STI management for women ⚠️

• Get help and advice from local ATSIHPs, health council, respected community members about doing STI work in a culturally sensitive way
• Offer treatment as soon as possible to prevent complications and to stop the spread

• If person has symptoms/syndromes that are likely to be caused by STI or has put themself at risk — treat straight away. Do not wait for laboratory or POC Test results. See individual protocols
• Genital ulcers and lumps
• Vaginal discharge
• Pelvic inflammatory disease

• Treat people with positive pathology and named partners and contacts 
• If positive result on Standard STI check or individual test do the remaining checks to complete Full STI check — men, women

Positive pathology results

Chlamydia

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

Do

• Give azithromycin oral — adult 1g, single dose
• Contact trace and give partner/s same treatment
• Offer condoms but advise better not to have sex for 7 days after person and partner/s treated
• Arrange recall for re-test in 3 months, 4 weeks if pregnant 
• STI and safer sex education
• Consider talking about contraception

Follow-up

• Re-test in 3 months — Standard STI check 
• 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 treatment of woman and partner/s at same time if possible 

Gonorrhoea

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

Do

• If person and all partners for last 3 months from a geographical area with penicillin SENSITIVE gonorrhoea
  
• 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 a geographical area with penicillin RESISTANT gonorrhoea OR partners unknown
  
• Give azithromycin oral — adult 1g, single dose
• AND ceftriaxone IM — adult 500mg, single dose mixed with lidocaine (lignocaine) 1%
  
• If allergy to penicillin — sexual health 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 to penicillin — sexual health 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 to penicillin — sexual health consult
• Contact trace and give partner/s same treatment
• Offer condoms but advise better not to have sex for 7 days after person and partner/s treated
• Arrange recall for re-test in 3 months, 4 weeks if pregnant 
• STI and safer sex education
• Consider talking about contraception

Follow-up

• Re-test in 3 months — Standard STI check
• Check HIV and syphilis serology has been done

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 partner/s at same time if possible

Genital herpes

• See — Genital ulcers and lumps 

Donovanosis

• Notifiable disease. Follow local protocols, check with sexual health unit if more information needed

Donovanosis sores

• Usually red, beefy, raised, raw, painless ulcer
• In early stages, 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 sore/s 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 for cancer
• Contact trace and give partner/s same treatment
• Offer condoms but advise better not to have sex for 7 days after person and partner/s treated
• STI and safer sex education
• Consider talking about contraception

Follow-up

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

Pregnancy considerations

• Medical consult

Do

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

• If known to be less than 2 years
  
• Give benzathine benzylpenicillin (Bicillin L-A) IM — adult 2,400,000U/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 2,400,000U/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 partner/s with same treatment. Very important if newly infected, get advice from sexual health unit
• Advise no sex for 7 days after person and partner/s treated
• Offer condoms, STI and safer sex education
• Consider talking about contraception

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

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

Pregnancy considerations

Medical consult — 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 for woman and her contact/s
• 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

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
• Contact trace and give partner/s same treatment
• Advise no sex for 7 days after person and partner/s treated
• Offer condoms, STI and safer sex education
• Consider talking about contraception

Follow-up

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

Pregnancy considerations

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

Mycoplasma genitalium

• Treatment varies — medical consult or contact sexual health unit

HIV

• Notifiable disease. HIV management 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
• Managing and monitoring antiretroviral medicines
• Contact tracing and management of contacts
• STI and safer sex education

Pregnancy considerations

• Anti-HIV treatment can
• Keep woman healthy during pregnancy, and afterwards
• Reduce 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
• Maintain confidentiality
• Develop comprehensive management plan
• 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 or infectious disease specialist at PHU about individual breastfeeding plan

Non STI results

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

Contact tracing

• 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
• 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
• No sex for 7 days after index and contact/s treated
• Offer condoms
• If contact treated more than 7 days after index and reinfection possible — retreat index if possible
• While contact tracing is important to manage all STIs, it is critical for syphilis, HIV and any infection during pregnancy

Contact tracing — asking about partners

• Ask about all sexual partners in last 3 months
• Explain if partner/s 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 contact/s
• Make sure you know how to find the person again if needed

Do

• Document details of contact/s (DOB or approximate age, address) using appropriate confidential process for your area
• Hand over contact information confidentially to staff member who can begin treatment of contact, as this needs to occur quickly

Contact tracing — follow-up of partners

Do

• Talk with ATSIHPs about best way/s 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
• STI and safer sex education
• Do Full STI check men,  women
• Treat straight away — Table 5.4 without waiting for laboratory or POC Test results — even if STI check declined

Condoms

• 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

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