STIs and HIV Notes

Pelvic Inflammatory Disease and STIs

• Lower abdominal pain can indicate pelvic inflammatory disease, especially if related to the uterus or bloating.
• Rectal infections may require discharge and can lead to sterility due to scarring in the spermatic ducts.

Chlamydia

• Chlamydia can lead to sterility by causing scarring in the spermatic ducts.
• Treatment typically involves a course of antibiotics like doxycycline for seven days or other antibiotics for ten days.
• Patients should refrain from sexual contact during antibiotic treatment due to continued infectiousness.
• If patients are non-compliant with abstinence, advise the use of male latex condoms.
• Multiple STIs can occur simultaneously; Gonorrhea is often found with chlamydia or syphilis.
• Post-treatment, patients should return in three to three months for retesting to ensure eradication and check for re-infection.

Gonorrhea

• Caused by direct sexual contact with Neisseria gonorrhoeae.
• Drug-resistant strains exist, thus necessitating patient education.
• Can infect various body parts, including the pharynx, urethra, prostate, epididymis, and fallopian tubes.
• Infection of spermatic ducts or fallopian tubes can lead to future sterility.
• Disseminated gonorrhea can affect the heart, joints, skin, and meninges; thus, early and aggressive treatment is crucial.
• Treatment usually involves a single injection of ceftriaxone.
• Many women with gonorrhea are asymptomatic; if symptoms occur, they typically appear two to ten days post-exposure.
• Asymptomatic individuals remain highly infectious.
• Erythromycin ophthalmic ointment is administered to newborns to prevent gonorrheal infection during delivery.
• Pregnant women are screened for STIs, including gonorrhea, toward the end of pregnancy.
• Patients should avoid sexual contact until cured; if not, advise latex condoms.

Syphilis

• Caused by the bacteria Treponema pallidum and has been prevalent throughout history.
• Transmitted through sexual contact in stages one and two, and via bloodborne transmission in latency and stage three. Extremely contagious during rash.
• Can cross the placenta, affecting the fetus.

Stages of Syphilis

Stage One

• Characterized by a painless sore (chancre) that starts as a blister and turns into an ulcer at the site of bacterial entry.
• Often goes unnoticed or mistaken for minor skin irritations.

Stage Two

• Involves a rash on the palms and soles, a characteristic symptom of syphilis.

• Painless red ulcer (chancre) that can last one to five weeks and then disappears, after which the infection moves into the bloodstream.

• Occurs one to six months after contact and presents with a rash on the chest, back, palms, and soles.

Latency

• The disease is no longer sexually transmitted.
• Cannot be cured at this stage.
• The individual is asymptomatic, but the bacteria are actively invading organs.

Tertiary Stage

• Occurs around three years after initial contact.
• Symptoms include headaches, arthritis, numbness in extremities, skin and internal organ lesions, heart and aorta damage, and nervous system symptoms.
• Historically, mercury was used as a treatment, evidenced by mercury traces at historical sites like those of the Lewis and Clark expedition.

Genital Herpes

• Herpes type one is often associated with infections above the waist, while herpes type two is typically below the waist, though this distinction isn't absolute.
• Transmitted through contact with lesions.
• A viral infection with no cure; the virus remains inactive for long periods.
• Patients should dry themselves with a hairdryer or gently with a towel to avoid contact with lesions.
• Most patients are asymptomatic.
• The first outbreak is usually the most severe, characterized by small blisters that ulcerate, causing itching and pain.
• Symptoms appear two to twelve days after exposure, with the first outbreak lasting two to three weeks.
• Some individuals experience prodromal symptoms like pain and itching before outbreaks.
• Antiviral drugs (ending in "-vir") can shorten the length and severity of outbreaks if started within one day of the outbreak.
• Episodic therapy: Antiviral drugs used when symptoms appear.
• Chronic suppressive therapy: Daily antiviral drugs to prevent outbreaks in individuals with frequent or severe occurrences.
• Topical anesthetics can be used for pain relief.

Human Papillomavirus (HPV)

• Very common with over 200 strains.
• Includes genital warts, which are associated with high-risk strains linked to cervical cancer.
• Incubation periods can vary significantly.
• HPV hides from the immune system, which may cause warts to disappear and reappear over time, as the immune system recognizes and combats the virus.
• Individuals with HPV should use latex barriers during sexual activity.

HPV Vaccines

• Gardasil: protects against four strains, including types six and eleven (ninety percent of genital warts) and types sixteen and eighteen (seventy percent of cervical cancers).
• Gardasil 9: Protects against all four strains and additional strains.
• Cervarix: Protects against strains sixteen and eighteen only.
• CDC recommends two doses for children between nine and fourteen and three doses for those between fifteen and twenty-six or who are immunocompromised.

Management of Genital Warts

• Screen for cervical cancer if the patient has warts.
• HPV testing can identify the specific strain to guide monitoring and management.
• Warts may resolve spontaneously.
• Treatments include topical medications, surgical removal, cryotherapy, acids, podophyllin resin, or injections.

Human Immunodeficiency Virus (HIV)

• Emerged in the early 1980s, with initial cases showing unusual conditions in young, healthy men, such as Candida infections, herpes, Pneumocystis pneumonia, and Kaposi's sarcoma.
• Screening involves asking patients if they are men who have sex with men, without inquiring about sexual orientation.

HIV Types

• HIV one: predominant worldwide and easily transmissible.
• HIV two: mainly confined to Africa. May spread worldwide in the future.

Statistics

• Approximately 1.2 million diagnosed cases.
• New diagnoses are more common in persons between 25 and 34 years old.
• Ten percent of diagnoses are in people 55 and older.

Transmission

• Male-to-male sexual contact, injection drug use, female-to-mother transmission (including through breast milk), and blood transfusions.

Pathophysiology

• HIV is a retrovirus (RNA virus) that infects macrophages and T helper cells (CD4 cells).
• The virus injects itself into these cells, hijacking their replication processes.
• The immune system can initially keep up with the destruction of CD4 cells, but eventually, it becomes overwhelmed, leading to symptoms.
• HIV integrates itself into the host's DNA, making eradication difficult.

Presence

• Present in blood, semen, vaginal secretions, and breast milk.
• Not present in sweat or tears; very low amounts in saliva are not considered infectious.

Stages of HIV Infection

Primary HIV Infection (Stage One)

• Lasts for a few weeks and may present with flu-like symptoms.
• Diagnosis may be overlooked because symptoms mimic the flu.
• High amount of HIV in the blood.
• Seroconversion occurs as the body produces antibodies and cytotoxic lymphocytes.
• CD4 cell count is normal (500 to 1,500 cells per cubic millimeter).
• Swollen lymph nodes may be present as the infection's only symptom, apart from initial flu-like indications.

Asymptomatic Phase (Stage Two)

• Typically lasts around ten years.
• Generally, no major symptoms but can include swollen lymph nodes and other clinical manifestations.
• Individuals remain infectious, and HIV antibodies are detectable in the blood.
• CD4 cell count is around 500 cells per cubic millimeter or higher.
• Symptoms can include moderate weight loss, recurrent respiratory tract infections, herpes zoster virus infection, angular cheilitis, oral ulcerations, seborrheic dermatitis, and fungal nail infections.

HIV Symptomatic Phase (Stage Three)

• Severe damage to the immune system.
• HIV virus mutates and becomes more pathogenic.