Guidelines>Zambia HIV National Guidelines>

• Prevalence: STI prevalence remains high in many developing countries. In Zambia, STIs account for up to 10% of diseases for which adults seek health care services.
• Complications: Symptomatic and asymptomatic STIs can lead to serious complications, especially in women and newborn babies: cervical cancer, PID, chronic pelvic pain, foetal wastage, ectopic pregnancy, infertility and related maternal mortality. Chlamydia and gonorrhoea are important causes of infertility, especially in women. Chlamydia is important cause of infant pneumonia. Neonatal gonococcal infections of eyes can lead to blindness. Congenital syphilis is significant cause of infant morbidity and mortality. In adults, syphilis can cause cardiac and neurological damage which can ultimately be fatal. Complications can be avoided if STIs recognised early and treated correctly.
• STI-HIV Synergy: Both ulcerative and non-ulcerative STIs facilitate HIV transmission. HIV can make people more susceptible to other STIs HIV increases severity and resistance to treatment of some STIs. Unprotected sex exposes people to both HIV and other STIs. Consistent use of condoms can prevent both kinds of infection.
• Breaking Cycle of Transmission: Requires patient education and counselling on (1) need to comply with treatment, (2) Risk reduction (avoid sex until cured or use condoms), and (3) Partner notification and treatment.
• Routine STI Screening and HIV Counselling and Testing: Routinely screen and examine all patients seen at VCT centres, PMTCT sites, home-based care centers, HIV care centres and other medical facilities to identify and treat STIs. Routinely offer HIV counselling and testing to all STI clinic patients. Knowledge of HIV status is important incentive for positive behaviour change.
• Standard Patient Education and Counselling: All patients with STIs must receive following minimum package of health education: Routine offer of HIV counselling and testing PLUS the "4 C's of Health Education": (1) Counsel and educate on risk reduction, (2) Condom promotion and provision, (3) Compliance with treatment, (4) Contacting and treating partners. These must be offered in setting that ensures privacy and confidentiality.

• 2 traditional approaches to Dx: (1) Etiological Dx (using lab tests to identify causative agent) and (2) Clinical Dx (using clinical experience to identify symptoms typical for specific STI). Both have limitations:
• -Etiological Dx: expensive and time-consuming, requiring special resources and delays in treatment.
• -Clinical Dx: Incorrect Dx occurs, and mixed infections often missed.
• Syndromic approach (used in Zambia): Identification of consistent group of symptoms and easily recognized signs (syndromes), and providing treatment which treats majority of organisms responsible for each syndrome. Treatment occurs on 1st encounter with health care system.

• Urethral discharge:
• Symptoms: urethral discharge, dysuria, frequent urination
• Signs: urethral discharge (if necessary, ask patient to milk urethra)
• Most common causes: gonorrhea, chlamydia
• Genital ulcer:
• Symptoms: genital sore
• Signs: genital ulcer
• Most common causes: syphilis, chancroid, genital herpes, LGV
• Vaginal discharge:
• Symptoms: unusual vaginal discharge, aginal itching, dysuria, dyspareunia
• Signs: abnormal vaginal discharge
• Most common causes: vaginitis (trichomoniasis, candidiasis, bacterial vaginosis), cervicitis: gonorrhoea, chlamydia
• Lower abdominal pain:
• Symptoms: Lower abdominal pain, dyspareunia
• Signs: vaginal discharge, lower abdominal tenderness, fever
• Most common causes: gonorrhoea, chlamydia, mixed anaerobic infection
• Scrotal swelling:
• Symptoms: scrotal pain and swelling
• Signs: scrotal swelling, tenderness
• Most common causes: gonorrhoea, chlamydia
• Inguinal bubo:
• Symptoms: painful enlarged inguinal lymph nodes
• Signs: inguinal lymphadenopathy, fluctuation, abscesses or fistulae
• Most common causes: LGV, chancroid
• Genital growths:
• Symptoms: genital growths or warts
• Signs: genital growths or warts
• Most common causes: genital warts (condylomata accuminata), syphilis (condylomata lata)
• Neonatal conjunctivitis:
• Symptoms: swollen eyelids, ocular discharge, inability to open eyes
• Signs: eyelid oedema, purulent discharge
• Most common causes: gonorrhoea, chlamydia

• Gonorrhoea: 
• Recommended: 
• -Adults: ciprofloxacin 500 mg PO stat
• -Pregnancy: spectinomycin 2 g IM stat
• -Children and adolescents (<17 years): spectinomycin 40 mg/kg IM (max. 2 g) stat
• Alternatives:
• Adults: spectinomycin 2 g IM stat OR cefixime 400 mg PO stat
• Pregnancy: cefixime 400 mg PO stat OR ceftriaxone 250 mg IM stat
• Children and adolescents (<17 years): ceftriaxone 125 mg IM in single dose (If >45kg, use adult dose) OR cefixime 8 mg /kg PO Stat (If >45kg, use adult dose)
• Chlamydia: 
• Recommended:
• -Adults, adolescents, and children >8 years: doxycycline 100 mg PO bd x 7 days
• -Pregnancy: erythromycin base 500 mg PO qid x 7 days.
• -Children <8 years: erythromycin base 50 mg/kg/day in 4 divided doses x 14 days.
• Alternatives:
• -Adults and adolescents: erythromycin 500 mg PO qid x 7 days OR amoxycillin 500 mg PO tds x 7 days
• -Pregnancy: amoxycillin 500 mg PO tds x 7 days OR azithromycin 1 g PO stat
• -Children: azithromycin 1 g PO stat
• Trichomoniasis:
• Recommended:
• -Adult and children >12 years: metronidazole 2 g PO stat
• -Pregnancy (preferably after 1st trimester) Metronidazole 250mg PO TDS x 7 days
• -Children <12 years: metronidazole 5 mg/kg PO tds x 7 days
• Alternatives:
• -Adults: metronidazole 400 mg PO bd x 7 days or tinidazole 2 g PO stat or tinidazole 500 mg PO bd x 5 days
• -Pregnancy (preferably after 1st trimester): metronidazole 400 mg PO bd x 7 days OR tinidazole 500 mg PO bd x 5 days
• Bacterial Vaginosis (BV): 
• Recommended:
• -Adults: metronidazole 2 g PO stat
• -Pregnancy (preferably after 1st trimester): metronidazole 250 mg PO tds x 7 days.
• Alternatives:
• -Adults: metronidazole 400 mg PO bd x 7 days OR metronidazole gel 0.75%, 5 gm intra-vaginal at bedtime x 7 days
• -Pregnancy: metronidazole gel 0.75%, 5 gm intravaginal at bedtime x 7 days
• Vaginal candidiasis: 
• Recommended:
• -Adults: fluconazole 150 mg PO stat (Avoid in 1st trimester of pregnancy)
• Alternatives:
• -Adults: clotrimazole 100 mg vaginal tablet, 2 tabs intra-vaginal daily x 3 days OR miconazole 200 mg vaginal suppository intravaginal daily x 3 days
• Syphilis: 
• Recommended:
• -Adults: benzathine penicillin 2.4 million units IM weekly x 3 doses
• -Children: benzathine penicillin 50,000 units/kg (max. 2.4 million units) IM weekly x 3 doses
• Alternatives:
• -Adults: procaine benzylpenicillin 1.2 million units IM od x 10 days OR erythromycin 500 mg PO qid x 14 days
• -Non-pregnant adults: doxycycline 100 mg PO bd x 14 days
• Chancroid: 
• Recommended:
• -Adults: ciprofloxacin 500 mg PO bd x 3 days
• -Pregnancy: erythromycin 500 mg PO qid x 7 days
• Alternatives:
• -Adults: erythromycin 500 mg PO qid x 7 days
• Lymphogranuloma Venereum (LGV): 
• Recommended:
• -Adults: doxycycline 100 mg PO bd x 14 days OR doxycycline 200 mg PO od X 14 days
• -Pregnancy: erythromycin 500 mg PO qid x 14 days
• Alternatives:
• -Adults: erythromycin 500 mg PO qid x 14 days
• Herpes Simplex Virus (HSV): 
• Recommended:
• -1st clinical episode: acyclovir 400 mg PO tds x 7 days days
• -Episodic reoccurrence: acyclovir 400 mg PO tds x 5 days
• -HIV coinfection-episodic reoccurrence: acyclovir 400 mg PO tds x 10 days
• Alternatives:
• -First clinical episode: acyclovir 200 mg PO 5x per day x 7 days
• -Episodic reoccurrence: acyclovir 200 mg PO 5x per day x 5 days
• -HIV coinfection-episodic reoccurrence: acyclovir 200 mg PO 5x per day x 10 days

• Urethral discharge:
• Treat for gonorrhea and chlamydia: ciprofloxacin 500 mg PO stat + doxycycline 100 mg PO bd x 7 days
• If discharge persists after 7 days despite treatment and no history of re-exposure, then treat for trichomoniasis (see above)
• Genital ulcer:
• Treat for syphilis, chancroid, LGV, and herpes simplex with benzathin penicillin 2.4 million units IM once weekly x 3 weeks, ciprofloxacine 500 mg PO bd x 3 days, doxycycline 100 mg PO bd x 14 days, and acyclovir 400 mg PO tds x 5 days
• Vaginal Ddischarge: risk assessment* negative (treat for vaginitis only)
• If neither speculum exam nor risk assessment positive, treat for bacterial vaginosis and trichomoniasis with metronidazole 2 gm PO stat
• If vulvar oedema, curd-linke discharge, vulvar erythema or excoriations present, also treat for candidiasis with fluconazole 150 mg PO stat
• Vaginal discharge: Risk assessment* positive (treat for vaginitis and cervicitis)
• Look for cervicitis with speculum. If not available, do risk assessment.
• If cervicitis confirmed or risk assessment positive, treat for vaginitis as above and also for gonorrhea, chlamydia, and trichomoniasis with ciprofloxacin 500 mg PO stat, doxycycline 100 mg PO bd x 7 days, metronidazole 2 gm PO stat
• If vulvar oedema, curd-like discharge, vulvar erythema or excoriations present, also treat for candidiasis with fluconazole 150 mg PO stat
• Lower abdominal pain:
• Treat for gonorrhea, chlamydia, and anaerobic bacteria with ciprofloxacin 500 mg PO stat, doxycycline 100 mg PO bd x 14 days, and metronidazole 2 gm PO stat
• Scrotal swelling:
• Treat for gonorrhea and chlamydia with ciprofloxacin 500 mg PO stat and doxycycline 100 mg bd x 14 days
• Inguinal bubo:
• Without genital ulcer: treat for chancroid and LGV with ciprofloxacin 500 mg PO bd x 3 days and doxycycline 100 mg PO bd x 14 days
• With genital ulcer: treat as for genital ulcer (above)
• Neonatal conjunctivitis:
• Treat baby for gonorrhea and chlamydia with spectinomycin 50 mg/kg IM stat, erythromycin 50 mg/kg PO qid x 7 days, plus saline lavage of eyes
• Treat mother and her partner(s) for gonorrhea and chlamydia with ciprofloxacin 500 mg PO stat and doxycycline 100 mg PO bd x 7 days
• *Risk assessment:
• Vaginal discharge algorithm not sensitive for predicting presence of cervical infection (gonorrhea and chlamydia).
• Speculum exam improves diagnostic utility. Presence of certain risk factors increases sensitivity and specificity of algorithm for discharge where speculum exam not available or feasible.
• Risk assessment positive if patient sexually active and has 1 or more of following:
• -Has engaged in sex with multiple partners in last 3 months
• -Has had new sex partner in last 3 months
• -Has current partner with STI
• -Has history of inappropriately treated STI
• -Is victim of sexualy assault

REFERENCED WITHIN THIS GUIDE

• Introduction
• Syphilis