National AIDS Programme

Department of Public Health

Ministry of Health and Sports, Myanmar

Sexually
Transmitted
Infection
Management Guideline

2017
Contents
PREFACE 1
BACKGROUND 3
1. INTRODUCTION 5
1.1 ESSENTIAL COMPONENTS OF MANAGEMENT OF STI PATIENTS 8
1.2 ESSENTIAL COMPONENTS OF SYNDROMIC MANAGEMENT 8
1.3 SYNDROMIC DIAGNOSIS AND TREATMENT 8
1.4 EDUCATION ON RISK REDUCTION AND CONDOM PROVISION 10
1.5 COUNSELLING, PARTNER NOTIFICATION AND FOLLOW-UP 10
1.6 HIV TESTING 10

2. PRACTICAL CONSIDERATIONS IN CASE MANAGEMENT 11

2.1 HISTORY TAKING 11
2.1.1 History of presenting symptom/s and sign/s 12
2.1.2 Medical, obstetric and menstrual history 12
2.1.3 Behavioural risk assessment 13
2.1.4 Sexual history 14
2.1.5 Clinical examination 14
2.1.6 Laboratory investigation, if available and indicated 14
2.2 DIAGNOSIS 15
2.3 COUNSELLING AND EDUCATION 15
2.4 CLINICAL FOLLOW UP 16
2.5 IDENTIFICATION, NOTIFICATION AND EVALUATION 17
OF SEXUAL PARTNER(S)
2.6 OFFICIAL REPORTING OF THE CASE 17

3. TREATMENT OF SPECIFIC INFECTIONS 19

3.1 GONOCOCCAL INFECTIONS 19
3.1.1 Uncomplicated Gonococcal Infection 19
It is important to note that dual therapy for gonorrhoea is 20
recommended to reduce the likelihood of developing resistance,
in addition to providing treatment for Chlamydial infection.
3.1.2 For Treatment Failure 20
3.1.3 Treatment in Pregnancy 21
3.1.4 Gonococcal Infection of the Pharynx 21
3.1.5 Disseminated Gonococcal Infection (DGI) 22
3.1.6 Gonococcal Infections in Infants 23
 3.2 CHLAMYDIAL INFECTIONS 25
3.3 SYPHILIS 28
3.3.1 Latent Syphilis 32
3.3.2 Tertiary (Late) Syphilis 33
3.3.3 Neurosyphilis 33
3.3.4 HIV Infected Persons with Syphilis 34
3.3.5 Syphilis during Pregnancy 34
3.3.6 Congenital Syphilis 36
3.4 CHANCROID 39
3.5 LYMPHOGRANULOMA VENEREUM (LGV) 40
3.6 GRANULOMA INGUINALE (DONOVANOSIS) 41
3.7 GENITAL HERPES SIMPLEX Type 2 42
3.8 HUMAN PAPILLOMAVIRUS INFECTION (HPV) 45
3.9 TRICHOMONIASIS 48
3.10 BACTERIAL VAGINOSIS (BV) 49
3.11 VULVO-VAGINAL CANDIDIASIS (VVC) 50
3.12 ECTOPARASITIC INFECTIONS 51
Pediculosis 51
Scabies 52
3.13 HEPATITIS B (HBV) 53

4. SYNDROMIC MANAGEMENT 55
4.1 GENITAL DISCHARGE 55
4.1.1 Urethral Discharge 55
4.1.2 Abnormal Vaginal Discharge 59
4.1.3 Anorectal Discharge 65
4.2 GENITAL ULCERATIVE DISEASES 66
4.2.1 Ano-rectal Ulcer 70
4.3 INGUINAL BUBO 71
4.4 SWELLING OF THE SCROTUM 72
4.5 PELVIC INFLAMMATORY DISEASE (PID) 75
4.6 NEONATAL CONJUNCTIVITIS 79
4.7 SYPHILIS TESTING FLOW CHARTS 79

REFERENCES: 82
 Sexually Transmitted Infection Management Guideline 2017

PREFACE

Sexually Transmitted Infection (STI) is common infections in many countries.

Nowadays, the STI infections are managed syndromically in most low
and middle-income countries. In Myanmar, syphilis and other STIs remain
prevalent. There is a need to update current STI guidelines based on the
current STI situation in Myanmar as well as adapting new evidence-based
international guidelines based on the current context. These guidelines aim
to increase coverage of STI services in Myanmar.

STIs remain prevalent and continue to present a major burden of morbidity

and mortality throughout the world, both directly, through their impact on
quality of life, reproductive health, and child health, and indirectly, through
their role in facilitating sexual transmission of HIV infection and their impact
on national and individual economies. The STIs are major causes of adverse
pregnancy outcomes. There are up to 35% of pregnancies among women
with untreated gonococcal infection. In the absence of prophylaxis, 30 – 50%
of infants born to mothers with untreated chlamydia or gonorrhoea develop
opthalmia neonatorum which can lead to blindness. Syphilis can lead to fetal
and neonate deaths due to stillbirths and congenital syphilis. Gonorrhoea
and chlamydial infection remains to be an important cause of infertility. In
addition the physical, psychological and social consequence of STIs severely
compromise people’s quality of life.

STIs are closely link to HIV. STI patients have an increased risk of transmitting
and acquiring HIV. It is estimated that STIs increases the risk of HIV by 2 to 9
fold in some population. In Myanmar, early and effective treatment of STIs is
one of the important strategies of National AIDS Programme.

Under Goal 3 of Sustainable Development Goals, there are an ambitious set

of health related goals including to reduce the global maternal mortality,
to end the epidemics communicable diseases including of AIDS and to
ensure universal access to sexual and reproductive health-care services by
2030. Appropriate management of STIs contribute to attaining this goal.
Moreover, adequate control of STIs will contribute the reducing disease and
human sufferings.
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Sexually Transmitted Infection Management Guideline 2017

STIs account of the ten most important causes for seeking health care services
among adults. In the South East Asia region, there are increased problems
of STI drug resistance and increased spread of infection due to large pool of
sexually active population, high population mobility, changing epidemiology
of STI, inadequate coverage of preventive interventions, poor treatment
seeking behaviours and changes of trend of health seeking behaviours that
most patients seek STI services in private sector. Inadequate screening and
case management of STI, unavailability of STI drugs, low quality of drugs,
and inappropriate use of antibiotic and limited laboratory facilities to make
appropriate diagnosis are factors in the development STI drug resistance
especially in Neisseria gonorrhoea.

The Syndromic Case Management is the cornerstone of STI management

as well as essential for STI surveillance. Syndromic management remains
to be the main approach in primary health care setting in both public and
private sector. It also facilitates standardization in the delivery of STI services
including procurement and capacity building.

For the future directions, the National AIDS/STD Control programme,

Myanmar will strengthen Gonococcal Antimicrobial Surveillance System to
inform the national treatment guidelines for low resource setting. We will
continue to strengthen integration with the Global AMR initiative for AMR
surveillance to ensure appropriate use of drugs. Myanmar will also strengthen
laboratory support for etiologic diagnosis of STI. In the meantime, this
guidelines focus on syndromic cases management in the context of limited
availability of laboratory diagnosis.

Finally, National AIDS/STD Control Programme would like to thank to Ministry

of Health and Sports for permitting to conduct the workshop for development
of updated STI Guideline in line with global updates on STI management.
We would like to express our sincere thanks to Assistant Directors, Regional
HIV Officers from State and Regions, other departments and units of Ministry
of Health, UN Organizations, International NGOs, National NGOs and WHO
colleagues for development and updates of our latest guidelines.

Programme Manager
National AIDS Programme
Department of Public Health
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 Sexually Transmitted Infection Management Guideline 2017

BACKGROUND

The National Guideline for management of Sexually Transmitted Infections

(STI) in Myanmar was last updated in 2007. It was first developed in
collaboration with UNICEF in 1994 and consequently the review and revised
workshop for this guideline was done in 2004 in collaboration with WHO
and all partners providing STIs services. The National AIDS Programme
(NAP) further updated, developed and distributed manuals for syndromic
management (2007) both in English and Myanmar. The STI Prevention &
Control Programme started in Myanmar under DOH (department of health)
in 1951 , initially with (7) AIDS/STI Teams and by 2009, expanded up to
(47) Teams. These teams played a pivotal role in implementing AIDS/STI
Prevention & Control activities in Myanmar. They are strategically located
throughout the country. Currently STI teams rely on syndromic management
rather than etiological diagnosis due to limited laboratory capacity. It will
be essential to increase laboratory capacity to provide a minimum service
package with STI laboratory, supported from regional reference laboratory/
ies.

NAP with support of WHO has been leading the coordination role for future
STI programme in Myanmar. Apart from AIDS/STI Prevention & Control
Programme under DoPH, there are NGOs namely AMI, AHRN, Alliance,
AZG, CARE, AFXB, Malteser, MAM, MANA, MDM, MSF-CH, MSI, PGK, PSI
providing STI services. Global and regional guidelines for STI management
have evolved over this period and there is increasing concern over
antimicrobial resistance.

As STIs are known to increase the risk of HIV transmission and are associated
with significant morbidity, updating the National Guideline of STI based
on evidence-based recommendations from global WHO guidelines is an
important activity of the National Strategic Plan for HIV/AIDS. A technical
consultation of key staff of the STI Control Programme in Myanmar, National
Health Laboratory and partners working on STI prevention and case
management was organized in Nay Pyi Taw from 28th to 30th May 2014 to
update the guidelines taking into considerations the experiences of STI service

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Sexually Transmitted Infection Management Guideline 2017

provision, challenges and barriers faced. This national guideline is updated

based on discussions and recommendations made during the consultation.
The national experts considered the health-care settings especially at the
primary health care level, availability of the drugs, convenience of the drug
regimen, effectiveness, compliance of the patient, cost, side effects and drug
interactions in developing the National STI Treatment Guidelines

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 Sexually Transmitted Infection Management Guideline 2017

1. INTRODUCTION

Sexually Transmitted Infections (STIs), previously known as Venereal

Disease(s) are caused by a wide range of organisms including bacteria,
viruses, protozoa, and ectoparasites. They are capable of causing local
and/or systemic manifestations. Their portals of entry and common sites
of infection are the skin and mucous membranes of the genitalia, and the
mucosal linings of the urethra, cervix, vagina, rectum and oro-pharynx.

Systemic diseases like HIV infection, hepatitis B, cytomegalovirus infection,

syphilis and gonorrhoea can disseminate through the blood stream. Thus,
all body fluids, tissues and any discharge, secretions, mucous or other fluid,
produced by or passing over an infected area, can be the portal of infection
to other persons.

Because of reported antibiotic resistance found to some drugs used for STI
case management, there is revision of guidelines based on the consensus of
participants from the brainstorming workshop in Nay Pyi Taw in May 2014.

Over 20 pathogens can be spread by sexual transmission causing serious

complications resulting in chronic ill health, infertility, disability and death as
shown in Table 1.

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Sexually Transmitted Infection Management Guideline 2017

Table 1: Sexually Transmitted Pathogens

Bacteria Viruses Other

Neisseria gonorrhoea; Human Trichomonas
Chlamydia trachomatis; immunodeficiency vaginalis ;
viruses (HIV-1 and 2); Phthirus pubis ;
Treponema pallidum;
Calymmatobacterium Human T lymphotropic Candida albicans ;
granulomatis; virus type I (HTLV-1);
Sarcoptes scabiei ;
Ureaplasma urealyticum; Herpes simplex virus
type 2 (HSV-2); Giardia lamblia;
Mycoplasma hominis; Entamoeba
Human papillomavirus
Gardnerella vaginalis and (multiple types); histolytica;
other vaginal bacteria;
Hepatitis B virus;
Group B streptococcus;
Cytomegalovirus;
Shigella spp.;
Molluscum contagiosum
Campylobacter spp.; virus
Human T lymphotrophic
virus type II (HTLV-II);
Hepatitis C virus;
Herpes simplex virus
type 1 (HSV-1);
Human herpes virus
type 8;
(Kaposi's sarcoma-
associated)
Epstein-Barr virus (EBV);
Hepatitis A virus;

The link between STIs and HIV/AIDS is well established. The role of genital
ulcerative diseases and genital inflammatory lesions as biological co-factors
for enhancing HIV transmission is important to remember in the management
of STIs. In addition, HIV alters the natural history of some STIs. For instance,
HIV has also been isolated from the genital tract and from the exudates of
genital ulcers in both males and females. The shedding of HIV in genital
fluids is increased by inflammatory responses and exudates from lesions,
making them more infective. Thus, treating STIs have shown to reduce the
proportion of HIV shedding in genital secretion.

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 Sexually Transmitted Infection Management Guideline 2017

The syndromic approach recommended by WHO aims to provide STI

services at first point of contact at all providers of health care services
especially those at the grass-root level where the patient is needed. Here,
the health-care provider needs not be an expert in the field of STIs, and with
limited resources, and in the absence of laboratory support, should be able
to deliver services to the patients with the expected outcome of

(a) a microbiologic cure

(b) alleviation of clinical manifestations
(c) prevention of serious complications and sequelae, both immediate
and remote,
(d) prevention of transmission to other persons

The National STI Treatment Guidelines into considerations the health-

care settings especially at the primary health care level, availability of the
drugs mentioned, and convenience of the drug regimen, effectiveness, and
compliance of the patient, cost, side effects and drug interactions in making
these considerations.

WHY IS SYNDROMIC MANAGEMENT IMPORTANT?

A fundamental goal of the STI control programmes is early detection and
treatment of the disease, preferably at the point of the patient's first contact
with the health system. In developing countries, the laboratory diagnosis of
most conditions can be difficult, and even in settings with access to reliable
laboratory facilities, there are delays in releasing of laboratory results causing
delays in initiating treatment. Moreover, delays in treatment result in loss of
follow-up of a significant proportion of clients and in continued transmission
of the infection. Majority of STI patients in almost all countries seek care in
private facilities (private physicians, clinics, or pharmacies) and primary health
care settings than in specialized STI clinics. It is therefore essential that, an
effective and efficient public health approach is implemented. Syndromic
approach is rapid, simple, accurate, and can be implemented on a large
scale by health providers with diverse levels of expertise and training.

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Sexually Transmitted Infection Management Guideline 2017

1.1. ESSENTIAL COMPONENTS OF MANAGEMENT OF STI

PATIENTS
The components of comprehensive case management of patients with STIs
include:

• Making a correct diagnosis by syndromic approach or with laboratory

support
• Providing early and effective treatment and follow up
• Offering/referring for HIV counselling and testing as well as linkage
for treatment and care
• Reducing/preventing future risk through education and counselling
• Promoting and providing condoms and,
• Ensuring that sexual partners are notified and treated

1.2. ESSENTIAL COMPONENTS OF SYNDROMIC MANAGE

MENT
These include diagnosis and treatment based on syndromes, education
on risk reduction, condom provision, counselling and HIV testing, partner
notification and follow up as described below:

Syndromic case management (SCM) is based on the identification of

syndromes (which consists of symptoms and easily recognized signs) and
treatment. Under the simplified syndromic-based approach developed and
promoted by WHO and currently being used, diagnosis is based on the
identification of consistent groups to symptoms and easily recognized signs
(syndromes). Treatment for each syndrome is directed towards the most
common organisms responsible for the syndrome. A great majority of STIs
present as urethral discharge/dysuria, genital ulcer/s, vaginal discharge and
lower abdominal pain. When a patient comes with such a complaint, a case-
management decision is made using the Flow-Chart.

1.3. SYNDROMIC DIAGNOSIS AND TREATMENT

The current methods of laboratory diagnosis of STI are often time consuming,
unreliable, expensive, require sophisticated equipment and training. In
addition, patients are required to return on or two days later for certain tests.
This is not feasible in many settings, where patients must travel long distances

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 Sexually Transmitted Infection Management Guideline 2017

to receive health care. Even if they return, the probability of developing

complications is increased and the period of infectivity is prolonged by this
delay in therapy. Few health institutions in developing countries have the
laboratory facilities required for accurate etiological diagnosis.

Under the simplified syndromic-based approach developed and promoted

by WHO and currently being used in a large number of countries in the
developing world, diagnosis is based on the identification of consistent
groups to symptoms and easily recognized signs (syndromes) and the
provision of effective treatment that will deal with the majority of organisms
responsible for producing each syndrome. A great majority of STI fall under
the categories of genital ulcer, vaginal discharge and urethral discharge.
When a patient comes with such a complaint, a case-management decision
is made using the Flow-Chart.

Syndromic case management performs well with urethral discharge and

genital ulcer disease. However, because cervical infections and ano-
genital infections are commonly asymptomatic, the performance of vaginal
discharge and ano-rectal discharge syndromic approach is less than ideal.
There is a need for simple and affordable laboratory diagnosis. As point-of-
care laboratory testing becomes available for gonorrhoea and chlamydial
infections, the issue of asymptomatic cervical infection and ano-genital
infection could be address in the future.

However, it is important to note that syndromic management does not

address asymptomatic and/or sub-clinical infections. This is more often
seen in women. Cervical infections in particular are mostly asymptomatic.
Therefore, where facilities are available screening both men and women
who are most at risk for STIs are recommended. If laboratory facilities are
available, appropriate tests could assist the healthcare provider to arrive
at an etiological diagnosis. In such places all persons attending STI clinics
should be screened for syphilis and offered counselling and testing for HIV.

Appropriate treatment of patients with STI is important to prevent the

development of complications and sequelae and reduce the spread of
infection. Wherever possible, single dose oral treatment is recommended
as it ensures compliance. When prescribing multi-dose treatment, it is
important to educate the patient on taking the full course of prescribed

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Sexually Transmitted Infection Management Guideline 2017

drugs for treatment to be effective. Countries should establish and use

national standardized treatment protocols for STIs to ensure that all patients
receive adequate treatment at all levels of healthcare services. Treatment
protocols are the same for both syndromic case management and etiologic
management.

1.4. EDUCATION ON RISK REDUCTION AND CONDOM

PROVISION
In every instance, the contact of STI patients with the health facility should
be utilized to promote safer sexual behaviour and to educate patients on
how to minimize or eliminate the risk of acquiring or transmitting STI/AIDS
to others. They should be taught how to use condoms correctly. Condoms
must be made available in all health facilities treating patients with sexually
transmitted diseases, either free of charge or at an affordable price.

1.5. COUNSELLING, PARTNER NOTIFICATION AND

FOLLOW-UP
Each patient should be properly counselled on a one-to-one basis about
his/her risk behaviour, chances of acquiring STI/AIDS, and the process of
safer sexual behaviour. The counselling services should be provided in a
confidential manner. If counselling services cannot be undertaken during
the routine outpatient sessions, it is necessary to schedule separate time
(appointment) to provide this service. The patient should be encouraged to
inform his/her partners of their possible infection and the need to refer them
for evaluation and treatment.

1.6. HIV TESTING

Every STI patient should be offered or referred for counselling and HIV
testing. During counselling, patients risk for HIV should be assessed.

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 Sexually Transmitted Infection Management Guideline 2017

2. PRACTICAL CONSIDERATIONS IN
CASE MANAGEMENT

Routine STI care should be delivered through general health services. For
individuals requesting health services for evaluation of STI, appropriate care
consists of the following components.

2.1. HISTORY TAKING

Patients with problems relating to the genital area tend to be guarded and
evasive in giving a history. With practice, the practitioner will be able to
obtain a satisfactory history, in the short time available, in a busy outpatient
clinic.
• Adopt a polite, friendly and non-judgmental attitude that would
encourage the client to develop confidence and trust in you.
• Ask an open-ended question, such as "what brought you to the
hospital?" to initiate a dialogue but thereafter ask brief, precise
questions which call for a brief response, mostly of the "yes" or "no"
type to save time.
• In order to make an accurate diagnosis it may be necessary to ask
more questions during examination of even after, giving the patient
privacy.
• Do not show annoyance if the patient's history has obvious
discrepancies or keeps changing.
• Phrase your questions in such a way so as to minimize the opportunity
for the patient to mislead you. For example, "when did you last
have sex with someone?" is preferable to "did you have sex with
someone?"
• History of partner’s STI symptom and treatment taken should be
inquired though they will not be obtained in every case because
partner sometime hides about taking STI treatment.
• In some instances, the occupation of the partners can provide indirect
indication of engaging in high risk behaviour.
• Reassure the patient, that all information will be kept confidential,
and that they may wish not disclose anything and will not affect the
services provide to them.
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Sexually Transmitted Infection Management Guideline 2017

2.1.1 History of presenting symptom/s and sign/s

Obtain a detail history about the presenting symptom/s. Inquire about

common symptoms like discharge from the urethra in a patient with genital
ulcers, or recurring genital ulcers in a patient presenting with urethral
discharge. If laboratory facilities permit, consider serological tests for syphilis
(VDRL/RPR together with TPHA; if the patient is low risk, without history of
syphilis, TPHA alone might be enough). Inquire about previous treatments as
it may indicate whether the patient has already had suboptimal medication.
It is also necessary to assess the risk of drug allergies and drug interactions.
If the patient is to receive proper education and counselling, these must be
preceded by behavioural risk assessment. Make sure that the patient feels
that all the history will be kept strictly confidential.

Box 1 – Symptoms of STI

Females Males
Dysuria, frequency, Dysuria, frequency
Vaginal discharge Urethral discharge
Genital ulceration Genital ulceration
Abnormal growth or mass in genital Abnormal growth or mass in genital
area area
Lower abdominal pain Acute scrotal swelling, pain
Inguinal lymphadenopathy Inguinal lymphadenopathy
Vulval itching Perianal pain
Dyspareunia Anal discharge
Perianal pain
Anal discharge

2.1.2 Medical, obstetric and menstrual history

History of other illnesses, medication (current and past) and allergies to

medication should be noted.

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 Sexually Transmitted Infection Management Guideline 2017

Box 2 – Medical, obstetric and menstrual history

Medical history Menstrual history Obstetric history

Date of last menstrual period Number of pregnancies and
Other illness Regular / irregular periods outcome
Missed or overdue period
Medications Pain during periods Mode of delivery
Drug allergies Excessive bleeding Contraception
Post coital bleeding

2.1.3 Behavioural risk assessment

If the patient is to receive proper education and counselling, these must

be preceded by behaviour risk assessment. Make sure that the patient is
aware that the history will be kept strictly confidential. Inquire regarding
the following:

Risk factors
(i) Marital status:
• Married, living together, single, separated, widowed
(ii) Occupation:
• Sex worker (male and female), seamen, workers in the tourist
industry, transport workers, migrant workers, etc.
(iii) History of travel:
• Travel abroad (holidays, business or employment)
• Coming home only on weekends
(iv) Unprotected casual sexual encounters (other than with regular
partner)
(v) Previous history of STI
(vi) Injections or blood transfusions
(vii) Substance abuse: alcohol, drugs (e.g., heroin)
(viii) Tattooing
(ix) Partner with symptoms suggestive of STIs; h/o partner’s confirmed
STI symptom and treatment taken h/o
(x) Multiple sexual partners

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Sexually Transmitted Infection Management Guideline 2017

Moreover, partner’s occupation (taxi driver, high way driver, migrant worker,
waiter, trishaw driver, uniform service etc.…) should be asked for possibility
indication of higher risk of acquiring an STI.

2.1.4 Sexual history

Sexual history must be taken from all patients before examining them and
managing their sexual health problems. All individuals should be asked
about the:

• Sex of the partner

• Type of exposure (oral, vaginal, anal)
• Use of condoms with any type of sex/partner
• Relationship to partner/s (spouse, regular non-spouse, casual)
• Problems or symptoms in the partner/s
• Date of last sexual intercourse
• Number of partners in the last three months

2.1.5 Clinical examination

This is an important step that will help health care providers to arrive at a
probable diagnosis and prevent making an incorrect diagnosis based on the
patient's history alone. Privacy and confidentiality should be ensured. Genital
examination includes a bimanual and speculum examination of the genital
tract for all female patients and rectal examination (including proctoscopy,
if indicated and available) for patients (male & female) practicing receptive
anal sex. In addition to genital examination, an adequate and appropriate
general examination is also required.

2.1.6 Laboratory investigation, if available and indicated

The syndromic management of STI is based on the presumption that

laboratory facilities are not available. Do not delay or withhold treatment
because the laboratory investigations are incomplete or the results of tests
are not available. If available, clients engaging in high-risk activities should
be offered the VDRL test and the test for HIV accompanied by pre-test and
post-test counselling. Treatment failures should be re-evaluated for possible
re-infection and then referred to a facility providing adequate laboratory
support.

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 Sexually Transmitted Infection Management Guideline 2017

2.2. DIAGNOSIS
On the basis of the history, clinical examination, and laboratory investigations
(if available) that have been carried out,

• use the appropriate Flow-Chart for managing patients

• Be particularly careful when confronted with low abdominal pain and
scrotal swelling
• Make certain that you are not dealing with a surgical emergency.

Early and Effective Treatment

Treat the patient using Flow-Charts and national treatment guidelines. While
in most instances, treatment will be curative, with viral STI only palliative
therapy is possible. Genital herpes is a good example where the therapy
is only palliative. This fact must be properly explained to the patient and
counselling provided, if needed.

2.3. COUNSELLING AND EDUCATION

Regarding the present episode of STI:
Educate the patient regarding his/her present STI, and how it was acquired.
In conditions like recurrent genital herpes and recurrent vulvo-vaginitis,
counselling is greatly needed, as the patients are usually very distressed.
Patients should also be informed of the importance of taking the right
dosage and duration of the medications prescribed.

Regarding the prevention of STI and HIV:

Explain to the patient the association between STI and HIV and that it is
the same risk behaviour that is responsible for acquisition of these two
conditions. Educate the patient on methods of risk reduction through safer
sex including abstinence.

Regarding condom use:

Discuss the use of condoms for risk reduction. It is recommended to provide
free condoms if feasible. It is necessary to demonstrate the correct way of
wearing a condom. Desensitize the patient about condoms, especially if
he is a regular risk-taker who should be a consistent condom user. Provide
condoms if possible.

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Sexually Transmitted Infection Management Guideline 2017

Counselling for STI:

Issues that should be addressed in a counselling session include:

• informing the partner(s) or spouse about the STI diagnosis (options:

either the patient or the health care provider informs the partner(s) or
spouse)
• assessing the patient’s risk for HIV and assisting patient’s decision on
HIV testing
• learning about, and coming to terms with, worrisome complications
of STIs, such as infertility and congenital syphilis
• dealing with an incurable STIs, such as genital herpes and genital
warts which may be transmitted to the partner(s) or spouse even in
the absence of visible lesions
• preventing future infections, including strategies to discuss and
introduce condom use with partner(s) or spouse
• confidentiality, disclosure and the risk of violence or stigmatizing
reactions from spouse, partner(s), family or friends and ways to
overcome
• enabling patients to take control of their own life and their
responsibilities for disease prevention.

2.4. CLINICAL FOLLOW UP

Clinical follow-up as appropriate is a part of comprehensive case management
of STI. Patients should be advised to return if symptoms get worse or persist
after prescribed period of therapy.

Patients with pelvic inflammatory disease are best reviewed in 2-3 days to
assess response to therapy.

Those with severe genital ulcers should be encouraged to return after 3 days
for review. If the ulcers have not healed in 7 days, treatment may have to be
extended or patient may have to be referred to a higher facility.

Depending on available facilities, encourage patient to come for repeat

syphilis serology and HIV counselling and testing.

Encourage patients to come back for follow- up visit especially when

symptoms persist and to ensure that the patient has been cured.

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 Sexually Transmitted Infection Management Guideline 2017

2.5. IDENTIFICATION, NOTIFICATION AND EVALUATION OF

SEXUAL PARTNER(S)
This is an important public health activity by which the partners of those
identified as having STI are traced, informed of their probable exposure to
infection, and offered medical and counselling services. The objective of this
exercise is to break the chain of transmission. Partner notification should
be considered whenever STI is diagnosed. In a categorized or specialized
STI clinic, it may be possible to carry out a complete partner management
programme.

2.6. OFFICIAL REPORTING OF THE CASE

Reporting of STI cases is required though this is often neglected. Confidential
reporting of cases is necessary to have a better estimate of the burden of
STI in the country. The type of STIs or syndrome, age and sex are essential
variables that need to be reported regularly to the STI focal point at the
health facility. Reports are the collated and submitted to the provincial focal
point, which in turn reports to the national STI focal point. The information
will be essential for STI programming and advocacy.

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Sexually Transmitted Infection Management Guideline 2017

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3. TREATMENT OF SPECIFIC INFECTIONS

3.1 GONOCOCCAL INFECTIONS

General considerations:
Gonococcal infection in men produces enough symptoms that cause the
person to seek immediate treatment, which may prevent serious sequelae,
but not soon enough to prevent transmission to other persons. Women, by
virtue of their anatomical and physiological make-up, do not usually produce
recognizable symptoms until complications such as pelvic inflammatory
disease (PID) sets in. PID is one of the most serious clinical manifestations,
whether symptomatic or asymptomatic, leading to infertility or ectopic
pregnancy. (Untreated gonococcal infection in men can cause epididymitis
and consequently may result to urethral stricture and infertility). Because
of the emerging resistance data for gonococcal infections and reduced
effectiveness of some medicines, good practice dictates that the choice of
treatment depends on reliable local data on antimicrobial susceptibility.

It is essential that gonococcal antimicrobial resistance is monitored and

treatment failure reported, to inform revisions in treatment recommendations.

3.1.1 Uncomplicated Gonococcal Infection

Recommended Regimen
Ceftriaxone 500 mg, IM, stat single dose
OR
Cefixime 400 mg, orally stat, single dose (Need AMR Monitoring whether
the efficacy is still acceptable in Myanmar)
PLUS
As co-infection with C. trachomatis is common, it is advisable to add a regimen
that is effective against C. trachomatis. In clinical trials, these recommended
regimens have a cure rate of > 95% especially for anal and genital infections.

Azithromycin 1 gm, orally, single dose

OR
Doxycycline 100 mg, orally, twice a day for 7 days

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It is important to note that dual therapy for gonorrhoea is recommended

to reduce the likelihood of developing resistance, in addition to providing
treatment for Chlamydial infection.

3.1.2 For Treatment Failure

Table 1 Working Case Definition for confirmed Treatment Failures:

clinical and laboratory criteria

1 A gonorrhoea patient who returns for test of cure or who has persistent
genital symptoms after having received treatment for laboratory-
confirmed gonorrhoea with a recommended cephalosporin regimen
(ceftriaxone or Cefixime in appropriate dose)
AND
2 Remains positive for one of the following for N. gonorrhoeae:
• Presence of intracellular Gram-negative diplococcic on microscopy
taken at least 72 hours after completion of treatment;
OR
• Isolation of N. gonorrhoeae by culture taken at least 72 hours after
completion of treatment;
OR
• Positive nucleic acid amplification test (NAAT) taken two to three
weeks after completion of treatment
AND
3 Denies sexual contact during the post-treatment follow-up period
AND
4 Decreased susceptibility to cephalosporin used for treatment*:
• Cefixime: MIC>0.25 mg/L
• Ceftriaxone: MIC>0.125 mg/L
*Ideally, the pre- and post-treatment isolates should be examined with an
appropriate and highly discriminatory molecular epidemiological typing
method (to confirm an identical strain) and with genetic methods (to confirm
the resistance determinants in order to show that the strain is truly resistant).

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Recommended Regimen
Ceftriaxone 1 gm IM stat (including pregnant women)
OR
Spectinomycin 2 gm, IM, single dose (contraindication to Pregnant Women)
PLUS
Azithromycin 2 gm oral stat

3.1.3 Treatment in Pregnancy

First Line Treatment

Ceftriaxone 500 mg, IM single dose
PLUS
Azithromycin 1-gram single dose (Azithromycin as first line treatment instead
of Erythromycin)

3.1.4 Gonococcal Infection of the Pharynx

Ceftriaxone 500mg, IM, single dose (usually higher dosage needed for
pharyngeal infection compared to uncomplicated GC.)
PLUS (dual therapy)
Azithromycin 1 gram single dose

Follow-Up
Because of the issue of emerging gonococcal antimicrobial resistance,
patients are advised to follow up after treatment has been completed or
if symptoms persist. Usually, patients who have been treated with any of
the above treatment regimens need not return for a test of cure. Those
patients who have persistent symptoms after treatment should be evaluated.
If possible culture for N. gonorrhoeae and gonococci isolated should be
tested for antimicrobial susceptibility. If infection is found to be present
despite treatment with one of the recommended regimens, re-infection
rather than treatment failure is the main problem. This calls for improved
patient education, compliance on the part of the patient and referral of
sex partners for proper management. It should be noted that persistent
urethritis, cervicitis, or proctitis also might be due to C. trachomatis and other
organisms.

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Management of Sex Partners

Patients should be encouraged to bring their sex partners, especially marital
partners, for evaluation and treatment. Sex partners of symptomatic patients
should be evaluated and treated for both gonorrhoea and C. trachomatis
infections if their last sexual contact with the patient was within 30 days of
onset of the patient's symptoms.

Patients should be instructed to avoid sex and alcohol until patients and
partners are cured and in the absence of microbiologic test of cure, this
means until therapy is completed and patient and partner(s) are without
symptoms.

Special Considerations
Pregnancy
Recommended treatment is to use cephalosporin, and in those patients who
cannot tolerate this drug, a single dose of Spectinomycin 2 gm. IM, single
dose can be used.

Gonococcal with HIV Infection

Persons with HIV infection and gonococcal infection should receive the same
treatment as persons not infected with HIV.

Gonococcal Conjunctivitis
This is a serious condition that requires systemic therapy and local irrigation
with saline or other appropriate solutions.

Recommended Regimens
Ceftriaxone 1 gm IM, as a single dose

3.1.5 Disseminated Gonococcal Infection (DGI)

It has been found that strains of N. gonorrhoeae that cause DGI tend to cause
very little genital inflammation. Clinically diagnosed cases of DGI are rare in
Myanmar but clinicians should be aware of the presenting features of petechial or
pustular acral skin lesions, asymmetrical arthralgia, tenosynovitis or septic arthritis
and sometimes complicated by hepatitis and rarely, by endocarditis or meningitis,
especially in a patient with history of GC infection. Patients treated for DGI should
also be treated for C. trachomatis infection. Hospitalization may be necessary for
moribund patients or who cannot be relied on to comply with treatment.

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Recommended Regimens
Ceftriaxone 1 gm, IM or IV, daily, for 7 days

Alternative Regimens
Cefotaxime 1 gm, IV, every 8 hours, for 7 days
OR
Ceftizoxime 1 gm, IV, every 8 hours, for 7 days
OR
Spectinomycin 2 gm, IM, every 12 hours, for 7 days
OR
Cefixime 400 mg, orally, twice a day, for 7 days

Management of Sex Partners

Management is the same as for patients with uncomplicated gonococcal
infection.

3.1.6 Gonococcal Infections in Infants

GC infection among neonates usually results from peri-partum exposure to

infected cervical exudates the mother, causing an acute illness beginning 2-5
days after birth.

Ophthalmia Neonatorum
Recommended Regimen
Ceftriaxone 50 mg/kg, IM, as a single dose, to a maximum of 75 mg

Alternative regimen
Spectinomycin 25 mg/kg, IM as a single dose, to a maximum of 75 mg

Ophthalmia Neonatorum Prophylaxis

Prevention
The diagnosis and treatment of gonococcal and chlamydial infections in
pregnant women is the best method for preventing neonatal gonococcal and
chlamydial disease. Since not all pregnant women receive proper prenatal
care, local ocular prophylaxis is to be encouraged always in all health care
settings.

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Recommended Regimen
Erythromycin (0.5 %) ophthalmic ointment in a single application
OR
Tetracycline ophthalmic ointment (1 %) in a single application
OR
Silver nitrate (1 %) aqueous solution in a single application

(One of these preparations should be instilled into both eyes as soon as

possible after delivery. All infants should receive this prophylaxis regardless
of whether delivery is vaginal or caesarean. Caution should be taken to avoid
touching eye tissue when applying the topical treatment)

Recommended Regimen for infants born to mothers with gonococcal

infection
Ceftriaxone 50 mg/kg, IM as a single dose, to a maximum of 75 mg

Alternative regimen
Spectinomycin 25 mg/kg, IM as a single dose, to a maximum of 75 mg

Gonococcal Infections in Children

Sexual abuse is the most common cause of GC infection in this age group.
Vaginitis, followed by ano-rectal and oro-pharyngeal infections are the
common presenting features.

Recommended Regimen
Children who weigh > 45 kg should receive the same treatment as those
recommended for adults.
Children who weigh < 45 kg should be given Ceftriaxone 50 mg / kg
(maximum 250 mg) IM or IV, as a single dose
(For meningitis, the duration of treatment is increased to 10 -14 days and the
maximum dose to 2 gm)

Alternative regimen
Spectinomycin 25 mg/kg IM as a single dose, to a maximum of 75 mg
Mycoplasma genitalium should be considered in the context of treatment
for persistent urethral discharge
Azithromycin, 1 gm PO in a single dose
OR
Azithromycin 500 mg PO stat then 250 mg for next 4 days

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OR
Doxycycline, 100 mg PO bid for 7 days (less effective than previous time)

For the persistent urethritis, the treatment for mycoplasma infection can be
added depending upon the location situation. The current magnitude of M.
genitalium in Myanmar is currently not known. Persistent urethral discharge
may be due to antimicrobial resistance in N. gonorrhoea ( See treatment
failure in N.gonorrhoea)

3.2 CHLAMYDIAL INFECTIONS

Although definite evidence is lacking, it is assumed that Chlamydial genital
infection is common among patients attending with STI complaints at the
peripheral level. At the same time, asymptomatic infection is also common
among both men and women, especially among those who indulge in
unprotected sex and who have new and multiple sex partners. The sequelae
resulting from C. trachomatis infection in women include Pelvic Inflammatory
Disease, ectopic pregnancy, and infertility. Cervical lesions usually precede
upper reproductive tract infection leading to these serious complications
and thus, it is widely accepted that treatment of cervical infection reduces
the likelihood of the above complications.

Treatment of infected patients prevents transmission to sex partners, and in

pregnant women, it may prevent transmission of C. trachomatis to infants
during birth. Treatment of sex partners will reduce reinfection of the index
patient and infection of other partners.

It is to be noted that co-infection with C. trachomatis is often seen in patients

with gonococcal infection and thus, it is beneficial to give presumptive
treatment of such patients for gonococcal infection, especially in places
where there is no diagnostic test available.

Recommended Regimen for C. Trachomatis Infection

Azithromycin 1 gm, orally, single dose
OR
Doxycycline 100 mg, twice a day, for 7 days

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Alternative Regimens
Erythromycin 500 mg, orally, four times a day, for 7 days
OR
Tetracycline 500 mg, oral, four times a day, for 7 days

The only drawback here is that the efficacy and safety of Azithromycin for
persons up to 5 years of age is still in question. The advantage here is that
single dosing is possible.

The efficacy of Ofloxacin is comparable to Doxycyline and azithromycin but

costlier and cannot be used during pregnancy or with persons under 17
years of age, and also there is no convenience in dosing, compared to the
other two drugs. Ofloxacin is the only quinolone with proven efficacy against
chlamydial infection, however it is not effective against gonorrhoea, given
the high rates if resistance in Asia.

Follow-Up
Retesting for chlamydia is usually not required, even if laboratory facilities
are available, after completion of treatment with doxycycline or azithromycin,
unless symptoms persist or re-infection is suspected. Retesting may be
required if the drugs used are erythromycin. It may be possible to see some
high rates of infection among women retested several months later and most
of the time; it is due to re-infection from their sex partners.

Management of Sex Partners

Patients should be instructed to bring their sex partners for evaluation and
treatment as follow:
• Sexual contacts of symptomatic patients should be investigated and
treated if their last sexual exposure to the index patient was within 30
days of onset of index’s symptoms.
• Sexual contacts of asymptomatic patients within 60 days of exposure
should be investigated and treated.
• Treatment should be given to the last sex contact even if the last sexual
exposure took place before the above mentioned time intervals.

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Special Considerations
Pregnancy
Doxycycline is contraindicated.

Recommended Regimen for Pregnant Women

First Line Treatment

Azithromycin 1 gm, orally, as a single dose

(Azithromycin as first line treatment instead of Erythromycin)

HIV Infection
HIV positive patients with chlamydial infection should receive the same
treatment regimen as those who are HIV negative.

Chlamydial Infection in Infants

Chlamydial infection in neonates results from perinatal exposure to the
mother’s infected cervix. Available data show that the prevalence of C.
trachomatis infection in pregnant women usually is quite low (> 5%),
regardless of race / ethnicity or socioeconomic status. Although neonatal
ocular prophylaxis with silver nitrate solution or antibiotic eye preparations
does not prevent transmission of C. trachomatis, it does prevent gonococcal
ophthalmia and so this procedure should be encouraged to continue.

The clinical signs are due to involvement of mucous membranes of the eye,
oropharynx, urogenital tract, and rectum. Conjunctivitis develops 5 - 12 days
after birth and it is the commonest cause of conjunctivitis in neonates. Most
cases of sub-acute, afebrile pneumonia at the age of 1 to 3 months are also
attributable to C. trachomatis infection. Asymptomatic infections also can
occur in the oropharynx, genital tract, and rectum of neonates.

Ophthalmia Neonatorum due to C. trachomatis

In the present health care settings, a Gram stained smear from the ocular
exudates can be used to exclude GC infection, and if the smear is negative
for GC, the following is recommended.

Recommended Regimen
Erythromycin 50 mg/kg/day, orally, divided into four doses daily for 14 days

(Topical antibiotic therapy alone is inadequate for treatment of chlamydial

infection and it is not needed when systemic antibiotic is used.)
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Follow - Up
Since the therapeutic efficacy of erythromycin is about 80%, a second
course of treatment may be required. The possible concomitant chlamydial
pneumonia should be considered in infected neonates. Thus, in treating a
neonate with chest infection, especially with conjunctivitis, the treatment
regimen should include antibiotics effective against C. trachomatis.

The mothers of infants thus treated and the sex partners of these women
should be examined and treated accordingly.

3.3 SYPHILIS
General Considerations
Syphilis is a systemic disease caused by T. pallidum. The presenting features
include ulcer or primary chancre in the Primary Stage; skin manifestations,
mucocutaneous lesions and adenopathy in the Secondary Stage; and
involvements of cardiovascular system, central nervous system and/ or
gummatous lesions are classified as Tertiary Syphilis. Syphilis acquired within
the preceding year is classified as Early Latent Syphilis, and all other cases of
latent syphilis are known as Late Latent Syphilis or Latent Syphilis of Unknown
Duration. Treatment for late latent syphilis including tertiary syphilis may
require a longer duration of therapy as the organisms are dividing more
slowly. Early syphilis consists of primary syphilis, secondary syphilis and early
latent syphilis, while late syphilis consists of late latent syphilis and tertiary
syphilis (neurosyphilis, cardiosyphilis and gumma).

The natural history of untreated syphilis is variable. Infection may remain latent
throughout, or clinical features may develop at any time. The classification of
syphilis is shown in Box 3. All infected patients should be treated. Penicillin
remains the drug of choice for all stages of infection.

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Box 3 Classification of Syphilis

Classification of Syphilis
Stage Acquired Congenital
Early Primary Clinical and latent
Secondary
Latent
Late Latent Clinical and latent
Benign tertiary
Cardiovascula
Neurosyphilis
Latent syphilis
This phase is characterized by the presence of positive syphilis serology or
the diagnostic cerebrospinal fluid (CSF) abnormalities of neuro-syphilis in
an untreated patient with no evidence of clinical disease. It is divided into
early latency (within 2 years of infection), when syphilis may be transmitted
sexually, and late latency, when the patient is no longer sexually infectious.
Transmission of syphilis from a pregnant woman to her fetus, and rarely by
blood transfusion, is possible for several years following infection.

Diagnostic Considerations
The use of Dark-field Examination and Direct Immunofluorescent Antibody
Test of lesion exudates are necessary for the diagnosis of early syphilis.
However, this is not feasible in most settings. It is therefore essential to treat
all patients presenting with genital ulcer disease for primary syphilis.

Presumptive diagnosis can be made with two types of serologic tests for
syphilis (a) non-treponemal tests like Venereal Disease Research Laboratory
(VDRL) test and Rapid Plasma Reagin (RPR) test, and (b) treponemal tests
like Fluorescent Treponemal Antibody Absorption (FTA-ABS) test, and
Microhemagglutination Assay for Antibody to T. pallidum (TPHA, MHA-
TP) test and Rapid Syphilis Test (RST). The use of one type of test alone is
insufficient for proper diagnosis.

A patient who has a reactive treponemal test usually will have a reactive test for
a lifetime, regardless of treatment or disease activity, which is being referred to
as "serological scar". About 15 - 25 % of patients treated during the primary
stage may revert to being serologically non-reactive after 2 - 3 years.
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Treponemal test antibody titres correlate poorly with disease activity and
should not be used as a marker for response to treatment.

Abnormal results of serologic testing e.g. unusually high, unusually low, and
fluctuating titres have been noted with HIV infected persons.

Serological tests for syphilis are accurate and reliable for the diagnosis of
syphilis and also for evaluation of response to therapy in most HIV infected
persons.

General Consideration for Treatment

Parenteral penicillin G (sodium or potassium salt) is the preferred drug for
treatment of all stages of syphilis. However, the preparations used (i.e.
benzathine, aqueous procaine, or aqueous crystalline), the dosage, and the
duration of treatment depend on the stage and clinical manifestations of the
disease.

Recommended Regimen for Early Syphilis

For Adults
Benzathine penicillin G 2.4 million units, IM in a single dose, because of the
volume involved, this dose is usually given as two injections as separate sites.
(Penicillin remains the treatment of choice)

Alternate treatment:
Procaine Penicillin G 1.2 million units IM in single dose for 10 to 14 days

For Children
Benzathine penicillin G 50,000 units/kg, IM (up to adult dose of 2.4 million
units), as a single dose

Other Management Considerations

• All patients with syphilis should be tested for HIV infection.
• Patients who have primary syphilis should be retested for HIV after
4-6 weeks if the first HIV test result was negative.
• Patients with syphilis who also have signs and symptoms suggesting
neurologic disease should be fully evaluated and treated for
neurosyphilis.

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Follow - Up
Treatment failure can occur with any regimen and assessing response to
treatment is difficult as there are no definite criteria for cure or failure exist.

Patients should be re-examined clinically and serologically at 1, 3, 6 months

and again at 1 year including evaluation for HIV infection.

Re-treatment is indicated in patients with signs or symptoms that persist or

recur or who have a sustained fourfold increase (two dilutions) in VDRL test
(non-treponemal test)

Special Considerations
Penicillin Allergy
Doxycycline 100 mg, orally, 2 times a day for 2 weeks (If not pregnant)
OR
Ceftriaxone 1 gram IM once a day for 14 days IM
OR
Erythromycin 500 mg, orally, 4 times a day for 2 weeks and treat infant base
on the clinical scenario (e.g. not Benzathine Penicillin 50,000 IU/kg body
weight IM as single dose
(This regimen is for penicillin - allergic pregnant women)

3.3.1. Latent Syphilis

It is defined as those periods after infection with T. pallidum when patients

are sero-reactive but show no other clinical evidence of the disease. The
classification of Early Latent Syphilis is arbitrary unless there is definite
evidence of acquiring syphilis within the preceding year like documented
sero-conversion, a fourfold or greater increase in titre of a non-treponemal
test and history of symptoms of primary or secondary syphilis. Thus, nearly
all other patients have latent syphilis of unknown duration and they should
be treated as if they had late latent syphilis.

Recommended Regimen
Early Latent Syphilis
Benzathine penicillin G 2.4 million units, IM, single dose

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Late Latent Syphilis or Latent Syphilis of Unknown Duration

Benzathine penicillin G administered as three doses of 2.4 million units, IM
1 week intervals for 3 consecutive weeks (Benzathine penicillin G 7.2 million
units total) - The interval between consecutive doses of benzathine penicillin
should not exceed 14 days.
OR
Procaine penicillin 1.2 million units IM once daily for 20 days.

Special Considerations
Penicillin Allergy
Doxycycline 100 mg, orally, 2 times a day, for 4 weeks
OR
Erythromycin 500 mg, orally, 4 times a day for 4 weeks

Recommended Regimen for Infant and Children

Infant and children, aged more than 1 month, in whom syphilis is diagnosed
should be evaluated whether the child has congenital or acquired syphilis
from birth and maternal medical records, if available, and older children with
acquired latent syphilis should be evaluated as for adults and treated as
follows.

Early Syphilis in children

Benzathine penicillin G 50,000 units /kg, IM, (up to the adult dose of 2.4
million units), single dose

Late Latent Syphilis or Latent Syphilis of Unknown Duration

Benzathine penicillin G 50,000 units /kg, IM, (up to the adult dose of 2.4
million units), administered as three doses at one-week interval (total 150,000
units /kg up to the adult total dose of 7.2 million units)

Other Management Considerations

All patients with latent syphilis should be evaluated clinically for evidence of
tertiary syphilis e.g. Aortitis, neurosyphilis, gumma, and iritis. Asymptomatic
neuro-syphilis can be diagnosed 4 years before the onset of signs and
symptoms.
HIV antibody testing should be done to all syphilis patients.

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Follow - Up
VDRL test should be repeated at 6 months and again at 12 months.
Re-treatment is indicated if the patient develops signs and symptoms
attributable to syphilis.

Special Considerations
Penicillin Allergy
Non-pregnant, penicillin-allergic patients should be given
Doxycycline 100 mg, orally, twice a day
The duration of therapy should be 2 weeks for Early Syphilis and 4 weeks for
Latent Syphilis.

3.3.2. Tertiary (Late) Syphilis

Late Syphilis refers to patients with gumma and patients with cardiovascular
involvement. Neurosyphilis is regarded as a separate entity.

Recommended Regimen
Benzathine penicillin G 7.2 million units total, administered as 3 doses of 2.4
million units IM, at 1 week intervals for 3 consecutive weeks.
(This regimen should be used in penicillin non-allergic patients without
evidence of neurosyphilis)

3.3.3. Neurosyphilis

CNS can be involved during any stage of syphilis. Thus, CSF examination
is mandatory in patients who present with clinical evidence of neurologic
involvement. It can be used for both diagnosis as well as evaluation of
response to anti-syphilitic therapy.

Recommended Regimen
Aqueous crystalline penicillin G, 18 - 24 million units daily, administered as
3 - 4 million units IV every 4 hours, for 10 - 14 days

Alternative Regimen
Procaine penicillin 2.4 million units, IM, daily
PLUS
Probenecid 500 mg, orally, 4 times a day, both for 10 - 14 days
(The duration of these regimens is shorter than that of the regimen used for
late syphilis and thus some experts advocate administration of benzathine
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penicillin 2.4 million units IM after completion of these neurosyphilis

treatment regimens to provide a comparable total duration of therapy).

3.3.4. HIV Infected Persons with Syphilis

• Abnormal serologic responses have been noted among HIV infected

persons when they acquire syphilis.i.e. the titres maybe higher than
expected or false negative serologic results or delayed response to
sero-reactivity may be noted.
• Both treponemal and non-treponemal serologic tests for syphilis are
accurate for nearly all patients with syphilis and HIV co-infection
• HIV infected persons with syphilis are prone to have neurologic
complications and also higher rates of treatment failure with current
recommended treatment regimens
• No treatment regimen has been proved to be more effective in
preventing development of neurosyphilis than those recommended
for patients without HIV

3.3.5. Syphilis during Pregnancy

• Ideally, screening for syphilis serology should be a part of ante-natal

care for every pregnant woman especially during the early trimester,
and again at the time of delivery
• A woman with a history of repeated abortion, stillbirth, especially at
12 - 20 weeks of gestation should be tested for syphilis
• In health-care settings where utilization of prenatal care is not
optimal, screening should be made possible by the use of rapid test
kit for Syphilis (ICT) or RPR card test, and if found positive, treatment
instituted at the time pregnancy is diagnosed
• Sero-reactive pregnant women should be considered infected unless
adequate treatment has been taken and the sequential serologic
titres have appropriately declined

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Recommended Regimen
Pregnant Women with Early Syphilis
Preferred first choice
Benzathine penicillin G 2.4 million units (ATD) once intramuscularly
Second choice
Procaine penicillin 1.2 million units intramuscularly (ATD) once daily for 10
days

When benzathine or procaine penicillin cannot be used (e.g. due to penicillin

allergy where penicillin desensitization is not possible) or are not available
(e.g. due to stock-outs), use, with caution,
• Ceftriaxone 1 g intramuscularly once daily x 10-14 days OR
• Azithromycin 2 g once orally OR
• Erythromycin 500 mg orally 4 times daily x 14 days

Although erythromycin and azithromycin treat the pregnant women, it

does not cross the placental barrier completely and as a result the fetus
is not treated. It is therefore necessary to treat the newborn infant soon
after delivery (see in congenital syphilis). Doxycycline should not be used
in pregnant women. Because syphilis during pregnancy can lead to severe
adverse complications to the fetus or newborn, stock-outs of benzathine
penicillin for use in antenatal care should be avoided.

Pregnant women with late syphilis or unknown stage of syphilis:

Preferred first choice
Benzathine penicillin G 2.4 million units (ATD) weekly for three consecutive
week
Second choice
Procaine penicillin 1.2 million units intramuscularly (ATD) once daily for 20
days

When benzathine or procaine penicillin cannot be used (e.g. due to penicillin

allergy where penicillin desensitization is not possible) or are not available
(e.g. due to stock-outs), use, with caution,
• Erythromycin 500 mg orally four times daily for 30 days.

These women should be advised to seek medical attention following

treatment if they experience any change in fetal movements or if they start to

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have contractions which may be due to Jarisch -Herxheimer reaction causing

premature labour or fetal distress or both. Since treatment is to be given to
prevent further fetal damage, this should not be a delay for therapy.

Follow -Up
Monthly serological check-up should be done until adequacy of treatment
has been established by the appropriate antibody response for the stage of
disease.

Alternative Regimen
There are no proven alternatives to penicillin. Desensitization, if possible,
should be done before treating with penicillin.

Tetracycline and doxycycline are contraindicated during pregnancy, and

erythromycin may be used but it cannot be relied upon to cure an infected
fetus.

3.3.6. Congenital Syphilis

Infants should be evaluated for congenital syphilis if the mother has the
following criteria: -
• The mother is sero-reactive (non-treponemal test confirmed by
treponemal test, if possible)
• Had untreated syphilis at delivery (a woman who had been treated
with a regimen other than those recommended in these guidelines
for treatment of syphilis should be considered untreated)
• Serological relapse or re-infection suspected after treatment (antibody
titre increases by at least two dilutions VDRL)
• Mother was treated with erythromycin or other non-penicillin regimen
for syphilis during pregnancy
• Was treated for syphilis <1 month before delivery
• No definite history of taking adequate treatment for syphilis
• Gave history of taking appropriate penicillin regimen for early syphilis
during pregnancy but VDRL did not reveal any decrease in antibody
titre by at least two dilutions
• Gave history of taking appropriate treatment before pregnancy but
had insufficient serologic follow-up to assure that they had responded
favourably to treatment and are not currently infected (i.e. at least a

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two-dilution decrease in VDRL test and a stable or declining antibody

titres of < 1:4 for other patients)

Among infants born to a mother with a positive treponemal or non-

treponemal syphilis test during pregnancy:
• Scenario 1: Infants with proven or highly probable disease
• Abnormal physical exam consistent with congenital syphilis * or
• Laboratory evidence of syphilis in infant (A serum quantitative
non treponema serologic titre (RPR) that is fourfold higher than
the mother’s titre** Or A positive darkfield test or PCR of lesions
or body fluid)
• Scenario 2: Infants with a normal physical examination but
• Mother not treated / inadequate / not documented or
• Mother treated with non-penicillin regimen or
• Mother treated less than 4 weeks before delivery
• Scenario 3: Infants with a normal physical examination and
• Mother treated appropriately during pregnancy
• Mother has no evidence of re-infection or relapse
*If mother not tested, use scenario 1 if infant has abnormal physical exam
consistent with congenital syphilis
** The absence of the fourfold or greater titre for a neonate does not exclude
congenital syphilis

Recommended Regimens
Scenario 1 and 2
• Aqueous benzyl penicillin 50,000 unit/kg/dose intravenously every
12 hours during the first 7 days of life and every 8 hours thereafter for
a total of 10 days (OR)
• Procaine penicillin 50,000 Unit/kg single daily dose intramuscularly
for 10 days
If the treatment is missed for more than 1day, entire course should be
restarted.

Scenario 3
For infants who are clinically normal and whose mothers had syphilis that was
adequately treated with no signs of reinfection,
• Injection IM Benzathine penicillin G 50,000 unit/kg in single dose

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Sexually Transmitted Infection Management Guideline 2017

The risk of transmission of syphilis to the fetus depends on a number of

factors, including maternal titres from non-treponemal tests (e.g. RPR),
timing of maternal treatment and stage of maternal infection, and therefore
this recommendation is conditional.

Treatment of Older Infants and Children with Congenital Syphilis

After the new-born period, children diagnosed with syphilis should be
reviewed and assessed as to whether the child has congenital or acquired
syphilis. And any child who is thought to have congenital syphilis (or who has
neurologic involvement) should be treated with
• Preferred first choice: Aqueous crystalline penicillin G, 50,000 units/
kg/dose every 6 hours for 10 days
• Alternative: Ceftriaxone Injection for 10-14 days
• Infants age ≥ 30 days, 75mg/kg IV/IM single daily dose
• For children more than 1 year , 100 mg/kg IV/IM single daily dose

Follow - Up
After treatment, VDRL antibody titre should decline by 3 months of age and
should be non-reactive at 6 months if the infant was not infected and the
titres were the result of passive transfer of antibody from the mother. This
passive transfer may be present for as long as one year. If these titres are
found to be stable or increasing, evaluation and full investigations should be
done and full treatment given.

Treated infants also should be followed every 2 -3 months to assure VDRL

antibody titres decline and these infants should have become non-reactive
by the age of 6 months, but the response may be slower for infants treated
after the neonatal period.

Follow-up of children treated for congenital syphilis after the new-born

period should be the same as that prescribed for congenital syphilis among
neonates.

HIV Infection
Mothers of congenital syphilis should be tested for HIV. Infants born to
mothers who have HIV infection should be referred for evaluation and
appropriate follow-up.

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 Sexually Transmitted Infection Management Guideline 2017

3.4. CHANCROID
The causative organism is a Gram-negative facultative anaerobic bacillus,
H. ducreyi. In the absence of supporting laboratory facilities, the following
criteria are to be used: -
- Presence of one or more painful genital ulcers,
- Patient gives relevant history of sex exposure, usually within 1 week,
- Presence of multiple erosive ulcerations with regional lymphadenopathy,
- Suppurative inguinal lymphadenopathy is almost always pathognomic of
chancroid

Recommended Regimens
Azithromycin 1 gm orally in a single dose
OR
Ceftriaxone 250 mg, IM, in a single dose
OR
Ciprofloxacin 500 mg orally twice a day for 3 days
OR
Erythromycin base 500 mg orally four times a day for 7 days

Notes: Ciprofloxacin should not be used for pregnant or lactating mothers

and for persons < 18 years.
Wet dressing to clean the ulcer by normal saline may help shorten the healing
time

Other Management Considerations

Persons who are uncircumcised and HIV infected persons might not respond
as well to treatment as those who are circumcised or HIV negative.

HIV infection should be tested at the time of diagnosis of cancroid. Re-

testing should be done after 4-6 weeks if the initial tests for syphilis and HIV
were negative.

Follow-Up
Patients should be re-examined 3 - 7 days after initiation of treatment. Ulcers
improve symptomatically within 3 days and complete healing take place
in about two weeks. If there is no clinical improvement, review should be
made whether (a) diagnosis is correct, (b) co-infection with another STI agent
exists, (c) the patient is infected with HIV, (d) treatment was not taken as
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Sexually Transmitted Infection Management Guideline 2017

instructed, or (e) the H. ducreyi strain from that particular patient develops
resistance to the antimicrobial drug used. The clinical resolution of fluctuant
lymphadenopathy takes place slower than that of the ulcers and may require
needle aspiration through adjacent intact skin and they should never be
incised.

Management of Sex Partners

Sexual contacts of the patient within 10 days prior to development of the
clinical signs and symptoms should be examined and treated whether they
have clinical signs and symptoms or not.

Special Considerations
Pregnancy
In the light of current information, the use of ciprofloxacin during pregnancy
is contraindicated. No adverse effects of chancroid on pregnancy outcome
or on the foetus have been reported.

HIV Infection
HIV co-infected patients may require longer courses of therapy. Treatment
failure or delayed or slow healing may occur especially after shorter-course
treatment regimens. The use of erythromycin 7 days’ course has been
advocated by some experts in such patients.

3.5. LYMPHOGRANULOMA VENEREUM (LGV)

LGV is caused by the invasive serovar’s L 1, L 2, or L 3 of C. trachomatis,
and the clinical features are the presence of genital ulcer(s) which may or
may not be recognizable, accompanied by tender inguinal and/or femoral
lymphadenopathy that is usually unilateral, which, later, suppurates forming
a multiple fistula.

The late stages of the disease are due to the blockage of the lymphatic
channels causing distal oedema resulting in gross elephantiasis of the
genitalia. Ano-rectal stricture may also occur due to para-colic lymphatic
damage.

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 Sexually Transmitted Infection Management Guideline 2017

Recommended Regimens
Doxycycline 100 mg orally twice a day for 21 days
OR
Azithromycin 1 gran orally weekly for 3 weeks

Note: Fluctuant lymph nodes should be aspirated through health skin.

Incision and drain may delay healing.

3.6. GRANULOMA INGUINALE (DONOVANOSIS)

It is a rare disease caused by the intracellular Gram-negative bacterium
Calymmatobacterium granulomatis and it occurs in endemic form in certain
tropical and developing countries, and it is not commonly seen in Myanmar.

The clinical features are painless, progressive, ulcerative lesions without

regional lymphadenopathy and the high vascularity causes it to appear as a
beefy red ulcer, which bleeds easily on touch.

The organism can be cultured only on a special media and the clinical
diagnosis is made by the presence of dark-staining Donovan bodies on
tissue crush preparation or biopsy.

Recommended Regimens
Doxycycline 100 mg orally twice a day for a minimum of 3 weeks
OR
Trimethoprim -sulfamethoxazole one double - strength tablet orally twice a
day for a minimum of 3 weeks

Alternative Regimens
Ciprofloxacin 750 mg orally twice a day for a minimum of 3 weeks
OR
Erythromycin 500 mg orally four times a day for a minimum of 3 weeks

Pregnancy
Sulphonamides are relatively contraindicated in pregnancy. Erythromycin
regimen can be used in conjunction with a parenteral aminoglycoside (e.g.
gentamycin)

Note: Treatment should be continued until all lesions have completely

epithelialized

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3.7. GENITAL HERPES SIMPLEX Type 2

Genital herpes is a viral infection characterized by recurrence of the lesions
and it has no cure. There are two serovars - HSV-1 and HSV-2 and most
genital infections are caused by HSV -2. Many infected persons usually do not
recognize signs suggestive of genital herpes and some will have symptoms
shortly after infection and then never again. HSV type 1 (HSV-1) typically
causes non-sexually-transmitted oral herpes infection. However, HSV-1 can
also be transmitted to the genitals through oral sex and is increasingly noted
as a cause of genital HSV, especially in high-income countries.

HSV -2 infection is normally seen after sexual contact in young adults who
later develop acute vulvo-vaginitis, penile or peri-anal lesions. Culture-
positive genital herpes simplex in a pregnant woman at the time of delivery
is an indication for Caesarean section, as neonatal infection can be fatal.

Recurrence is a hallmark of herpes simplex infection and occurs at a similar

site each time and usually, the outbreak of group of vesicles is preceded
by a feeling of tingling or burning sensation. Some cases of first clinical
episode of genital herpes are manifested by extensive disease that requires
hospitalization.

Many cases of genital herpes are acquired from asymptomatic infected

persons at the time of sexual contact. Moreover, the signs and symptoms in
the infected person are so mild that they might not recognize that they have
the infection, and because of the intermittent viral shedding in the genital
tract, the infection is passed on to other persons.

Present day systemic anti-viral drugs do not eradicate the latent virus or affect
the risk, frequency, or severity of recurrences after the drug is discontinued.
The three anti-viral drugs are: acyclovir, valacyclovir, and famciclovir. Topical
therapy with acyclovir is less effective than the systemic drug and its use
should be discouraged.

Recommended Regimens for First Episode of Genital Herpes

Acyclovir 400 mg orally three times a day for 10 days
OR
Valacyclovir 500 mg orally twice a day for 10 days
OR
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 Sexually Transmitted Infection Management Guideline 2017

Famciclovir 250 mg orally three times a day for 10 days

(This treatment may be extended if healing is not complete after 10 days of
therapy.)

Given that follow-up visits may not be possible during the course of treatment
and symptoms of the first clinical episode may be prolonged, therapy is
provided for 10 days. Although the benefits of the medicines are probably
similar, the costs of valacyclovir and famciclovir are higher than aciclovir, and
therefore acyclovir is preferred. The choice of medicine may also depend on
compliance considerations.

Recurrent Clinical Episodes of Genital Herpes Simplex Virus Infection

Two types of treatment regimens are available for recurrent herpes:

Episodic Therapy
Treatment is started during the prodromal or within one day after onset of
genital lesions.
Acyclovir 400 mg orally three times a day for 5 days
OR
Acyclovir 800 mg orally twice a day for 5 days
OR
Valacyclovir 500 mg orally twice a day for 3 days
OR
Famciclovir 250 mg orally twice a day for 5 days

Daily Suppressive Therapy

When to provide suppressive treatment
Individuals who have frequent recurrences (e.g. 4–6 times a year or more),
severe symptoms or episodes which cause distress will likely choose
suppressive therapy over episodic therapy.

It reduces the frequency of recurrences by > 75 %. Acyclovir orally has been

known to be used for as long as 6 years with no ill effects upon its safety
and efficacy, but, as for the other two drugs, limited experience prevents
recommendation of these drugs for over 1 year. Caution needed for daily
suppressive therapy of Acyclovir to Pregnant women.

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Acyclovir 400 mg orally twice a day

OR
Valacyclovir 500 mg orally once a day
OR
Famciclovir 250 mg orally twice a day

Comparative Studies of the Efficacy of the Three Drugs

Although the benefits of the medicines are probably similar, the costs of
valaciclovir and famciclovir are higher than acyclovir, and therefore acyclovir is
preferred. The choice of dosage may depend on compliance considerations.

Severe HSV Infection without complication

In majority of cases, sever HSV episode is treated similarly as first clinical
episode of genital HSV infection.

Severe cases with complications such as disseminated infection, pneumonitis,

hepatitis, or complications of the central nervous system should be
hospitalized and IV therapy instituted.

Recommended Regimen
Acyclovir 5 - 10 mg/kg bodyweight IV every 8 hours for 5 - 7 days or until
clinical cure is attained.

Management of Sex Partners

The symptomatic sex partners of patients who have genital herpes should be
evaluated and treated in the same way as the index patients. For asymptomatic
sex partners, evaluation and counselling, together with health education,
should be provided with a view to encourage them to seek medical attention
the moment skin lesions appear.

Special Considerations
HIV Infection
Like other viral infections, lesions due to HSV are common among HIV-
infected patients and may be very severe, extensive, painful, and atypical.

Intermittent or suppressive therapy with oral anti-viral agents is often beneficial

but increased dosage is required Valacyclovir 8 gm per day has been known
to be associated with a syndrome resembling haemolytic uremic syndrome
or thrombotic thrombocytopenic purpura. However, recommended dosages

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for genital herpes are safe for use in HIV-infected persons.

Episodic therapy for recurrent clinical episode of genital HSV infection

Dosages for people living with HIV and people who are immunocompromised:
Acyclovir 400 mg orally three times a day for 5 days
OR
Valacyclovir 500 mg orally twice a day for 5 days
OR
Famciclovir 500 mg orally twice a day for 5 days

Suppressive therapy for recurrent clinical episodes of genital HSV that are
frequent, severe and cause distress

Dosages for people living with HIV and people who are immunocompromised:
Acyclovir 400 mg orally twice a day
OR
Valacyclovir 500 mg orally twice a day
OR
Famciclovir 500 mg orally twice a day

Pregnancy
The safety of systemic acyclovir and other two drugs are still under
investigation but current registry findings do not indicate an increased risk
for major birth defects after acyclovir therapy. Thus, the first clinical episode
of genital herpes during pregnancy may be treated with oral acyclovir and
IV route is reserved for life-threatening maternal HSV infection. However,
routine administration of acyclovir to pregnant women who have a history of
recurrent genital herpes is not recommended in the light of present situation.

3.8. HUMAN PAPILLOMAVIRUS INFECTION (HPV)

Genital Warts (Condylomata accuminata)
Exophytic genital and anal warts are benign growths due to HPV types 6 or
11. Other types like 16, 18, 31, 33, and 35 have been known to be associated
with genital dysplasia and carcinoma.

Treatment Regimens
The aim of treatment is removal of these exophytic growths. Treatment is
guided by the available resources, and the experience of the health-care

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provider. None of the available treatments is superior to the other treatments

and no single treatment is ideal for all patients or all warts.

Considerations, before therapy, should include wart size, wart number,

anatomic site, wart morphology, patient preference, cost of treatment,
convenience, adverse effects and provider experience. The available
treatments for visible ano-genital warts are either patient-applied or provider
-administered therapy.

Provider - Administered Regimens

Podophyllin resin 10% - 25% in compound tincture of benzoin can be used.
A small amount is applied and allowed to air. It should be washed off 1 -
4 hours after application to reduce local irritation. It is repeated weekly if
necessary.
OR
Podophyllotoxin 0.5%, the active constituent of podophyllin resin is
recommended if available. The use of podophyllin and podophylotoxin in
pregnancy is not to be encouraged.
OR
Trichloroacetic acid (TCA) or Bichloroacetic acid (BCA) 80% - 90% can be
used. A small amount is applied to the wart only and allowed to dry. Talc
powder or sodium bicarbonate can be used to remove unreacted acid if an
excess amount has been used. This may be repeated weekly if necessary.

Electrocautery and cryotherapy with liquid nitrogen or cryoprobe under

local anaesthesia is the common procedure performed by the health -care
personnel.

Patient-applied regimens
Podophyllotoxin 0.5% solution or gel, twice daily for 3 days (total volume of
podophyllotoxin should not exceed 0.5 ml per day), followed by 4 days of no
treatment, the cycle repeated up to 4 times.
OR
Imiquimod 5% cream applied at bed time, left on overnight, 3 times a week
for as long as 16 weeks.

The safety of both podophyllotoxin and imiquimod during pregnancy has

not yet been established.

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Follow-Up
Patients should be cautioned to watch for recurrences, which occur most
frequently during the first 3 months. Earlier follow up visits may be useful
for some patients to document the absence of warts, to monitor for or treat
complication of therapy.

Management of Sex Partners

Treatment of sex partners is necessary only when they have exophytic
warts. The use of condoms may prevent transmission to sex partners. Many
experts agree that HPV infection may persist throughout a patient’s lifetime
in a dormant state and becomes infectious intermittently. Thus, subclinical
infection can persist in both the patient and the sex partners at the same
time and their contagiousness is very hard to determine.

Special Considerations
Pregnancy
Podophyllin and podophyllin preparations are contraindicated during
pregnancy. Warts tend to proliferate and to become friable during pregnancy
and many experts encourage removal of visible warts during pregnancy.
Caesarean delivery should be considered if the pelvic outlet is obstructed of
if vaginal delivery would result in excessive bleeding.

HIV Infection
Persons infected with HIV may not respond to therapy for HPV as well as
person without HIV, and they may have more frequent recurrences after
treatment.

HPV vaccinations:
HPV vaccination is recommended for young girls aged 9 to 13 with three
doses of HPV vaccines over a period of 6 months.

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3.9. TRICHOMONIASIS
The presenting gross clinical features are a diffuse, malodorous, yellow-green
discharge with vulva irritation. Most men who are infected with T. vaginalis
do not usually have symptoms and many women have fewer symptoms
Diagnosis of vaginal trichomoniasis is usually performed by microscopy of
vaginal secretion.

T. vaginalis infection may be associated with adverse pregnancy outcomes,

especially premature rupture of the membranes and preterm delivery.

Recommended Regimen
Metronidazole 2 gm oral single dose
OR
Metronidazole 500 mg, oral, twice a day for 5 to 7 days
OR
Tinidazole 2gm single dose stat (which is more tolerable, less pill burden)

Follow-Up
Follow-up is usually unnecessary for men and women who become
asymptomatic after treatment. Re-treatment may be given if treatment failure
occurs or the dosage may be increased to 2 gm once a day for 3 - 5 days.

Management of Sex Partners

Sex partners should be treated with the same regimen until the patient and
partner(s) are free from symptoms.

Special Considerations
Allergy, Intolerance, or Adverse Reactions
Adjust Alcohol Intake but there are no Effective alternatives in place of
metronidazole are available.

Pregnancy
Pregnant women can use Tinidazole and Metronidazole in first trimester.

HIV Infection
Persons with HIV infection and trichomoniasis should receive the same
treatment as persons without HIV.

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3.10. BACTERIAL VAGINOSIS (BV)

BV is a clinical syndrome caused by the replacement of normal vaginal
bacterial flora by a high concentration of anaerobic bacteria. Although it
causes vaginal discharge or malodour, most of the women are asymptomatic.
It is usually associated with having multiple sex partners, and women who
have never been sexually active are rarely affected.

BV can be diagnosed by the use of clinical or Gram-stain criteria. Clinical

criteria require three of the following symptoms or signs:
• a homogeneous, white, non-inflammatory discharge that smoothly
coats the vaginal walls;
• the presence of clue cells on microscopic examination;
• a pH of vaginal fluid > 4.5; and
• a fishy odour of vaginal discharge before or after addition of 10%
KOH (i.e., the whiff test)

Treatment of Bacterial Vaginosis

Here, the main aim is to relieve vaginal symptoms and signs, and therefore
treatment is to be given to women who are symptomatic. As male sex
partners are usually asymptomatic, preventing transmission to men is not a
goal of therapy.

Recommended Regimens
Metronidazole 2 gm oral, single dose
OR
Metronidazole 500 mg, oral, twice a day for 5 to 7 days
OR
Tinidazole 2 gm stat (which is more tolerable, less pill burden)
OR
Patients should abstain from consuming alcohol during treatment with
metronidazole and for 24 hours thereafter.

Pregnancy and BV
All symptomatic pregnant women should be tested and treated. BV has been
associated with adverse pregnancy outcomes (e.g., premature rupture of the
membranes, chorioamnionitis, preterm labour, preterm birth, postpartum
endometritis, and post-caesarean wound infection). Some specialists prefer

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using systemic therapy to treat possible subclinical upper genital tract

infections among women at low risk for preterm delivery (i.e., those who
have on history of delivering an infant before term). Existing data do not
support the use of topical agents during pregnancy.

HIV Infection
HIV infected persons with BV should receive the same treatment as those
who are HIV negative.

3.11. VULVO-VAGINAL CANDIDIASIS (VVC)

Candida albicans is the commonest organism among candida species to
cause VVC and the clinical presentations are vaginal pruritus with erythema
of the vagina or vulva and white discharge. Other symptoms may include
vaginal soreness, vulvar burning, dyspareunia, and external dysuria. It
should be noted that VVC usually is not sexually acquired or transmitted. If
laboratory facilities are available, an initial diagnosis can be made from a wet
preparation or Gram stain of vaginal discharge which will show the presence
of yeasts or pseudohyphae.

Intravaginal Agents
Clotrimazole 500 mg, vaginal tablet, one tablet in a single application
OR
Clotrimazole 200 mg, vaginal tablets single dose, one tablet for 3 days
OR
(but there is concerns for FSW if they use Clotrimazole vaginal tablet (which
is oil based) and there is risk of condom rupture).
Miconazole 100 mg vaginal suppository, one suppository for 7 days,
OR
Nystatin 100,000 - unit vaginal tablet, one tablet for 14 days,
OR
Fluconazole 150 mg oral tablet, one tablet, single dose
OR
Ketoconazole 200mg OD for 7 days

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Alternative:
Fluconazole 150 mg oral tablet, one tablet, single dose
Single dose treatment should be reserved for uncomplicated mild to
moderate cases and multi-day regimens (3- 7) days are to be used for severe
or complicated VVC.

Follow-Up
Patients should report back only if symptoms persist or recur.

Management of sex partners

VVC is not generally transmitted through sexual intercourse and thus, routine
treatment of sex partners is not necessary. A few male sex contacts may
have balanitis characterized by erythematous areas on the glans penis
accompanied by pruritus and irritation. It should be treated with topical anti-
fungal agents.

Special Considerations
Pregnancy
VVC is common during pregnancy in which case only topical azole therapies
should be used.

HIV Infection
Acute VVC is common in women with HIV infection and may be more severe
for these women than for other women. Management is the same as for
women without HIV infection.

3.12. ECTOPARASITIC INFECTIONS

Pediculosis
Infestation with lice can take place in the head (pediculosis capitis), on
the body (pediculosis corporis - found in the seams of clothes), and in the
pubic area (pediculosis pubis). They induce intense itching, which, through
scratching, results in excoriation and secondary infection. The pubic louse
is transmitted mainly through sexual contact and commonly seen in young
adults.

Recommended Regimens
Permethrin 1 % cream applied to affected areas and washed off after 10
minutes or Lindane (gamma-benzene hexachloride) 1 % shampoo applied

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for four minutes and then thoroughly washed off (not recommended for
pregnant or lactating mother or for children < 2 years of age).

Scabies
The scabies mite, Sarcoptes scabiei, is spread by direct physical transfer,
including sexual contact. It is characterised by intense nocturnal pruritus and
the presence of burrows in the skin lesions and the mite can be demonstrated
from the end of a burrow.

Recommended Regimens
Permethrin cream 5% can be applied to all areas from the neck down and
washed off after 8-14 hours.
OR
Lindane 1% 1 oz. of lotion or 30 gm of cream applied thinly to all areas of the
body from the neck down and washed off thoroughly after 8 hours.

Alternative Regimens
The alternatives are malathion, monosulfiram (Tetmosol), crotamiton (Eurax),
benzyl benzoate (Burscabe), and 10% sulphur ointment.

Other Management Considerations

Personal cleanliness is essential and beddings, clothing’s should be thoroughly
washed and heat dried. Fumigation of living areas is not necessary.

Follow - Up
Re-treatment is indicated after one week for patients who are still symptomatic.
Patients who are not responding to one regimen may be tried with another
alternative regimen.

Management of Sex Partners and Household Contacts

Both sexual and close household contacts within the last month should be
examined and treated.

Special Considerations
Pregnant Women, Infants, and Young Children
Lindane should not be used for this group but may be treated with permethrin,
crotamiton (Eurax) or sulphur ointment.

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HIV Infection
HIV infected persons with uncomplicated infection should receive the same
treatment as persons without HIV infection. Immunosuppressed patients are
at increased risk for an extensive crusted eruption known as "Norwegian
scabies", where the skin lesions are teeming with the mites. Management
should be done in consultation with a specialist (Ivermectin 200 microgram /
kg orally repeated in 2 weeks)

3.13. HEPATITIS B (HBV)

Hepatitis B is a sexually transmitted disease commonly seen in male
homosexuals and it has been estimated that it accounts for two-thirds of new
HBV cases (need source of information) annually with 6% - 10% becoming
chronic HBV carriers. These persons are capable of transmitting HBV to
others and are at risk for developing fatal complications like cirrhosis of the
liver and hepatocellular carcinoma.

Prevention
Infection of both adults and neonates can be readily prevented with a safe
and effective vaccine, and the following high risk group for acquiring HBV
are to be recommended for vaccination: -

- Sexually active homosexual and bisexual men with multiple sex partners
- Sex partners of HBV patients and carriers
- Injecting drug users
- Men and women diagnosed as having recently acquired another STI

In general, they should be advised of their risk for HBV infection (as well as
HIV) and the means to reduce their risk i.e. no. of sexual partner, in sexual
relationship, use of condoms, disposable sterile drug injecting equipment
and HBV vaccination.

Special Considerations
Pregnancy
Pregnancy is not a contraindication to HBV vaccination.

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HIV Infection
HIV infected persons are more likely to become chronic HBV carriers and
they may develop impaired response to HBV vaccine, and re-vaccination
may have to be considered for those who do not respond to vaccination
initially.

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4. SYNDROMIC MANAGEMENT

4.1 GENITAL DISCHARGE

4.1.1. Urethral Discharge

Clinical Features: Burning micturition

Mucoid/Mucopurulent/Purulent-urethral discharge
Asymptomatic infection common
Common Organisms N. gonorrhoeae
C. trachomatis
Ureaplasma urealyticum
T. vaginalis

Diagnosis:
If laboratory facilities are available: Gram-stained smear from urethral swab
will be useful to confirm the presence of gonococcal infections in men.
Presence of gram negative intracellular diplococci): - Gonococcal urethritis
(GCU)
Absence of gram negative intracellular diplococci with polymorphonuclear
cells > 5 per oil immersion field: - Non-gonococcal urethritis (NGU)

Management:
Treatment should be given depending on the laboratory results.
If laboratory facilities are not available, treat for both GC and NGU infections.

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Figure 1 Urethral Discharge

Patient complains of
urethral discharge and/
or dysuria

Take history, assess risk 1

and examine
Milk urethra if no visible
discharge
• Educate and counsel
• Promote condom use and
provide condoms
2
No
• Do VDRL/RPR/rapid syphilis
test if available
Yes
• Offer counselling and
testing for HIV
TREAT FOR GONOCOCCAL 3 AND
CHLAMYDIAL INFECTIONS
• Educate and counsel
• Promote condom use and provide
condoms
• Counsel and treat partner/s
• Do VDRL/RPR/rapid syphilis test
if available
• Offer counselling and testing for HIV
• Ask patient to return in 7 days
if symptoms persist

7 days

Examine for discharge;

milk urethra if no visible discharge Cured
• Educate and counsel

Discharge present? No
• Promote condom use and
provide condoms
• Offer HIV counselling and
Yes
testing if not done at
previous visit
Refer to higher level of care
Follow persistent urethral discharge
flow chart

1 Assess risk for

• u nprotected sex • Condom breakage or slippage • New partner
2 If feasible, encourage patient to return the following day after holding the urine for 4 hours
and reassess for discharge.
3 If microscopy is available, do Gram stain on urethral smear.
If Gram-negative intracellular diplococci are seen, treat for gonococcal and chlamydial infections.
If no Gram-negative diplococci are seen, treatment for chlamydial infection only may be considered.

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Recommended regimen for urethral discharge syndrome: -

Ceftriaxone 500 mg IM single dose
OR
Cefixime 400 mg, oral, single dose
OR
Spectinomycin 2 gm, IM as a single dose
PLUS
Azithromycin 1 gm, oral, single dose
OR
Doxycycline 100 mg, oral, twice a day for 7 days

Follow-Up for Patients Who Have Urethritis

Instruct the patient to return for follow-up if urethritis persists or recurs
after complete treatment. Symptoms alone, without any history of sexual
re-exposure or laboratory evidence of urethral inflammation, are not an
indication for re-treatment.

Management of Partners
All sexual partners within the last 30 days should be referred by the patient
for evaluation and treatment. Patients should be encouraged to bring their
marital partners to the clinic as, most of the time; the patient can hardly find
the sexual contact after the sexual encounter, either casually or on a paid basis.

Persistent Urethritis
Recurrent or persistent urethritis is a common clinical condition seen in
Myanmar in STI patients who have been treated for gonorrhoea as well as
for non-gonococcal urethritis. Most of the time, the laboratory evidence is
negative for gonorrhoea and yet the patient returns with symptoms and
signs of urethral discharge which is very disturbing and frustrating. Objective
signs of urethritis should be present before starting antimicrobial therapy.
Patients who have persistent urethritis should be retreated with the initial
regimen if bad compliance is suspected or if there is a history of re-exposure
to an untreated sex partner(s). If possible, a wet mount preparation should be
made and examined for T. vaginalis. Usually, urologic examination is negative
for a specific etiology.

The following treatment regime is recommended for a patient with good

compliance and in whom re-exposure can be excluded: -

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Figure 2. Persistent Urethral Discharge

Patient complains
of
persistent urethral discharge

Take history, and examine

Evaluate for compliance and reinfection

• Educate and counsel

• Promote condom use and provide
Discharge confirmed No condoms
• Offer HIV counselling and testing
if not done at previous visit

Yes

1
TREAT FOR N.Gonorrhoea, Trichomonas vaginalis AND Mycoplasma INFECTION
• Educate and counsel
• Promote condom use and provide condoms
• Manage and treat partner/s
• Ask patient to return in 7 days if symptoms persist
• Offer HIV counselling and testing if not tested at previous visit
• Partner Management Treatment (GC,CT,MG,TV)

Discharge
Present

2
Yes

Refer to a higher facility

1 Add treatment for Mycoplasma infection depending on the local situation.

2 Consider infection with cephalosporin-resistant Neisseria gonorrhoeae refer for GC culture
and AMR surveillance.

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Recommended Treatment for Persistent Urethritis

Injection Ceftriaxone 500 mg
PLUS
Azithromycin 2 grams
PLUS
Metronidazole 2 gm, oral, single dose
OR
Tinidazole 2gm, oral, as a single dose
OR
Metronidazole 400 or 500 mg, twice daily, for 7 days

Special Considerations
HIV Infection: - Urethritis syndrome including gonococcal, Chlamydia, non-
gonococcal, non-Chlamydia urethritis are known to facilitate HIV transmission.
Patients with NGU who are HIV-positive should receive the same treatment
regime as those who are HIV- negative.

4.1.2 Abnormal Vaginal Discharge

A spontaneous complaint of abnormal vaginal discharge (in terms of quantity,

colour or odour) is most commonly a result of a vaginal infection. It may, in
rare cases, be caused by mucopurulent STI related cervicitis. T. vaginalis, C.
albicans and bacterial vaginosis (BV) are the commonest causes of vaginal
infection. N. gonorrhoeae and C. trachomatis cause cervical infection. The
clinical detection of cervical infection is difficult because a large proportion
of women with gonococcal or chlamydial cervical infection is asymptomatic.
The symptom of abnormal vaginal discharge is highly indicative of vaginal
infection, but poorly predictive for cervical infection. Thus, all women
presenting with vaginal discharge should receive treatment for trichomoniasis
and BV.

Among women presenting with discharge, one can attempt to identify those
with an increased likelihood of being infected with N. gonorrhoeae and/
or C. trachomatis. To identify women at greater risk, therefore, of cervical
infection, an assessment of a woman’s risk status may be useful, especially
when risk factors are adapted to the local situation. Given that microscopy
requires special training, is time consuming and adds relatively little given the
amount of time and resources it requires, it is generally not recommended

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at the primary health care level. However, in settings where Gram stain can
be carried out in an efficient manner, such as a referral clinic, identification of
Gram-negative intracellular diploccoci and/or T. vaginalis can be attempted.

Knowledge of the local prevalence of gonococcal and/or chlamydia in women

presenting with vaginal discharge is important when making the decision
to treat for cervical infection. The higher the prevalence, the stronger the
justification for treatment. Women with a positive risk assessment have
a higher likelihood of cervical infection than those who are risk negative.
Women with vaginal discharge and a positive risk assessment should,
therefore, be offered treatment for gonococcal and chlamydia cervicitis.

Where resources permit, the use of laboratory tests to screen women with
vaginal discharge should be considered. Such screening could be applied
to all women with discharge or selectively to those with discharge and a
positive risk assessment.

Recommended treatment for abnormal vaginal discharge

Cervical Infection
Women with vaginal discharge and a positive risk assessment or in settings
with high prevalence of gonorrhoea and /or chlamydial infection, should be
treated for gonococcal and chlamydia cervicitis as follow:
Ceftriaxone 500 mg IM single dose
OR
Cefixime 400 mg, oral, single dose
OR
Spectinomycin 2 gm, IM, single dose
PLUS
Azithromycin 1 gm, oral, single dose
OR
Doxycycline 100 mg, oral, twice a day for 7 days
OR
Erythromycin 500 mg, oral, four times a day for 7 days
OR
Tetracycline 500 mg, oral, four times a day for 7 days

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Vaginal Infection
Vaginitis is characterised by a vaginal discharge, or vulvar itching and
irritation and a vaginal odour may be present. The three common diseases
are trichomoniasis (due to T. vaginalis), bacterial vaginosis (BV) (caused by
replacement of the normal vaginal flora by an overgrowth of anaerobic
microorganisms and Gardnerella vaginalis), and candidiasis (usually due to
Candida albicans).

Recommended treatment for vaginitis (BV and TV)

Metronidazole 2 gm, oral, single dose
OR
Tinidazole 2gm, oral, single dose
OR
Metronidazole 500 mg, oral, twice a day for 7 days

And treat for C. albicans where indicated

Clotrimazole 500 mg, vaginal tablet, one tablet in a single application,
OR
Clotrimazole 200 mg, vaginal tablets, one tablet for 3 days,
OR
Miconazole 200 mg vaginal suppository, one suppository for 3 days,
OR
Miconazole 100 mg vaginal suppository, one suppository for 7 days,
OR
Nystatin 100,000 - unit vaginal tablet, one tablet for 14 days,
OR
Fluconazole 150 mg oral tablet, one tablet, single dose
OR
Ketoconazole 200mg OD for 7 days

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Figure 3 Vaginal Discharge

Patient complains of
vaginal discharge, and/or dysuria,
vulval itching or burning

• Take history and assess risk 1

• Examine
• Exclude physiological discharge

• Educate and counsel

Abnormal discharge No
• Promote condom use and
provide condoms
• Do VDRL/RPR/rapid syphilis
Yes
test
• Offer counselling and
testing for HIV

Risk assessment TREAT FOR GONOCOCCAL and CHLAMYDIAL

Yes
positive? INFECTIONS, BACTERIAL VAGINOSIS,
TRICHOMONIASIS

No

Vulval oedema/curd like

TREAT FOR
discharge, erythema, No
BACTERIAL VAGINOSIS,
excoriations present?
TRICHOMONIASIS VAGINAUS

Yes

TREAT FOR CANDIDIASIS

• Educate and counsel.

• Promote condom use and provide condoms.
• Counsel and treat partner for gonococcal, chlamydial and trichomoniasis
infections if risk assessment is positive.
• Do VDRL/RPR/rapid syphilis test.
• Offer counselling and testing for HIV.
• Ask patient to return in 7 days if symptoms persist and refer to a higher facility.

1 Risk factors such as multiple partners and partner with symptoms are frequently associated with cervicitis.

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Figure 4 Vaginal Discharge with Speculum Examination

Patient complains of vaginal discharge,

and/or dysuria, vulval itching or burning

• Take history and assess risk 1

• Examine patient (external, speculum, bimanual)
• Exclude physiological discharge

No

TREAT FOR GONOCOCCAL and

Signs of cervicitis present 2 CHLAMYDIAL INFECTIONS, BACTERIAL
Yes
or risk assessment positive? VAGINOSIS, TRICHOMONIASIS

No

Vulval oedema/curd like

TREAT FOR BACTERIAL VAGINOSIS, discharge, erythema, No
TRICHOMONIASIS excoriations present?

Yes

TREAT FOR CANDIDIASIS

• Educate and counsel.

• Promote condom use and provide condoms.
• Counsel and treat partner for gonococcal, chlamydial and trichomoniasis
infections if risk assessment is positive.
• Do VDRL/RPR/rapid syphilis test.
• Offer counselling and testing for HIV.
• Ask patient to return in 7 days if symptoms persist and refer to a higher facility.

1 Risk factors such as multiple partners and partner with symptoms are frequently associated with cervicitis.
2 Signs of cervicitis include cervical mucopus/erosion, easily induced cervical bleeding.

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Figure 5 Vaginal Discharge with Speculum and Laboratory Diagnosis

Patient complains of vaginal discharge

and/or dysuria, vulval itching or burning

• Take history and assess risk 1

• Examine patient (external, speculum and bimanual examination)
• Exclude physiological discharge

TREAT FOR GONOCOCCAL INFECTION,

CHLAMYDIASIS
Signs of cervicitis present 2
Yes PLUS
or risk assessment positive?
Vaginal infection according to speculum
examination and microscopic finding as
shown below
No

Perform wet mount / Gram stain microscopy of vaginal specimen and cervical smear (if cervical smear + for)

Motile Clue cells seen Budding yeasts Gram - intra/extra No

trichomonads plus pH>4.5 or or pseudohyphae cellular diplococci abnormal
seen KOH positive seen or pus cell 20+ findings

TREAT FOR TREAT FOR TREAT FOR TREAT FOR

TRICHOMONAISIS BACTERIAL VAGINOSIS CANDIDIASIS GC and CT

• Educate and counsel.

• Promote condom use and provide condoms.
• Treat partner if microscopy demonstrates trichomonads.
• Counsel and treat partner for gonococcal and chlamydial infections if signs of
cervicitis present or risk assessment is positive.
• Do VDRL/RPR/rapid syphilis test.
• Offer counselling and testing for HIV or refer.
• Ask patient to return in 7 days if symptoms persist and refer to a higher facility.

1 Risk factors such as multiple partners and partner with symptoms are frequently associated with cervicitis.
2 Signs of cervicitis include cervical mucopus/erosion, easily induced cervical bleeding.

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4.1.3. Anorectal Discharge

Figure 6 Ano-rectal Discharge

Patient presents with

anorectal discharge and/or
symptoms of proctitis 1

2
Take history, assess risk and
examine (external and perianal)
± anoscopy • Educate and counsel
• Promote condom use
and provide condoms
• Do VDRL/RPR/
Discharge seen? No
rapid syphilis test if
available
• Offer counselling and
Yes
testing for HIV

Treat for Gonorrhoea and Chiamydial

infections 3

• Educate and counsel

• Promote condom use and provide
condoms
• Do VDRL/RPR/rapid syphilis test
• Offer HIV counselling and testing
• Treat partner/s for gonorrhoea and
chlamydial infection
• Ask patient to return in 7 days

7 days

Improved?

No

Refer to a higher facility

1 Symptoms of proctitis include perianal pain, mucopurulent anal discharge, anorectal bleeding, constipation,
sensation of rectal fullness or of incomplete defecation, tenesmus and discomfort.
2 Receptive anal sex during past 6 months, insertive partner has STI, multiple partners, unprotected sex
(risk factors need to be validated according to the country setting)
3 If syphilis serology results are available and are positive, treat patient and partner/s for syphilis.

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Recommended Regimen for C. Trachomatis Infection

Doxycycline 100 mg, twice a day, for 7 days
OR
Azithromycin 1 gm, orally, single dose

Recommended Regimen for Gonorrhoea Infection

Ceftriaxone 500 mg, IM, stat single dose
OR
Cefixime 400 mg, orally stat, single dose (Need AMR Monitoring whether
the efficacy is still acceptable in Myanmar)
PLUS
As co-infection with C. trachomatis is common, it is advisable to add a regimen
that is effective against C. trachomatis. In clinical trials, these recommended
regimens have a cure rate of > 95% especially for anal and genital infections.

4.2. GENITAL ULCERATIVE DISEASES

The common genital ulcerative diseases seen in the local health settings
are syphilis, chancroid and genital herpes. The demographic situation in
Myanmar has not been established scientifically yet and the reports compiled
by the health personnel concerned, with the available limited resources, do
not reveal the true situation at any given time.

At the peripheral level, diagnosis is based mainly on history and physical

examination except at the categorical STI clinics, which are few in number
to provide adequate etiology services for the whole country, and even in
these clinics, laboratory facilities are still limited such as facilities for culture
methods. Ideally, evaluation of a person with genital ulcerative disease
should include a serologic test for syphilis, Dark-field examination or direct
immunofluorescence test for T. pallidum, culture or antigen test for HSV and
culture for H. ducreyi. In addition to this, HIV testing should be included
especially for those with syphilis or chancroid.

After examination to confirm the presence of genital ulceration, treatment

appropriate to local aetiologies and antimicrobial sensitivity patterns should be
given. In areas where both syphilis and chancroid are prevalent, for example,
patients with genital ulcers should be treated for both conditions at the time of
their initial presentation, to ensure adequate therapy in case of loss to follow-up.

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Genital ulcers and HIV infection

There have been a number of anecdotal reports in the literature suggesting
that the natural history of syphilis may be altered as a result of concomitant
HIV infection.

Some reports have indicated atypical presentations of both primary and

secondary syphilis lesions. Some have noted an increase in treatment failure
rates among patients with early syphilis who are treated with single-dose
therapies of penicillin.

In chancroid, atypical lesions have been reported in HIV-infected individuals.

The lesions tend to be more extensive, or multiple lesions may form that are
sometimes accompanied by systemic manifestations such as fever and chills.
Reports of rapidly aggressive lesions have been noted by some clinicians.
This emphasizes the need for early treatment, especially in HIV-infected
individuals. There is evidence to suggest that HIV infection may increase
rates of treatment failure in chancroid, especially when single-dose therapies
are given. More researches are needed to confirm these observations. In
immunosuppressed individuals, herpes simplex lesions may present as
persistent multiple ulcers that require medical attention, as opposed to
the self-limiting vesicles and ulcers, which occur in immune-competent
individuals. Thus, antiviral treatment is particularly important in such
instances, to be given therapeutically or prophylactically to offer comfort to
the patient. Adequate education needs to be given to the patient as well,
to explain the nature and purpose of treatment and in order to avoid false
expectations of cure.

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Figure 7 Genital Ulcer Diseases

Patient complains of a
genital sore or ulcer

Take history and examine

Sore of Ulcers
present ?

Yes

TREAT FOR SYPHILIS , HSV , CHANCROID *

• Educate and counsel

• Promote condom use and provide
condoms
• Do VDRL/RPR/rapid syphilis test **
• Offer HIV counselling and testing
• Treat partner/s for gonorrhoea and
chlamydial infection
• Ask patient to return in 7 days

Not Improved?

Refer to a higher facility

* The patient will be treated for both Syphilis and Chancroid because they were highly infections.
Herpes infection can be diagnosed from history taking and examination .
** Syphilis may be negative in early syphilis.

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Recommended treatment for genital ulcers syndrome: Treat for syphilis

and chancroid
Benzathine penicillin G 2.4 million units IM in a single dose
PLUS
Azithromycin 1 gm orally in a single dose
OR
Ceftriaxone 250 mg, IM, in a single dose
OR
Ciprofloxacin 500 mg orally twice a day for 3 days
OR
Erythromycin base 500 mg orally four times a day for 7 days
PLUS
Genital Herpes Simplex Management
Acyclovir 400 mg orally three times a day for 10 days
OR
Valacyclovir 500 mg orally twice a day for 10 days
OR
Famciclovir 250 mg orally three times a day for 10 days

Specific treatment for herpes genitalis is recommended as it offers clinical

benefits to most symptomatic patients. Health education and counselling
regarding the recurrent nature of genital herpes lesions, the natural history,
sexual transmission, probable perinatal transmission of the infection and
available methods to reduce transmission, are an integral part of genital
herpes management.

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4.2.1 Ano-rectal Ulcer

Figure 8: Ano-rectal Ulcer

Patient presents with

anorectal ulcer with or without
Inguinal Lymphadenopathy 1

2
Take history, assess risk and
examine (external and perianal)
± anoscopy • Educate and counsel
• Promote condom use
and provide condoms
• Do VDRL/RPR/
Ulcers seen? No
rapid syphilis test if
available 4
• Offer counselling and
Yes
testing for HIV

Treat for HSV , LGV , Chancroid and

Syphilis infections 3

• Educate and counsel

• Promote condom use and provide
condoms
• Do VDRL/RPR/rapid syphilis test 4
• Offer HIV counselling and testing
• Treat partner/s for gonorrhoea and
chlamydial infection
• Ask patient to return in 7 days

7 days

Improved?

No

Refer to a higher facility

1 Symptoms of proctitis include perianal pain, mucopurulent anal discharge, anorectal bleeding, constipation,
sensation of rectal fullness or of incomplete defecation, tenesmus and discomfort.
2 Receptive anal sex during past 6 months, insertive partner has STI, multiple partners, unprotected sex
(risk factors need to be validated according to the country setting)
3 Treat for Mycoplasma infection depending on the local situation.
4 If syphilis serology results are available and are positive, treat patient and partner/s for syphilis.

Include treatment recommendations for HSV, Chancroid and Syphilis ( As in

genital ulcer disease)

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4.3. INGUINAL BUBO

Inguinal and femoral buboes are localised enlargements of the lymph nodes
in the groin area, which are painful and may be fluctuant. They are frequently
associated with LGV and chancroid. In many cases of chancroid, an associated
genital ulcer is visible. Non-sexually transmitted local and systemic infections
(e.g. infections of the lower limb or tuberculous lymphadenopathy) can also
cause swelling of inguinal lymph nodes.

Figure 9 Inguinal Bubo

Patient complains of
inguinal swelling

Take history
and examine
• Educate and counsel
• Promote condom use and
Inguinal/femoral provide condoms
No
bubo(s) present? • Do VDRL/RPR/rapid syphilis
test if available
Yes • Offer counselling and
testing for HIV

u lcer(s) present? No TREAT FOR

LYMPHOGRANULOMA VENEREUM

Yes • If lymph nodes fluctuant, aspirate through healthy skin

• Educate on treatment compliance
• Counsel on risk reduction
• Promote condom use and provide condoms
• Manage and treat partner/s
REFER TO GENITAL ULCER
• Do VDRL/RPR/rapid syphilis test
FLOWCHART
• Offer counselling and testing for HIV
• If fluctuant, aspirate through • Review in 7 days, and continue treatment if improving
healthy skin or refer if not improving/worse
• Educate on treatment
compliance
• Promote condom use and
provide condoms
• Manage and treat partner/s
• Do VDRL/RPR/rapid syphilis
test
• Offer counselling and testing
for HIV
• Review in 7 days, and continue
treatment if improving or refer
if not improving/worse

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Recommended treatment for inguinal bubo

Doxycycline, 100mg orally, twice daily for 21 days
OR
Erythromycin, 500 mg orally, four times daily for 21 days’ Fluctuant lymph
nodes should be aspirated through healthy skin. Incision and drainage or
excision of nodes may delay healing and should not be attempted.

4.4. SWELLING OF THE SCROTUM

The common organisms responsible for epididymitis in men < 35 years of
age are N. gonorrhoeae and C. trachomatis, and E. coli infection is common
among male homosexuals, especially insertive partners during anal sex.

Typical presenting features are unilateral testicular pain and tenderness, and
swelling of the testis. Testicular torsion should be excluded especially if the
onset of pain is sudden, severe and with very little evidence of urethritis or
urinary tract infection.

In older men, where there may have been no risk of a sexually transmitted
infection, other general infections may be responsible, for example,
Escherichia coli, Klebsiella spp. or Pseudomonas aeruginosa. A tuberculous
orchitis, generally accompanied by an epididymitis, is always secondary to
lesions elsewhere, especially in the lungs or bones.

In pre-pubertal children, the usual etiology is coliform, pseudomonas

infection or mumps virus. Mumps epididymo-orchitis is usually noted within
a week of parotid enlargement.

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Figure 10 Scrotal Swelling

Patient complains of scrotal

swelling/pain

Take history
and examine

• Reassure patient and educate

• Provide analgesics, if necessary
Swelling/pain confirmed? • Promote condom use and provide condoms
No
Refer if seen at PHC BHS • Do VDRL/RPR/rapid syphilis test
• Offer counselling and testing for HIV
Yes

Testis rotated or
elevated, or history No TREAT FOR GONOCOCCAL AND
of trauma? CHLAMYDIAL INFECTION

• Educate and counsel

Yes • Promote condom use and provide condoms
• Counsel and treat partner/s
• Do VDRL/RPR/rapid syphilis test
Refer for urgent surgical assessment • Offer counselling and testing for HIV
• Review in 3 days or earlier if necessary.

3 days

No Clinically
improved?

Yes

• Continue treatment to complete the course of antibiotics

• Check if partner/s treated
• Offer counselling and testing for HIV if not done at previous visit

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Recommended Regimens
Ceftriaxone 500 mg IM in single dose
PLUS
Doxycycline 100 mg orally twice a day for 14 days
(This regimen will cover both gonococcal and chlamydial infection)

Alternative Regimen
Spectinomycin 2 gm IM
PLUS
Azithromycin 250 mg bid for 3 days
OR
Erythromycin 500 mg, four times a day for 14 days
Supportive measures like bed rest, scrotal elevation, and analgesics, are
recommended until fever and local inflammation have subsided.

Follow - Up
If there is no improvement, the differential diagnosis includes tumour, abscess,
infarction, testicular cancer, and tuberculosis or deep fungus infection.

Management of Sex Partners

Sex partners of these patients should be evaluated and treated especially
if the sexual contact with the index patient was within the last 60 days
preceding onset of symptoms in the patient.

Special Considerations
HIV Infection: - Patients with HIV infection and uncomplicated epididymitis
should be treated with the same regimen as persons without HIV.

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4.5. PELVIC INFLAMMATORY DISEASE (PID)

STI organisms, especially N. gonorrhoeae and C. trachomatis, are the main
causes of PID and other organisms like vaginal anaerobes, G. vaginalis, H.
influenzae, enteric Gram negative rods, and some streptococci species may
also cause PID.

Clinical features of Lower Abdominal Pain in Female (PID):

Symptoms : Dyspareunia
Lower Abdominal pain
Irregular bleeding
Signs : Abnormal vaginal or cervical discharge
Lower abdominal tenderness on palpation/cervical
motion tenderness
Temperature more than 38C
Common causes : Gonorrhoea, Chlamydia infection and mixed
anaerobes
Since there is a wide range of variations in symptoms and signs, it is with
difficulty that diagnosis of acute PID is made. Many women with PID often
exhibit mild symptoms that are not easily recognized. Thus, delay in diagnosis
and treatment probably contributes to serious sequelae. At the present
health care settings, no single historical, physical or laboratory finding is
both sensitive and specific for diagnosis of acute PID.

The following recommendations for diagnosis of PID are intended to

promote awareness of health care providers to recognize when PID should be
suspected and when to obtain additional information to clinch the diagnosis.

Diagnostic Criteria
Minimum criteria are
• Lower abdominal tenderness
• Adnexal tenderness
• Cervical motion tenderness

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Additional criteria supporting the diagnosis of PID include

• Fever, > 101 F or 38.3 C
• Abnormal cervical or vaginal mucopurulent discharge
• Presence of WBC on microscopy of vaginal secretion
• Elevated erythrocyte sedimentation rate
• Laboratory documentation of cervical infection with N. gonorrhoeae
or C. trachomatis

Management of PID
It is recommended that all patients with severe clinical signs be hospitalized
so that supervised treatment with parenteral antibiotics can be initiated. Oral
therapy can be started within 24 hours of clinical improvement. Criteria for
hospitalization include:
- The diagnosis is uncertain, and surgical conditions like appendicitis and
ectopic pregnancy cannot be excluded
- Pelvic abscess is suspected
- Patient is pregnant
- No clinical response to oral antimicrobial therapy
- Patient unable to follow or tolerate an out-patient oral regimen
- Patient has severe illness, nausea, vomiting or high fever

OPD treatment Regimes

Ceftriaxone 500 mg IM once
PLUS
Doxycycline 100 mg orally twice a day for 14 days
PLUS
Metronidazole 400-500 mg, orally twice a day for 14 days

Parenteral Regimen (In patient)

Cefoxitin 2 gm IV every 6 hours
OR
Cefotetan 2 gm IV every 12 hours
PLUS
Doxycycline 100 mg orally every 12 hours for 14 days
PLUS
Metronidazole 400-500 mg orally twice a day for 14 days

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 Sexually Transmitted Infection Management Guideline 2017

NOTE: Either of these regimens can be used. Parenteral therapy may be

discontinued 24 hours after the patient improves clinically and oral therapy
can be continued with doxycycline 100 mg orally twice a day to complete a
total of 14 days of treatment.

Follow-Up
Clinical improvement should be seen within 3 - 5 days from the start of
therapy (defervescence, reduction in direct or rebound tenderness and
reduction in uterine, adnexal and cervical motion tenderness. Patients who
do not show any clinical improvement may need further diagnostic work up,
or surgical intervention, or both.

Management of Sex Partners

Evaluation and treatment of sex partners of patients with PID is compulsory
because of the risk for reinfection of urethral gonococcal or chlamydial
infection from the partner.

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Figure 11 Lower Abdominal Pain

Patient complains of lower

abdominal pain

Take history, assess risk 1 and examine

(abdominal and gynaecological)

Is there lower
Any of the following present? abdominal
• Missed/overdue period tenderness,
• Recent delivery/abortion cervical motion Any other
• Abdominal guarding and / No tenderness No illness
or rebound tenderness or adenexal found?
• Abnormal vaginal bleeding tenderness
• Abdominal mass and/or vaginal Yes
discharge?
Yes
Yes

Refer patient for immediate surgical or

gynaecological management TREAT FOR PID 2 Manage appropriately
Before referral, set up an IV line and apply Review in 3 days
resuscitatory measures if necessary
3 days

Patient has Refer to a

No
improved? higher facility

Yes

• Continue treatment until completed

• Educate and counsel
• Promote condom use and provide condoms
• Do VDRL/RPR/rapid syphilis test
• Offer counselling and testing for HIV
• Ask patient to return in 4 days if symptoms persist and refer to a higher facility
• Counsel and treat partner/s for gonococcal and chlamydial infections

1 Risk factors such as multiple partners and partner with STI symptoms are frequently associated with cervicitis.
2 Patients with acute PID should be referred for hospitalization, when:
• they have severe illness, nausea and vomiting, and/or high fever (>38°C)
• the patient is pregnant
• the patient is unable to follow or tolerate an outpatient regimen
• the patient has failed to respond to outpatient therapy, or
• there are clinical signs of tubo-ovarian abscess or pelvic peritonitis

Special Considerations
Pregnancy : Pregnant women with suspected PID should be hospitalized
and treated with parenteral antibiotics.
HIV Infection : HIV infected women who develop PID should be treated
aggressively and they may need surgical intervention.

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4.6. NEONATAL CONJUNCTIVITIS

Neonatal conjunctivitis (ophthalmia neonatorum) can lead to blindness when
caused by N. gonorrhoeae and treatment is delayed. The most important
sexually transmitted pathogens which cause ophthalmia neonatorum are N.
gonorrhoeae and C. trachomatis. In developing countries, N. gonorrhoeae
accounts for 20–75% and C. trachomatis for 15–35% of cases brought to
medical attention. Other common causes are Staphylococcus aureus,
Streptococcus pneumoniae, Haemophilus spp. and Pseudomonas spp.
Newborn babies are generally presented because of redness and swelling of
the eyelids or “sticky eyes”, or because of discharge from the eye(s).

As the clinical manifestations and possible complications of gonococcal

and chlamydial infections are similar, in settings where it is impossible to
differentiate between the two infections, treatment should be provided to
cover both. This would include single-dose therapy for gonorrhoea and
multiple dose therapy for chlamydia.

Recommended treatment for neonatal conjunctivitis

Ceftriaxone 25-50 mg/kg IM as a single dose, to a maximum of 75 mg
OR
Spectinomycin 25 mg/kg IM as a single dose, to a maximum of 75 mg
PLUS
Erythromycin 50 mg/kg/day, oral, divided into four doses daily for 14 days

4.7. SYPHILIS TESTING FLOW CHARTS

Mother-to-child transmission of syphilis (congenital syphilis) is usually
devastating to the foetus if maternal infection is not detected and treated
sufficiently early in pregnancy. Most untreated primary and secondary
syphilis infections in pregnancy result in severe adverse pregnancy outcomes,
often foetal deaths and in congenital syphilis. Latent (asymptomatic) syphilis
infections in pregnancy also cause serious adverse pregnancy outcomes in
more than half of cases.

Severe adverse pregnancy outcomes and congenital syphilis is preventable,

however, and elimination of mother-to-child transmission of syphilis can be
achieved through implementation of effective early screening and treatment
strategies for syphilis in pregnant women. The fetus can be easily cured with
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treatment, and the risk of adverse outcomes to the fetus is minimal if the
mother receives adequate treatment during early pregnancy ideally before
the second trimester. There are indications that mother to child transmission
of syphilis is beginning to decline globally due to increased efforts to screen
and treat pregnant women for syphilis.

Syphilis Screening by only Rapid Test

In settings in which RPR and TPHA test is being implemented successfully,
including adequate access to current syphilis testing and treatment, high
coverage or pregnant women being screened and good quality test, then
continue the same flowchart. The treponemal RST can be introduced as a
rapid method of confirming RPR seropositive tests, either as a laboratory-
based confirmatory test or at the same facility where the RPR is being
performed.

This allows for confirmatory testing or treatment to be initiated at the first

visit – same day testing and treatment. The use of the treponemal RST at the
primary point-of-care also avoids transportation of samples to a laboratory
and saves on laboratory time and cost. Additionally, in a few areas where
current diagnosis depends on non-treponemal testing alone, the addition
of RSTs to the clinical flowchart avoids the overtreatment of persons with
biological false positive results.

Figure 12 Syphilis Screening by only Rapid Test

Rapid Plasma Reagin (RPR) / VDRL testing available

Serum

RPR/VDRL

+ve —ve

Rapid Syphilis Test Treponemal

+ve —ve No treatment necessary

Confirmed Syphilis
TREAT

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Syphilis Screening started with Serological Testing

In settings in which no RPR testing is being performed and where it would not
be feasible to introduce it consider rapid syphilis test (treponemal test) This
applies to remote areas without the prerequisite facilities for the RPR, such as
electricity for refrigeration of reagents, rotator and blood centrifugation, or even
in some urban settings with a high turnover rate of patients where RPR testing
becomes impractical. In this case the treponemal RST result is used to direct
treatment for syphilis. This is particularly relevant for screening pregnant women
in poorly-resourced areas and can be perfomed by a trained midwife.
While this approach fails to identify those with active syphilis and will
consequently lead to overtreatment of some patients who have been cured
and not re-infected, it has the overwhelming advantage that it will prevent
congenital infection in the majority of pregnant women at risk of infection
with syphilis (Figure 13). Women who test positive with a treponemal RST
will most likely be still positive at a subsequent pregnancy. Therefore, either
they should be assessed with a quantitative RPR test, where available, or be
offered treatment for syphilis without a repeat treponemal RST, especially if
the risk of reinfection is assessed to be high.
For treatment of syphilis in pregnancy, refer them to the appropriate
treatment page.

Figure 13 Syphilis Screening started with Serological Testing

Only syphilis rapid test available , no Rapid Plasma Reagin (RPR)

testing available or possible (midwife for ANC testing ???)

Blood

Rapid Syphilis Test (Treponemal)

+ve —ve

Previously treated or No treatment necessary

current active syphilis

TREAT for syphilis

Note: Some patients may be overtreated
Note
1. The treponemal test does not distinguish between previously adequately treated and untreated syphilis.
2. The sensitivity of treponemal RDTs is reduced with whole blood. Serum performs better.
3. In pregnant women, subsequent testing will likely be still seropositive, therefore, previously RDT-positive women could
be treated without re-testing if risk of reinfection is considered high. Alternatively, seek quantitative RPR testing.

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REFERENCES:

1. Global Action Plan to control the spread and impact of

Antimicrobial Resistance in Neisseria Gonorrhoea by World
Health Organization

2. Regional Strategy for the Prevention and Control of Sexually

Transmitted Infections 2007 to 2015 by World Health Organization

3. Management of Sexually Transmitted Infections, Regional

Guidelines by WHO Regional Office for South East Asia

4. Elimination of New Paediatric HIV infections and Congenital

Syphilis in Asia Pacific 2011-2015

5. Regional Health Sector Strategy on HIV 2011-2015

6. Sexually Transmitted Diseases Treatment Guidelines, Center for

Disease Control and Prevention, 2015

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