Resistant
Intermediate resistance
0.0
3.0
6.0
9.0
12.0
1990 91 92 93 94 95 96 97 98 99 2000 01 02 03 04 05

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Gonorrhea: Treatment Considerations
 Intramuscular Ceftriaxone
 For pregnant women only:
 Ceftriaxone single dose but substitute Quinolones
with Erythromycin
 Do not treat with Quinolones or Tetracyclines
 Evaluate and treat all sexual partners

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Trichomoniasis

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Trichomoniasis: Clinical Presentation
Signs and symptoms:
 Vulvar irritation
 Dysuria
 Dyspareunia
 Pale yellow, malodorous - gray/green frothy
discharge
 Strawberry cervix, inflamed and friable

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Strawberry Cervix
Credit: Claire E. Stevens and Seattle STD/HIV Prevention Training Center

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 Flagellated, motile trichomonads on wet mount
 Vaginal pH > 4.5
 Diagnosis confirmed by microscopy
 Other FDA approved tests:
 OSOM Trichomonas Rapid Test
 Affirm VP III
Trichomoniasis: Diagnosis

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Trichomoniasis: Treatment Considerations
 For HIV-infected women: same treatment as
non-HIV infected women
 Metronidazole or Tinidazole
 Sex partners have to be treated

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Providing Culturally Competent Care
The following factors can influence a woman’s
understanding of STDs and need for screening:
 Language and literacy level
 Cultural and social background and its impact on her
understanding of health, illness, and the female anatomy
 Comfort with discussing sexual health issues
 Comfort and previous experience with STD screening or
testing
 History of sexual abuse and/or domestic violence may
cause anxiety and exam refusal

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Pearls of Wisdom
 Get comfortable with obtaining a thorough sexual
history
 Check oral cavity if genital STD suspected
 Minimum of annual screening for STDs is
recommended, with more frequent screening if
high risk behaviors are reported
 Partner notification and risk reduction
counseling for both patient and partner is an
important part of treatment and follow-up.

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Conclusion
 STD screening and treatment should be a
primary intervention and a standard of care in
all health care settings.
 Women infected with STDs have increased
chances of contracting HIV.
 Studies show STD and HIV co-infection
increases HIV virus shedding in the patients’
genital secretions.
 If co-infection is present, proper diagnosis and
treatment of STDs will decrease the chances
of transmitting HIV.

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Helpful Resources
 AETC National Resource Center (NRC), www.aidsetc.org
 Clinical Manual for Management of the HIV-Infected Adult
 AIDSMAP,http://www.aidsmap.com
 Centers for Disease Control and Prevention,
http://www.cdc.gov/std
 STD Treatment guidelines 2006
 HIV / AIDS and STDs
 Health Resources and Services Administration HIV/AIDS
Bureau, http://hab.hrsa.gov/
 A Guide to the Clinical Care of Women with HIV/AIDS
 HIVInsite, http://hivinsite.ucsf.edu
 Transgender Awareness Training & Advocacy
http://www.tgtrain.org/

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References
Anderson, J.R, ed. (2005). A Guide to the Clinical Care of Women with HIV.
Health Resources and Services Administration HIV/AIDS Bureau.
Centers for Disease Control and Prevention. Sexually Transmitted Diseases
Treatment Guidelines 2006. MMWR, Aug 4, 2006, 55.
Centers for Disease Control and Prevention. Sexually Transmitted Diseases
Treatment Guidelines 2006. MMWR, April 13, 2007, 56
Centers for Disease Control and Prevention. The Role of STD Detection and
Treatment in HIV Prevention. Retrieved on September 16, 2007 from
http://www.cdc.gov/std/hiv/STDFact-STD&HIV.htm#WhatIs
Health Resources and Services Administation, HIV/AIDS Bureau, AETC
National Resource Center. (2006). Guiding Principles for Cultural
Competency. Retrieved on September 20, 2007 from
http://www.aidsetc.org/doc/workgroups/cc-principles.doc
US Preventive Services Task Force. Screening for gonorrhea:
recommendation Statement. Ann Fam Med 2005;3:263-7.