STI management ⚠️

Get help and advice from local ATSIHPs, health council or respected community members about doing STI work in culturally sensitive way

  • Offer treatment as soon as possible to prevent complications and stop spread
  • Treat people with positive pathology and their named partners and contacts 
  • If positive result on Standard STI check or individual test — do remaining checks to complete Full STI check — men or women

Positive pathology results

Chlamydia

  • Notifiable disease — follow local protocols and check with sexual health unit if more information needed
  • If woman has positive test result — always ask about symptoms of PID
    • Lower abdominal pain is not a normal symptom of uncomplicated chlamydia

Do

  • For genital or oral infections — give azithromycin oral — adult 1g, single dose
  • For anal (anorectal) infections — give doxycycline oral  — adult 100mg, twice a day (bd) for 7 days
  • Contact trace and treat partners with same treatment
  • Arrange recall for re-test in 3 months — 4 weeks if pregnant
  • Advise not to have sex for 7 days after person and partners treated
  • Offer condoms, STI and safer sex education
  • Consider talking about contraception

Follow-up

  • Re-test in 3 months — Standard STI check — men, women
  • For anal chlamydia infections — repeat anal swab NAAT test 4 weeks after treatment is completed
  • Check HIV and syphilis serology done
  •  Urine NAAT can still be positive for 4 weeks after treatment

Pregnancy considerations

  • Re-test after 4 weeks — send urine or low vaginal swab for NAAT
  • High priority for contact tracing and treatment of woman and partners, at same time if possible 

Gonorrhoea

  • Notifiable disease — follow local protocols and check with sexual health unit if more information needed
  • If woman has positive test result — always ask about symptoms of PID
    • Lower abdominal pain is not a normal symptom of uncomplicated gonorrhoea

Do

  • If person and all partners for last 3 months from area with penicillin SENSITIVE gonorrhoea — Table 6.1  
    • Give azithromycin oral — adult 1g, single dose
      AND amoxicillin oral — adult 3g, single dose
      AND probenecid oral — adult 1g, single dose
    • If allergy to penicillin — sexual health consult
  • If person and/or any partner for last 3 months from area with penicillin RESISTANT gonorrhoea  OR partners unknown — Table 6.1
    • Give azithromycin oral — adult 1g, single dose
      AND ceftriaxone IM — adult 500mg, single dose mixed with lidocaine (lignocaine) 1%
    • If allergy — medical consult
  • If anal gonorrhoea — regardless of geographical area
    • Give azithromycin oral — adult 1g, single dose
      AND ceftriaxone IM — adult 500mg, single dose mixed with lidocaine (lignocaine) 1%
    • If allergy — medical consult
  • If oral gonorrhoea — regardless of geographical area
    • Give azithromycin oral — adult 2g, single dose
      AND ceftriaxone IM — adult 500mg, single dose mixed with lidocaine (lignocaine) 1%
    • If allergy — medical consult
  • Contact  trace and treat partners with same treatment
  • Arrange recall for re-test in 3 months — 4 weeks if pregnant
  • Advise no sex for 7 days after person and partners treated
  • Offer condoms, STI and safer sex education
  • Consider talking about contraception

Table 6.1  Geographical treatment areas for gonorrhoea  

Follow-up

  • Re-test in 3 months, 4 weeks if pregnant — Standard STI check men, women
  • If anal, oral or cervical infection — ‘test of cure’ by NAAT 2 weeks after treatment
  • Check HIV and syphilis serology done

Pregnancy considerations

  • Re-test after 4 weeks — send urine or low vaginal swab for NAAT
  • High priority for contact tracing and coordinated treatment of woman and partners, at same time if possible

Genital herpes

Donovanosis

  • Notifiable disease — follow local protocols and check with sexual health unit if more information needed
  • Donovanosis sores are usually a red, beefy, raised, raw, painless ulcer
    • In early stages a small sore may look like primary syphilis
    • Sores won't go away without treatment. Will slowly get larger

Do

  • Give azithromycin oral — adult 1g, once a week for 4 weeks
  • Check sores each week when giving medicine
    • If not healed after 4 weeks — medical consult
    • Continue azithromycin oral — adult 1g, once a week until healed
    • If not improving — may need biopsy to test for cancer
  • Contact trace and treat partners with same treatment
  • Offer condoms, STI and safer sex education
  • Advise no sex for 7 days after person and partners treated
  • Consider talking about contraception

Follow-up

  • Check 3 months after sores completely healed — to make sure sores haven’t come back

Pregnancy considerations

  • Medical consult

Syphilis

  • Notifiable disease — follow local protocols and check with sexual health unit if more information needed
  • If ever had syphilis — positive result for life
    • Check for reinfection by comparing new and past results
  • Syphilis is diagnosed by positive test with no history of previous treatment OR 4-fold (2 titre) increase in RPR level (eg 1:4 to 1:16)
    • Syphilis serology can be hard to understand. Talk with sexual health unit or syphilis register
  • If pregnant — can cause miscarriage, stillbirth or congenital syphilis in baby

Primary syphilis

  • 1 or 2 chancres  (ulcers, usually painless) in genital and/or anal area or mouth
    • Usually red and round with firm rolled edge, base clean
  • Sore goes away in 4–6 weeks without treatment but syphilis still in blood

Secondary syphilis

  • Condylomata lata (fleshy, moist, wart-like lesions in genital or perianal area)
  • May also have
    • Skin rashes — especially palms of hands, soles of feet
    • Patchy hair loss including outer eyebrow, beard
    • Oral lesions — ulcers, mucous patches
    • Swollen lymph glands all over body
    • Liver and/or spleen enlargement 

Tertiary syphilis

  • Dementia or change in personality
  • Shooting pain, numbness, pins and needles
  • Weakness of hands, arms, legs, gait (unusual way of walking)
  • Cranial nerve palsy (problems with nerves of head and face), abnormal pupil reactions
  • Deafness that is new
  • Eye problems, eg retinal disease, uveitis, iritis
  • Aortic incompetence (heart valve weakness)
  • Dilation (widening) of ascending aorta on x-ray or echocardiogram

Do

Syphilis treatment depends on how long person has been infected — sexual health unit or syphilis register can give history and advice on management

  • Take blood for syphilis serology just before starting treatment for accurate pre-treatment baseline RPR level
  • If known to be less than 2 years
    • Give benzathine benzylpenicillin (Bicillin L-A) IM — adult 2,400,000 units/4.6mL (1.8g) (2 x 2.3mL syringes), single dose
    • If allergy to penicillin — sexual health consult
  • If unknown or known to be more than 2 years
    • Give benzathine benzylpenicillin (Bicillin L-A) IM — adult 2,400,000 units/4.6mL (1.8g) (2 x 2.3mL syringes), once a week for 3 weeks
    • If more than 7 days between injections — talk with sexual health unit or syphilis register — may need to start course again
    • If allergy to penicillin — sexual health consult
  • If neurosyphilis or cardiovascular syphilis
    • Talk with specialist, sexual health unit, syphilis register
    • Usually needs to go to hospital for more tests
  • Contact trace and treat partners with same treatment — very important if newly infected. Get advice from sexual health unit
  • Advise no sex for 7 days after person and partners treated
  • Offer condoms, STI and safer sex education
  • Consider talking about contraception

If recent syphilis — often harmless febrile reaction to treatment (Jarisch-Herxheimer) — starts in 3–4 hours and gets better within 24 hours

  • Give paracetamol — adult 1g up to 4 times a day (qid) 

Follow-up

  • Check syphilis serology again at 3, 6 and 12 months after base line RPR and first treatment
  • Advise syphilis register of treatment given and contacts — ask local PHU for number 
  • Contact Syphilis Register or PHU for reinfection or treatment failure if
    • RPR increases following treatment
    • RPR does not fall 4-fold and below 1:16 within 6 to 12 months

Pregnancy considerations 

Medical consult — this is an STI emergency

  • If woman has had syphilis for less than 2 years — high risk of transmission to baby — must treat woman as soon as possible
  • Late latent syphilis (infection more than 12 months ago) can sometimes be transmitted to baby
  • High priority for contact tracing and coordinated treatment of woman and her contacts

Trichomonas

  • Notifiable disease in the Northern Territory — follow local protocols and check with sexual health unit if more information needed

Do

  • Give metronidazole oral — adult 2g, single dose

OR metronidazole oral — adult 400mg, twice a day (bd) for 7 days — best for breastfeeding. Take after baby fed

Follow-up

  • Re-test in 3 months — Standard STI check — men, women
  • Check HIV and syphilis serology done

Pregnancy considerations

  • If asymptomatic — consider delaying treatment until after first trimester
  • Treatment same as for non-pregnant woman

Mycoplasma genitalium

  • Treatment varies — medical consult or contact sexual health unit

HIV

  • Notifiable disease —  HIV management is always directed by sexual health or infectious diseases unit
  • HIV treatment can now keep people healthy and prevent transmission to others, especially if started as soon as possible
  • HIV pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) are available

Do

  • Follow advice from sexual health unit and local protocols where appropriate
    • Aim to start treatment early
  • Continued involvement of primary care services is important. Usually involves

Pregnancy considerations

  • Anti-HIV treatment can keep woman healthy during and after pregnancy and reduce the risk of transmission to baby — almost completely if started early enough
  • If woman HIV positive — urgent medical consult — urgent referral to sexual health or infectious disease specialist to develop comprehensive management plan 
    • Maintain confidentiality
    • Provide education and support about lifestyle factors such as diet, exercise and stopping smoking, alcohol and use of other substances
  • Most women can have vaginal birth — elective caesarean section is rarely recommended
  • Talk with sexual health unit or infectious specialist at PHU about individual breastfeeding plan

Non STI results

  • If MC&S results report candida (thrush) or bacterial vaginosis — see Vaginal discharge

Contact tracing

  • Contact tracing is important to manage all STIs — critical for syphilis, HIV and any infection during pregnancy
  • Person initially diagnosed with infection is referred to as the index case
  • All sexual partners are referred to as contacts
  • If contact has a positive result they will then become an index case
  • All index cases need contact tracing
  • Contacts have the right to STI check and treatment
  • Untreated contacts can re-infect the index and also infect other people

Ask

  • Give yourself enough time to talk with person about issues
  • Ensure process is kept confidential (private)
    • Contact must never be made aware of name of index
    • Do not write name of contact in index file notes

Asking about partners

  • Ask about all sexual partners in last 3 months
  • Explain if partners not treated they may get infected again and there can be serious effects of ongoing infection — miscarriages, infertility, ectopic pregnancy, babies can become sick or die
  • If person prefers they can write down name/s of sexual contacts
  • Make sure you know how to find the person again if needed

Do

  • Document details of contacts — DOB or approximate age and address —  use appropriate confidential process for your area
  • Hand over contact information confidentially to a staff member who can begin treatment of contact — this needs to occur quickly
  • Advise no sex for 7 days after index and contacts are treated
  • Offer condoms
  • If contact treated more than 7 days after index and reinfection is possible — re-treat index if able

Follow-up of partners

  • Talk with ATSIHPs about the best way to do this in your community
  • Tell person they have been in contact with someone who has an infection and it is best that they have both a check and treatment today
    • Advise that most people with STIs don’t know they have one
  • Do Full STI check — men, women
  • Treat straight away — Table 6.2 — without waiting for laboratory or POC Test results. Even if STI check declined
  • Offer STI and safer sex education

Table 6.2 Treatment of contacts  

Education

  • Not needed with every sexual health check-up
  • Best for people asking for test or with STI needing treatment

STI education

  • What STIs are, why they matter and how to protect themself
  • How you get one, signs and symptoms, asymptomatic infections
  • Need to test for reinfection in 3 months
  • Get STI check
    • If under 35 years — every 6 months (twice a year)
    • Straight away if they have unsafe sex, symptoms of an STI
  • Important to treat sexual partners from past 3 months
    • To prevent reinfection — no sex or use condoms for 7 days after person and partners treated
  • Complications of STIs
    • Infertility
    • Increased risk of HIV
    • PID in women
    • Problems in pregnancy — ectopic pregnancy, miscarriage, preterm labour, infections in newborn baby

Safer sex education

  • If person has safer sex — less chance of an STI
    • Make sure they know what this means — don’t just think they will know
  • Safer sex is
    • Using a condom properly every time
    • OR having sex with just 1 partner after both have ‘clear’ STI check-up
Condom education
  • Only contraceptive method that protects against most STIs
  • Show them how to use a condom
  • Offer condoms to take away. Talk about where they can get more

Supporting resources

  • Mycoplasma genitalium guidelines
  • Australian STI management guidelines for use in primary care