NATIONAL GUIDELINES ON PREVENTION, MANAGEMENT AND CONTROL OF REPRODUCTIVE TRACT INFECTIONS INCLUDING SEXUALLY TRANSMITTED INFECTIONS

Maternal Health Division

Ministry of Health and Family Welfare Government of India August 2007

National Guidelines on Prevention, Management and Control of Reproductive Tract Infections including Sexually Transmitted Infections

Maternal Health Division

Ministry of Health and Family Welfare Government of India

August 2007 Produced and published by National AIDS Control Organisation Ministry of Health & Family Welfare, Government of India

August 2007

© NACO, 2007

All rights reserved National Guidelines on Prevention, Management and Control of Reproductive Tract Infections including Sexually Transmitted Infections

Coordinated by

National Institute for Research in Reproductive Health Indian Council of Medical Research

Supported by

Maternal Health Division

Ministry of Health and Family Welfare Government of India iv N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres

Contents

S.No. Topic Page Nos.

Preface vi Acknowledgement viii List of Abbreviations x List of Figures xii 1. Introduction 1 2. Clinical Spectrum of RTIs/STIs 4 3. Objectives of RTI/STI Case Management Services 8 4. Case Management 9 5. Diagnosis and Management of RTIs/STIs 22 6. RTIs/STIs among Special Populations 47 7. Management of Sexual Violence 53 8. Counselling Testing for RTIs/STIs 56 9. Annexures 1. Laboratory tests for RTIs/STIs 58 2. Condoms and their proper usage technique 68 3. STI Clinic Setup 71 4. List of Drugs 73 5. Disinfection and Universal Precaution 74 6. Monthly monitoring format 81 7. References and Source 85 8. List of Contributors 87

♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n v Preface

Reproductive tract infections (RTIs) including sexually transmitted infections (STIs) present a huge burden of disease and adversely impacts the reproductive health of people. They cause suffering for both men and women around the world, but their consequences are far more devastating and widespread among women than among men. The exact data on STI prevalence in India especially in the general population is lacking. The disease prevalence is estimated to be 6% in India and a total of 30 million people may be affected out of 340 million world over. The estimates also indicate that about 40% of women have RTI/STI at any given point of time but only 1% completes the full treatment of both partners. The emergence of HIV and identification of STIs as a co­ factor have further lent a sense of urgency for formulating a programmatic response to address this important public health problem. It has been prominently agreed in the 10 th Plan document of the Government of India and the need has been reflected in the National Population Policy (2000) “to include STD/RTI and HIV/AIDS prevention, screening and management in maternal and child health services”. In the Phase­I of the National Reproductive and Child Health (RCH) program in India, STI/RTI services could not be operationalised below the district level and remain fragmented under National AIDS Control Programme (NACP). Therefore, management of RTIs is the most needed inclusion, particularly in the rural and urban slum areas of our country in Phase 2 of the RCH Programme and Phase 3 of NACP. The National Rural Health Mission (NRHM), launched in April, 2005, aims to provide accessible, affordable, effective, accountable and reliable health care consistent with the general principles laid down in the National and State policies. Under the umbrella of NRHM, the RCH 2 envisages operationalization of First Referral Units, Community Health Centres and at least 50% of 24x7 Primary Health Centres. All these facilities shall provide a range of maternal health services including skilled care at birth, essential and emergency obstetric care, safe abortion and RTI/STI prevention and management services. On the operational side, Indian Public Health Standards (IPHS) are being prescribed to achieve and maintain quality care to the community. The current guidelines under NRHM converge the needs of the two programs and bring uniformity in protocols for RTI/STI management across the country. These guidelines are intended as a resource document for the programme managers and service providers in RCH 2 and NACP 3 and would enable the RCH service providers in organizing effective case management services through the public health system especially through the network of 24 hour PHCs and CHCs. It would also facilitate up­ scaling of targeted interventions (TIs) for sex workers by programme managers and provision of quality STI management services. The guidelines have been developed keeping in mind the variability in the two programme settings and is a very good example

vi N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres of convergence between the RCH and NACP. It will also succeed in bringing in a focus on HIV/AIDS with uniform protocols for treatment and management of RTIs/STIs. The Division of Maternal Health and National AIDS Control Organisation, Ministry of Health & Family Welfare in collaboration with National Institute for Research in Reproductive Health (NIRRH), Indian Council of Medical Research have prepared the technical guidelines which will help Medical Officers, and Programme Managers to mainstream RTI/STI prevention, management, and control in the health care delivery system. I congratulate the concerned departments, NIRRH, ICMR, WHO Country Office, UNFPA, and experts who have given their valuable assistance for the development of these guidelines. I am sure that these guidelines, when implemented in word and spirit, will go a long way in correctly positioning RTI/STI management in our country.

(Naresh Dayal) Secretary Ministry of Health & Family Welfare Government of India

♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n vii Acknowledgement

Reproductive tract infections including sexually transmitted infections (RTIs/STIs) are recognized as a public health problem, particularly due to their relationship with HIV infection. The prevention, control and management of RTIs/STIs is a well recognized strategy for controlling the spread of HIV/AIDS in the country as well as to reduce reproductive morbidity among sexually active population. The convergence framework of National Rural Health Mission (NRHM) provided the directions for synergizing the strategies for prevention, control and management for RTI/STI services under Phase 2 of Reproductive and Child Health Programme (RCH 2) and Phase 3 of National AIDS Control Programme (NACP 3). While the RCH draws its mandate from the National Population Policy (2000) which makes a strong reference “to include STI/RTI and HIV/AIDS prevention, screening and management in maternal and child health services”, the NACP includes services for management of STIs as a major programme strategy for prevention of HIV. The NACP Strategy and Implementation Plan (2006­2011) makes a strong reference to expanding access to a package of STI management services both in general population groups and for high risk behavior groups and also acknowledges that expanding access to services will entail engaging private sector in provision of services. The highlights of the document include comprehensive RTI/STI case management approach including detailed history taking and clinical examination; user friendly management flowcharts including syndrome­specific partner management and management of pregnant women; effective drug regimens, single oral dosages wherever possible; issues of privacy and confidentiality, and partner management is given special focus. The guidelines also emphasize on counseling for safe sex, condom promotion, dual protection options and integration of RTIs/STIs assessment into Family Planning services. Special population segments like neonates, adolescents and high risk groups are addressed separately. The vision and constant encouragement provided by Shri Prasanna Hota, former Secretary, Ministry of Health and Family Welfare enabled us to bring out these guidelines. We also express our sincere thanks to Shri Naresh Dayal, Secretary, Health and Family Welfare under whose leadership these guidelines have been finalized. A number of organizations, individuals and professional bodies have contributed towards the development of these guidelines. National Institute of Research in Reproductive Health (NIRRH), Mumbai under ICMR led the process of country wide rapid assessment survey and coordinated the development of technical guidelines. We express our sincere appreciation to Dr Chander Puri, Director and Dr Sanjay Chauhan, Deputy Director of NIRRH who provided the support in the development of these

viii N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres guidelines. We would also like to thank the members of the operational, clinical and laboratory working and advisory groups constituted at the NIRRH and NACO for providing their expertise, experience and guidance in outlining the guidelines. These guidelines have been prepared and designed with technical assistance and other related support provided by WHO, UNFPA, FHI and other experts in the field. Special thanks are due to Dr Arvind Mathur, Coordinator, Family & Community Health, WHO, ­India for providing continued support and contributing technically to bring the guidelines to the current shape. We are particularly thankful to Dr Dinesh Agarwal, Technical Advisor, Reproductive Health, UNFPA India office, Dr H. K. Kar, Professor and Head, Department of Dermatology & STD, RML Hospital, Dr. N. Usman, Professor of Dermatology and STD, Chennai for their constant technical inputs, unstinted support and guidance through out the process of developing these guidelines. We would like to express our sincere appreciation for the encouragement and guidance provided by Shri S. S. Brar, Joint Secretary (RCH), Dr. I. P. Kaur, Deputy Commissioner, Maternal Health and Dr. Jotna Sokhey, Additional Project Director, NACO. We also appreciate guidance provided by Dr. V. K. Manchanda, the erstwhile Deputy Commissioner, Maternal and Child Health during the preparation of this document. The hard work and contributions of Dr. Ajay Khera, Joint Director, NACO, Dr. Himanshu Bhushan and Dr. Manisha Malhotra, Assistant Commissioners, Maternal Health Division have been invaluable in shaping the document. We also appreciate the excellent contributions of Dr. Vinod Khurana, Consultant, NACO in finalizing the guidelines.

S. Jalaja Sujatha Rao Additional Secretary Additional Secretary Mission Director Project Director National Rural Health Mission National AIDS Control Organisation

Ministry of Health and Family Welfare Government of India New Delhi

♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ix List of Abbreviations

AIDS Acquired Immunodeficiency Syndrome ANC Anti Natal Care ART Anti Retroviral Therapy ANMs Auxiallary Nurse Midwives BV Bacterial Vaginosis CA Candidiasis, yeast infection CHCs Community Health Centres CMV Cyto MegaloVirus CDC Centre for Disease Control EC Emergency Contraception ESR Erythrocyte Sedimentation Rate ELISA Enzyme Linked Immuno Sorbent Assay Endo Endogenous FPFHI Family PlanningFamily Health International FTA­Abs Fluorescent Treponema Antibody Absorption Test GUD Genital Ulcer Disease HBV Hepatitis B Virus HIV Human Immunodeficiency Virus HPV Human Papilloma Virus HSV Herpes Simplex Virus Iatro Iatrogenic IPHS Indian Public Health Standards ICTC Integrated Counselling and Testing Centre IDUs Intravenous Drug Users IM Intramuscular IU International Units IUD Intra Uterine Device IV Intravenous KOH Potassium Hydroxide LGV LymphoGranuloma Venereum LHV Lady Health Visitor MOHFW Ministry of Health and Family Welfare

x N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres

MSMs Men having Sex with Men MCH Maternal and Child Health MHA­TP MicroHaemagglutination Assay for antibodies to Treponema Pallidum MTCT Mother­To­Child Transmission MVA Manual Vacuum Aspiration NACP National Aids Control Program NRHM National Rural Health Mission NPCP­III National Aids Control Program­Phase III NIRRH National Institute for Research in Reproductive Health NACO National Aids Control Organization NGO Non Governmental Organization NGU Non Gonococcal Urethritis PHC Primary Health Centre PLHAs Persons Living with HIV/AIDS PAP Test Papanicolaou Test PPTCT Prevention of Parent­To­Child Transmission of HIV PSI Population Services International PCR Polymerase Chain Reaction PEP Post Exposure Prophylaxis PID Pelvic Inflammatory Disease ROM Rupture Of Membrane RPR Rapid Plasma Reagin RTI Reproductive Tract Infection(s) RCH Reproductive and Child Health Program RCH­II Reproductive and Child Health Program­Phase II STI Sexually Transmitted Infection STD Sexually Transmitted Disease SACS State Aids Control Society TPHA Treponema Pallidum Haemagglutination Test TI Target Intervention TV Trichomonas Vaginalis UTI Urinary Tract Infection UNFPA United Nations Population Funds VCT Voluntary Counseling and Testing VDRL Venereal Disease Research Laboratory WBC White Blood Cells WHO World Health Organization

♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n xi List of Figures

Fig 4a: Lesions of secondary syphilis Fig 4b: Mucous patches in secondary syphilis Fig 4c: Vesicles of Genital Herpes Fig 4d: Abrasions of Intertrigo Fig 4e: Extensive mucopurulent cervicitis infection Fig 4f: Pus pouring out of endocervix in Chlamydia infection Fig 4g: Growth of genital warts Fig 4h: Chancre of Syphilis Fig 4i: Uretheral discharge in gonorrhea Fig 4j: Herpes ulcers Fig 4k: Multiple grouped erosions over shaft of penis Fig 4l: Chancre of glans in Syphilis Fig 4m: Chancre of coronal sulcus in Syphilis Fig 4n: Ulcer of Donovanosis Fig 4o: Condyloma lata of Syphilis Fig 4p: Veneral warts Fig 4q: Candidial balanoposthitis Fig 4r: Chancroidal bubo: note the single pointing Fig 4s: LGV Fig 5a: Perivulval warts Fig 5b: Penile warts Fig 5c: Perianal warts Fig 5d: Molluscum contagiosum Fig 5e: Genital Scabies Fig A1a: Collection of specimen on swab Fig A1b: Potassium hydroxide preparation of vaginal fluid showing budding yeast and mycelia

xii N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres

Fig A1c : “Clue cells” in vaginal wet mount (x 400) Fig A1d: Trichomonas vaginalis in a wet mount of vaginal discharge (x 400) Fig A1e: Gram stained vaginal smear showing a normal flora of lactobacilli (x 1000) Fig A1f: Gram stained vaginal smear with typical “clue cell” (x 1000) Fig A1g: Gram stained vaginal smear showing large Gram­ negative rods (Mobilincus mulieris) (x 1000) Fig A1h: Gram stain smear ­ Gram­negative diplococci of Neisseria gonorrhoeae Fig A1i: Test serum is mixed with antigen and the card is placed on appropriate rotator Fig A1j: Reading RPR results for 10 undiluted sera showing reactive and non reactive samples. Fig: A5a: Hand washing Procedures

LIST OF TABLES Table 2.1: Causative organisms and presenting symptoms & signs of specific RTIs/STIs Table A5a: Management of health care waste Table A5b: Hypochlorite solution of 0.5 % 1% and 2 % available chlorine Table A5c: Common disinfectants used for environmental cleaning in health center

LIST OF BOXES Box 4.1: Sample questions on history taking Box 4.2: Signs to look for during external genital examination of a female Box 4.3: Speculum examination in women Box 4.4: Signs to look for during speculum examination Box 4.5: Bimanual pelvic examination Box 4.6: Signs to look for during a bimanual examination Box 4.7: Signs to look for when examining men Box 5.1: Important considerations for management of all clients of RTIs/STIs Box 5.2: Coupon for free examination Box 5.3: Management of treatment failure and re­infection

♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n xiii Box 7.1: Post exposure prophylaxis with Emergency contraceptives Box 7.2: STI presumptive treatment options for adults and older children and adolescents weighing more than 45 kg Box 7.3: STI Presumptive treatment options for children Box A1.1: Wet mount microscopy examination of vaginal discharge Box A1.2: Clinical criteria for Bacterial vaginosis Box A1.3: Gram stain microscopy of vaginal smears Box A1.4: Nugent score Box A1.5: Procedure of RPR test Box A1.6: Interpreting serological test results Box A2.1: How to use a male condom Box A2.2: How to use a Female condom

LIST OF FLOWCHARTS Flowchart 5.1: Management of Urethral Discharge/Burning Micturition in Males Flowchart 5.2: Management of Scrotal Swelling Flowchart 5.3: Management of Inguinal Bubo Flowchart 5.4: Management of Genital Ulcers Flowchart 5.5: Management of Vaginal Discharge in Females Flowchart 5.6: Management of Lower Abdominal Pain in Females Flowchart 5.7: Management of Oral & Anal STIs Flowchart 6.1: Management of STIs during routine visit by female sex workers Flowchart 6.2: Flowchart for routine visit by male and transgender sex workers in clinics

xiv N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres 1 Introduction

Sexually transmitted infections (STIs) contraceptive acceptance and continuation. present a huge burden of disease and Similarly some of the RTIs are associated adversely impact reproductive health of with poor pregnancy outcome and high people. As per recent STI prevalence study morbidities and mortalities in neonates (2003), over 6 percent of adult population and infants. in the country suffers from STIs and most In developing countries, both the incidence regions of country show relatively high and prevalence of RTIs/STIs are very high, levels. It is well known that risk of they rank second as the cause of healthy acquiring HIV infection increases manifold life lost among women of reproductive age in people with current or prior STI. STIs group, after maternal morbidity and are linked to HIV transmission as common mortality. In men, sexually transmitted sexual behaviour put persons at the risk infections combined with HIV infection of infection which directly increases the account for nearly 15 percent of all healthy chances of acquiring and transmitting HIV. life lost in the same age group. These The emergence of HIV and identification infections pose a significant potential drain of STIs as a co­factor have further lent a on public health system resources and sense of urgency for formulating a contribute substantially to the patterns of programmatic response to address this major health care expenditure at the important public health problem. HIV household level. prevalence rates among STIs Clients also remains high: 22.8 percent in Andhra Programmatic response to address Pradesh, 15.2 percent in Maharashtra, 12.2 prevention, management and control of percent in Manipur and 7.4 percent in RTIs/STIs largely falls under the National Delhi. Reproductive and Child Health (RCH 2) Programme, which was launched in year Besides HIV infections, RTIs including STIs 2005. The programme draws its mandate cause suffering for both men and women from the National Population Policy (2000), around the world, but their consequences which makes a strong reference “to include are far more devastating and widespread STD/RTI and HIV/AIDS prevention, among women than among men. These screening and management in maternal infections often go undiagnosed and and child health services”. National Rural untreated, and when left untreated, they Health Mission (NRHM) was launched in lead to complications such as infertility; April, 2005 with an aim to provide ectopic pregnancy and cervical cancer. accessible, affordable, effective, Pelvic inflammatory disease arising from accountable and reliable health care STIs poses a major public health problem consistent with the outcomes envisioned and adversely affects the reproductive in the Millennium Development Goals health of poor and untreated women. and general principles laid down in the Presence of STIs also compromises with

♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n 1 National and State policies, including the countrywide Rapid Assessment Survey in National Population Policy, 2000 and the six zones of the country to assess their National Health Policy, 2002. On the management practices (operational, operational side, Indian Public Health clinical, laboratory) on RTI/STIs at Standards (IPHS) are being prescribed to different levels (District, CHC, PHC and achieve and maintain quality of care to the Subcentre) of the health system, review of community through public health care available guidelines, technical discussions delivery system. Clearly there is renewed with STI care practitioners, and programme emphasis on making public health systems managers in public systems as well as from effective to deliver quality services to NGO and private sector. achieve programme goals. The guidelines presented in this document The National AIDS Control Programme 3 are designed for qualified Doctors to (NACP 3) includes services for enable them to quickly and confidently management of STIs as a major programme diagnose and treat the majority of the strategy for prevention of HIV. The RTIs/STIs caseload. Some part of these Strategy and Implementation Plan (2006­ guidelines could be extracted and adopted 2011) makes a strong reference to for nursing personnel as per requirements expanding access to package of STI for service delivery in different settings. management services both in general The main purpose of this document is to population groups and for high risk present comprehensive RTI/STI case behavior groups. Programme also management guidelines including acknowledges that expanding access to detailed history taking and clinical services will entail engaging private sector examination supported by a number of in provision of services. Several studies photographs of RTIs/STIs in men and indicate preference of Clients to access women to provide a visual impression; services from private providers. It is also user friendly management flowcharts important that treatment facilities in both including partner management and public and private sector are linked to management of pregnant women; effective targeted interventions being supported for drug regimens, single oral dosages high risk behavior groups in the NACP 3. wherever possible, with special instructions incorporated in the flowcharts This document is guided by the National itself. This document also provides Programme Implementation Plan for guidance to service providers to address RCH 2 and NACP 3. The RCH 2 RTIs/STIs among special population programme is to be implemented within groups such as adolescents, sex workers the framework of inter­sectoral and men having sex with men; and simple convergence as envisaged in the laboratory tests which can be done at implementation framework of NRHM. various facility levels with relevant Linkages are to be established between the photographs and details of procedures. In RCH 2 strategy for prevention and addition to this, the document also management of RTIs including STIs and provides information on organisation of prevention strategy as articulated in integrated counseling and testing services. NACP 3. The inputs required for framing these guidelines are drawn from many These guidelines cater to information sources which also include a multi centric needs of the programme managers and

2 N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres service providers in RCH 2 and also in for sex workers and TI managers will find NACP 3. The RCH service providers will useful information for provision of quality find the information useful in organizing STI management services. effective case management services Recognizing the fact that a significantly through public health system especially high proportion of these clients are being through network of 24 hour PHCs and treated through private sectors, the private CHCs. Similarly programme managers providers/ NGO service providers are specially State AIDS Control Society highly encouraged to use these national officers entrusted with the responsibility protocols. of up scaling targeted interventions (TIs)

♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n 3 Clinical Spectrum of 2 RTIs/STIs

Clients suspected of having RTIs/STIs usually present with one or more of the following complaints: (i) Vaginal or urethral discharge; (ii) Vesicular and/or non­vesicular genital ulcers; (iii) Inguinal bubo; (iv) Lower abdominal and/or scrotal pain; and (v) Genital skin conditions.

The following table depicts presenting symptoms, signs, clinical conditions, and causative organisms. Table 2.1: Causative organisms and presenting symptoms & signs of specific RTIs/STIs RTI/STI Causative Organism Symptoms/Signs Presenting symptoms: Vaginal/Urethral Discharge and or burning micturition

Gonorrhea Neisseria gonorrhea Women

• Purulent (containing mucopus) vaginal discharge • Pain or burning on passing urine (dysuria) • Inflamed (red and tender) urethral opening

Men • Pain or burning on passing urine (dysuria) • Purulent (containing mucopus) urethral discharge (drip). • Infection of the epididymis (coiled tube leading from the testis to the vas deferens)

• Urethral abscess or narrowing (stricture)

Trichomoniasis Trichomonas • May produce few symptoms Vaginalis in either sex

4 N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres

• Women often will have a frothy (bubbly), foul­ smelling, greenish vaginal discharge . • Men may have a urethral discharge

Chlamydia Chlamydia Women trachomatis • Produces few symptoms, even with upper genital tract infection (silent PID)

• Purulent cervical discharge, frequently a “beefy” red cervix which is friable (bleeds easily) Men

• Most frequent cause of non­gonococcal urethritis (NGU)

Bacterial Overgrowth of • Not necessarily sexually vaginosis anaerobes (e.g., transmitted Gardnerella vaginalis) • Vaginal discharge with fishy odor, grayish in color

Candidiasis Candida albicans Women • Curd­like vaginal discharge, whitish in color • Moderate to intense vaginal or vulval itching (pruritus) Men

• Itchy penile irritation (balanitis)

Presenting symptoms: Genital Ulcers and Buboes

Chancroid Haemophilus • Painful, “dirty” ulcers (Soft chancre) ducreyi located anywhere on the external genitalia. • Development of painful enlarged lymph nodes (bubo) in the groin. Lymphogranuloma Chlamydia • Small, usually painless venereum (LGV) trachomatis papules (like pimples) on (serovars L1, L2, L3) the penis or vulva, followed by • Buboes in the groin which ultimately breaks down forming multiple fistulae (draining openings) • If untreated, the lymphatic system may become blocked, producing elephantiasis (swelling of the genitals or extremities)

Syphilis Treponema • Occurs in 3 stages : primary and secondary Pallidum and late

♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n 5 Primary syphilis • Initially, painless ulcer (chancre): in women on the external genitalia (labia), in men on the penis; in both sexes oral and anal ulcers and enlarged rubbery lymph nodes Secondary (disseminated) syphilis • Several months' later non­itchy body rash, headaches, muscle aches, weight loss, low grade fever. The rashes may disappear spontaneously Late syphilis • Develops in about 25% of untreated cases and is often fatal due to involvement of the heart, great blood vessels and brain

Granuloma Calymmatobacterium • An uncommon cause of inguinale granulomatis ulcerative genital tract (Donovanosis) infection

• Typically, the infected person develops lumps under the skin which break down to form “beefy” red, painless ulcers

Genital herpes Herpes simplex virus • Multiple painful vesicles later forming shallow ulcers which clear in 2 to 4 weeks (first attack) and may be accompanied by watery vaginal discharge in women • Recurrent (multiple episodes) more than 50% of the time.

Pelvic • Neisseria gonorrhea • Lower abdominal pain, Inflammatory • Chlamydia fever, vaginal discharge, Disease (PID) trachomatis menstrual irregularities like • Anaerobes heavy irregular vaginal bleeding, dysmenorrhoea, dyspareunia (pain during sexual intercourse), dysuria, tenesmus, low backache • Temperature> 39 0C • Vaginal/cervical discharge, congestion or ulcers • Lower abdominal tenderness or guarding • Uterine/adnexal tenderness, cervical movement tenderness, presence of a pelvic mass

6 N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres

Presenting symptoms: Acute scrotal pain and /or swollen scrotum

Epididymitis/ Orchitis • Neisseria gonorrhea • Chlamydia trachomatis • Acute: severe pain in one or both testes, sudden swelling of the testes. Presenting symptoms: Genital Skin Conditions

Genital warts Human • Single or multiple soft, (Condyloma papilloma painless, “cauliflower” acuminata) virus growth which appear around the anus, vulvo­ vaginal area, penis, urethra and perineum Molluscum Pox virus • Multiple, smooth, glistening, contagiosum globular papules of varying size from a pinhead to a split pea can appear anywhere on the body. Sexually transmitted lesions on or around genitals can be seen. • Not painful except when secondary infection sets in.

Pediculosis pubis Pthirus pubis • There may be small red papules with a tiny central clot caused by lice irritation. • General or local urticaria with skin thickening may or may not be present.

Scabies Sarcoptes scabiei • Severe pruritis (itching) is experienced by the client which becomes worse at night. • The burrow is the diagnostic sign. It can be seen as a slightly elevated grayish dotted line in the skin, best seen in the soft part of the skin.

♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n 7 Objectives of RTI/STI Case 3 Management Services

Provision of quality RTI/STI case 4. Emphasis on treatment compliance management services through a network and better treatment outcomes. of public health care delivery institutions, private sector providers, franchisee clinics 5. Behaviour change communication and in targeted intervention settings will leading to improved knowledge on result in achieving following objectives: causation, transmission and prevention of RTIs/STIs. 1. Enhance access to services to all; especially for women and 6. Ensure that providers offer adolescents who are constrained to counseling and testing services for seek services and face several access HIV/AIDS and establish linkages related barriers. with ART systems with respect to 2. Standardized treatment protocols persons detected positives. will improve prescription practices 7. Screen asymptomatic women by reducing poly pharmacy, especially contraceptive users and irrational drug combinations. antenatal clients for STIs. 3. Focus on prevention, with special reference to partner management, 8. Ensure service provision for groups condom use, follow­ups and practicing high risk behaviors such management of side effects. as sex workers, MSMs and IDUs.

8 N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres 4 Case Management

The most important elements of RTI/STI Thus, quality case management consists case management are accurate diagnosis not only of antimicrobial therapy to obtain and effective treatment. This needs time cure and reduce infectivity, but also focus and skill in taking a detailed sexual history on prevention of recurrence and partner for both client and his/her sexual contacts management. and in carrying out a comprehensive physical examination and minimal History taking investigations in resource poor settings. In • History must be taken in a language, some settings where even minimal which the client understands well. laboratory setup and facilities for clinical (Some examples of framed questions examinations are not available, syndromic are given in Box 1). Clients are often management is recommended as per the reluctant to talk about these protocols in following pages. To prevent conditions due to shyness or fear of the complications and spread, treatment stigmatization. Hence health care must be effective. This means selecting the providers should ensure privacy, correct drugs for the disease, carefully confidentiality, be sympathetic, monitoring its administration and carrying understanding, non­judgmental and out regular follow up. The sexual partners culturally sensitive. must be treated so as to prevent recurrence. Clients should also receive • Ensure privacy by having a separate counseling services with special reference room for history taking and to risk reduction, safer sex behaviour and examination, which is not access to testing. stigmatized with a nameplate for STIs. There should be auditory as The components of case management well as visual privacy for history include: taking as well as examination.

• History taking • Start the conversation by welcoming • Clinical examination your client, taking them into confidence and encouraging him/her • Correct diagnosis to talk about their complaints. If a • Early and effective treatment couple comes together, each of them needs to be interviewed and • Counseling: Risk reduction and examined separately. voluntary HIV testing • Often, because the client feels • Provision of condoms uncomfortable talking about RTIs/ • Partner management STIs, individuals may come to the clinic with other non­specific • Follow­up as appropriate.

♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n 9 complaints or requesting a check­up, same conditions of privacy as those assuming that the health care in which history was taken. provider will notice anything abnormal that needs treatment. • It is advisable to have an assistant of Therefore, health care workers the same sex as the client present, should maintain a high index of during examination of clients of sex suspicion about RTIs/STIs. opposite to the doctors.

• Clients seeking antenatal care and • Clients should be told about the family planning services should be examination with the help of viewed as opportunities to provide diagrams and charts. general information about RTIs/STIs and should be asked about RTI/STI • The examination should be done in symptoms and contraception. a well­lit room while providing

• The health care personnel should be adequate comfort and privacy. Before aware of the commonly used RTI/STI you start, keep the examination table related terminology as well as those with proper illumination ready as used for high­risk behavior. These well as sterilized speculums (for terms may vary in different examination of female clients), geographical settings. collection swabs and labeled slides for smears. Clinical examination • As far as possible, complete body Pre­requisites for clinical examination examination of the client should be carried out so that none of the skin • Clients should be examined in the lesions or lymph nodes is missed.

Box 4.1: Sample questions on history taking

Framing Statement “In order to provide the best care for you today and to understand your risk for certain infections, it is necessary for us to talk about your sexual behavior.”

Screening Questions

• Have you recently developed any of these symptoms? STI (Genital infections) Symptoms Checklist For Men i. Discharge or pus (drip) from the penis ii. Urinary burning or frequency iii. Genital sores (ulcers) or rash or itching iv. Scrotal swelling

10 N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres

v. Swelling in the groin vi. Infertility For Women i. Abnormal vaginal discharge (increased amount, abnormal odor, abnormal color) ii. Genital sores (ulcers), rash or Itching iii. Urinary burning or frequency iv. Pain in lower abdomen v. Dysmenorrhoea, menorrhagia, irregular menstrual cycles? vi. Infertility High risk sexual behavior

• For all adolescents: Have you begun having any kind of sex yet?

• If sexually active do you use condom consistently?

• Do you have any reason to think you might have a sexually transmitted disease? If so, what reason?

• Have you had sex with any man, woman, with a gay or a bisexual?

• Have you or your partner had sex with more than one partner?

• Has your sex partner(s) had any genital infections? If so, which ones?

• Do you indulge in high risk sexual activity like anal sex

• Do you practice correct and consistent condom usage while having sex? If yes, whether every time or sometimes?

• Sex workers: Frequency of partner change: use of condoms with regular partners and also with clients STI History

• In the past have you ever had any genital infections, which could have been sexually transmitted? If so, can you describe? STI treatment history

• Have you been treated in the past for any genital symptoms? By whom? (qualified or unqualified person)

• Did your partner receive treatment for the same at that time?

• Has your partner been treated in the past for any genital symptoms? By whom? (qualified or unqualified person)

♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n 11 Injection Drug Use

• Have you had substance abuse? (If yes, have you ever shared needles or injection equipment?)

• Have you ever had sex with anyone who had ever indulged in any form of substance abuse? Menstrual and obstetric history in women and contraceptive history in both sexes should be asked

General Examination

• All examinations should begin with a general assessment, including vital signs and inspection of the skin and mucous patches, to detect signs of systemic disease.

Fig 4a Lesions of Secondary Fig 4b Mucous patches in Syphilis Secondary Syphilis

Clinical examination of female clients While examining a female client, a male doctor should ensure that a female attendant is present. Genital examination in females must be performed with client in lithotomy position.

12 N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres

Box 4.2 Signs to look for during external genital examination of a female client a) Inspection Staining of underclothes: Vaginal and urethral discharge, exudative ulcers Inguinal region • Swelling, ulcer, lesions of fungal infections • Lymph nodes: look for enlargement, number, location (horizontal or vertical group), single or multiple, scars and puckering, signs of inflammation on the surface and surrounding region • Abrasions due to scratching and lesions on inner aspect of thighs Pubic area • Matting of hairs, pediculosis, folliculitis, or other skin lesions Labia majora and minora • Separate the labia majora with both hands and look for erythema, edema, esthiomene formation (lobulated fibrosed masses due to chronic lymphedema), fissuring, ulcers, warts or other skin lesions Ulcers • Location, number (single, multiple), superficial (erosions) or deep, edge (undermined/punched out), margins (regular/irregular) and floor (presence of exudates, slough/granulation tissue) Bartholin glands • Enlargement, ductal opening, discharge Introitus • Discharge – colour, odour, profuse or scanty, curdy or thin, back drop of redness and inflammation Urethral meatus • Discharge (pressing under the urethra with one finger may show drops of discharge), inflammation Perianal examination • Separate the buttocks with two hands for better visualization. Look for ulcer, macerated papules of condyloma lata, warts, discharge, patulous anus, haemorrhoids, fissures, fistula b) Palpation Inguinal region • Lymphnodes: tenderness, increased warmth, superficial or deep, discrete or matted, free mobility or fixed to deeper structures, consistency (firm or soft) and fluctuant. • Rule out hernia Palpation of ulcer at any site • Tenderness, induration of the floor and edges, bleeding on maneuvering Signs of various RTIs/STIs are shown as pictures in fig 4c – 4h. During external genital examination of female clients, one should look for these signs.

♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n 13 Fig 4c Vesicles of Genital Herpes Fig 4d Abrasions of Intertrigo

Fig 4e Extensive mucopurulent Fig 4f Pus pouring out of cervicitis infection endocervix in Chlamydia infection

Fig 4g Growth of genital warts Fig 4h Chancre of Syphilis

14 N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres

Box 4.3: Speculum examination in women How to do speculum examination in women

• Ask the woman to pass urine.

• Ask her to loosen her clothing. Use a sheet or clothing to cover her.

• Have her lie on her back, with her heels close to her bottom and her knees up.

• Wash your hands well with clean water and soap.

• Put clean gloves on both hands.

• Look at the outside genitals – using the gloved hand to gently look for lumps, swelling, unusual discharge, sores, tears and scars around the genitals and in between the skin folds of the vulva. Speculum examination

• Be sure the speculum has been properly disinfected before you use it. Wet the speculum with clean water before inserting it.

• Put the first finger of your gloved hand in the woman’s vagina. As you put your finger in, push gently downward on the muscle surrounding the vagina (push slowly, waiting for the woman to relax her muscles).

• With the other hand, hold the speculum blades together between the pointing finger and the middle finger. Turn the blades sideways and slip them into the vagina. (be careful not to press on the urethra or clitoris because these area are very sensitive). When the speculum is halfway in, turn it so the handle is down. Remove your gloved finger.

• Gently open the blades a little and look for the cervix. Move the speculum slowly and gently until you can see the cervix between the blades. Tighten the screw on the speculum so it will stay in place.

• Check the cervix which should look pink and round and smooth. Notice if the opening is open or closed, and whether there is any discharge or bleeding. If you are examining the woman because she is bleeding from the vagina after birth, abortion or miscarriage, look for tissue coming from the opening of the cervix.

• Look for signs of cervical infection by checking for yellowish discharge, redness with swelling, or easy bleeding when the cervix is touched with a swab. If the woman has been leaking urine or stools gently turn the speculum to look at the walls of the vagina. Bring the blades closer together to do this.

• To remove the speculum, gently pull it toward you until the blades are clear of the cervix. Then bring the blades together and gently pull back. Be sure to disinfect your speculum again.

♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n 15 Box 4.4: Signs to look for during speculum examination

• Vaginal discharge and redness of the vaginal walls are common signs of vaginitis. Note the color, smell and characteristics of any vaginal discharge. When the discharge is white and curd­like, candidiasis is likely. • Foreign body, IUD thread. • Ulcers, warts, sores or blisters. • Redness of cervical and vaginal epithelium • Look for cervical erosions. If the cervix bleeds easily when touched or the discharge appears muco­purulent with discoloration, cervical infection is likely. A strawberry appearance of the cervix may be due to trichomoniasis. A uniform bluish discoloration of the cervix may indicate pregnancy, which needs to be kept in mind. • When examining a woman after childbirth, induced abortion or miscarriage, look for bleeding from the vagina or tissues fragments and check whether the cervix is normal. • Tumors or other abnormal­looking tissue on the cervix.

• PAP smear can be obtained during speculum examination

16 N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres

Box 4.5: Bimanual pelvic examination

How to do a bimanual pelvic examination

• Put the pointing finger of your gloved hand in the woman’s vagina. As you put your finger in, push gently downward on the muscles surrounding the vagina. When the woman’s body relaxes, put the middle finger in too. Turn the palm of your hand up.

• Feel the opening of her womb (cervix) to see if it is firm (feels like tip of the nose and round. Then put one finger on either side of the cervix and move the cervix gently. It should move easily without causing pain. If it does cause pain, she may have infection of the womb, tubes or ovaries. If her cervix feels soft, she may be pregnant.

• Feel the womb by gently pushing on her lower abdomen with your outside hand. This moves the inside parts (womb, tubes and ovaries) closer to your inside hand. The womb may be tipped forward or backward. If you do not feel it in front of the cervix, gently lift the cervix and feel around it for the body of the womb. If you feel it under the cervix, it is pointed back.

• When you find the womb, feel for its size and shape. Do this by moving your inside fingers to the sides of the cervix, and then ‘walk’ your outside fingers around the womb. It should feel firm, smooth and smaller than a lemon. If the womb:

• Feels soft and large, she is probably pregnant.

• Feels lumpy and hard, she may have a fibroid or other growth.

• Hurts when you touch it, she may have an infection inside.

• Does not move freely, she could have scars from an old infection.

• Feel her tubes and ovaries. If these are normal, they will not be felt. But if you feel any lumps that are bigger than an almond or that cause severe pain, she could have an infection or other emergency. If she has a painful lump, and her monthly bleeding is late, or scanty, she could be pregnant in the tube. She needs medical help right away.

• Move your finger and feel along with inside of the vagina. If she has a problem with leaking urine or stool, check for a tear. Make sure there are no unusual lumps or sores.

• Have the woman cough or push down as if she were passing stool. Watch to see if something bulges out of the vagina. If it does, she could have a fallen womb or fallen bladder (prolapse).

• When you are finished, clean and disinfect your glove. Wash your hands well with soap and water.

♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n 17 Box 4.6: Signs to look for during a bimanual examination

• Soft enlarged uterus with missed periods suggestive of pregnant uterus

• Adnexal mass with missed periods suggestive of ectopic pregnancy

• Cervical movement tenderness and or adnexal tenderness suggestive of PID

• Adnexal mass with fever suggestive of pelvic abscess

• Any other hard pelvic mass like fibroid or malignancy

Digital rectal examination: Performed if symptoms suggestive of prostatic disease. Should not be carried out if the client has painful perianal diseases such as herpetic ulcers, fissures, haemorrhoids. Proctoscopic examination: Indicated if history of unprotected anal intercourse, or complain of rectal discharge.

Note: If a woman has missed periods (menses), pregnancy should be ruled out by doing a urine pregnancy test.

18 N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres

Box 4.7: Signs to look for when examining men a) Inspection Staining of underclothes : due to urethral discharge, subprepucial discharge or from exudative ulcers. Inguinal region: swelling, ulcer, candidial intertrigo, tinea, enlarged lymph nodes: look for number, location (horizontal or vertical group), single or multiple pointings, scars and puckering, signs of inflammation on the surface and surrounding region Pubic area: matting of hairs, pediculosis, folliculitis, or other skin lesions. Scrotum: erythema, skin lesions (condyloma lata), asymmetry, scrotal swelling. Penis: Size, oedema, deformity, phimosis, paraphimosis, autoamputation of genitals, foreign bodies, old scars, circumcision, retraction of prepuce. Inspection of ulcers: Number (single, multiple), superficial (erosions) or deep, edge (undermine/punched out), margins (regular/irregular) and floor (presence of exudates, slough/granulation tissue). Meatal examination: Erythema, discharge: thick, creamy or mucopurulent, wart, ulcer. If no discharge then milk the penis (urethra) and look for discharge at the meatus. Prepucial skin examination: Erosions, ulcer, warts, posthitis or other skin lesions. Coronal sulcus: Ulcer, warts, pearly penile papules. Glans penis examination: Erosions, ulcers, warts, balanitis (candidial, trichomonial). Shaft of penis: papules, nodules, ulcers or other skin lesions, fibrosis. Perianal examination: Separate the buttocks with two hands for better visualization. Look for ulcer, macerated papules of condyloma lata, warts, discharge, patulous anus, haemorrhoids, fissures, fistula. b) Palpation Inguinal region: Lymphnodes: tender or not, increased warmth, superficial or deep, discrete or matted, free mobility or fixed to deeper structures, consistency: firm or soft and fluctuant. Rule out hernia. Palpation of spermatic cords: Tenderness, asymmetry, and thickening, varicocoeles. Palpation of scrotum: Asymmetry, tenderness, consistency of testes and epididymis, transillumination for hydrocoele. Rule out hernia.

♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n 19 Palpation of ulcer at any site: Tenderness, induration of the floor and edges, bleeding on maneuvering. c) Digital rectal examination: Performed if symptoms suggestive of prostatic disease. Should not be carried out if the client has painful perianal disease such as herpetic ulcers, fissures, or haemorrhoids. d) Proctoscopic examination: Indicated if unprotected anal intercourse, rectal discharge.

Signs of various RTIs/STIs are shown as pictures in fig . During external genital examination of male clients, one should look for this signs.

Fig 4i Uretheral discharge in gonorrhea

Fig 4j Herpes ulcers Fig 4k Multiple grouped erosions over shaft of penis

20 N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres

Fig 4l Chancre of glans in Syphilis Fig 4m Chancre of coronal sulcus in Syphilis

Fig 4n Ulcer of Donovanosis Fig 4o Condyloma lata of Fig 4p Venereal warts Syphilis

Fig 4q Candidial Fig 4r Chancroidal bubo: note the Fig 4s LGV balanoposthitis single pointing

♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n 21 Diagnosis and 5 Management of RTIs/STIs

A simplified tool (flowchart) will help to examination is highlighted. If facilities and guide health workers in the management skills are available, the laboratory tests of RTIs/STIs. The flowcharts describe the which need to be done are also mentioned. clinical syndrome, specific RTIs/STIs The treatment protocols to be followed at under the syndrome and the causative the primary health care system with organisms of the RTI/STI syndrome. appropriate referrals where indicated is Differential diagnosis of the conditions is also given. Special emphasis is given on also mentioned wherever appropriate. The syndrome specific partner management approach to the lient with specific points and management issues specific to to be considered during history taking and pregnancy.

Box 5.1 Important considerations for management of all clients of RTIs/ STIs

Important considerations for management of all clients of RTIs/STIs • Educate and counsel client and sex partner(s) regarding RTIs/STIs, genital cancers, safer sex practices and importance of taking complete treatment • Treat partner(s) where ever indicated • Advise sexual abstinence during the course of treatment • Provide condoms, educate about correct and consistent use • Refer for voluntary counseling and testing for HIV, Syphilis and Hepatitis B • Consider immunization against Hepatitis B • Schedule return visit after 7 days to ensure treatment compliance as well as to see reports of tests done. • If symptoms persist, assess whether it is due to treatment failure or re­infection and advise prompt referral.

22 N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres

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26 N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres

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34 N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres

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♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n 35

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36 N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres

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♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n 37 Management of Anogenital warts

Fig 5 a to c: Anogenital warts

Fig 5a: Perivulval warts

Fig 5b: Penile warts

Fig 5c:Perianal warts

38 N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres

Causative Organism tincture of benzoin applied to the warts, while carefully protecting the Virus: Human Papilloma Virus (HPV) surrounding area with Vaseline, to be Clinical features washed off after 3 hours. It should not be used on extensive areas per Single or multiple soft, painless, pink in session. color, “cauliflower” like growths which appear around the anus, vulvo­vaginal • Treatment should be repeated area, penis, urethra and peri­neum. Warts weekly till the lesions resolve could appear in other forms such as completely. papules which may be keratinized. Note: Podophyllin is contra­indicated in pregnancy. Treatment should be given under Diagnosis medical supervision. Clients should be warned Presumptive diagnosis by history of against self­medication. exposure followed by signs and symptoms. Cervical warts • Podophyllin is contra­indicated. Differential diagnosis • Biopsy of warts to rule out malignant i. Condyloma lata of syphilis change. ii. Molluscum contagiousm • Cryo cauterization is the treatment of Treatment choice. Recommended regimens: • Cervical cytology should be periodically done in the sexual Penile and Perianal warts partner(s) of men with genital warts. • 20% Podophyllin in compound

♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n 39 Management of Molluscum contagiosum and Ectoparasitic infestation

Clinical features There may be small red papules with a tiny central clot caused by lice irritation. General or local urticaria with skin thickening may or may not be present. Eczema and Impetigo may be present.

Treatment Recommended regimen:

Fig 5d: Molluscum contagiosum • Permethrin 1% creme rinse applied to affected areas and wash off after 10 minutes Causative Organism Special instructions Pox virus • Retreatment is indicated after 7 days Clinical features if lice are found or eggs observed at Multiple, smooth, glistening, globular the hair­skin junction. papules of varying size from a pinhead to • Clothing or bed linen that may have a split pea can appear anywhere on the been contaminated by the client body. Sexually transmitted lesions on or should be washed and well dried or around genitals can be seen. The lesions dry cleaned. are not painful except when secondary infection sets in. When the lesions are • Sexual partner must also be treated squeezed, a cheesy material comes out. along the same lines. Diagnosis Scabies Diagnosis is based on the above clinical Causative Organism: Mite ­ Sarcoptes features. Scabiei. Treatment • Individual lesions usually regress without treatment in 9­12 months. • Each lesion should be thoroughly opened with a fine needle or scalpel. The contents should be exposed and the inner wall touched with 25% phenol solution or 30% trichloracetic acid. Pediculosis pubis Causative Organism Fig 5e: Genital Scabies Lice ­ Phthirus pubis

40 N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres

Clinical features Partner management

Severe pruritis (itching) is experienced by Partner management is an activity in which the client, which becomes worse at night. the partners of those identified as having Other members of family also affected (apart from sexual transmission to the RTI/STI are located, informed of their partner, other members may get infected potential risk of infection, and offered through contact with infected clothes, linen treatment and counseling services. or towels). Timely partner management serves Complications following purpose: • Eczematization with or without • Prevention of re­infection secondary infection • Prevention of transmission from • Urticaria infected partners and • Glomerulonephritis • Help in detection of asymptomatic individuals, who do not seek • Contact dermatitis to antiscabetic treatment. drug Critical issues on partner management Diagnosis • Confidentiality: Partners should be The burrow is the diagnostic sign. It can assured of confidentiality. Many be seen as a slightly elevated grayish times partners do not seek services, dotted line in the skin, best seen in the soft as they perceive confidentiality as a part of the skin. serious problem. Respecting dignity of client and ensuring confidentiality Treatment will promote partner management. Recommended regimens: • Voluntary reporting: Providers must • Permethrin cream (5%) applied to all not impose any pre­conditions giving areas of the body from the neck down treatment to the index client. and washed off after 8—14 hours. Providers may need to counsel client several times to emphasize the • Benzyl benzoate 25% lotion, to be importance of client initiated referral applied all over the body, below the of the partners. neck, after a bath, for two consecutive nights. Client should bathe in the • Client initiated partner management: morning, and have a change of Providers should understand that clothing. Bed linen is to be because of prevailing gender disinfected. inequities, women may not be in position always to communicate to Special instructions their partners regarding need for • Clothing or bed linen that have been partner management. Such client used by the client should be imitated partner management may not work in some relationships and thoroughly washed and well dried or may also put women at the risk of dry cleaned. violence. Hence alternative • Sexual partner must also be treated approaches should be considered in along the same lines at the same time. such situations.

♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n 41 • Availability of services: RTI/STI Sample Partner reporting card diagnostic and treatment services should be available to all partners. Note: A two­step strategy can be used where This may mean finding ways to avoid clients are first asked to contact partners long waiting times. This is important themselves. If no response till one or two weeks, because many asymptomatic clinic or health department staff can attempt to partners are reluctant to wait or pay trace the contact for treatment. for services when they feel healthy. General principles for partner Approaches for partner management management There are two approaches to partner • In general, partners should be management: treated for the same STI as the index i. Referral by index client client, whether or not they have In this approach, index client informs symptoms or signs of infection. the partner/s of possible infection. • Health care providers should be as This appears to be a feasible sure as possible about the presence approach, because it does not involve of an STI before informing and extra personnel, is inexpensive and treating the partner, and should does not require any identification of partners. A partner notification card remember that other explanations are with relevant diagnostic code should possible for most RTI symptoms like be given to each index client, where vaginal discharge. partner management is indicated. This • Special care is required in notifying approach may also include use of partners of women with lower client initiated therapy for all contacts. abdominal pain who are being ii. Referral by providers treated for possible pelvic In this approach service provider inflammatory disease. Because of the contacts client’s partners through serious potential complications of issuing appropriate partner PID (infertility, ectopic pregnancy), notification card. The information partners should be treated to prevent provided by client is used possible re­infection. It should be confidentially to trace and contact recognized, however, that the partners directly. This approach diagnosis of PID on clinical grounds needs extra staff and is expensive. is inaccurate, and the couple should be adequately counseled about this Box 5.1: Coupon for a free examination uncertainty. It is usually better to Coupon for a free examination offer treatment as a precaution to preserve future fertility than to Date: mislabel someone as having an STI Please attend following centers along with when they may not have one. the card Follow­up visits Stamp of the Facility Follow up visits should be advised Timings: • To see reports of tests done for HIV, Diagnostic Code: Syphilis and Hepatitis B.

42 N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres

• If symptoms persist, advise clients to For re­infection come back for follow up after 7 days. In case of PID, follow up should be • Consider re­treatment with same antibiotics. done after 2 to 3 days. • Refer to higher health facility if Management of treatment failure and symptoms persist. re­infection When clients with an RTI/STI do not Screening for Asymptomatic Clients respond to treatment, it is usually because It is well known that most RTIs/STIs are of either treatment failure or re­infection. asymptomatic, especially amongst the Ask the following questions to ascertain women. The case finding is a process of the cause: opportunistic screening for an infection at the time when an individual presents to a To probe for treatment failure health facility, regardless of presence of • Did you take all your medicines as symptoms. Case findings opportunities directed? are most commonly seen while providing services for contraception. Providers • Did you share your medicine with should use opportunities for potential anyone, or stop taking medicines contraceptive clients to screen for RTIs/ after feeling some improvement? STIs. The National Guidelines for IUD, Oral • Was treatment based on the national Pills, National Standards for Sterilization treatment guidelines? Also consider Services provide detailed guidelines the possibility of drug resistance if regarding screening of RTIs/STIs. cases of treatment failure are showing an increasing trend. Similar opportunities exist in pregnancy care settings. Most common screening To probe for re­infection programmes worldwide are those for • Did your partner(s) come for detecting syphilis in pregnant women. treatment? Untreated syphilis in pregnant female is associated with number of adverse • Did you use condoms or abstain from outcomes such as pregnancy loss, sex after starting treatment? stillbirths and congenital syphilis. Note: Recurrence is also common with Providers are recommended to follow endogenous vaginal infections, especially when Government of India’s following underlying reasons (douching, vaginal drying guidelines while providing services to agents, diabetes mellitus hormonal pregnant women: contraceptives) are not addressed. 1. Guidelines for Pregnancy Care and Box 5.2: Management of treatment Management of Common Obstetric failure and re­infection Complications by Medical Officers, 2005. For treatment failure 2. Guidelines for Ante­Natal Care and All cases of treatment failures should Skilled Attendance at Birth by ANMs be referred to higher health facility. and LHVs, 2006.

♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n 43 RTI/STI Among Special 6 Populations

6.1 Sexually Transmitted Infections adolescent girls is due to the presence of (RTIs) among children and greater cervical ectopy which makes the adolescents cervix more susceptible to gonorrhea, chlamydia and HPV. Adolescents today Reproductive tract infections in children face enhanced vulnerability to unwanted are acquired through three different ways pregnancy and STIs including HIV/AIDS. (i) transplacental transmission occurring in Studies from African countries suggest that utero, intrapartum transmission (during girls marrying at an early age are at high labour and delivery) e.g. syphilis, HIV, risk of HIV infections. Many interrelated cytomegalovirus (CMV) and human and complex factors that put adolescents papilloma virus infection (HPV) ; (ii) at risk of STIs include poor education, postnatal transmission (during breast­ unemployment and poverty. Urbanization feeding, accidental and through sexual tends to disrupt family relationships, social abuse) (iii) due to sexual abuse or in networks and traditional values while sexually active adolescents who are at risk. generating more opportunity for sexual encounters. Lack of information about Child sexual abuse is the use of a child as sexual matters, as well as STI prevention, an object of gratification for adult sexual symptoms and treatment also put both needs or desire. The common sexual abuse male and female adolescents at risk of STIs. encountered by girls is genital contact, Even when adolescents have accurate masturbation, vaginal, oral or anal knowledge about STD’s, some incorrectly intercourse by a male perpetrator, while perceive their risk as low either due to boys are subjected to felatio and anal familiarity with a sexual partner or as intercourse. relationship matures or simply because they are passing through a stage of life in Adolescents and youth in the age group which risk taking is particularly attractive 10­24 years contribute to about 30% of our especially under the strong influence of population. The data from various Indian their peers, migration and displacement, studies reveal that adolescents indulge in multiple and concurrent sexual pre­marital sex more frequently and at an partnership, lack of access to effective and early age. STIs, including HIV, are most affordable STI services. Therefore there is common among young people aged 15­24 an urgent need for improving the years and more so in young women. The accessibility of adolescents to preventive physiological risk of increased and curative services including susceptibility to infections among information and counseling.

44 N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres

In the RCH 2, Adolescent Reproductive bleeding and an increase in vaginal and Sexual Health (ARSH) Strategy is to secretions. be implemented in the primary health care • Candida albicans is uncommon in setting based on the implementation adolescents prior to puberty. If Guide for state and district program present, the adolescent may have a managers. Under this strategy, it is discharge, vulval itching, dyspareunia, expected that a core package of promotive, peri­anal soreness or a fissuring at the preventive, curative, counseling, referral introitus. Attacks of candida vulvitis and outreach services would be provided may be cyclical in nature and through the public health care facilities. It corresponds to menstruation. states that services for adolescents must demonstrate relevance to the needs and • Bacterial vaginosis does not produce wishes of the young people. vulvitis and the adolescent will not complain of itching or soreness. Clinical presentation of RTIs/STIs in • The signs of acquired syphilis in children and adolescents children present with small chancres The presenting symptoms of adolescents or mucocutaneous moist lesions is very peculiar as very often they present either on the vulva or anus. with symptoms other than those of RTI/ Presentation of syphilis is the same STI. Therefore risk assessment plays a in adolescents and adults. crucial role. The increasing tendency of Boys : homosexual behavior as reported by some studies must also be kept in mind and ano­ • Gonorrhea among boys presents as genital lesions must be looked for. proctitis, urethral discharge, asymptomatic pyuria, penile edema, Girls epididyimitis and testicular swelling. Disseminated gonorrhoea presents • In general, endogenous vaginitis with multiple systemic rather than an STI is the main cause manifestations. of vaginal discharge among adolescent females. • Chlamydia in males presents as urethritis. • Approximately 85% of gonococcal infection in females will be 6.2 Sexually Transmitted Infections asymptomatic. However, there may (STIs) among Sex Workers and MSMs be vulval itching, minor discharge, In some groups of population with high urethritis or proctitis. In pre­ risk practices such as sex workers, men pubescent girls, a purulent vulvo­ having sex with men and intravenous drug vaginitis may occur. users, the prevalence of STIs and HIV is • Similarly, Chlamydia trachomatis higher than the general population. infection is asymptomatic in the Treating these clients early and majority of cases. Symptoms that may appropriately will reduce risk of HIV occur in the adolescent are inter­ infection and if already infected, they can menstrual bleeding, postcoital be advised for seeking the available

♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n 45 services at the integrated testing and no evidence of infection, treatment is counseling facilities for knowing of HIV recommended if: status and further follow up action as indicated. It is desirable that all clients • the sex worker is visiting the clinic with risky behaviour are tested. for the first time; • six months have passed since the sex 6.3 Clinical Management of STI in worker last received treatment. Most at Risk Groups The rationale for presumptively treating High rates of curable STIs have been sex workers who are asymptomatic is that observed worldwide in commercial sex they are frequently exposed to STIs and settings where condom use rates are low they often do not show signs or symptoms and access to effective STI treatment even when infected. A sex worker is likely services is limited. to be exposed and infected with a STI, if Effective prevention and treatment of STIs the time lapse is more since her last among female sex workers requires treatment. (Note: This recommendation attention to both symptomatic and will be reviewed and revised as data on asymptomatic infections. The prevention the epidemiology of STIs among sex and treatment of STIs in female sex workers workers become available). in STI clinics should have the following It is anticipated as STI prevalence falls, two components: periodic presumptive treatment of • Treatment of Symptomatic Infections asymptomatic STI treatment among sex workers will be tapered to first visit ­ As per the flow charts included asymptomatic treatment under the in these guidelines. following conditions: • Screening and Treatment of Asymptomatic Infections • Evidence of low gonococcal and chlamydial infections (10% and ­ Periodic history taking, clinical below); examination and simple laboratory diagnostics (where • High condom use among sex workers available); (>70%); and ­ Periodic presumptive treatment • High quality STI services for sex for asymptomatic gonococcal workers have been established, with and chlamydial infections (in almost 80% of sex workers having areas with high STI rates and access to STI services (80% provided minimal STI services); and with asymptomatic treatment at least ­ Semi­annual serologic screening once and are coming to the clinic for for syphilis. regular STI screening). Female sex workers should be encouraged In such situations, regular visits for routine to attend the clinic for routine check­ups. examination and counseling should be During the visit, the clinic staff should take promoted. Sex workers should be a detailed history and perform an counseled at every opportunity (in the examination. In addition, even if there is clinic and in the community) on the

46 N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres importance of using condoms. Peer Outreach staff should also remind sex educators, outreach workers and clinic workers about their clinic appointments staff should reinforce the following and help them keep their appointments. message to sex workers visiting the clinic: It is also important to cater for STI • The only reliable way to protect management needs of MSM population oneself from HIV and STIs is to use groups. Emergence of anal STIs is cause condoms consistently and correctly; of concern. Service providers should be and sensitive to the needs of the MSM population groups and counsel them • Antibiotics dispensed at the clinic are about risk reduction, use of condoms and effective only for the few curable STIs. HIV testing.

Flowchart 6.1: Management of STIs during routine visit by female sex workers

♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n 47 Flowchart 6.2: Flowchart for routine visit by male and transgender sex workers in clinics

48 N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres

Management of Sexual 7 Violence

Sexual violence is defined as “any sexual Staff should be trained in how to take act, attempt to obtain a sexual act, forensic specimens, or referral links unwanted sexual comments or advances, should be made. Forensic examination or acts to traffic women’s sexuality, using must include physical and genital coercion, threats of harm or physical force, examination. (Refer to the State­ by any person regardless of relationship specific guidelines for forensic to the victim, in any setting, including but examination). not limited to home and work”. Often, because the victims feel uncomfortable C. Collection of samples for detecting talking about sexual violence, they may STIs come to the clinic with other non­specific complaints or requesting a check­up, If facilities permit, swabs must be assuming that the health care provider will collected from various sites for wet notice anything abnormal that needs mount examination or culture of a treatment. Therefore, health care workers number of causative organisms. should maintain a high index of suspicion Blood could be collected for VDRL/ and ask about experience of sexual RPR, HIV and HbsAg tests. violence or abuse. The following services D. Essential medical care for should be available, on­site or through injuries and health problems referral, for clients who have experienced sexual violence: Medical management includes i. Prevention of pregnancy by A. Visual inspection offering emergency contraception Before proceeding for examination ii. STI prophylaxis consent of the victim or the legal iii. Care of injuries guardian in case of minors must be taken. Counseling of the victim must Note: It is important to obtain informed consent for any examination, treatment or referral in a be done. Examination of clothes, case of a victim of sexual assault. injuries and genital must be carried out. Look for bleeding, discharge, odour, Essential medical care for injuries and irritation, warts and ulcerative lesions. health problems would consist of: B. Collection of forensic evidence • Post exposure prophylaxis against pregnancy Forensic examination should be Emergency Contraception (EC) to available to document evidence if the prevent unwanted pregnancy should person chooses to take legal action. be given within 72 hrs of unprotected sexual intercourse.

♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n 49 Box 7.1 : Post exposure prophylaxis with Emergency contraceptives

Type of First dose Second dose Emergency (within 72 hours after (12 hours later) contraception unprotected intercourse)

Levonorgestrel­ Levonorgestrel Repeat same only pills for in 2 doses First dose of dose after 12 hrs emergency 0.75 mg of levonorgestrel contraception

• Post exposure prophylaxis of STI STI prophylaxis should be started as early as possible, although the doses should be spread out (and taken with food) to reduce side­effects such as nausea.

Box 7.2: Post exposure prophylaxis of STI for adults and older children and adolescents weighing more than 45 kg

1. For protection against syphilis, gonorrhea and chlamydia • Tab. Azithromycin 1gm orally, single dose under supervision PLUS • Tab. Cefixine 400mg orally single dose 2. For protection against T. Vaginalis • Tab Metronidazole 2gm single dose OR • Tab Tinidazole 2gm single dose

Box 7.3 : Post exposure prophylaxis of STI for children

1. For protection against syphilis and chlamydia

• Erythromycin 12.5 mg/kg of body weight orally 4 times a day for 14 days

2. For protection against gonorrhea

• Cefixime 8 mg/kg of body weight as a single dose, or

• Ceftriaxone 125 mg by intramuscular injection

3. For protection against T. Vaginalis

• Metronidazole 5 mg/kg of body weight orally 3 times a day for 7 days

50 N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres

• Post exposure prophylaxis of HIV

• Refer to district hospital and follow NACO guidelines for the same. • Post exposure prophylaxis against Hepatitis B

• If not vaccinated earlier, it is recommended. If vaccine is not available, refer to the centre where Hepatitis B vaccination facilities are available.

An evaluation of the person’s personal safety should be made by a protective services agency or shelter, if available, and arrangements made for protection if needed.

A. Psychosocial support (both at time of crisis and long­term) Psychosocial management includes counseling and supportive services, which should be available on­site or by referral. Women or children who have been sexually abused may need shelter and legal protection. Adolescents in particular may need crisis support, as they may not be able or willing to disclose the assault to parents or care takers. B. Follow­up services for all of the above It is essential to explain the importance of follow­up appointments and services during the first visit itself. The woman should be clearly told whom to contact if she has other questions or subsequent physical or emotional problems related to the incident.

♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n 51 Counseling and Testing 8 for RTIs/STIs

Effective communication of information Guidelines for counseling on prevention, especially on behavior a) Welcome your client warmly by change, linked with effective treatment is name and introduce yourself. a key to the control of RTIs/STIs. When clear communication is linked to effective b) Sit closely enough so that you can talk treatment there can be additional benefits. comfortably and privately. Even when treatment is not available at c) Make eye contact and look at the outreach RCH service delivery settings, client as s/he speaks. prevention information and condoms can d) Use language that the client be provided. Effective communication can understands. be done in the following ways: e) Listen and take note of the client’s Interpersonal communication: The face­ body language (posture, facial to­face process of giving and receiving expression, looking away, etc.). Seek information between two or more people. to understand feelings, experiences This involves both verbal and non­verbal and points of view. communication. f) Be encouraging. (Nod or say, “Tell • Verbal communication: The way we me more about that.”) talk with clients, the words we use, g) Use open­ended questions. and their meanings. h) Provide relevant information. • Non­verbal communication: The way we behave with clients, i) Try to identify the client’s real including actions, behaviors, concerns. gestures and facial expressions. j) Provide various options for the Counseling: Face­to­face, personal, client. confidential communication in which one k) Respect the client’s choices. person helps another to make decisions l) Always verify that the client has and then to act on them. Good counseling understood what has been discussed has two major elements: mutual trust by having the client repeat back the between client and provider and the giving most important messages or and receiving of relevant, accurate and instructions. complete information that enables the client to make a decision. It requires Barriers to good counseling conversational and listening skills. • Lack of privacy. • Not greeting or not looking at the prevents complications and re­ client. infection in the client.

• Appearing to be distracted (for What the client needs to know example, by looking at your watch or reading papers while s/he is Prevention of RTIs/STIs talking). • Risk reduction • Using a harsh tone of voice or making • Using condoms, correctly and angry gestures. consistently, availability of condoms • Sitting while the client stands or • Limiting the number of partners sitting far away from the client. • Alternatives to penetrative sex • Allowing interruptions during the consultation. • Negotiating skills

• Being critical, judgmental, sarcastic Information about RTIs/STIs or rude. • How they are spread between people • Interrupting the client. • Consequences of RTIs/STIs • Making the client wait for a long time. • Links between RTIs/STIs and HIV • Not allowing enough time for the visit. • RTI/STI Symptoms ­ what to look for and what symptoms mean Client counseling on RTIs/STIs: During counseling session, provider should talk RTI/STI Treatment about causation, transmission, recommended treatment, prevention, risk • How to take medications reduction, behavior change, and partner • Signs that call for a return visit to the referral. Clinics can have take away clinic information brochures in simple • Importance of partner referral and languages with illustrations to reinforce treatment messages. • Acknowledge gender inequalities Goals of client education and counselling which may impact male partners coming forward to seek services • Primary prevention or preventing infection in uninfected clients. This Principles of effective client is the most effective strategy to education reduce the spread of RTIs/STIs and can be easily integrated into all health • Shows respect and concern for the care settings. safety of clients through body language, telling clients you are • Curing the current infection. concerned, being attentive to and • Secondary prevention, which acknowledging clients’ feelings, and prevents further transmission of that taking more time with them. infection in the community and • Is client­centered. Provides messages that are tailored for each Counselors and Lab Technicians working individual –different messages for in ICTC, PPTCT, Blood Safety, STI, ART/ married men, women, and OIs and HIV ­ TB together to offer round adolescents. the clock counseling and testing services. This common facility will remove fear, • Involves 3 kinds of learning: through stigma and discrimination among the ideas, actions, and feelings (cognitive, clients and Clients, PLHAs and the psycho­motor, and affective). referrals. • Uses multiple channels (eyes, ears and face­to­face/visual, auditory, The ICTC have common television and interpersonal). Delivers messages video based health education materials that via the eyes, ears, and face­to­face are screened continuously in the Clients communication. waiting area. The information related to preventive, promotive and curative health Integrated Counselling and Testing care along with information regarding Centers (ICTC) and their role in STI HIV/AIDS, and various services provided prevention and Management by the hospital is provided to all the Clients. Clients with STI have shown high risk sexual behaviour. Based on this high risk Further two strategies are adopted in ICTC behavior, the health care worker should for HIV testing. inform the Client about the links between • Opt­out strategy – In this, the STIs and HIV and should encourage all counselor “assumes” that the Client Clients to undergo an HIV test as the risk has come to get an HIV test (implied of HIV among STD is upto 10 times higher. consent). The HIV test will be done In order to get HIV test, Integrated unless the Client actively denies the counseling and testing centers (ICTC) have test. been established. Each ICTC has counselor(s) and a laboratory technician. • Opt­in strategy – In this, the As of November 2006, there are 3394 counselor specifically asks the client, counseling centers and more are being whether s/he would like to undergo established. ICTCs are located in the the HIV test. The client has to actively medical colleges, district hospitals in all agree to the HIV test. states and in addition in selected CHCs As per the National AIDS Prevention and and PHCs especially in the high Control Policy, all HIV tests are voluntary, prevalence states. It is envisaged to based on the clients consent, accompanied establish ICTCs at all CHC and additional by counseling and confidentiality of the at selected PHCs in all states. results. In Integrated Counseling and Testing Aims of Pre­test counseling Centers the STI Client will receive comprehensive and accurate information • To ensure that any decision to take on HIV/AIDS and HIV counseling to the test is fully informed & voluntary facilitate an informed choice regarding an • To prepare the client for any type of HIV test. The integrated centers serve as result, whether negative or positive single window system by pooling all or indeterminate

54 N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres

• To provide client risk reduction infection to others including condom, information & strategies irrespective avoiding multiple partners and other of whether testing proceeds high risk behaviour (Positive prevention. • The Clients are advised about preventive measures and use of • Help Clients access the medical and condoms. social care and support they need If the Client declines to take the test, he/ • Establish link with PLHA groups, if she leaves the ICTC. Some Clients return needed to the ICTC after a few days for the test. If the client agrees to undergo the test, he/ In STI settings, the following is she proceeds to the attached laboratory for recommended blood collection. After the blood sample is taken, the client either waits for the (i) HIV testing should be recommended results or is asked to return on assigned for all STIs Clients after pre­test date with Patient Identification Digit (PID) counseling and informed consent. number There should be guarantee for confidentiality. HIV counseling and The tests are performed by using the rapid testing can either be performed in the test kits. If the test is negative and the client STI clinic (if counselor is available) has history of high risk factors, he/she is or Clients can be referred to the advised to repeat the test after 3 months nearest ICTC. as he/she may be in the window period. If the result is positive the test is repeated (ii) In some cases of STIs in the presence with kits using a different method of of HIV infection, larger doses and antibody detection. The result is longer treatment duration of the considered positive if all three tests are drugs listed under the different STIs positive. Before the results are revealed may be required. These Clients to the client, post counseling is done. should be followed up regularly for longer duration. Aims of Post­ test counseling aims to: (iii) Excessive use of anti­microbials • Help client understand and cope should be avoided, as it is likely to with the HIV test results lead to more rapid development of • Provide the client with any further antibiotic resistance. information required (iv) Although counseling of individual • Help Clients decide what to do about Clients on risk reduction, and disclosing their test result to partners prevention of STI transmission to the and others partners should be done in all Clients • Help Clients reduce their risk of of STI, this is of vital importance for HIV/ AIDS and take action to prevent those infected with HIV.

♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n 55 lkj;dgjldfkgj

56 N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres

Annexure

♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n 57 ANNEXURE 1

LABORATORY TESTS FOR RTIs/STIs

Laboratory tests improve the diagnostic sensitivity and specificity of symptomatic RTIs/ STIs, particularly in women, to differentiate serious infections, i.e., cervicitis, from milder but more common infections, i.e., vaginitis. Simple laboratory tests incorporated in syndromic management of urethral discharge also help distinguish between mixed and single infections, reducing the administration of unnecessary antibiotics. The tests also help in detection of infections in asymptomatic individuals, specifically in female Clients, who carry the burden of RTIs/STIs complications and sequelae. Laboratory testing is even more important in pregnant women to prevent the adverse consequences of syphilis, gonococcal and chlamydial infection in newborns. Laboratory diagnosis of RTIs includes three major equally important steps i.e; collection of specimen, its transport and use of a reasonable sensitive and specific test. Laboratory procedures at PHC level should include microscopic examination of fresh and stained specimens. Microscopic examination of urethral discharge helps to single out nongonococcal infection. Wet mount microscopy in vaginal discharge helps to detect trichomoniasis, (Trichomonas vaginalis) candidiasis and bacterial vaginosis (BV). Simple additional tests to identify bacterial vaginosis are the KOH sniff test and measurement of pH of vaginal fluid. Lab procedures may also include simple nontreponemal syphilis screening tests: rapid plasma reagin (RPR) or Venereal Disease Research Laboratory (VDRL). Effective diagnosis of vaginitis by vaginal pH, amine test and wet smear of vaginal smear can be achieved with a sensitivity of 75­80%. The sensitivity of detecting candida organisms by 10% KOH preparation, saline microscopy and Gram stain is 70%, 40­ 60% and 65% respectively. The sensitivity of wet mount to identify trichomonads in symptomatic women is approximately 80% while it decreases to 50% in asymptomatic women. The sensitivity of Fig A1a : Collection of specimen on swab papanicolaou (PAP) smear for T. vaginalis is around 60%. Gram stain is more reliable than PAP for diagnosis of BV infection. For other RTIs/STIs, it is advisable to use ELISA based assays or molecular diagnostics to achieve good sensitivity and specificity. Vaginal pH

The pH of vaginal fluid should be measured using pH paper of appropriate range (3.8

58 N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres to 6.0). The vaginal fluid sample is collected with a swab from the lateral and posterior fornices of the vagina and the swab is then touched directly on to the paper strip. Alternatively, the pH paper can be touched to the tip of the speculum after it has been withdrawn from the vagina. Care must be taken not to use any jelly (eg K.Y jelly) or disinfectant (eg.savlon) before doing pH test. Contact with cervical mucus must be avoided since it has a higher pH. The normal vaginal pH is 4.0. In BV, the pH is generally elevated to more than 4.5. The vaginal pH test has the highest sensitivity (true negative) of the four characteristics used for identification of BV, but the lowest specificity (true positive); an elevated pH is also observed if the vaginal fluid is contaminated with menstrual blood, cervical mucus or semen, and in women with a T. vaginalis infection. In simple words it means that if pH test is negative the result can be taken as it is but if it is positive one has to rule out the other factors contaminating the sample such as menstrual blood, cervical mucus or semen or presence of T. vaginalis infection

Wet mount microscopy Wet mount microscopy is the direct microscopic examination of vaginal discharge for the diagnosis of trichomoniasis, candidiasis and BV.

Box A1.1: Wet mount microscopy examination of vaginal discharge Collect specimen Take a specimen of discharge with a spatula from the side walls or deep in the vagina where discharge accumulates. Prepare slide Mix specimen with 1 or 2 drops of saline on a glass slide and cover with a cover slip. What to look for • Examine at 100X magnification and look for typical jerky movement of motile trichomonads (ovoid, globular, pear­ shaped flagellated protozoan). • Examine at 400X magnification to look for yeast cells (round to ovoid cells with typical budding) and trichomonads. • To make identification of yeast cells easier in wet mount slides, mix the vaginal swab in another drop of saline and add a drop of 10% potassium hydroxide to dissolve other cells and note any fishy odour. • Presence of clue cells (squamous epithelial cells covered with many small coccobacillary organisms). Wet mount shows stippled granular cells without clearly defined edges because of the large numbers of adherent bacteria present and an apparent disintegration of the cells. The adhering bacteria are predominantly G. vaginalis, sometimes mixed with anaerobes). Important Look for evidence of other vaginal or cervical infections as multiple infections are common.

♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n 59 Fig A1b : Potassium hydroxide preparation of vaginal fluid showing budding yeast and mycelia

Fig A1c : “Clue cells” in vaginal wet mount (x 400)

Fig A1d: Trichomonas vaginalis in a wet mount of vaginal discharge (x 400)

60 N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres

Box A1.2: Clinical criteria for Bacterial vaginosis (BV) BV can be diagnosed using simple clinical criteria with or without the aid of a microscope.

Collect specimen Note color and consistency of discharge. Take a specimen of discharge from the side walls or deep in the vagina where discharge pools (or use discharge remaining on speculum). Touch pH paper to discharge on swab or speculum and note pH.

Prepare slide • Place specimen on a glass slide. Add a drop of 10% potassium hydroxide (KOH) and note for any fishy smell. • Make a wet smear with 0.9% normal saline, cover with coverslip and see under microscope for clue cells.

What to look for The diagnosis of BV is based on the presence of at least 3 of the 4 following characteristics • Homogeneous white­grey discharge that sticks to the vaginal walls • Vaginal fluid pH >4.5 • Release of fishy amine odour from the vaginal fluid when mixed with 10% potassium hydroxide (positive whiff test)· “Clue cells” visible on microscopy on wet preparation

Important Look for evidence of other vaginal or cervical infections as multiple infections are common.

Whiff test Women with BV often complain of a foul vaginal smell. This odour is due to the release of amines, produced by decarboxylation of the amino acids lysine and arginine by anaerobic bacteria. When potassium hydroxide is added to the vaginal fluid, these amines immediately become volatile, producing the typical fishy odour. Place a drop of vaginal fluid on a glass slide and add a drop of 10% potassium hydroxide. Hold the slide close to nose to detect the amine odour. After a positive reaction, upon standing the specimen will quickly become odourless because the amines will be rapidly and completely volatilized.

Gram stain microscopy A gram stain of a vaginal smear has a higher specificity for the detection of clue cells than a wet mount preparation. Moreover, a Gram stain allows good evaluation of the vaginal bacterial flora. Normal vaginal fluid contains predominantly Lactobacillus

♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n 61 species and exceedingly low numbers of streptococci and coryneform bacteria. In BV, lactobacilli are replaced by a mixed flora of anaerobic bacterial morphotypes and G. vaginalis. However, gram stain microscopy has a very low sensitivity for detecting gonorrhea among women; culture remains the method of choice. For men, gram stain microscopy of urethral discharge smear will show gram­negative intracellular diplococci in case of gonorrhea. In case of non­gonococcal urethritis more than 5 neutrophils per oil immersion field (1000X) in the urethral smear or more than 10 neutrophils per high power field in the sediment of the first void urine are observed.

Box A1.3 Gram stain microscopy of vaginal smears

Collect specimen A Gram stain slide can be prepared at the same time as the wet mount by rolling the spatula/swab on a separate slide. Prepare slide 1. Heat fix. 2. Stain with crystal violet (60 seconds) and rinse. 3. Stain with iodine (60 seconds) and rinse. 4. Decolorize with acetone­ethanol for few seconds (until the liquid runs clear). 5. Stain with safranin (60 seconds) and rinse. 6. Gently blot dry and examine under oil immersion (1000X) and count each type of organisms.

What to look for 1. Lactobacilli only: Normal 2. Mixed flora, mainly lactobacilli with a few short rods (coccobacilli): Considered normal 3. Presence of clue cells; mixed flora, mainly Gardnerella and anaerobic bacteria with a few lactobacilli diagnose as BV 4. Presence of clue cells, mixed flora of Gram­positive, Gram­ negative and Gram­variable rods; no lactobacilli diagnose as BV 5. Count each type of organism and use the Nugent score to record the infection.

Important Look for evidence of other vaginal or cervical infections as multiple infections are common.

62 N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres

Box A1.4: *Nugent score Scoring system (0 to 10) from Gram­stained vaginal smearsa

Total Score Lactobacillus Gardnerella and Curved gram­ morphotypes Bacteriodes spp. variable rods morphotypes

0 4 +(>30/oif) 0(0/oif) 0

1 3 +(5­30/oif) 1 +(<1/oif) 1+ or 2+

2 2 +(1­4/oif) 2 +(1­4/oif) 3+ or 4+

3 1 + (<1/oif) 3 +(5­30/oif)

4 0 (0/oif) 4 +(>30/oif) aM orphotypes are scored as the average number seen per oil immersion field(oif). Note that less weight is given to curved Gram ­ variable rods. Total score = lactobacilli + G. vaginalis and Bacteriodes spp. + curved rods.

0 = no morphotypes present 1 = <1morphotypes present 2 = 1 to 4 morphotypes present 3 = 5 to 30 morphotypes present 4 = 30 or more morphotypes present.

Interpretation of Nugent score 0­3 = normal, never treat 4­6 = intermediate, decide on symptoms for treatment 7­10 = Treat

♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n 63 Fig A1e: Gram stained vaginal smear showing a normal flora of lactobacilli (x 1000)

Fig A1f: Gram stained vaginal smear with typical “clue cell” (x 1000)

Fig A1g: Gram stained vaginal smear showing large Gram­ negative rods (Mobilincus mulieris) (x 1000)

64 N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres

Use of gram stain for diagnosis of cervical infection 1. The Gram stain method in female does not provide conclusive evidence of the presence of Gonococcal infection. Presence of gram negative diplococci indicates infection but their absence does not rule out infection. 2. The costs associated with the method, including the cost of maintaining microscopes, outweigh the benefits in terms of improved quality of care.

Fig A1h: Gram stain smear ­ Gram­negative diplococci of Neisseria gonorrhoeae

Rapid Plasma Reagin (RPR) test for Syphilis The current nontreponemal tests for syphilis are Venereal Disease Research Laboratory (VDRL) and rapid plasma reagin (RPR) test. RPR test is most suitable for the primary health care set­up. Box A1.5 : Procedure of RPR test

Procedure of RPR test • Inform about the infection and the procedure for diagnosis • Seek consent • Use a sterile needle and syringe. Draw 5 ml of blood from a vein. Put in a plain test tube • Let the test tube stand for 20 minutes to allow serum to separate(Or centrifuge 3–5 minutes at 2000–3000 rpm). In the separated sample, serum will be on top.

♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n 65 • Use sampling pipette to transfer the serum. Take care not to include any red blood cells from the lower part of the separated sample. • Hold the pipette vertically over a test card circle. Squeeze teat to allow one drop (50 µl) of serum to fall onto a circle. Spread the drop to fill the circle using a toothpick or other clean spreader. Important: Several samples may be done on one test card. Be careful not to contaminate the remaining test circles. Use new tip and spreader for each sample. Carefully label each sample with a Client name or number • Attach dispensing needle to a syringe. Shake antigen.* Draw up enough antigen for the number of tests done (one drop per test). • Holding the syringe vertically, allow exactly one drop of antigen to fall onto each test sample. Do not stir. • Rotate the test card smoothly on the palm of the hand for 8 minutes (or rotate on a mechanical rotator.) Interpreting results After 8 minutes rotation, inspect the card in good light. Turn or tilt the card to see whether there is clumping (reactive result). Test cards include negative and positive control circles for comparison. Example test card 1. Non­reactive (no clumping or only slight roughness): Negative for syphilis 2. Reactive (highly visible clumping): Positive for syphilis 3. Weakly reactive (minimal clumping): Positive for syphilis Note: Weakly reactive can also be more finely granulated and difficult to see than this illustration * Make sure antigen was refrigerated (not frozen) and has not expired. If RPR positive: • Enquire if the woman and her partner have received proper treatment. • If not, treat woman and partner for syphilis with benzathine penicillin. • Treat newborn with benzathine penicillin. • Follow­up newborn in 2 weeks. • Counsel on safer sex.

66 N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres

Correlation and confirmation of test results • Syphilis tests detect antibodies, which are evidence of current or past infection. Syphilis tests are not needed to diagnose Clients with genital ulcers (who should be managed using Flowchart). • Non­treponemal tests (such as RPR and VDRL) are the preferred tests for screening. These tests detect almost all cases of early syphilis, but false positives are possible. RPR can be performed without a microscope. Treponemal tests, such as Treponema pallidum haemagglutination test (TPHA), fluorescent Treponema antibody absorption test (FTA­Abs), microhaemagglutination assay for antibodies to Treponema pallidum (MHA­TP), if available, can be used to confirm non­treponemal test results. Quantitative RPR titres can help evaluate the response to treatment. The following table can be used to interpret syphilis test results. Note: where additional tests are not available, all Clients with reactive RPR or VDRL should be treated. Box A1.6: Interpreting serological test results

RPR RPR titre TPHA Active infection + >1:8 + Latent syphilis + Often <1:4 + False positive + Usually <1:4 ­ Successful treatment + or ­ 2 titres decrease (e.g. from 1:16 to 1:4) +

FigA1i : Test serum is mixed with antigen and FigA1j: Reading RPR results for 10 undiluted the card is placed on appropriate rotator sera showing reactive and non reactive samples. The presence of small to large flocculated clumps indicates reactivity, whereas no clumping or a very slight roughness indicates non­reactivity

♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n 67 ANNEXURE 2

CONDOM AND ITS PROPER USAGE TECHNIQUE

Condom is one of the barrier methods of contraception. They are made by using either latex or polyurethane, which cannot be penetrated by sperm, STIs or HIV, so it provides dual protection, helps in avoiding unwanted pregnancies and gives protection against STIs. Therefore promotion of the use of condoms and ready accessibility of condoms is important for the control of STIs and HIV. Management of STIs includes counseling on preventive measures and use of condoms. All health facilities providing STI services must always have in stock the essential drugs and condoms. The necessity of using condoms must be explained to the Clients along with the advice on the treatment schedule and important for compliance of the full course of medicines prescribed.

General Instructions for Condom Use Remember: • The condom does not include spermicide. If you want additional protection, you must add your own spermicide. • Because it is made from polyurethane, you can use oil­based lubricants with the condom. • Use a new condom each time you have sex. • Use a condom only once. • For best results, store condoms in a cool, dry place. • Do not use a condom that may be old or damaged.

Do not use a condom if: • The package is broken. • The condom is brittle or dried out. • The color is uneven or has changed. • The condom is unusually sticky.

Male Condom Most male condoms are made of latex, while some are made of polyurethane. Male condoms are of two types: Non lubricated and lubricated.

68 N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres

Box A2.1: How to use a male condom

Step­1: Open Package • Use a new condom each time you have sex • Check that it has not expired and that the packaging has no holes by pressing the pack between your fingers • Push condom to one side of package to allow room to tear open other side • Remove condom carefully • DO NOT use finger nails, teeth or sharp objects to open package or remove condom

Step­2: Put it on • Squeeze closed top end of condom to make sure no air is inside (can make it break) • Place condom over top of erect penis • With other hand, unroll condom gently down the full length of your penis (one hand still squeezing top end)

Step­3: During sex • Make sure condom stays in place • If it comes off, withdraw your penis and put on a new condom before intercourse continues • Once sperm has been released into condom (ejaculation), withdraw the erect penis and HOLD the condom in place on penis

Step­4: Dispose of condom

• Remove condom ONLY when penis is fully withdrawn

• Keep both penis and condom clear from contact with your partners body

• Knot the end of the used condom

• Place in tissue or bag before throwing it in dustbin • DO NOT flush condoms down the toilet. It will block the system

♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n 69 Female Condom Female condoms are made of polyurethane. One advantage of it over the male condom is that its size and shape enable it to cover the wider surface area including some of the external genitalia, thus it may offer additional protection against infections that can be transmitted by contact with skin normally not covered by a male condom. However, the female condom is expensive. It is freely available in open market but not yet included in the National family Welfare program.

Box A2.2: How to use a female condom Before Intercourse Step 1 : Open Package • Remove the female condom from the package, and rub it between two fingers to be sure the lubricant is evenly spread inside the sheath. If you need more lubrication, squeeze two drops of the extra lubricant included in the package into the condom sheath. Step 2 : Put it in • The closed end of the female condom will go inside your vagina. Squeeze the inner ring between your thumb and middle finger. Step 3 : Assure right position • Insert the ring into your vagina. Using your index finger, push the sheath all the way into your vagina as far as it will go. It is in the right place when you cannot feel it. Do not worry, it can’t go too far.Note: The lubrication on the female condom will make it slippery, so take your time to insert it. During sex Step 4 • The ring at the open end of the female condom should stay outside your vagina and rest against your labia (the outer lip of the vagina). Be sure the condom is not twisted. • Once you begin to engage in intercourse, you may have to guide the penis into the female condom. If you do not, be aware that the penis could enter the vagina outside of the condom’s sheath. If this happens, you will not be protected. After Intercourse Step 5: Dispose of condom • You can safely remove the female condom at any time after intercourse. If you are lying down, remove the condom before you stand to avoid spillage. • Throw the female condom away. Do not reuse it.

During intercourse remember to remove and insert a new female condom if: condom rips or tears during insertion or tears during insertion or use, the outer ring is pushed inside, the penis enters outside the pouch, the condom bunches inside the vagina, or you have sex again.

70 N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres

ANNEXURE 3 STI ­ Clinic Setup A. Internal structure The internal structure of the clinic should provide physical privacy, auditory privacy and confidentiality for Client interviews and information in the following areas: • Waiting and registration area; • Consultation and examination room, with door; • Laboratory area (if feasible); and • Counseling room, with door. All areas should have adequate lighting and ventilation.

B. Staffing Staffing should be adequate for the following clinic functions to be carried out in a timely manner, without excessive waiting times: • Clinic administration, Client registration, record­keeping and reporting; • Sexual and reproductive health history­taking, clinical examination and Client management, including counseling and education; • Laboratory­based diagnostic testing (where applicable); • Maintenance of clinical standards for STI management; and • Procurement and maintenance of clinic supplies. All clinic staff positions should be filled at all time with appropriately trained personnel. New staff should be trained in elements of STI Case management.

C. Equipment and Drugs Equipment should be maintained in good working order. Equipment should be maintained by: • Wiping / dusting daily with clean cloth • Cover with protective covering Condoms, drugs and other supplies should always be in stock in the clinic. Availability of blister pack of drugs colour coded for different syndromes may be considered.

D. Coordination between clinic staff and outreach services (wherever applicable) Close collaboration and communication between the clinic and outreach staff will help in identifying and addressing problems and removing misunderstandings between the clinic and community in a timely manner. • Regularly scheduled meetings should be held with clinic staff, project outreach staff and peer educators to discuss

♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n 71 ­ Clinic activities; ­ Community needs and concerns; ­ Ways of promoting the clinic; ­ Follow­up of cases in the community; and ­ The ongoing process of coordination. • Outreach worker should be encouraged to report back to clinic staff on issues such as community perception of the clinic, treatment compliance, side effects of medications, etc. • A community monitoring system should be in place. • Clinic staff should participate in outreach visits on a regular basis. E. Client friendly environment Five components of a clinic environment that are acceptable to Clients and promote trust within the community are: • Respectful attitude of staff; • Convenient location and clinic opening hours; • Confidentiality; • Anonymity; and • Right of refusal of services. Confidentiality should be ensured at all times. This must be continually reinforced with the staff. • Clinics should have a confidentiality policy that is enforced and communicated to the Clients and community. • Clients should be informed about how their medical information is handled, and when and how such data may be used for evaluation purposes. • All staff should receive training in the confidentiality policies of the clinic. • All staff should sign a confidentiality agreement. Anonymity can be preserved by allowing Clients to provide identifying information, such as a “working name”, age, date of birth, etc., instead of their official birth name. It is not necessary to ask for identification papers. A registration number can be assigned to each Client as his/her identifying information. S/he should be instructed to keep this to ensure continuity of service in the clinic. All Clients have a right to refuse services, even when the clinic staff may think they are in the Client’s best interest. Clients should not be forced into attending the clinic or receiving treatment. If the Client still refuses treatment after exploring and discussing the reasons for resisting examination or treatment, the clinician must respect the Client’s choice. It is possible that the Client will allow examination on a subsequent visit after a trust in the clinic’s staff is established.

72 N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres

ANNEXURE 4 LIST OF DRUGS

Drugs to be stocked at STI Clinics All clinics must maintain adequate stock of drugs required for treatment of STIs as per the standard protocol. Following is the inventory of essential STI treatment drugs. They should be stored in a secure location and used before their expiry date. 1. Inj. Benzathene Penicillin – 24 lakhs unit vial 2. Inj. Ceftriaxone (250 mg & 1 gm) 3. Tab. Azithromycin (1g) 4. Tab. Cefixime (400mg) 5. Tab. Fluconazole (150 mg) 6. Tab. Secnidazole (500 mg) 7. Tab Metronidazole (400 mg) 8. Tab. Erythoromycin (500 mg) base/stearate 9. Cap. Doxycycline (100 mg) 10. Cap. Acyclovir (400 mg) 11. Clotrimazole Vaginal pessary (500 mg) 12. Podophyllin tincture 20% 13. Permethrin cream (5%) and (1%)

♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n 73 ANNEXURE 5 DISINFECTION AND UNIVERSAL PRECAUTIONS

The terms “standard precautions” and additional (transmission­based) precautions have replaced previous terms such as universal blood and body fluid precautions, universal precautions and barrier nursing. Standard precautions require that health care workers assume that the blood and body substances of all patients are potential sources of infection, regardless of the diagnosis or presumed infectious status. Additional (transmission­based) precautions are needed for diseases transmitted by air, droplets and contact. A number of RTIs can be spread from patient to health care provider or to other patients if basic precautions are not followed. Hepatitis B and C viruses and HIV are incurable infections that are easily transmitted by reuse of contaminated sharps. Because RTIs are often asymptomatic, it is not possible to know which patients have an infection. For this reason, standard precautions should be followed by all the health care workers.

Standard precautions Standard precautions include the following­ 1. Hand washing and antisepsis (hand hygiene) 2. Use of personal protective equipment when handling blood, body substances, excretions and secretions 3. Appropriate handling of patient equipment and soiled linen 4. Prevention of needle­stick/sharp injuries 5. Management of health care waste 1. Hand washing and antisepsis (hand hygiene) Hand washing breaks the chain of infection transmission and reduces person—to­person transmission. It is the most important way to kill germs on the skin. You need to wash your hands even more thoroughly and for a longer time in the following situations: • before and after helping someone give birth; • before and after touching a wound or broken skin; • before and after giving an injection, or cutting or piercing a body part; • after touching blood, urine, stool, mucus, or fluid from the vagina; and • after removing gloves; • between contact with different patients

74 N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres

The hands must be washed for a minimum of 10­15 seconds, count to 30 as you scrub your hands all over with the soapy lather. Use soap or other disinfectant to remove dirt and germs. Use a brush or soft stick to clean under your nails, then rinse, using running water. Do not reuse the same water. Immersion of hands in bowls of antiseptics is not recommended. Common towels must not be used as they facilitate transmission of infection. If there is no clean dry towel, it is best to air­dry hands.

FigA5a: Hand washing Procedures

Source : World Health Organization. Regional Office for Western Pacific. Interim guidelines for national SARS preparedness. Manila : WHO, 2003, Page 45

• Hand washing is the simplest and most cost­effective way of preventing the transmission of infection • The hands must be washed for a minimum of 10­15 seconds with soap or other disinfectant • Common towels must not be used as they facilitate transmission of infection

♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n 75 2. Use of personal protective equipment when handling blood, body substances, excretions and secretions Using personal protective equipment offers protection by helping to prevent micro­ organisms from­ • Contamination of hands, eyes, clothing, hair • Being transmitted to other patients and staff Personal protective equipment includes: • Gloves • Masks • Aprons • Gowns • caps/hair covers Gloves – • Use of gloves (clean, non­sterile) or a piece of plastic for handling dirty bandages, cloths, blood, vomit or stool. • Disposable gloves should not be reused • Gloves must be changed not only between contacts with different patients but between tasks/ procedures on the same patient to prevent cross­contamination between different body sites.

Personal protective equipment must be used effectively, correctly and at all times where there is contact with patient’s blood, body fluids, excretions and secretions may occur

3. Appropriate handling of patient equipment and soiled linen Ensure that all reusable equipment is cleaned and reprocessed appropriately before being used on another patient. Keep bedding and clothing clean. This helps in keeping sick people comfortable and helps in preventing skin problems. Handle clothing and/ or sheets carefully, which are stained with blood, urine, stool or other body fluids. Separate from other laundry for washing. Dry laundry thoroughly in the sun if possible or iron after drying.

4. Prevention of needle­stick/sharp injuries All the used disposable syringes and needles, scalpel blades and other sharp items should be placed in a puncture resistant container having a proper lid. These containers must be located close to the area. Never recap or bend needles.

76 N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres

5. Management of health­care waste Daily collection of waste must be encouraged and uncollected, long stored waste or waste within the premises must be avoided. The bio­medical waste should be segregated into containers/bags at the point of its generation into colour coded containers/bags. Table 12a gives the colour, coding, type of containers used and multiple treatment options for disposal of the bio­medical waste.

Table A5a: Management of health care waste

* Deep burial should be done in a secure area. Burial should be 2 to 3 meters deep and at least 1.5 meters above the groundwater table. # Chemical treatment using at least 1% hypochlorite solution or any other equipment chemical reagent. It must be ensured that chemical treatment ensures disinfection ## Shredding must be such so as to prevent unauthorized use of sharp waste.

♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n 77 Standard precautions require that health care workers assume that the blood and body substances of all patients are potential sources of infection, regardless of the diagnosis or presumed infectious status. Additional (transmission­based) precautions are needed for diseases transmitted by air, droplets and contact. A number of RTIs can be spread from patient to health care provider or to other patients if basic precautions are not followed. Hepatitis B and C viruses and HIV are incurable infections that are easily transmitted by reuse of contaminated sharps. Because RTIs are often asymptomatic, it is not possible to know which patients have an infection. For this reason, standard precautions should be followed by all the health care workers.

Disinfection of instruments Disinfect or sterilize equipment and instruments. Instruments must first be washed and then disinfected if they are to be used to: • cut or pierce skin; • give an injection; • cut the cord during childbirth; • examine the vagina, especially during or after childbirth, a miscarriage, or an induced abortion; • perform any transcervical procedure. High­level disinfection: three steps Cleaning instruments and equipment to get rid of nearly all the germs is called high­ level disinfection. The following procedures could be followed to achieve it: 1. Soaking: Soak instruments for 10 minutes in 0.5% solution of bleach (chlorine). Soaking instruments in bleach solution will help protect you from infection when cleaning them. If you do not have bleach, soak your instruments in water. 2. Washing: Wash all instruments with soapy water and a brush until each one looks very clean, and rinse them with clean water. Be careful not to cut yourself on sharp edges or points. Wear gloves when washing instruments; if possible, use heavy gloves. 3. Disinfecting: Steam or boil the instruments for 20 minutes. • To steam them, you need a pot with a lid. The water does not need to cover the instruments, but use enough water to keep steam coming out of the sides of the lid for 20 minutes. Do not overload with instruments. No instruments should protrude above the rim of the pot. • To boil them, you do not need to fill the whole pot with water. But you should make sure the water covers all the instruments in the pot for the entire time. Put a lid on the pot. • For both steaming and boiling, start timing the 20 minutes after the water

78 N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres

with the instruments is fully boiling. Do not add any new instrument to the pot once you begin to count. Table shows how to make a disinfection solution of 0.5%, 1% and 2% available chlorine

Table A5b: Hypochlorite solution of 0.5 % 1% and 2 % available chlorine

Note: Bleach solution becomes unstable rapidly, hence it needs to be freshly prepared daily or changed on becoming dirty/ turbid. Chlorine bleach can be corrosive. Protect metal instruments by thoroughly rinsing them with water after soaking for 10 minutes.

Cleaning of the Heath Centers Patient care areas must be cleaned by wet mopping. Only dry sweeping is not recommended. Any areas visibly contaminated with blood or body fluids should be cleaned immediately with detergent and water.

♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n 79 Table A5c: Common disinfectants used for environmental cleaning in health centers

Note: A neutral detergent and warm water solution should be used for all routine and general cleaning. When a disinfectant is required for surface cleaning, e.g. after spillage or contamination with blood or body fluids, the manufacture’s recommendation for use and occupational health and safety instruction should be followed.

80 N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres

ANNEXURE 6

MONTHLY REPORT FORMAT ( National AIDS Control Programme)

Reporting Month : ______Name of Centre : ______Name of Block : ______Name of District : ______Name & Phone No. of Officer In Charge : ______

♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n 81 82 N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres

Laboratory Clinical Diagnosis Age Group & Sex Type of Diseases Laboratory Tests Nos. Tested Nos. Found Positive

1. Syphilis Dark Field Microscopy

Serology ­VDRL/RPR

Total

2. Gonorrhoea Direct Smear (Grams’s Stain)

Culture

3. Chlamydia ELISA Antibody

4. Chancroid Gram’s / Glemsa Staning

5. Trichomonasis Direct wet mount

6. Candiadiasis (Candidaalbicons) KOH wet mount

7. Bacterial Vaginosis Wet mount preparation for clue cells

8. Others (specify)

Details of Condom Distribution, Partner Treatment and Counseling Services

Details Male Female Total

1. Number of condoms distributed

2. Number of female condoms distributed

3. Number of partners managed

4. Number of patients referred to ICTC

♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n 83 Status of Availability of Medicines and Consumables (Stock Details)

Details Whether available in adequate If no, List the ones not quantity for the next available in adequate three months? quantity Yes / No

1. Consumables

2. Medicines for Treating STD

3. Male Condoms

4. Female Condoms

84 N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres

ANNEXURE 7 REFERENCES AND SOURCE We gratefully acknowledge the use of material that has been adapted from the following sources:

Source Publication Year World Health Organisation STI/RTI Management in Reproductive Health Care Settings: A Pocket Guide for Essential Practice 2001 World Health Organisation Guidelines for the Management of Sexually Transmitted Infections 2003 World Health Organisation Sexually Transmitted and Other Reproductive Tract Infections – A Guide to essential Practice 2005 World Health Organisation Draft Global Strategy for the Prevention and Control of Sexually Transmitted infections 2005 World Health Organisation Practical guidelines for Infection Control in Health Care Facilites, SEARO, New Delhi 1999 Centre for Disease Control Guidelines for Treatment of STDs 2002 Clinical Effectiveness Group UK National Guidelines on STIs 2002 Population Services International Flowcharts for STIs in Males 2004 Family Health International Handbook for design and management of programs 2005

Indian Council of Medical Guidelines for Management of Research Reproductive Tract Infections: For Medical Officers at PHCs 1996 National AIDS Control Sexually Transmitted Infections­ Organisation Treatment Guidelines Draft National AIDS Flowcharts on the Syndromic Control Organisation Management of Sexually Transmitted Infections 2004 United Nations Population Fund Reference Material on Case Management of RTIs/STIs in PHC Settings for Medical Officers 2004 Pathfinder International Comprehensive Reproductive Health and Family Planning Training Curriculum (Module 12) 2000 Engender Health Sexually Transmitted Infections – Online minicourse 2006

We gratefully acknowledge the use of pictures from the following sources:

1. Dept of Skin & Venereal diseases, Lokmanya Tilak Medical College and Sion Hospital, Sion , Mumbai 2. Dept of Skin & Venereal diseases, Seth G S Medical College and KEM Hospital, Parel, Mumbai 3. Bharatiya Vidya Bhavan’s Swami Prakashananda Ayurveda Research Centre (SPARC), Juhu, Mumbai

♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n 85 ANNEXURE 8

Coordinating Unit at National Institute for Research In Reproductive Health, Mumbai

Dr. Chander Puri, Director Dr. Sanjay Chauhan, Deputy Director Dr. Beena Joshi, Research Officer Dr. Ragini Kulkarni, Research Officer Dr. Kamal Hazari, Deputy Director Dr. Rajashree Manjrekar, Project Research Officer

CORE GROUP MEMBERS Department of Maternal Health, Ministry of Health and Family Welfare, Government of India Dr. V.K. Manchanda, Deputy Director General (retired) Dr. (Mrs) I. P. Kaur, Deputy Commissioner Dr. Himanshu Bhushan, Assistant Commissioner Dr. (Mrs) Manisha Malhotra, Assistant Commissioner

National AIDS Control Organisation Dr. Jotna Sokhey, Additional Project Director Dr. Ajay Khera, Joint Director (Surveillance) Dr. Vinod Khurana, Consultant & Programme Officer

World Health Organisation, India Office Dr. Arvind Mathur, Coordinator, Family & Community Health

United Nations Population Fund Dr. Dinesh Agarwal, Technical Advisor (Reproductive Health)

86 N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n ♦ Guidelines for Setting Up Blood Storage Centres

*LIST OF CONTRIBUTERS

Prof (Ms) Sajida Ahmed Dr. Jayanti Mania Prof & Head, Department of Community Medicine, Assistant Director, National Institute for Research Medical College, Guwahati, Assam in Reproductive Health, (ICMR), Parel, Mumbai

Dr (Ms) Rekha Daver Dr. B. N. Mali Prof. & Head, Dept. of OBGYN, Grant Medical SRO, National Institute for Research in Reproductive College & J.J. Hospital, Byculla, Mumbai Health, (ICMR), Parel, Mumbai

Dr. (Mrs) Alka Gogate Dr. Deoki Nandan Consultant Microbiologist (UNAIDS) 12, Sahyog Principal & Dean of Hospital, S. N. Medical College, Hsg Society, Mahim, Mumbai Agra

Dr. R.R. Gangakhedkar Surg. Cdr (Dr.) Shankar Narayan Deputy Director, National AIDS Research Institute, Specialist in Neonatology, Dept. of PaediatricsINHS ICMR, MIDC , Bhosari, Pune Ashvini, Colaba, Mumbai

Dr. S. D. Gupta Dr. P. Padmanaban Director, International Institute of Health Director, RCH Project, Govt.of Tamil Nadu, DMS Management & Research, Sanganer, Jaipur Bldg, Anna Salai, Chennai

Dr. Jayashree Joshi Dr. Deepak Raut Deputy Director, Bharatiya Vidya Bhavan’s SPARC, Prof. and Head, Dept. of Epidemiology, All India Vithalnagar, Juhu, Mumbai Institute of Hygiene & Public Health, Kolkata

Dr. Surinder Jaiswal Dr. Foujdar Ram Professor, Tata Institute of Social Sciences, Deonar, Professor, International Institute for Population Mumbai Sciences, Deonar, Mumbai

Dr. Hema Jerajani Dr. Jayanti Shastri Professor and Head, Dept. of Skin and VD, LTMC & Professor, Dept of Microbiology, TNMC & BYL Nair LTM General Hospital, Sion, Mumbai Hospital, Mumbai Central, Mumbai

Dr. H. K. Kar Dr. Sudha Salhan Professor and Head, Department of Dermatology Prof and Head, Dept. of OBGYNV.M. Medical and Venerology, R.M.L. Hospital, New Delhi College, Safdarjung Hospital, Delhi

Dr. Usha Krishna Dr. Usha Sariya Consulting Gynecologist, Clinic for Women, Girgaon, Consultant Gynaecologist and Cytophathologist, Mumbai Albess Cama Hospital, Mumbai

Dr. Sunil Khaparde Dr. N. Usman Director, Institute of Family Welfare Research & Professor of Dermatology & STDInstitute of Training, Khetwadi, Mumbai Venerology, Chennai

Dr. Uday Khopkar Dr. Kaushal Verma Professsor and Head, Department of Skin and VD, Dept. of Skin and Venereal Diseases, All India Seth G.S. Medical College, Parel, Mumbai Institute of Medical Sciences, Ansari Nagar, Delhi

Dr. Renuka Kulkarni Dr. Teodora Elvira Wi Professor, Dept of Clinical ParmacologyTNMC & Director, STI Capacity Training, Family Health BYL Nair hospital, Mumbai International, Mumbai

Dr. (Mrs) Meenakshi Mathur Dr. Sanjay Zodpey Prof and Head, Department of Microbiology, LTMC Prof & Head, Dept of Preventive & Social Medicine, & LTM General Hospital, Sion, Mumbai Govt. Medical College, Nagpur

* Names in alphabetical order

♦ N a t i o n a l A I D S C o n t r o l O r g a n i s a t i o n 87 l;kfgjlkdfjg NATIONAL GUIDELINES ON PREVENTION, MANAGEMENT AND CONTROL OF REPRODUCTIVE TRACT INFECTIONS INCLUDING SEXUALLY TRANSMITTED INFECTIONS

Maternal Health Division

Ministry of Health and Family Welfare Government of India August 2007