Wcms 117313

Matcrna! Hca!
th DIvIsInn
MInIstry nf Hca!th and FamI!y Wc!farc
Gnvcrnmcnt nf IndIa
August 2007
NATIONAL GUIDELINE5 ON
PREVENTION, MANAGEMENT AND CONTROL OF
REPRODUCTIVE TRACT INFECTION5
INCLUDING
5EXUALLY TRAN5MITTED INFECTION5
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
Government of India
Maternal Health Division
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 i v
Guidelines for Setting Up Blood Storage Centres
v 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
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 vi
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
vii 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
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 viii
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
i 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. 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
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 x
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
xi 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
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 xii
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
xiii 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
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 xiv
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
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
Inlioduclion
SexuaIIy liansnilled infeclions (STIs)
piesenl a huge luiden of disease and
adveiseIy inpacl iepioduclive heaIlh of
peopIe. As pei iecenl STI pievaIence sludy
(2OO3), ovei 6 peicenl of aduIl popuIalion
in lhe counliy suffeis fion STIs and nosl
iegions of counliy shov ieIaliveIy high
IeveIs. Il is veII knovn lhal iisk of
acquiiing HIV infeclion incieases nanifoId
in peopIe vilh cuiienl oi piioi STI. STIs
aie Iinked lo HIV liansnission as connon
sexuaI lehavioui pul peisons al lhe iisk
of infeclion vhich diieclIy incieases lhe
chances of acquiiing and liansnilling HIV.
The eneigence of HIV and idenlificalion
of STIs as a co-facloi have fuilhei Ienl a
sense of uigency foi foinuI aling a
piogiannalic iesponse lo addiess lhis
inpoilanl pulIic heaIlh piolIen. HIV
pievaIence iales anong STIs CIienls aIso
ienains high: 22.8 peicenl in Andhia
Iiadesh, 15.2 peicenl in Mahaiashlia, 12.2
peicenl in Manipui and 7.4 peicenl in
DeIhi.
esides HIV infeclions, RTIs incIuding STIs
cause suffeiing foi lolh nen and vonen
aiound lhe voiId, lul lheii consequences
aie fai noie devaslaling and videspiead
anong vonen lhan anong nen. These
infeclions oflen go undiagnosed and
unliealed, and vhen Iefl unliealed, lhey
Iead lo conpIicalions such as infeiliIily
eclopic piegnancy and ceivicaI cancei.
IeIvic infIannaloiy disease aiising fion
STIs poses a najoi pulIic heaIlh piolIen
and adveiseIy affecls lhe iepioduclive
heaIlh of pooi and unliealed vonen.
Iiesence of STIs aIso conpionises vilh
conliaceplive acceplance and conlinualion.
SiniIaiIy sone of lhe RTIs aie associaled
vilh pooi piegnancy oulcone and high
noilidilies and noilaIilies in neonales
and infanls.
In deveIoping counliies, lolh lhe incidence
and pievaIence of RTIs/STIs aie veiy high,
lhey iank second as lhe cause of heaIlhy
Iife Iosl anong vonen of iepioduclive age
gioup, aflei naleinaI noilidily and
noilaIily. In nen, sexuaIIy liansnilled
infeclions conlined vilh HIV infeclion
accounl foi neaiIy 15 peicenl of aII heaIlhy
Iife Iosl in lhe sane age gioup. These
infeclions pose a significanl polenliaI diain
on pulIic heaIlh syslen iesouices and
conliilule sulslanliaIIy lo lhe palleins of
najoi heaIlh caie expendiluie al lhe
househoId IeveI.
Iiogiannalic iesponse lo addiess
pievenlion, nanagenenl and conlioI of
RTIs/STIs IaigeIy faIIs undei lhe NalionaI
Repioduclive and ChiId HeaIlh (RCH 2)
Iiogianne, vhich vas Iaunched in yeai
2OO5. The piogianne diavs ils nandale
fion lhe NalionaI IopuIalion IoIicy (2OOO),
vhich nakes a sliong iefeience lo incIude
STD/RTI and HIV/AIDS pievenlion,
scieening and nanagenenl in naleinaI
and chiId heaIlh seivices. NalionaI RuiaI
HeaIlh Mission (NRHM) vas Iaunched in
ApiiI, 2OO5 vilh an ain lo piovide
accessi lIe, affoidalIe, effecli ve,
accounlalIe and ieIialIe heaIlh caie
consislenl vilh lhe oulcones envisioned
in lhe MiIIenniun DeveIopnenl CoaIs
and geneiaI piincipIes Iaid dovn in lhe
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 2
NalionaI and Slale poIicies, incIuding lhe
NalionaI IopuIalion IoIicy, 2OOO and lhe
NalionaI HeaIlh IoIicy, 2OO2. On lhe
opeialionaI side, Indian IulIic HeaIlh
Slandaids (IIHS) aie leing piesciiled lo
achieve and nainlain quaIily of caie lo lhe
connunily lhiough pulIic heaIlh caie
deIiveiy syslen. CIeaiIy lheie is ieneved
enphasis on naking pulIic heaIlh syslens
effeclive lo deIivei quaIily seivices lo
achieve piogianne goaIs.
The NalionaI AIDS ConlioI Iiogianne 3
(NACI 3) incIudes seivi ces foi
nanagenenl of STIs as a najoi piogianne
slialegy foi pievenlion of HIV. The
Slialegy and InpIenenlalion IIan (2OO6-
2O11) nakes a sliong iefeience lo
expandi ng access lo package of STI
nanagenenl seivices lolh in geneiaI
popuIalion gioups and foi high iisk
lehavi oi gioups. Iiogianne aI so
acknovIedges lhal expanding access lo
seivices viII enlaiI engaging piivale secloi
in piovision of seivices. SeveiaI sludies
indicale piefeience of CIienls lo access
seivices fion piivale piovideis. Il is aIso
inpoilanl lhal liealnenl faciIilies in lolh
pulIic and piivale secloi aie Iinked lo
laigeled inleivenlions leing suppoiled foi
high iisk lehavioi gioups in lhe NACI 3.
This docunenl is guided ly lhe NalionaI
Iiogianne InpIenenlalion IIan foi
RCH 2 and NACI 3. The RCH 2
piogianne is lo le inpIenenled vilhin
lhe fianevoik of inlei-secloiaI
conveigence as envisaged in lhe
inpIenenlalion fianevoik of NRHM.
Linkages aie lo le eslalIished lelveen lhe
RCH 2 slialegy foi pievenli on and
nanagenenl of RTIs incIuding STIs and
pievenlion slialegy as ailicuIaled in
NACI 3. The inpuls iequiied foi fianing
lhese guideIines aie diavn fion nany
souices vhich aIso incIude a nuIli cenliic
counliyvide Rapid Assessnenl Suivey in
six zones of lhe counliy lo assess lheii
nanagenenl piaclices (opeialionaI,
cI inicaI, Ialoialoiy) on RTI/STIs al
diffeienl IeveIs (Disliicl, CHC, IHC and
Sulcenlie) of lhe heaIlh syslen, ieviev of
avaiIalIe guideIines, lechnicaI discussions
vilh STI caie piaclilioneis, and piogianne
nanageis in pulIic syslens as veII as fion
NCO and piivale secloi.
The guideIines piesenled in lhis docunenl
aie designed foi quaIified Doclois lo
enalIe lhen lo quickIy and confidenlIy
diagnose and lieal lhe najoiily of lhe
RTIs/STIs caseIoad. Sone pail of lhese
guideIines couId le exliacled and adopled
foi nuising peisonneI as pei iequiienenls
foi seivice deIiveiy in diffeienl sellings.
The nain puipose of lhis docunenl is lo
piesenl conpiehensive RTI/STI case
nanagenenl gui deI ines incIudi ng
delaiI ed hisloiy laking and cI inicaI
exaninalion suppoiled ly a nunlei of
phologiaphs of RTIs/STIs in nen and
vonen lo piovide a visuaI inpiession
usei fiiendIy nanagenenl fIovchails
incIuding pailnei nanagenenl and
nanagenenl of piegnanl vonen effeclive
diug ieginens, singIe oiaI dosages
vheievei possi lIe, vi lh speci aI
insliuclions incoipoialed in lhe fIovchails
ilseIf. This docunenl aIso piovides
guidance lo seivice piovideis lo addiess
RTIs/STIs anong speciaI popuIalion
gioups such as adoIescenls, sex voikeis
and nen having sex vilh nen and sinpIe
Ialoialoiy lesls vhich can le done al
vaii ous faciIily IeveI s vilh ieIevanl
phologiaphs and delaiIs of pioceduies. In
addili on lo lhis, lhe docunenl aI so
piovides infoinalion on oiganisalion of
inlegialed counseIing and lesling seivices.
These guideIines calei lo infoinalion
needs of lhe piogianne nanageis and
seivice piovideis in RCH 2 and aIso in
NACI 3. The RCH seivice piovideis viII
find lhe infoinalion usefuI in oiganizing
effecli ve case nanagenenl seivi ces
lhiough pulIic heaIlh syslen especiaIIy
lhiough nelvoik of 24 houi IHCs and
CHCs. SiniIaiIy piogianne nanageis
speciaIIy Slale AIDS ConlioI Sociely
officeis enliusled vilh lhe iesponsiliIily
of up scaIing laigeled inleivenlions (TIs)
foi sex voikeis and TI nanageis viII find
usefuI infoinalion foi piovision of quaIily
STI nanagenenl seivices.
Recognizing lhe facl lhal a significanlIy
high piopoilion of lhese cIienls aie leing
liealed lhiough piivale seclois, lhe piivale
piovideis/ NCO seivice piovideis aie
highIy encouiaged lo use lhese nalionaI
piolocoIs.
CIienls suspecled of having RTIs/STIs usuaIIy piesenl vilh one oi noie of lhe foIIoving
conpIainls:
(i) VaginaI oi uielhiaI dischaige
(ii) VesicuIai and/oi non-vesicuIai genilaI uIceis
(iii) InguinaI lulo
(iv) Lovei aldoninaI and/oi sciolaI pain and
(v) CenilaI skin condilions.
The foIIoving lalIe depicls piesenling synplons, signs, cIinicaI condilions, and causalive
oiganisns.
Tab!c 2. CausatIvc nrganIsms and prcscntIng symptnms
sIgns nf spccIfIc RTIs5TIs
RTI5TI CausatIvc OrganIsm 5ymptnms5Igns
PrcscntIng symptnms agIna!rcthra! DIschargc and nr burnIng mIcturItInn
Conoiihea Neisseiia gonoiihea Wnmcn
IuiuIenl (conlaining nucopus) vaginaI
dischaige
Iain oi luining on passing uiine (dysuiia)
InfIaned (ied and lendei) uielhiaI opening
Mcn
Iain oi luining on passing uiine (dysuiia)
IuiuIenl (conlaining nucopus) uielhiaI
dischaige (diip).
Infeclion of lhe epididynis (coiIed lule
Ieading fion lhe leslis lo lhe vas defeiens)
UielhiaI alscess oi naiioving (sliicluie)
Tiichononiasis Tiichononas May pioduce fev synplons
VaginaIis in eilhei sex
2
C!InIca! 5pcctrum nf
RTIs5TIs
Wonen oflen viII have a fiolhy (lullIy), fouI-
sneIIing, gieenish vaginaI dischaige .
Men nay have a uielhiaI dischaige
ChIanydia ChIanydia Wnmcn
liachonalis Iioduces fev synplons, even vilh uppei
genilaI liacl infeclion (siIenl IID)
IuiuIenl ceivicaI dischaige, fiequenlIy a
leefy ied ceivix vhich is fiialIe (lIeeds
easiIy)
Mcn
Mosl fiequenl cause of non-gonococcaI
uielhiilis (NCU)
acleiiaI Oveigiovlh of Nol necessaiiIy sexuaIIy
vaginosis anaeioles (e.g., liansnilled
CaidneieIIa vaginaIis) VaginaI dischaige vilh fishy odoi, giayish in
coIoi
Candidiasis Candida aIlicans Wnmcn
Cuid-Iike vaginaI dischaige, vhilish in coIoi
Modeiale lo inlense vaginaI oi vuIvaI ilching
(piuiilus)
Mcn
Ilchy peniIe iiiilalion (laIanilis)
Presenting symptoms: cnia| |ccrs an ccs
Chancioid HaenophiIus IainfuI, diily uIceis
(Sofl chancie) ducieyi Iocaled anyvheie on lhe exleinaI genilaIia.
DeveIopnenl of painfuI enIaiged Iynph
nodes (lulo) in lhe gioin.
LynphogianuIona ChIanydia SnaII, usuaIIy painIess
veneieun (LCV) liachonalis papuIes (Iike pinpIes) on
(seiovais L1, L2, L3) lhe penis oi vuIva, foIIoved ly
uloes in lhe gioin vhich uIlinaleIy lieaks
dovn foining nuIlipIe fisluIae (diaining
openings)
If unliealed, lhe Iynphalic syslen nay
lecone lIocked, pioducing eIephanliasis
(sveIIing of lhe genilaIs oi exlienilies)
SyphiIis Tieponena Occuis in 3 slages : piinaiy and secondaiy
IaIIidun and Iale
PrImary syphI!Is
IniliaIIy, painIess uIcei (chancie): in vonen
on lhe exleinaI genilaIia (Ialia), in nen on
lhe penis in lolh sexes oiaI and anaI uIceis
and enIaiged iulleiy Iynph nodes
5ccnndary (dIsscmInatcd) syphI!Is
SeveiaI nonlhs Ialei non-ilchy lody iash,
headaches, nuscIe aches, veighl Ioss, Iov
giade fevei. The iashes nay disappeai
sponlaneousIy
Latc syphI!Is
DeveIops in aloul 25 of unliealed cases and
is oflen falaI due lo invoIvenenl of lhe heail,
gieal lIood vesseIs and liain
CianuIona CaIynnalolacleiiun An unconnon cause of
inguinaIe gianuIonalis uIceialive genilaI liacl
(Donovanosis) infeclion
TypicaIIy, lhe infecled peison deveIops Iunps
undei lhe skin vhich lieak dovn lo foin
leefy ied, painIess uIceis
CenilaI heipes Heipes sinpIex viius MuIlipIe painfuI vesicIes Ialei foining shaIIov
uIceis vhich cIeai in 2 lo 4 veeks (fiisl allack)
and nay le acconpanied ly valeiy vaginaI
dischaige in vonen
Recuiienl (nuIlipIe episodes) noie lhan 5O
of lhe line.
IeIvic Neisseiia gonoiihea Lovei aldoninaI pain,
InfIannaloiy ChIanydia fevei, vaginaI dischaige,
Disease (IID) liachonalis nensliuaI iiieguIaiilies Iike
Anaeioles heavy iiieguIai vaginaI lIeeding,
dysnenoiihoea, dyspaieunia (pain duiing
sexuaI inleicouise), dysuiia, lenesnus, Iov
lackache
Tenpeialuie 39
O
C
VaginaI/ceivicaI dischaige, congeslion oi
uIceis
Lovei aldoninaI lendeiness oi guaiding
Uleiine/adnexaI lendeiness, ceivicaI
novenenl lendeiness, piesence of a peIvic
nass
Presenting symptoms: cc scrca| ain an cr sc||cn scrcn
Lpididynilis/ Oichilis Neisseiia gonoiihea
ChIanydia liachonalis
Acule: seveie pain in one oi lolh lesles, sudden sveIIing
of lhe lesles.
Presenting symptoms: cnia| in cniicns
CenilaI vails Hunan SingIe oi nuIlipIe sofl,
(CondyIona papiIIona painIess, cauIifIovei
acuninala) viius giovlh vhich appeai aiound lhe anus,
vuIvo- vaginaI aiea, penis, uielhia and
peiineun
MoIIuscun Iox viius MuIlipIe, snoolh, gIislening,
conlagiosun gIoluIai papuIes of vaiying size fion a
pinhead lo a spIil pea can appeai anyvheie
on lhe lody. SexuaIIy liansnilled Iesions on
oi aiound genilaIs can le seen.
Nol painfuI excepl vhen secondaiy infeclion
sels in.
IedicuIosis pulis Ilhiius pulis Theie nay le snaII ied papuIes vilh a liny
cenliaI cIol caused ly Iice iiiilalion.
CeneiaI oi IocaI uilicaiia vilh skin lhickening
nay oi nay nol le piesenl.
Scalies Saicoples scaliei Seveie piuiilis (ilching) is expeiienced ly lhe
cIienl vhich lecones voise al nighl.
The luiiov is lhe diagnoslic sign. Il can le
seen as a sIighlIy eIevaled giayish dolled Iine
in lhe skin, lesl seenin lhe sofl pail of lhe skin.
Iiovisi on of quaIily RTI/STI case
nanagenenl seivices lhiough a nelvoik
of pulIic heaIlh caie deIiveiy inslilulions,
piivale secloi piovideis, fianchisee cIinics
and in laigeled inleivenlion sellings viII
iesuIl in achieving foIIoving oljeclives:
1. Lnhance access lo seivices lo aII
especi aIIy foi vonen and
adoIescenls vho aie consliained lo
seek seivices and face seveiaI access
ieIaled laiiieis.
2. Slandaidized liealnenl piolocoIs
viII inpiove piesciiplion piaclices
ly ieducing poI y phainacy,
iiialionaI diug conlinalions.
3. Iocus on pievenlion, vilh speciaI
iefeience lo pailnei nanagenenl,
condon use, foI Iov-ups and
nanagenenl of side effecls.
3
Oljeclives of RTI/STI Case
Managenenl Seivices
4. Lnphasis on liealnenl conpIiance
and lellei liealnenl oulcones.
5. ehavioui change connunicalion
Ieading lo inpioved knovIedge on
causalion, liansnissi on and
pievenlion of RTIs/STIs.
6. Lnsuie lhal piovi deis offei
counseIing and lesling seivices foi
HIV/AIDS and eslalIish Iinkages
vilh ART syslens vilh iespecl lo
peisons delecled posilives.
7. Scieen asynplonalic vonen
especiaIIy conliaceplive useis and
anlenalaI cIienls foi STIs.
8. Lnsuie seivice piovision foi gioups
piaclicing high iisk lehaviois such
as sex voikeis, MSMs and IDUs.
The nosl inpoilanl eIenenls of RTI/STI
case nanagenenl aie accuiale diagnosis
and effeclive liealnenl. This needs line
and skiII in laking a delaiIed sexuaI hisloiy
foi lolh cIienl and his/hei sexuaI conlacls
and in caiiying oul a conpiehensive
physicaI exani nali on and nininaI
invesligalions in iesouice pooi sellings. In
sone selli ngs vheie even nininaI
Ialoialoiy selup and faciIilies foi cIinicaI
exaninalions aie nol avaiIalIe, syndionic
nanagenenl is ieconnended as pei lhe
piolocoIs in foIIoving pages. To pievenl
lhe conpIicalions and spiead, liealnenl
nusl le effeclive. This neans seIecling lhe
coiiecl diugs foi lhe disease, caiefuIIy
noniloiing ils adninislialion and caiiying
oul ieguIai foIIov up. The sexuaI pailneis
nusl le liealed so as lo pievenl
iecuiience. CIienls shouId aIso ieceive
counseIing seivices vilh speciaI iefeience
lo iisk ieduclion, safei sex lehavioui and
access lo lesling.
The conponenls of case nanagenenl
incIude:
Hisloiy laking
CIinicaI exaninalion
Coiiecl diagnosis
LaiIy and effeclive liealnenl
CounseIing: Risk ieduclion and
voIunlaiy HIV lesling
Iiovision of condons
Iailnei nanagenenl
IoIIov-up as appiopiiale.
Case Managenenl
4
Thus, quaIily case nanagenenl consisls
nol onIy of anlinicioliaI lheiapy lo ollain
cuie and ieduce infeclivily, lul aIso focus
on pievenlion of iecuiience and pailnei
nanagenenl.
HIstnry taIng
Hisloiy nusl le laken in a Ianguage,
vhich lhe cIienl undeislands veII.
(Sone exanpIes of fianed queslions
aie given in ox 1). CIienls aie oflen
ieI uclanl lo laIk aloul lhese
condilions due lo shyness oi feai of
slignalizalion. Hence heaIlh caie
piovideis shouId ensuie piivacy,
confidenliaIily, le synpalhelic,
undeislanding, non-judgnenlaI and
cuIluiaIIy sensilive.
Lnsuie piivacy ly having a sepaiale
ioon foi hisloiy laki ng and
exaninalion, vhich is nol
slignalized vilh a nanepIale foi
STIs. Theie shouId le audiloiy as
veII as visuaI piivacy foi hisloiy
laking as veII as exaninalion.
Slail lhe conveisalion ly veIconing
youi cI ienl, laking lhen inlo
confidence and encouiaging hin/hei
lo laIk aloul lheii conpIainls. If a
coupIe cones logelhei, each of lhen
needs lo le inleivieved and
exanined sepaialeIy.
Oflen, lecause lhe cI ienl feeIs
unconfoilalIe laIking aloul RTIs/
STIs, individuaIs nay cone lo lhe
cIi nic vilh olhei non-speci fic
conpIainls oi iequesling a check-up,
assuning lhal lhe heaIlh caie
piovidei vi II nolice anylhi ng
alnoinaI lhal needs liealnenl.
Theiefoie, heaI lh caie voikeis
shouId nainlain a high index of
suspicion aloul RTIs/STIs.
CIienls seeking anlenalaI caie and
faniIy pIanning seivices shouId le
vieved as oppoilunilies lo piovide
geneiaI infoinalion aloul RTIs/STIs
and shouId le asked aloul RTI/STI
synplons and conliaceplion.
The heaIlh caie peisonneI shouId le
avaie of lhe connonIy used RTI/STI
ieIaled leininoIogy as veII as lhose
used foi high-iisk lehavioi. These
leins nay vaiy in diffeienl
geogiaphicaI sellings.
C!InIca! cxamInatInn
PrcrcuIsItcs fnr c!InIca! cxamInatInn
CIienls shouId le exanined in lhe
sane condilions of piivacy as lhose
in vhich hisloiy vas laken.
Il is advisalIe lo have an assislanl of
lhe sane sex as lhe cIienl piesenl,
duiing exaninalion of cIienls of sex
opposile lo lhe doclois.
CIienls shouId le loId aloul lhe
exaninalion vi lh lhe heIp of
diagians and chails.
The exaninalion shouId le done in
a veII-Iil ioon vhiIe pioviding
adequale confoil and piivacy. efoie
you slail, keep lhe exaninalion lalIe
vilh piopei iIIuninalion ieady as
veII as sleiiIized specuIuns (foi
exaninalion of fenaIe cIi enls),
coIIeclion svals and IaleIed sIides
foi sneais.
As fai as possilIe, conpIele lody
exaninalion of lhe cIienl shouId le
caiiied oul so lhal none of lhe skin
Iesions oi Iynph nodes is nissed.
Bnx . 5amp!c ucstInns nn hIstnry taIng
FramIng 5tatcmcnt
In oidei lo piovide lhe lesl caie foi you loday and lo undeisland youi iisk foi ceilain
infeclions, il is necessaiy foi us lo laIk aloul youi sexuaI lehavioi.
5crccnIng ucstInns
Have you iecenlIy deveIoped any of lhese synplons
5TI (GcnIta! InfcctInns) 5ymptnms Chcc!Ist
Fnr Mcn
i. Dischaige oi pus (diip) fion lhe penis
ii. Uiinaiy luining oi fiequency
iii. CenilaI soies (uIceis) oi iash oi ilching
iv. SciolaI sveIIing
v. SveIIing in lhe gioin
vi. InfeiliIily
Fnr Wnmcn
i. AlnoinaI vaginaI dischaige (incieased anounl, alnoinaI odoi, alnoinaI
coIoi)
ii. CenilaI soies (uIceis), iash oi Ilching
iii. Uiinaiy luining oi fiequency
iv. Iain in Iovei aldonen
v. Dysnenoiihoea, nenoiihagia, iiieguIai nensliuaI cycIes
vi. InfeiliIily
HIgh rIs scxua! bchavInr
Ioi aII adoIescenls: Have you legun having any kind of sex yel
If sexuaIIy aclive do you use condon consislenlIy
Do you have any ieason lo lhink you nighl have a sexuaIIy liansnilled disease
If so, vhal ieason
Have you had sex vilh any nan, vonan, vilh a gay oi a lisexuaI
Have you oi youi pailnei had sex vilh noie lhan one pailnei
Has youi sex pailnei(s) had any genilaI infeclions If so, vhich ones
Do you induIge in high iisk sexuaI aclivily Iike anaI sex
Do you piaclice coiiecl and consislenl condon usage vhiIe having sex If yes,
vhelhei eveiy line oi sonelines
Sex voikeis: Iiequency of pailnei change: use of condons vilh ieguIai
pailneis and aIso vilh cIienls
5TI HIstnry
In lhe pasl have you evei had any genilaI infeclions, vhich couId have leen
sexuaIIy liansnilled If so, can you desciile
5TI trcatmcnt hIstnry
Have you leen liealed in lhe pasl foi any genilaI synplons y vhon
(quaIified oi unquaIified peison)
Did youi pailnei ieceive liealnenl foi lhe sane al lhal line
Has youi pailnei leen liealed in lhe pasl foi any genilaI synplons y vhon
(quaIified oi unquaIified peison)
IncctInn Drug sc
Have you had sulslance aluse (If yes, have you evei shaied needIes oi injeclion
equipnenl)
Have you evei had sex vilh anyone vho had evei induIged in any foin of
sulslance aluse
Mcnstrua! and nbstctrIc hIstnry In nmcn and cnntraccptIvc hIstnry In bnth scxcs
shnu!d bc ascd
Gcncra! ExamInatInn
AII exaninalions shouId legin vilh a geneiaI assessnenl, incIuding vilaI signs
and inspeclion of lhe skin and nucous palches, lo delecl signs of syslenic
disease.
Fig 4a csicns c cccnar
ni|is
Fig 4b ccs acncs in
cccnar ni|is
C!InIca! cxamInatInn nf fcma!c c!Icnts
WhiIe exanining a fenaIe cIienl, a naIe docloi shouId ensuie lhal a fenaIe allendanl is
piesenl. CenilaI exaninalion in fenaIes nusl le peifoined vilh cIienl in Iilholony
posilion.
Bnx .2 5Igns tn !nn fnr durIng cxtcrna! gcnIta!
cxamInatInn nf a fcma!c c!Icnt
a) InspcctInn
5taInIng nf undcrc!nthcs VaginaI and uielhiaI dischaige, exudalive uIceis
InguIna! rcgInn
SveIIing, uIcei, Iesions of fungaI infeclions
Lymph nndcs Iook foi enIaigenenl, nunlei, Iocalion (hoiizonlaI oi veilicaI
gioup), singIe oi nuIlipIe, scais and puckeiing, signs of infIannalion on lhe
suiface and suiiounding iegion
Aliasions due lo scialching and Iesions on innei aspecl of lhighs
PubIc arca
Malling of haiis, pedicuIosis, foIIicuIilis, oi olhei skin Iesions
LabIa manra and mInnra
Sepaiale lhe Ialia najoia vilh lolh hands and Iook foi eiylhena, edena,
eslhionene foinalion (IoluIaled filiosed nasses due lo chionic Iynphedena),
fissuiing, uIceis, vails oi olhei skin Iesions
!ccrs
Localion, nunlei (singIe, nuIlipIe), supeificiaI (eiosions) oi deep, edge
(undeinined/punched oul), naigins (ieguIai/iiieguIai) and fIooi (piesence of
exudales, sIough/gianuIalion lissue)
Barthn!In g!ands
LnIaigenenl, duclaI opening, dischaige
IntrnItus
Dischaige coIoui, odoui, piofuse oi scanly, cuidy oi lhin, lack diop of iedness
and infIannalion
rcthra! mcatus
Dischaige (piessing undei lhe uielhia vilh one fingei nay shov diops of
dischaige), infIannalion
PcrIana! cxamInatInn
Sepaiale lhe lullocks vilh lvo hands foi lellei visuaIizalion. Look foi uIcei,
naceialed papuIes of condyIona Iala, vails, dischaige, paluIous anus,
haenoiihoids, fissuies, fisluIa
b) Pa!patInn
InguIna! rcgInn
Lynphnodes: lendeiness, incieased vainlh, supeificiaI oi deep, disciele oi
nalled, fiee noliIily oi fixed lo deepei sliucluies, consislency (fiin oi sofl) and
fIucluanl.
RuIe oul heinia
Pa!patInn nf u!ccr at any sItc
Tendeiness, induialion of lhe fIooi and edges, lIeeding on naneuveiing
Signs of vaiious RTIs/STIs aie shovn as picluies in fig 4c 4h. Duiing exleinaI
genilaI exaninalion of fenaIe cIienls, one shouId Iook foi lhese signs.
ig g rcn c gcnia| ars
ig n nancrc c ni|is
ig c csic|cs c cnia| crcs ig rasicns c ncrrigc
ig c cnsitc nccr|cn
ccrticiis inccicn
ig s cring c c
cncccrti in n|ania inccicn
Bnx . 5pccu!um cxamInatInn In nmcn
Hn tn dn spccu!um cxamInatInn In nmcn
Ask lhe vonan lo pass uiine.
Ask hei lo Ioosen hei cIolhing. Use a sheel oi cIolhing lo covei hei.
Have hei Iie on hei lack, vilh hei heeIs cIose lo hei lollon and hei knees up.
Wash youi hands veII vilh cIean valei and soap.
Iul cIean gIoves on lolh hands.
Look al lhe oulside genilaIs using lhe gIoved hand lo genlIy Iook foi Iunps,
sveIIing, unusuaI dischaige, soies, leais and scais aiound lhe genilaIs and in
lelveen lhe skin foIds of lhe vuIva.
5pccu!um cxamInatInn
e suie lhe specuIun has leen piopeiIy disinfecled lefoie you use il. Wel lhe
specuIun vilh cIean valei lefoie inseiling il.
Iul lhe fiisl fingei of youi gIoved hand in lhe vonans vagina. As you pul
youi fingei in, push genlIy dovnvaid on lhe nuscIe suiiounding lhe vagina
(push sIovIy, vailing foi lhe vonan lo ieIax hei nuscIes).
Wilh lhe olhei hand, hoId lhe specuIun lIades logelhei lelveen lhe poinling
fingei and lhe niddIe fingei. Tuin lhe lIades sidevays and sIip lhen inlo lhe
vagina. (le caiefuI nol lo piess on lhe uielhia oi cIiloiis lecause lhese aiea aie
veiy sensilive). When lhe specuIun is haIfvay in, luin il so lhe handIe is dovn.
Renove youi gIoved fingei.
CenlIy open lhe lIades a IillIe and Iook foi lhe ceivix. Move lhe specuIun
sIovIy and genlIy unliI you can see lhe ceivix lelveen lhe lIades. Tighlen lhe
sciev on lhe specuIun so il viII slay in pIace.
Check lhe ceivix vhich shouId Iook pink and iound and snoolh. Nolice if lhe
opening is open oi cIosed, and vhelhei lheie is any dischaige oi lIeeding. If
you aie exanining lhe vonan lecause she is lIeeding fion lhe vagina aflei
liilh, aloilion oi niscaiiiage, Iook foi lissue coning fion lhe opening of lhe
ceivix.
Look foi signs of ceivicaI infeclion ly checking foi yeIIovish dischaige, iedness
vilh sveIIing, oi easy lIeeding vhen lhe ceivix is louched vilh a sval. If lhe
vonan has leen Ieaking uiine oi slooIs genlIy luin lhe specuIun lo Iook al lhe
vaIIs of lhe vagina. iing lhe lIades cIosei logelhei lo do lhis.
To ienove lhe specuIun, genlIy puII il lovaid you unliI lhe lIades aie cIeai of
lhe ceivix. Then liing lhe lIades logelhei and genlIy puII lack. e suie lo
disinfecl youi specuIun again.
Bnx . 5Igns tn !nn fnr durIng spccu!um cxamInatInn
VaginaI dischaige and iedness of lhe vaginaI vaIIs aie connon signs of
vaginilis. Nole lhe coIoi, sneII and chaiacleiislics of any vaginaI dischaige.
When lhe dischaige is vhile and cuid-Iike, candidiasis is IikeIy.
Ioieign lody, IUD lhiead.
UIceis, vails, soies oi lIisleis.
Redness of ceivicaI and vaginaI epilheIiun
Look foi ceivicaI eiosions. If lhe ceivix lIeeds easiIy vhen louched oi lhe
dischaige appeais nuco-puiuIenl vilh discoIoialion, ceivicaI infeclion is IikeIy.
A sliavleiiy appeaiance of lhe ceivix nay le due lo liichononiasis. A unifoin
lIuish discoIoialion of lhe ceivix nay indicale piegnancy, vhich needs lo le
kepl in nind.
When exanining a vonan aflei chiIdliilh, induced aloilion oi niscaiiiage,
Iook foi lIeeding fion lhe vagina oi lissues fiagnenls and check vhelhei lhe
ceivix is noinaI.
Tunois oi olhei alnoinaI-Iooking lissue on lhe ceivix.
IAI sneai can le ollained duiing specuIun exaninalion
Bnx . BImanua! pc!vIc cxamInatInn
Hn tn dn a bImanua! pc!vIc cxamInatInn
Iul lhe poinling fingei of youi gIoved hand in lhe vonans vagina. As you pul
youi fingei in, push genlIy dovnvaid on lhe nuscIes suiiounding lhe vagina.
When lhe vonans lody ieIaxes, pul lhe niddIe fingei in loo. Tuin lhe paIn of
youi hand up.
IeeI lhe opening of hei vonl (ceivix) lo see if il is fiin (feeIs Iike lip of lhe nose
and iound. Then pul one fingei on eilhei side of lhe ceivix and nove lhe ceivix
genlIy. Il shouId nove easiIy vilhoul causing pain. If il does cause pain, she
nay have infeclion of lhe vonl, lules oi ovaiies. If hei ceivix feeIs sofl, she nay
le piegnanl.
IeeI lhe vonl ly genlIy pushing on hei Iovei aldonen vilh youi oulside hand.
This noves lhe inside pails (vonl, lules and ovaiies) cIosei lo youi inside hand.
The vonl nay le lipped foivaid oi lackvaid. If you do nol feeI il in fionl of
lhe ceivix, genlIy Iifl lhe ceivix and feeI aiound il foi lhe lody of lhe vonl. If
you feeI il undei lhe ceivix, il is poinled lack.
When you find lhe vonl, feeI foi ils size and shape. Do lhis ly noving youi
inside fingeis lo lhe sides of lhe ceivix, and lhen vaIk youi oulside fingeis aiound
lhe vonl. Il shouId feeI fiin, snoolh and snaIIei lhan a Ienon. If lhe vonl:
IeeIs sofl and Iaige, she is piolalIy piegnanl.
IeeIs Iunpy and haid, she nay have a filioid oi olhei giovlh.
Huils vhen you louch il, she nay have an infeclion inside.
Does nol nove fieeIy, she couId have scais fion an oId infeclion.
IeeI hei lules and ovaiies. If lhese aie noinaI, lhey viII nol le feIl. ul if you
feeI any Iunps lhal aie liggei lhan an aInond oi lhal cause seveie pain, she
couId have an infeclion oi olhei eneigency. If she has a painfuI Iunp, and hei
nonlhIy lIeeding is Iale, oi scanly, she couId le piegnanl in lhe lule. She needs
nedicaI heIp iighl avay.
Move youi fingei and feeI aIong vilh inside of lhe vagina. If she has a piolIen
vilh Ieaking uiine oi slooI, check foi a leai. Make suie lheie aie no unusuaI
Iunps oi soies.
Have lhe vonan cough oi push dovn as if she veie passing slooI. Walch lo see
if sonelhing luIges oul of lhe vagina. If il does, she couId have a faIIen vonl oi
faIIen lIaddei (pioIapse).
When you aie finished, cIean and disinfecl youi gIove. Wash youi hands veII
vilh soap and valei.
Bnx . 5Igns tn !nn fnr durIng a bImanua! cxamInatInn
Sofl enIaiged uleius vilh nissed peiiods suggeslive of piegnanl uleius
AdnexaI nass vilh nissed peiiods suggeslive of eclopic piegnancy
CeivicaI novenenl lendeiness and oi adnexaI lendeiness suggeslive of IID
AdnexaI nass vilh fevei suggeslive of peIvic alscess
Any olhei haid peIvic nass Iike filioid oi naIignancy
DIgIta! rccta! cxamInatInn Ieifoined if synplons suggeslive of pioslalic disease.
ShouId nol le caiiied oul if lhe cIienl has painfuI peiianaI diseases such as heipelic
uIceis, fissuies, haenoiihoids.
PrnctnscnpIc cxamInatInn Indicaled if hisloiy of unpiolecled anaI inleicouise, oi
conpIain of ieclaI dischaige.
Note: a cnan nas nissc crics ncnscs rcgnanc snc| c r|c c cing a rinc
rcgnanc cs
Bnx .7 5Igns tn !nn fnr hcn cxamInIng mcn
a) InspcctInn
5taInIng nf undcrc!nthcs due lo uielhiaI dischaige, sulpiepuciaI dischaige oi fion
exudalive uIceis.
InguIna! rcgInn sveIIing, uIcei, candidiaI inleiliigo, linea, enIaiged Iynph nodes:
Iook foi nunlei, Iocalion (hoiizonlaI oi veilicaI gioup), singIe oi nuIlipIe poinlings,
scais and puckeiing, signs of infIannalion on lhe suiface and suiiounding iegion
PubIc arca nalling of haiis, pedicuIosis, foIIicuIilis, oi olhei skin Iesions.
5crntum eiylhena, skin Iesions (condyIona Iala), asynneliy, sciolaI sveIIing.
PcnIs Size, oedena, defoinily, phinosis, paiaphinosis, auloanpulalion of genilaIs,
foieign lodies, oId scais, ciicuncision, ieliaclion of piepuce.
InspcctInn nf u!ccrs Nunlei (singIe, nuIlipIe), supeificiaI (eiosions) oi deep, edge
(undeinine/punched oul), naigins (ieguIai/iiieguIai) and fIooi (piesence of
exudales, sIough/gianuIalion lissue).
Mcata! cxamInatInn Liylhena, dischaige: lhick, cieany oi nucopuiuIenl, vail, uIcei.
If no dischaige lhen niIk lhe penis (uielhia) and Iook foi dischaige al lhe nealus.
PrcpucIa! sIn cxamInatInn Liosions, uIcei, vails, poslhilis oi olhei skin Iesions.
Cnrnna! su!cus UIcei, vails, peaiIy peniIe papuIes.
G!ans pcnIs cxamInatInn Liosions, uIceis, vails, laIanilis (candidiaI, liichononiaI).
5haft nf pcnIs papuIes, noduIes, uIceis oi olhei skin Iesions, filiosis.
PcrIana! cxamInatInn Sepaiale lhe lullocks vilh lvo hands foi lellei visuaIizalion.
Look foi uIcei, naceialed papuIes of condyIona Iala, vails, dischaige, paluIous anus,
haenoiihoids, fissuies, fisluIa.
b) Pa!patInn
InguIna! rcgInn Lynphnodes: lendei oi nol, incieased vainlh, supeificiaI oi deep,
disciele oi nalled, fiee noliIily oi fixed lo deepei sliucluies, consislency: fiin oi sofl
and fIucluanl. RuIe oul heinia.
Pa!patInn nf spcrmatIc cnrds Tendeiness, asynneliy, and lhickening, vaiicocoeIes.
Pa!patInn nf scrntum Asynneliy, lendeiness, consislency of lesles and epididynis,
liansiIIuninalion foi hydiocoeIe. RuIe oul heinia.
Signs of vaiious RTIs/STIs aie shovn as
picluies in fig . Duiing exleinaI genilaI
exaninalion of naIe cIienls, one shouId
Iook foi lhis signs.
ig i rcncra| iscnargc in gcncrrnca
ig crcs |ccrs
ig |i|c grcc crcsicns
ctcr sna c cnis
Pa!patInn nf u!ccr at any sItc Tendeiness, induialion of lhe fIooi and edges, lIeeding
on naneuveiing.
c) DIgIta! rccta! cxamInatInn Ieifoined if synplons suggeslive of pioslalic disease.
ShouId nol le caiiied oul if lhe cIienl has painfuI peiianaI disease such as heipelic
uIceis, fissuies, oi haenoiihoids.
d) PrnctnscnpIc cxamInatInn Indicaled if unpiolecled anaI inleicouise, ieclaI
dischaige.
ig | nancrc c g|ans in ni|is
ig n nancrc c ccrcna| s|cs in ni|is
ig n |ccr c cnctancsis
ig c cn|cna |aa c
ni|is
ig cncrca| ars
ig aniia|
a|anccsniis
ig r nancrcia| c ncc nc
single pointing
ig s
A sinpIified looI (fIovchail) viII heIp lo
guide heaIlh voikeis in lhe nanagenenl
of RTIs/STIs. The fIovchails desciile lhe
cIinicaI syndione, specific RTIs/STIs
undei lhe syndione and lhe causalive
oiganisns of lhe RTI/STI syndione.
DiffeienliaI diagnosis of lhe condilions is
aIso nenlioned vheievei appiopiiale. The
appioach lo lhe Iienl vilh specific poinls
lo le consideied duiing hisloiy laking and
Diagnosis and
Managenenl of RTIs/STIs
5
exaninalion is highIighled. If faciIilies and
skiIIs aie avaiIalIe, lhe Ialoialoiy lesls
vhich need lo le done aie aIso nenlioned.
The liealnenl piolocoIs lo le foIIoved al
lhe piinaiy heaIlh caie syslen vilh
appiopiiale iefeiiaIs vheie indicaled is
aIso given. SpeciaI enphasis is given on
syndione specific pailnei nanagenenl
and nanagenenl issues speci fic lo
piegnancy.
Bnx . Impnrtant cnnsIdcratInns fnr managcmcnt nf a!! c!Icnts nf RTIs
5TIs
Impnrtant cnnsIdcratInns fnr managcmcnt nf a!! c!Icnts nf RTIs5TIs
Lducale and counseI cIienl and sex pailnei(s) iegaiding RTIs/STIs, genilaI
canceis, safei sex piaclices and inpoilance of laking conpIele liealnenl
Tieal pailnei(s) vheie evei indicaled
Advise sexuaI alslinence duiing lhe couise of liealnenl
Iiovide condons, educale aloul coiiecl and consislenl use
Refei foi voIunlaiy counseIing and lesling foi HIV, SyphiIis and Hepalilis
Considei innunizalion againsl Hepalilis
ScheduIe ieluin visil aflei 7 days lo ensuie liealnenl conpIiance as veII as lo
see iepoils of lesls done.
If synplons peisisl, assess vhelhei il is due lo liealnenl faiIuie oi ie-infeclion
and advise pionpl iefeiiaI.
FLOWCHART5
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Managcmcnt nf AnngcnIta! arts
FIg a tn c AnngcnIta! arts
ig a crit|ta| ars
ig ccriana| ars
ig cni|c ars
CausatIvc OrganIsm
Viius: Hunan IapiIIona Viius (HIV)
C!InIca! fcaturcs
SingIe oi nuIlipIe sofl, painIess, pink in
coIoi, cauIifIovei Iike giovlhs vhich
appeai aiound lhe anus, vuIvo-vaginaI
aiea, penis, uielhia and peii-neun. Wails
couId appeai in olhei foins such as
papuIes vhich nay le keialinized.
DIagnnsIs
Iiesunplive diagnosis ly hisloiy of
exposuie foIIoved ly si gns and
synplons.
DIffcrcntIa! dIagnnsIs
i. CondyIona Iala of syphiIis
ii. MoIIuscun conlagiousn
Trcatmcnt
Reconnended ieginens:
PcnI!c and PcrIana! arts
2O IodophyIIi n i n conpound
lincluie of lenzoin appIied lo lhe
vails, vhiIe caiefuIIy piolecling lhe
suiiounding aiea vilh VaseIine, lo le
vashed off aflei 3 houis. Il shouId nol
le used on exlensive aieas pei
session.
Tiealnenl shouId le iepealed
veekIy liI I lhe I esions iesoI ve
conpIeleIy.
Note: ccn||in is ccnrainicac in
rcgnanc Trcancn snc| c gitcn ncr
ncica| scrtisicn |icns snc| c arnc
agains sc|ncicaicn
CcrvIca! arts
IodophyIIin is conlia-indicaled.
iopsy of vails lo iuIe oul naIignanl
change.
Ciyo cauleiizalion is lhe liealnenl of
choice.
CeivicaI cyloI ogy shouId le
peiiodicaIIy done in lhe sexuaI
pailnei(s) of nen vilh genilaI vails.
ig c||scn ccnagicsn
CausatIvc OrganIsm
Iox viius
C!InIca! fcaturcs
MuIlipIe, snoolh, gIislening, gIoluIai
papuIes of vaiying size fion a pinhead lo
a spIil pea can appeai anyvheie on lhe
lody. SexuaIIy liansnilled Iesions on oi
aiound genilaIs can le seen. The Iesions
aie nol painfuI excepl vhen secondaiy
infeclion sels in. When lhe Iesions aie
squeezed, a cheesy naleiiaI cones oul.
DIagnnsIs
Diagnosis is lased on lhe alove cIinicaI
fealuies.
Trcatmcnt
IndividuaI Iesions usuaIIy iegiess
vilhoul liealnenl in 9-12 nonlhs.
Lach Iesion shouId le lhoioughIy
opened vilh a fine needIe oi scaIpeI.
The conlenls shouId le exposed and lhe
innei vaII louched vilh 25 phenoI
soIulion oi 3O liichIoiacelic acid.
PcdIcu!nsIs pubIs
CausatIvc OrganIsm
Lice - Ihlhiius pulis
C!InIca! fcaturcs
Theie nay le snaII ied papuIes vilh a
liny cenliaI cIol caused ly Iice iiiilalion.
CeneiaI oi IocaI uili caiia vilh skin
lhickening nay oi nay nol le piesenl.
Lczena and Inpeligo nay le piesenl.
Trcatmcnt
Reconnended ieginen:
Ieinelhiin 1 ciene iinse appIied
lo affecled aieas and vash off aflei
1O ninules
5pccIa! InstructInns
Reliealnenl is indicaled aflei 7 days
if Iice aie found oi eggs olseived al
lhe haii-skin junclion.
CIolhing oi led Iinen lhal nay have
leen conlaninaled ly lhe cIienl
shouId le vashed and veII diied oi
diy cIeaned.
SexuaI pailnei nusl aIso le liealed
aIong lhe sane Iines.
5cabIcs
CausatIvc OrganIsm Mile - Saicoples
Scaliei.
Managcmcnt nf Mn!!uscum cnntagInsum and EctnparasItIc
InfcstatInn
ig c cnia| caics
C!InIca! fcaturcs
Seveie piuiilis (ilching) is expeiienced ly
lhe cIienl, vhich lecones voise al nighl.
Olhei nenleis of faniIy aIso affecled
(apail fion sexuaI liansnission lo lhe
pailnei, olhei nenleis nay gel infecled
lhiough conlacl vilh infecled cIolhes, Iinen
oi loveIs).
Cnmp!IcatInns
Lczenalizalion vilh oi vilhoul
secondaiy infeclion
Uilicaiia
CIoneiuIonephiilis
Conlacl deinalilis lo anliscalelic
diug
DIagnnsIs
The luiiov is lhe diagnoslic sign. Il can
le seen as a sIighlIy eIevaled giayish
dolled Iine in lhe skin, lesl seen in lhe sofl
pail of lhe skin.
Trcatmcnt
Reconnended ieginens:
Ieinelhiin ciean (5) appIied lo aII
aieas of lhe lody fion lhe neck dovn
and vashed off aflei 814 houis.
enzyI lenzoale 25 Iolion, lo le
appIied aII ovei lhe lody, leIov lhe
neck, aflei a lalh, foi lvo conseculive
nighls. CIienl shouId lalhe in lhe
noining, and have a change of
cIolhing. ed Iinen is lo le
disinfecled.
5pccIa! InstructInns
CIolhing oi led Iinen lhal have leen
used ly lhe cI ienl shouId le
lhoioughIy vashed and veII diied oi
diy cIeaned.
SexuaI pailnei nusl aIso le liealed
aIong lhe sane Iines al lhe sane line.
Partncr managcmcnt
arncr nanagcncn is an aciti in nicn
nc arncrs c ncsc icniic as nating
TT arc |ccac incrnc c ncir
ccnia| ris c inccicn an ccrc
rcancn an ccnsc|ing scrticcs
Ti neIy pailnei nanagenenl seives
foIIoving puipose:
Iievenlion of ie-infeclion
Iievenlion of liansnission fion
infecled pailneis and
HeIp in deleclion of asynplonalic
individuaIs, vho do nol seek
liealnenl.
CrItIca! Issucs nn partncr managcmcnt
CnnfIdcntIa!Ity Iailneis shouId le
assuied of confidenliaIily. Many
lines pailneis do nol seek seivices,
as lhey peiceive confidenliaIily as a
seiious piolIen. Respecling dignily
of cIienl and ensuiing confidenliaIily
viII pionole pailnei nanagenenl.
n!untary rcpnrtIng Iiovideis nusl
nol inpose any pie-condilions giving
liealnenl lo lhe index cIienl.
Iiovideis nay need lo counseI cIienl
seveiaI lines lo enphasize lhe
inpoilance of cIienl inilialed iefeiiaI
of lhe pailneis.
C!IcntInItIatcd partncr managcmcnt
Iiovideis shouId undeisland lhal
lecause of pievaiI ing gendei
inequilies, vonen nay nol le in
posilion aIvayslo connunicale lo
lheii pailneis iegaidingneed foi
pailnei nanagenenl. Such cIienl
inilaled pailnei nanagenenl nay
nol voik in sone ieIalionships and
nay aIso pul vonen al lhe iisk of
vi oIence. Hence aIleinali ve
appioachesshouId le consideied in
such silualions.
AvaI!abI!Ity nf scrvIccs RTI/STI
diagnoslic and liealnenl seivices
shouId le avaiIalIe lo aII pailneis.
This nay nean finding vays lo avoid
Iong vailing lines. This is inpoilanl
lecause nany asynplonalic
pailneis aie ieIuclanl lo vail oi pay
foi seivices vhen lhey feeI heaIlhy.
Apprnachcs fnr partncr managcmcnt
Theie aie lvo appioaches lo pailnei
nanagenenl:
i. RefeiiaI ly index cIienl
In lhis appioach, index cIienl infoins
lhe pailnei/s of possilIe infeclion.
Thi s appeais lo le a feasilIe
appioach, lecause il does nol invoIve
exlia peisonneI, is inexpensive and
does nol iequiie any idenlificalion of
pailneis. A pailnei nolificalion caid
vilh ieIevanl diagnoslic code shouId
le given lo each index cIienl, vheie
pailnei nanagenenl is indicaled. This
appioach nay aIso incIude use of
cIienl inilialed lheiapy foi aII conlacls.
ii. RefeiiaI ly piovideis
In lhis appioach seivice piovidei
conlacls cIienls pailneis lhiough
issuing appiopiiale pailnei
nolificalion caid. The infoinalion
piovided ly cIi enl is used
confidenliaIIy lo liace and conlacl
pailneis diieclIy. This appioach
needs exlia slaff and is expensive.
Bnx . Cnupnn fnr a frcc cxamInatInn
Cnupnn fnr a frcc cxamInatInn
Dale:
IIease allend foIIoving cenleis aIong vilh
lhe caid
Slanp of lhe IaciIily
Tinings:
Diagnoslic Code:
5amp!c Partncr rcpnrtIng card
Nntc csc sracg can c sc ncrc
c|icns arc irs asc c ccnac arncrs
ncnsc|tcs nc rcscnsc i|| cnc cr c ccs
c|inic cr nca|n carncn sa can acn c
racc nc ccnac cr rcancn
Gcncra! prIncIp!cs fnr partncr
managcmcnt
In geneiaI, pailneis shouId le
liealed foi lhe sane STI as lhe index
cIienl, vhelhei oi nol lhey have
synplons oi signs of infeclion.
HeaIlh caie piovideis shouId le as
suie as possilIe aloul lhe piesence
of an STI lefoie infoining and
liealing lhe pailnei, and shouId
ienenlei lhal olhei expIanalions aie
possilIe foi nosl RTI synplons Iike
vaginaI dischaige.
SpeciaI caie is iequiied in nolifying
pailneis of vonen vilh Iovei
aldoni naI pain vho aie lei ng
liealed foi possi lIe peIvic
infIannaloiy disease. ecause of lhe
seiious polenliaI conpIicalions of
IID (infeiliIily, eclopic piegnancy),
pailneis shouId le liealed lo pievenl
possilIe ie-infeclion. Il shouId le
iecogni zed, hovevei, lhal lhe
diagnosis of IID on cIinicaI giounds
is inaccuiale, and lhe coupIe shouId
le adequaleIy counseIed aloul lhis
unceilainly. Il is usuaIIy lellei lo
offei liealnenl as a piecaulion lo
pieseive fuluie feiliIily lhan lo
nisIaleI soneone as having an STI
vhen lhey nay nol have one.
Fn!!nup vIsIts
Fn!!n up vIsIts shnu!d bc advIscd
To see iepoils of lesls done foi HIV,
SyphiIis and Hepalilis .
If synplons peisisl, advise cIienls lo
cone lack foi foIIov up aflei 7 days.
In case of IID, foIIov up shouId le
done aflei 2 lo 3 days.
Managcmcnt nf trcatmcnt faI!urc and
rcInfcctInn
When cIienls vilh an RTI/STI do nol
iespond lo liealnenl, il is usuaIIy lecause
of eilhei liealnenl faiIuie oi ie-infeclion.
Ask lhe foIIoving queslions lo asceilain
lhe cause:
Tn prnbc fnr trcatmcnt faI!urc
Did you lake aII youi nedicines as
diiecled
Did you shaie youi nedicine vilh
anyone, oi slop laking nedicines
aflei feeIing sone inpiovenenl
Was liealnenl lased on lhe nalionaI
liealnenl guideIines AIso considei
lhe possiliIily of diug iesislance if
cases of liealnenl faiIuie aie shoving
an incieasing liend.
Tn prnbc fnr rcInfcctInn
Di d youi pailnei(s) cone foi
liealnenl
Did you use condons oi alslain fion
sex aflei slailing liealnenl
Nntc ccrrcncc is a|sc ccnncn in
cncgcncs tagina| inccicns csccia|| ncn
ncr|ing rcascns ccning tagina| ring
agcns iaccs nc||is ncrncna|
ccnraccitcs arc nc arcssc
Bnx .2 Managcmcnt nf trcatmcnt
faI!urc and rcInfcctInn
Fnr trcatmcnt faI!urc
AII cases of liealnenl faiIuies shouId
le iefeiied lo highei heaIlh faciIily.
Fnr rcInfcctInn
Considei ie-liealnenl vilh sane
anliliolics.
Refei lo highei heaIlh faciIily if
synplons peisisl.
5crccnIng fnr AsymptnmatIc C!Icnts
Il is veII knovn lhal nosl RTIs/STIs aie
asynplonalic, especiaIIy anongsl lhe
vonen. The case finding is a piocess of
oppoilunislic scieening foi an infeclion al
lhe line vhen an individuaI piesenls lo a
heaIlh faciIily, iegaidIess of piesence of
synplons. Case findings oppoilunilies
aie nosl connonIy seen vhiIe pioviding
seivices foi conliaceplion. Iiovideis
shouId use oppoilunilies foi polenliaI
conliaceplive cIienls lo scieen foi RTIs/
STIs. The NalionaI CuideIines foi IUD, OiaI
IiIIs, NalionaI Slandaids foi SleiiIizalion
Seivices piovide delaiIed guideIines
iegaiding scieening of RTIs/STIs.
SiniIai oppoilunilies exisl in piegnancy
caie sellings. Mosl connon scieening
piogiannes voiIdvide aie lhose foi
delecling syphiIis in piegnanl vonen.
Unliealed syphiIis in piegnanl fenaIe is
associaled vilh nunlei of adveise
oulcones such as piegnancy Ioss,
sliIIliilhs and congenilaI syphiIi s.
Iiovideis aie ieconnended lo foIIov
Coveinnenl of Indias foI Iovi ng
guideIines vhiIe pioviding seivices lo
piegnanl vonen:
1. CuideIines foi Iiegnancy Caie and
Managenenl of Connon Olsleliic
ConpIicalions ly MedicaI Officeis,
2OO5.
2. CuideIines foi Anle-NalaI Caie and
SkiIIed Allendance al iilh ly ANMs
and LHVs, 2OO6.
6
RTI/STI Anong SpeciaI
IopuIalions
. 5cxua!!y TransmIttcd InfcctInns
(RTIs) amnng chI!drcn and
adn!csccnts
Repioduclive liacl infeclions in chiIdien
aie acquiied lhiough lhiee diffeienl vays
(i) lianspIacenlaI liansnission occuiiing in
uleio, inliapailun liansnission (duiing
Ialoui and deIiveiy) e.g. syphiIis, HIV,
cylonegaIoviius (CMV) and hunan
papiIIona viius infeclion (HIV) (ii)
poslnalaI liansnission (duiing lieasl-
feeding, accidenlaI and lhiough sexuaI
aluse) (iii) due lo sexuaI aluse oi in
sexuaIIy aclive adoIescenls vho aie al iisk.
ChiId sexuaI aluse is lhe use of a chiId as
an oljecl of gialificalion foi aduIl sexuaI
needs oi desiie. The connon sexuaI aluse
encounleied ly giiIs is genilaI conlacl,
nasluilali on, vagi naI , oiaI oi anaI
inleicouise ly a naIe peipelialoi, vhiIe
loys aie suljecled lo feIalio and anaI
inleicouise.
AdoIescenls and youlh in lhe age gioup
1O-24 yeais conliilule lo aloul 3O of oui
popuIalion. The dala fion vaiious Indian
sludies ieveaI lhal adoIescenls induIge in
pie-naiilaI sex noie fiequenlIy and al an
eaiIy age. STIs, incIuding HIV, aie nosl
connon anong young peopIe aged 15-24
yeais and noie so in young vonen. The
physioIogi caI iisk of incieased
suscepliliI ily lo i nfeclions anong
adoIescenl giiIs is due lo lhe piesence of
giealei ceivicaI eclopy vhich nakes lhe
ceivix noie susceplilIe lo gonoiihea,
chIanydia and HIV. AdoIescenls loday
face enhanced vuIneialiIily lo unvanled
piegnancy and STIs incIuding HIV/AIDS.
Sludies fion Afiican counliies suggesl lhal
giiIs naiiying al an eaiIy age aie al high
iisk of HIV infeclions. Many inleiieIaled
and conpIex faclois lhal pul adoIescenls
al iisk of STIs incIude pooi educalion,
unenpIoynenl and poveily. Uilanizalion
lends lo disiupl faniIy ieIalionships, sociaI
nelvoiks and liadilionaI vaIues vhiIe
geneialing noie oppoilunily foi sexuaI
encounleis. Lack of infoinalion aloul
sexuaI nalleis, as veII as STI pievenlion,
synplons and liealnenl aIso pul lolh
naIe and fenaIe adoIescenls al iisk of STIs.
Lven vhen adoIescenls have accuiale
knovIedge aloul STDs, sone incoiieclIy
peiceive lheii iisk as Iov eilhei due lo
faniIiaiily vilh a sexuaI pailnei oi as
ieIalionship naluies oi sinpIy lecause
lhey aie passing lhiough a slage of Iife in
vhich iisk laking is pailicuIaiIy alliaclive
especiaIIy undei lhe sliong infIuence of
lheii peeis, nigialion and dispIacenenl,
nuI lipI e and concuiienl sexuaI
pailneiship, Iack of access lo effeclive and
affoidalIe STI seivices. Theiefoie lheie is
an uigenl need foi inpiovi ng lhe
accessiliIily of adoIescenls lo pievenlive
and cuiali ve seivices incIudi ng
infoinalion and counseIing.
In lhe RCH 2, AdoIescenl Repioduclive
and SexuaI HeaIlh (ARSH) Slialegy is lo
le inpIenenled in lhe piinaiy heaIlh caie
selling lased on lhe inpIenenlalion
Cuide foi slale and disliicl piogian
nanageis. Undei lhis slialegy, il is
expecled lhal a coie package of pionolive,
pievenlive, cuialive, counseIing, iefeiiaI
and oulieach seivices vouId le piovided
lhiough lhe pulIic heaIlh caie faciIilies. Il
slales lhal seivices foi adoIescenls nusl
denonsliale ieIevance lo lhe needs and
vishes of lhe young peopIe.
C!InIca! prcscntatInn nf RTIs5TIs In
chI!drcn and adn!csccnts
The piesenling synplons of adoIescenls
is veiy pecuIiai as veiy oflen lhey piesenl
vilh synplons olhei lhan lhose of RTI/
STI. Theiefoie iisk assessnenl pIays a
ciuciaI ioIe. The incieasing lendency of
honosexuaI lehavioi as iepoiled ly sone
sludies nusl aIso le kepl in nind and ano-
genilaI Iesions nusl le Iooked foi.
GIr!s
In geneiaI, endogenous vaginilis
ialhei lhan an STI is lhe nain cause
of vagi naI dischaige anong
adoIescenl fenaIes.
AppioxinaleIy 85 of gonococcaI
infeclion in fenaI es viII le
asynplonalic. Hovevei, lheie nay
le vuIvaI ilching, ninoi dischaige,
uielhiilis oi pioclili s. In pie-
pulescenl giiIs, a puiuIenl vuIvo-
vaginilis nay occui.
SiniIaiIy, ChIanydia liachonalis
infeclion is asynplonalic in lhe
najoiily of cases. Synplons lhal nay
occui in lhe adoIescenl aie inlei-
nensliuaI lIeeding, poslcoi laI
lIeeding and an inciease in vaginaI
secielions.
Candida aIlicans is unconnon in
adoIescenls piioi lo puleily. If
piesenl, lhe adoIescenl nay have a
dischaige, vuIvaI ilching, dyspaieunia,
peii-anaI soieness oi a fissuiing al lhe
inlioilus. Allacks of candida vuIvilis
nay le cycI icaI in naluie and
coiiesponds lo nensliualion.
acleiiaI vaginosis does nol pioduce
vuIvilis and lhe adoIescenl viII nol
conpIain of ilching oi soieness.
The signs of acquiied syphiIis in
chiIdien piesenl vilh snaII chancies
oi nucoculaneous noisl Iesions
ei lhei on lhe vuIva oi anus.
Iiesenlalion of syphiIis is lhe sane
in adoIescenls and aduIls.
Bnys
Conoiihea anong loys piesenls as
pioclilis, uielhiaI dischaige,
asynplonalic pyuiia, peniIe edena,
epididyinilis and leslicuIai sveIIing.
Disseninaled gonoiihoea piesenls
vilh nuIlipIe syslenic
nanifeslalions.
ChIanydia in naIes piesenls as
uielhiilis.
.2 5cxua!!y TransmIttcd InfcctInns
(5TIs) amnng 5cx Wnrcrs and M5Ms
In sone gioups of popuIalion vilh high
iisk piaclices such as sex voikeis, nen
having sex vilh nen and inliavenous diug
useis, lhe pievaIence of STIs and HIV is
highei lhan lhe geneiaI popuIali on.
Tieali ng lhese cIi enls eaiIy and
appiopiialeIy viII ieduce iisk of HIV
infeclion and if aIieady infecled, lhey can
le advised foi seeking lhe avaiIalIe
seivices al lhe inlegialed lesling and
counseIing faciIilies foi knoving of HIV
slalus and fuilhei foIIov up aclion as
indicaled. Il is desiialIe lhal aII cIienls
vilh iisky lehavioui aie lesled.
. C!InIca! Managcmcnt nf 5TI In
Mnst at RIs Grnups
High iales of cuialIe STIs have leen
olseived voiIdvide in conneiciaI sex
sellings vheie condon use iales aie Iov
and access lo effeclive STI liealnenl
seivices is Iiniled.
Lffeclive pievenlion and liealnenl of STIs
anong fenaI e sex voikeis iequiies
allenli on lo lolh synplonalic and
asynplonalic infeclions. The pievenlion
and liealnenl of STIs in fenaIe sex voikeis
in STI cIinics shouId have lhe foIIoving
lvo conponenls:
Trcancn c ncnaic nccicns
- As pei lhe fIov chails incIuded
in lhese guideIines.
crccning an Trcancn c
sncnaic nccicns
- Ieiiodic hisloiy laking, cIinicaI
exaninalion and sinpIe
Ialoialoiy diagnoslics (vheie
avaiIalIe)
- Ieiiodic piesunplive liealnenl
foi asynplonalic gonococcaI
and chIanydiaI infeclions (in
aieas vilh high STI iales and
nininaI STI seivices) and
- Seni-annuaI seioIogic scieening
foi syphiIis.
IenaIe sex voikeis shouId le encouiaged
lo allend lhe cIinic foi iouline check-ups.
Duiing lhe visil, lhe cIinic slaff shouId lake
a delai Ied hisloiy and peifoin an
exaninalion. In addilion, even if lheie is
no evidence of infeclion, liealnenl is
ieconnended if:
lhe sex voikei is visiling lhe cIinic
foi lhe fiisl line
six nonlhs have passed since lhe sex
voikei Iasl ieceived liealnenl.
The ialionaIe foi piesunpliveIy liealing
sex voikeis vho aie asynplonalic is lhal
lhey aie fiequenlIy exposed lo STIs and
lhey oflen do nol shov signs oi synplons
even vhen infecled. A sex voikei is IikeIy
lo le exposed and infecled vilh a STI, if
lhe line Iapse is noie since hei Iasl
liealnenl. (Nole: This ieconnendalion
viII le ievieved and ievised as dala on
lhe epidenioIogy of STIs anong sex
voikeis lecone avaiIalIe).
Il is anlicipaled as STI pievaIence faIIs,
peiiodi c piesunplive liealnenl of
asynplonalic STI liealnenl anong sex
voikeis viII le lapeied lo fiisl visil
asynplonalic liealnenl undei lhe
foIIoving condilions:
Lvidence of Iov gonococcaI and
chIanydiaI infeclions (1O and
leIov)
High condon use anong sex voikeis
(7O) and
High quaIily STI seivices foi sex
voikeis have leen eslalIished, vilh
aInosl 8O of sex voikeis having
access lo STI seivices (8O piovided
vilh asynplonalic liealnenl al Ieasl
once and aie coning lo lhe cIinic foi
ieguIai STI scieening).
In such silualions, ieguIai visils foi iouline
exaninalion and counseIing shouId le
pionoled. Sex voikeis shouId le
counseIed al eveiy oppoilunily (in lhe
cIinic and in lhe connunily) on lhe
inpoilance of using condons. Ieei
educalois, oulieach voikeis and cIinic
slaff shouId ieinfoice lhe foIIoving
nessage lo sex voikeis visiling lhe cIinic:
The onIy ieIialIe vay lo piolecl
oneseIf fion HIV and STIs is lo use
condons consislenlIy and coiieclIy
and
Anliliolics dispensed al lhe cIinic aie
effeclive onIy foi lhe fev cuialIe STIs.
Oulieach slaff shouId aIso ienind sex
voikeis aloul lheii cIinic appoinlnenls
and heIp lhen keep lheii appoinlnenls.
Il is aIso inpoilanl lo calei foi STI
nanagenenl needs of MSM popuIalion
gioups. Lneigence of anaI STIs is cause
of concein. Seivice piovideis shouId le
sensili ve lo lhe needs of lhe MSM
popuIalion gioups and counseI lhen
aloul iisk ieduclion, use of condons and
HIV lesling.
F!nchart . Managcmcnt nf 5TIs durIng rnutInc vIsIt by fcma!c scx nrcrs
F!nchart .2 F!nchart fnr rnutInc vIsIt by ma!c and transgcndcr
scx nrcrs In c!InIcs
SexuaI vioIence is defined as any sexuaI
acl, allenpl lo ollain a sexuaI acl,
unvanled sexuaI connenls oi advances,
oi acls lo liaffic vonens sexuaIily, using
coeicion, lhieals of hain oi physicaI foice,
ly any peison iegaidIess of ieIalionship
lo lhe viclin, in any selling, incIuding lul
nol Iiniled lo hone and voik. Oflen,
lecause lhe viclins feeI unconfoilalIe
laIking aloul sexuaI vioIence, lhey nay
cone lo lhe cIinic vilh olhei non-specific
conpIainls oi iequesling a check-up,
assuning lhal lhe heaIlh caie piovidei viII
nolice anylhing alnoinaI lhal needs
liealnenl. Theiefoie, heaIlh caie voikeis
shouId nainlain a high index of suspicion
and ask aloul expeiience of sexuaI
vioIence oi aluse. The foIIoving seivices
shouId le avaiIalIe, on-sile oi lhiough
iefeiiaI, foi cIienls vho have expeiienced
sexuaI vioIence:
A. Isua! InspcctInn
efoie pioceeding foi exaninalion
consenl of lhe viclin oi lhe IegaI
guaidian in case of ninois nusl le
laken. CounseIing of lhe viclin nusl
le done. Lxaninalion of cIolhes,
injuiies and genilaI nusl le caiiied oul.
Look foi lIeeding, dischaige, odoui,
iiiilalion, vails and uIceialive Iesions.
B. Cn!!cctInn nf fnrcnsIc cvIdcncc
Ioiensic exaninalion shouId le
avaiIalIe lo docunenl evidence if lhe
peison chooses lo lake IegaI aclion.
7
Managenenl of SexuaI
VioIence
Slaff shouId le liained in hov lo lake
foiensic specinens, oi iefeiiaI Iinks
shouId le nade. Ioiensic exaninalion
nusl incIude physicaI and genilaI
exaninalion. (Refei lo lhe Slale-
specific guideIines foi foiensic
exaninalion).
C. Cn!!cctInn nf samp!cs fnr dctcctIng
5TIs
If faciIilies peinil, svals nusl le
coIIecled fion vaiious siles foi vel
nounl exaninalion oi cuIluie of a
nunlei of causalive oiganisns.
Iood couId le coIIecled foi VDRL/
RIR, HIV and HlsAg lesls.
D. EsscntIa! mcdIca! carc fnr
InurIcs and hca!th prnb!cms
MedicaI nanagenenl incIudes
i. Iievenlion of piegnancy ly
offeiing eneigency conliaceplion
ii. STI piophyIaxis
iii. Caie of injuiies
Nntc is incran c cain incrnc ccnscn
cr an caninaicn rcancn cr rccrra| in a
casc c a ticin c sca| assa|
LssenliaI nedicaI caie foi injuiies and
heaIlh piolIens vouId consisl of:
Pnst cxpnsurc prnphy!axIs agaInst
prcgnancy
Lneigency Conliaceplion (LC) lo
pievenl unvanled piegnancy shouId
le given vilhin 72 his of unpiolecled
sexuaI inleicouise.
Bnx 7. Pnst cxpnsurc prnphy!axIs Ith Emcrgcncy cnntraccptIvcs
Typc nf FIrst dnsc 5ccnnd dnsc
Emcrgcncy (IthIn 72 hnurs aftcr (2 hnurs !atcr)
cnntraccptInn unprntcctcd Intcrcnursc)
LevonoigeslieI- LevonoigeslieI Repeal sane
onIy piIIs foi in 2 doses Iiisl dose of dose aflei 12 his
eneigency O.75 ng of IevonoigeslieI
conliaceplion
Pnst cxpnsurc prnphy!axIs nf 5TI
STI piophyIaxis shouId le slailed as eaiIy as possilIe, aIlhough lhe doses shouId
le spiead oul (and laken vilh food) lo ieduce side-effecls such as nausea.
Bnx 7.2 Pnst cxpnsurc prnphy!axIs nf 5TI fnr adu!ts and n!dcr chI!drcn and
adn!csccnts cIghIng mnrc than g
. Fnr prntcctInn agaInst syphI!Is, gnnnrrhca and ch!amydIa
Tal. Azilhionycin 1gn oiaIIy, singIe dose undei supeivision
ILUS
Tal. Cefixine 4OOng oiaIIy singIe dose
2. Fnr prntcctInn agaInst T. agIna!Is
Tal MelionidazoIe 2gn singIe dose
OR
Tal TinidazoIe 2gn singIe dose
Bnx 7. Pnst cxpnsurc prnphy!axIs nf 5TI fnr chI!drcn
. Fnr prntcctInn agaInst syphI!Is and ch!amydIa
Liylhionycin 12.5 ng/kg of lody veighl oiaIIy 4 lines a day foi 14 days
2. Fnr prntcctInn agaInst gnnnrrhca
Cefixine 8 ng/kg of lody veighl as a singIe dose, oi
Cefliiaxone 125 ng ly inlianuscuIai injeclion
. Fnr prntcctInn agaInst T. agIna!Is
MelionidazoIe 5 ng/kg of lody veighl oiaIIy 3 lines a day foi 7 days
Pnst cxpnsurc prnphy!axIs nf HI
Refei lo disliicl hospilaI and foIIov NACO guideIines foi lhe sane.
Pnst cxpnsurc prnphy!axIs agaInst HcpatItIs B
If nol vaccinaled eaiIiei, il is ieconnended. If vaccine is nol avaiIalIe, iefei
lo lhe cenlie vheie Hepalilis vaccinalion faciIilies aie avaiIalIe.
n cta|aicn c nc crscns crscna| sac snc| c nac a rcccitc scrticcs agcnc cr
snc|cr i atai|a|c an arrangcncns nac cr rcccicn i nccc
A. PsychnsncIa! suppnrt (bnth at tImc nf crIsIs and !nngtcrm)
IsychosociaI nanagenenl incIudes counseIing and suppoilive seivices, vhich
shouId le avaiIalIe on-sile oi ly iefeiiaI. Wonen oi chiIdien vho have leen
sexuaIIy alused nay need sheIlei and IegaI pioleclion. AdoIescenls in pailicuIai
nay need ciisis suppoil, as lhey nay nol le alIe oi viIIing lo discIose lhe assauIl
lo paienls oi caie lakeis.
B. Fn!!nup scrvIccs fnr a!! nf thc abnvc
Il is essenliaI lo expIain lhe inpoilance of foIIov-up appoinlnenls and seivices
duiing lhe fiisl visil ilseIf. The vonan shouId le cIeaiIy loId vhon lo conlacl if
she has olhei queslions oi sulsequenl physicaI oi enolionaI piolIens ieIaled lo
lhe incidenl.
8
CounseIing and Tesling
foi RTIs/STIs
Lffeclive connunicalion of infoinalion
on pievenlion, especiaIIy on lehavioi
change, Iinked vilh effeclive liealnenl is
a key lo lhe conlioI of RTIs/STIs. When
cIeai connunicalion is Iinked lo effeclive
liealnenl lheie can le addilionaI lenefils.
Lven vhen liealnenl is nol avaiIalIe al
oulieach RCH seivice deIiveiy sellings,
pievenlion infoinalion and condons can
le piovided. Lffeclive connunicalion can
le done in lhe foIIoving vays:
Intcrpcrsnna! cnmmunIcatInn The face-
lo-face piocess of giving and ieceiving
infoinalion lelveen lvo oi noie peopIe.
This invoIves lolh veilaI and non-veilaI
connunicalion.
crba! cnmmunIcatInn The vay ve
laIk vilh cIienls, lhe voids ve use,
and lheii neanings.
Nnnvcrba! cnmmunIcatInn The
vay ve lehave vilh cI ienls,
incIudi ng aclions, lehaviois,
gesluies and faciaI expiessions.
Cnunsc!Ing Iace-lo-face, peisonaI,
confidenliaI connunicalion in vhich one
peison heIps anolhei lo nake decisions
and lhen lo acl on lhen. Cood counseIing
has lvo najoi eIenenls: nuluaI liusl
lelveencIienl and piovidei and lhe giving
and ieceiving of ieIevanl, accuiale and
conpIele infoinalion lhal enalIes lhe
cIienl lo nake a decision. Il iequiies
conveisalionaI and Iislening skiIIs.
GuIdc!Incs fnr cnunsc!Ing
a) WeIcone youi cIienl vainIy ly
nane and inlioduce youiseIf.
l) Sil cIoseIyenoughso lhal youcanlaIk
confoilalIy and piivaleIy.
c) Make eye conlacl and Iook al lhe
cIienl as s/he speaks.
d) Use Ianguage lhal lhe cIienl
undeislands.
e) Lislen and lake nole of lhe cIienls
lody Ianguage (posluie, faci aI
expiession, Iooking avay, elc.). Seek
lo undeisland feeIings, expeiiences
and poinls of viev.
f) e encouiaging. (Nod oi say, TeII
ne noie aloul lhal.)
g) Use open-ended queslions.
h) Iiovide ieIevanl infoinalion.
i) Tiy lo idenlify lhe cIienls ieaI
conceins.
j) Iiovide vaiious oplions foi lhe
cIienl.
k) Respecl lhe cIienls choices.
I) AIvays veiify lhal lhe cIienl has
undeislood vhal has leen discussed
ly having lhe cIienl iepeal lack lhe
nosl inpoilanl nessages oi
insliuclions.
BarrIcrs tn gnnd cnunsc!Ing
Lack of piivacy.
Nol gieeling oi nol Iooking al lhe
cIienl.
Appeaiing lo le disliacled (foi
exanpIe, ly Iooking al youi valch
oi ieading papeis vhiIe s/he is
laIking).
Using a haishlone of voice oi naking
angiy gesluies.
Silling vhiIe lhe cIienl slands oi
silling fai avay fion lhe cIienl.
AIIoving inleiiuplions duiing lhe
consuIlalion.
eing ciilicaI, judgnenlaI, saicaslic
oi iude.
Inleiiupling lhe cIienl.
Making lhe cIienl vail foi a Iongline.
Nol aIIoving enough line foi lhe
visil.
C!Icnt cnunsc!Ing nn RTIs5TIs Duiing
counseIing session, piovidei shouId laIk
aloul causalion, liansni ssion,
ieconnended liealnenl, pievenlion, iisk
ieduclion, lehavioi change, and pailnei
iefeiiaI. CIinics can have lake avay
infoinalion liochuies in sinpIe
Ianguages vilh iIIuslialions lo ieinfoice
nessages.
CoaIs of cIienl educalion and counseIIing
Iiinaiy pievenlion oi pievenling
infeclion in uninfecled cIienls. This
is lhe nosl effeclive slialegy lo
ieduce lhe spiead of RTIs/STIs and
can le easiIy inlegialedinlo aII heaIlh
caie sellings.
Cuiing lhe cuiienl infeclion.
Secondaiy pievenlion, vhi ch
pievenls fuilhei liansnission of lhal
infeclion in lhe connunily and
pievenls conpIicalions and ie-
infeclion in lhe cIienl.
What thc c!Icnt nccds tn nn
PrcvcntInn nf RTIs5TIs
Risk ieduclion
Usi ng condons, coiieclIy and
consislenlIy, avaiIaliIily of condons
Liniling lhe nunlei of pailneis
AIleinalives lo penelialive sex
Negolialing skiIIs
InfnrmatInn abnut RTIs5TIs
Hovlhey aie spiead lelveen peopIe
Consequences of RTIs/STIs
Links lelveen RTIs/STIs and HIV
RTI/STI Synplons - vhal lo Iook
foi and vhal synplons nean
RTI5TI Trcatmcnt
Hov lo lake nedicalions
Signs lhal caII foi a ieluin visil lo lhe
cIinic
Inpoilance of pailnei iefeiiaI and
liealnenl
AcknovIedge gendei inequaIilies
vhich nay inpacl naIe pailneis
coning foivaid lo seek seivices
PrIncIp!cs nf cffcctIvc c!Icnt
cducatInn
Shovs iespecl and concein foi lhe
safely of cIienls lhiough lody
Ianguage, leIIing cIienls you aie
conceined, leing allenlive lo and
acknovIedging cIienls feeIings, and
laking noie line vilh lhen.
Is cIienl-cenleied. Iiovides
nessages lhal aie laiIoied foi each
individuaI diffeienl nessages foi
naiiied nen, vonen, and
adoIescenls.
InvoIves 3 kinds of Ieaining: lhiough
ideas, aclions, and feeIings (cognilive,
psycho-noloi, and affeclive).
Uses nuIlipIe channeIs (eyes, eais
and face-lo-face/visuaI, audiloiy,
inleipeisonaI). DeIiveis nessages
via lhe eyes, eais, and face-lo-face
connunicalion.
Intcgratcd Cnunsc!!Ing and TcstIng
Ccntcrs (ICTC) and thcIr rn!c In 5TI
prcvcntInn and Managcmcnt
CIienls vilh STI have shovn high iisk
sexuaI lehavioui. ased on lhis high iisk
lehavioi, lhe heaIlh caie voikei shouId
infoin lhe CIienl aloul lhe Iinks lelveen
STIs and HIV and shouId encouiage aII
CIienls lo undeigo an HIV lesl as lhe iisk
of HIV anong STD is uplo 1O lines highei.
In oidei lo gel HIV lesl, Inlegialed
counseIing and lesling cenleis (ICTC) have
leen eslalIished. Lach ICTC has
counseIoi(s) and a Ialoialoiy lechnician.
As of Novenlei 2OO6, lheie aie 3394
counseIing cenleis and noie aie leing
eslalIished. ICTCs aie Iocaled in lhe
nedicaI coIIeges, disliicl hospilaIs in aII
slales and in addilion in seIecled CHCs
and IHCs especiaI Iy i n lhe hi gh
pievaIence slales. Il is envisaged lo
eslalIish ICTCs al aII CHC and addilionaI
al seIecled IHCs in aII slales.
In Inlegialed CounseIing and Tesling
Cenleis lhe STI CI ienl vi II iecei ve
conpiehensive and accuiale infoinalion
on HIV/AIDS and HIV counseIing lo
faciIilale an infoined choice iegaiding an
HIV lesl. The inlegialed cenleis seive as
singIe vindov syslen ly pooIing aII
CounseIois and Lal Technicians voiking
in ICTC, IITCT, Iood Safely, STI, ART/
OIs and HIV - T logelhei lo offei iound
lhe cIock counseIing and lesling seivices.
This connon faciIily viII ienove feai,
sligna and disciininalion anong lhe
cIi enls and CIi enls, ILHAs and lhe
iefeiiaIs.
The ICTC have connon leIevision and
video lased heaIlh educalion naleiiaIs lhal
aie scieened conlinuousIy in lhe CIienls
vailing aiea. The infoinalion ieIaled lo
pievenlive, pionolive and cuialive heaIlh
caie aIong vilh infoinalion iegaiding
HIV/AIDS, and vaiious seivices piovided
ly lhe hospilaI is piovided lo aII lhe
CIienls.
Iuilhei lvo slialegies aie adopled in ICTC
foi HIV lesling.
Opl-oul slialegy In lhi s, lhe
counseIoi assunes lhal lhe CIienl
has cone lo gel an HIV lesl (inpIied
consenl). The HIV lesl viII le done
unIess lhe CIienl acliveIy denies lhe
lesl.
Opl-in slialegy In lhis, lhe
counseIoi specificaIIy asks lhe cIienl,
vhelhei s/he vouId Iike lo undeigo
lhe HIV lesl. The cIienl has lo acliveIy
agiee lo lhe HIV lesl.
As pei lhe NalionaI AIDS Iievenlion and
ConlioI IoIicy, aII HIV lesls aie voIunlaiy,
lased on lhe cIienls consenl, acconpanied
ly counseIing and confidenliaIily of lhe
iesuIls.
AIms nf Prctcst cnunsc!Ing
To ensuie lhal any decision lo lake
lhe lesl is fuIIy infoined & voIunlaiy
To piepaie lhe cIienl foi any lype of
iesuIl, vhelhei negalive oi posilive
oi indeleininale
To piovide cIienl iisk ieduclion
infoinalion & slialegies iiiespeclive
of vhelhei lesling pioceeds
The CIi enls aie advised aloul
pievenlive neasuies and use of
condons.
If lhe CIienl decIines lo lake lhe lesl, he/
she Ieaves lhe ICTC. Sone CIienls ieluin
lo lhe ICTC aflei a fev days foi lhe lesl. If
lhe cIienl agiees lo undeigo lhe lesl, he/
she pioceeds lo lhe allached Ialoialoiy foi
lIood coIIeclion. Aflei lhe lIood sanpIe
is laken, lhe cIienl eilhei vails foi lhe
iesuIls oi is asked lo ieluin on assigned
dale vilh Ialienl Idenlificalion Digil (IID)
nunlei
The lesls aie peifoined ly using lhe iapid
lesl kils. If lhe lesl is negalive and lhe cIienl
has hisloiy of high iisk faclois, he/she is
advised lo iepeal lhe lesl aflei 3 nonlhs
as he/she nay le in lhe vindov peiiod.
If lhe iesuIl is posilive lhe lesl is iepealed
vilh kils using a diffeienl nelhod of
anlilody deleclion. The iesuIl is
consideied posilive if aII lhiee lesls aie
posilive. efoie lhe iesuIls aie ieveaIed
lo lhe cIienl, posl counseIing is done.
AIms nf Pnst tcst cnunsc!Ing aIms tn
HeIp cIienl undeisland and cope
vilh lhe HIV lesl iesuIls
Iiovide lhe cIienl vilh any fuilhei
infoinalion iequiied
HeIp CIienls decide vhal lo do aloul
discIosing lheii lesl iesuIl lo pailneis
and olheis
HeIp CIienls ieduce lheii iisk of
HIV/ AIDS and lake aclion lo pievenl
infeclion lo olheis incIuding condon,
avoiding nuIlipIe pailneis and olhei
high ii sk lehavioui (Iosili ve
pievenlion.
HeIp CIienls access lhe nedicaI and
sociaI caie and suppoil lhey need
LslalIish Iink vilh ILHA gioups, if
needed
In 5TI scttIngs, thc fn!!nIng Is
rccnmmcndcd
(i) HIV lesling shouId le ieconnended
foi aII STIs CIienls aflei pie-lesl
counseIing and infoined consenl.
Theie shouI d le guaianlee foi
confidenliaIily. HIV counseIing and
lesling can eilhei le peifoined in lhe
STI cIinic (if counseIoi is avaiIalIe)
oi CIienls can le iefeiied lo lhe
neaiesl ICTC.
(ii) In sone cases of STIs in lhe piesence
of HIV infeclion, Iaigei doses and
Iongei liealnenl duialion of lhe
diugs Iisled undei lhe diffeienl STIs
nay le iequiied. These CIienls
shouId le foIIoved up ieguIaiIy foi
Iongei duialion.
(iii) Lxcessive use of anli-nicioliaIs
shouId le avoided, as il is IikeIy lo
Iead lo noie iapid deveIopnenl of
anliliolic iesislance.
(iv) AIlhough counseIing of individuaI
CIi enls on iisk ieducli on, and
pievenlion of STI liansnission lo lhe
pailneis shouId le done in aII CIienls
of STI, lhis is of vilaI inpoilance foi
lhose infecled vilh HIV.
IkjdgjIdfkgj
Anncxurc
ANNEXRE
LABORATOR TE5T5 FOR RTIs5TIs
Laloialoiy lesls inpiove lhe diagnoslic sensilivily and specificily of synplonalic RTIs/
STIs, pailicuIaiIy in vonen, lo diffeienliale seiious infeclions, i.e., ceivicilis, fion niIdei
lul noie connon infeclions, i.e., vaginilis. SinpIe Ialoialoiy lesls incoipoialed in
syndionic nanagenenl of uielhiaI dischaige aIso heIp dislinguish lelveen nixed and
singIe infeclions, ieducing lhe adninislialion of unnecessaiy anliliolics. The lesls aIso
heIp in deleclion of infeclions in asynplonalic individuaIs, specificaIIy in fenaIe CIienls,
vho caiiy lhe luiden of RTIs/STIs conpIicalions and sequeIae. Laloialoiy lesling is
even noie inpoilanl in piegnanl vonen lo pievenl lhe adveise consequences of
syphiIis, gonococcaI and chIanydiaI infeclion in nevloins.
Laloialoiy diagnosis of RTIs incIudes lhiee najoi equaIIy inpoilanl sleps i.e coIIeclion
of specinen, ils lianspoil and use of a ieasonalIe sensilive and specific lesl. Laloialoiy
pioceduies al IHC IeveI shouId incIude nicioscopic exaninalion of fiesh and slained
specinens. Micioscopic exaninalion of uielhiaI dischaige heIps lo singIe oul
nongonococcaI infeclion. Wel nounl nicioscopy in vaginaI dischaige heIps lo delecl
liichononiasis, (Tiichononas vaginaIis) candidiasis and lacleiiaI vaginosis (V). SinpIe
addilionaI lesls lo idenlify lacleiiaI vaginosis aie lhe KOH sniff lesl and neasuienenl
of pH of vaginaI fIuid. Lal pioceduies nay aIso incIude sinpIe nonlieponenaI syphiIis
scieening lesls: iapid pIasna ieagin (RIR) oi VeneieaI Disease Reseaich Laloialoiy
(VDRL).
Lffeclive diagnosis of vaginilis ly
vaginaI pH, anine lesl and vel sneai
of vaginaI sneai can le achieved vilh
a sensilivily of 75-8O. The sensilivily
of delecling candida oiganisns ly
1O KOH piepaiali on, saIi ne
nicioscopy and Cian slain is 7O, 4O-
6O and 65 iespecliveI y. The
sensilivily of vel nounl lo idenlify
liichononads in synplonalic vonen
is appioxinaleI y 8O vhiIe il
decieases lo 5O in asynplonalic
vonen. The sensili vily of
papanicoIaou (IAI) sneai foi T.
vaginaIis is aiound 6O. Cian slain is noie ieIialIe lhan IAI foi diagnosis of V
infeclion. Ioi olhei RTIs/STIs, il is advisalIe lo use LLISA lased assays oi noIecuIai
diagnoslics lo achieve good sensilivily and specificily.
agIna! pH
The pH of vaginaI fIuid shouId le neasuied using pH papei of appiopiiale iange (3.8
ig a c||ccicn c sccincn cn sa
lo 6.O). The vaginaI fIuid sanpIe is coIIecled vilh a sval fion lhe IaleiaI and posleiioi
foinices of lhe vagina and lhe sval is lhen louched diieclIy on lo lhe papei sliip.
AIleinaliveIy, lhe pH papei can le louched lo lhe lip of lhe specuIun aflei il has leen
vilhdiavn fion lhe vagina. Caie nusl le laken nol lo use any jeIIy (eg K. jeIIy) oi
disinfeclanl (eg.savIon) lefoie doing pH lesl. Conlacl vilh ceivicaI nucus nusl le
avoided since il has a highei pH. The noinaI vaginaI pH is 4.O. In V, lhe pH is geneiaIIy
eIevaled lo noie lhan 4.5.
The vaginaI pH lesl has lhe highesl sensilivily (liue negalive) of lhe foui chaiacleiislics
used foi idenlificalion of V, lul lhe Iovesl specificily (liue posilive) an eIevaled pH
is aIso olseived if lhe vaginaI fIuid is conlaninaled vilh nensliuaI lIood, ceivicaI
nucus oi senen, and in vonen vilh a T tagina|is infeclion. In sinpIe voids il neans
lhal if pH lesl is negalive lhe iesuIl can le laken as il is lul if il is posilive one has lo
iuIe oul lhe olhei faclois conlaninaling lhe sanpIe such as nensliuaI lIood, ceivicaI
nucus oi senen oi piesence of T tagina|is infeclion
Wct mnunt mIcrnscnpy
Wel nounl nicioscopy is lhe diiecl nicioscopic exaninalion of vaginaI dischaige foi
lhe diagnosis of liichononiasis, candidiasis and V.
Bnx A. Wct mnunt mIcrnscnpy cxamInatInn nf vagIna! dIschargc
Cn!!cct spccImcn Take a specinen of dischaige vilh a spaluIa fion lhe side vaIIs
oi deep in lhe vagina vheie dischaige accunuIales.
Prcparc s!Idc Mix specinen vilh 1 oi 2 diops of saIine on a gIass sIide and
covei vilh a covei sIip.
What tn !nn fnr Lxanine al 1OO nagnificalion and Iook foi lypicaI jeiky
novenenl of noliIe liichononads (ovoid, gIoluIai, peai-
shaped fIageIIaled piolozoan).
Lxanine al 4OO nagnificalion lo Iook foi yeasl ceIIs (iound
lo ovoid ceIIs vilh lypicaI ludding) and liichononads.
To nake idenlificalion of yeasl ceIIs easiei in vel nounl
sIides, nix lhe vaginaI sval in anolhei diop of saIine and add
a diop of 1O polassiun hydioxide lo dissoIve olhei ceIIs
and nole any fishy odoui.
Iiesence of cIue ceIIs (squanous epilheIiaI ceIIs coveied vilh
nany snaII coccolaciIIaiy oiganisns). Wel nounl shovs
slippIed gianuIai ceIIs vilhoul cIeaiIy defined edges lecause
of lhe Iaige nunleis of adheienl lacleiia piesenl and an
appaienl disinlegialion of lhe ceIIs. The adheiing lacleiia aie
piedoninanlIy tagina|is, sonelines nixed vilh anaeioles).
Impnrtant Look foi evidence of olhei vaginaI oi ceivicaI infeclions as
nuIlipIe infeclions aie connon.
ig cassin nrcic rcaraicn c tagina|
|i sncing ing cas an ncc|ia
ig c |c cc||s in tagina| c ncn
ig Tiichononas vaginaIis in a c ncn c
tagina| iscnargc
Bnx A.2 C!InIca! crItcrIa fnr BactcrIa! vagInnsIs (B)
B can bc dIagnnscd usIng sImp!c c!InIca! crItcrIa Ith nr
Ithnut thc aId nf a mIcrnscnpc.
Cn!!cct spccImcn Nole coIoi and consislency of dischaige. Take a specinen of
dischaige fion lhe side vaIIs oi deep in lhe vagina vheie
dischaige pooIs (oi use dischaige ienaining on specuIun).
Touch pH papei lo dischaige on sval oi specuIun and nole
pH.
Prcparc s!Idc IIace specinen on a gIass sIide. Add a diop of 1O
polassiun hydioxide (KOH) and nole foi any fishy sneII.
Make a vel sneai vilh O.9 noinaI saIine, covei vilh
coveisIip and see undei nicioscope foi cIue ceIIs.
What tn !nn fnr The diagnosis of V is lased on lhe piesence of al Ieasl 3 of
lhe 4 foIIoving chaiacleiislics
Honogeneous vhile-giey dischaige lhal slicks lo lhe
vaginaI vaIIs
VaginaI fIuid pH 4.5
ReIease of fishy anine odoui fion lhe vaginaI fIuid vhen
nixed vilh 1O polassiun hydioxide (posilive vhiff lesl)
CIue ceIIs visilIe on nicioscopy on vel piepaialion
WhIff tcst
Wonen vilh V oflen conpIain of a fouI vaginaI sneII. This odoui is due lo lhe ieIease
of anines, pioduced ly decailoxyIalion of lhe anino acids Iysine and aiginine ly
anaeiolic lacleiia. When polassiun hydioxide is added lo lhe vaginaI fIuid, lhese anines
innedialeIy lecone voIaliIe, pioducing lhe lypicaI fishy odoui.
IIace a diop of vaginaI fIuid on a gIass sIide and add a diop of 1O polassiun hydioxide.
HoId lhe sIide cIose lo nose lo delecl lhe anine odoui. Aflei a posilive ieaclion, upon
slanding lhe specinen viII quickIy lecone odouiIess lecause lhe anines viII le iapidIy
and conpIeleIy voIaliIized.
Gram staIn mIcrnscnpy
A gian slain of a vaginaI sneai has a highei specificily foi lhe deleclion of cIue ceIIs
lhan a vel nounl piepaialion. Moieovei, a Cian slain aIIovs good evaIualion of lhe
vaginaI lacleiiaI fIoia. NoinaI vaginaI fIuid conlains piedoninanlIy LaclolaciIIus
species and exceedingIy Iov nunleis of slieplococci and coiynefoin lacleiia. In V,
IaclolaciIIi aie iepIaced ly a nixed fIoia of anaeiolic lacleiiaI noipholypes and
tagina|is Hovevei, gian slain nicioscopy has a veiy Iov sensilivily foi delecling
gonoiihea anong vonen cuIluie ienains lhe nelhod of choice.
Ioi nen, gian slain nicioscopy of uielhiaI dischaige sneai viII shov gian-negalive
inliaceIIuIai dipIococci in case of gonoiihea. In case of non-gonococcaI uielhiilis noie
lhan 5 neuliophiIs pei oiI inneision fieId (1OOO) in lhe uielhiaI sneai oi noie lhan 1O
neuliophiIs pei high povei fieId in lhe sedinenl of lhe fiisl void uiine aie olseived.
Bnx A. Gram staIn mIcrnscnpy nf vagIna! smcars
Cn!!cct spccImcn A Cian slain sIide can le piepaied al lhe sane line as lhe
vel nounl ly ioIIing lhe spaluIa/sval on a sepaiale sIide.
Prcparc s!Idc 1. Heal fix.
2. Slain vilh ciyslaI vioIel (6O seconds) and iinse.
3. Slain vilh iodine (6O seconds) and iinse.
4. DecoIoiize vilh acelone-elhanoI foi fev seconds (unliI
lhe Iiquid iuns cIeai).
5. Slain vilh safianin (6O seconds) and iinse.
6. CenlIy lIol diy and exanine undei oiI inneision
(1OOO) and counl each lype of oiganisns.
What tn !nn fnr 1. LaclolaciIIi onIy: NoinaI
2. Mixed fIoia, nainIy IaclolaciIIi vilh a fev shoil iods
(coccolaciIIi): Consideied noinaI
3. Iiesence of cIue ceIIs nixed fIoia, nainIy CaidneieIIa
and anaeiolic lacleiia vilh a fev IaclolaciIIi diagnose
as V
4. Iiesence of cIue ceIIs, nixed fIoia of Cian-posilive,
Cian- negalive and Cian-vaiialIe iods no IaclolaciIIi
diagnose as V
5. Counl each lype of oiganisn and use lhe Nugenl scoie
lo iecoid lhe infeclion.
Bnx A. Nugcnt scnrc
5cnrIng systcm (0 tn 0) frnm GramstaIncd vagIna! smcars
a
Tnta! 5cnrc LactnbacI!!us Gardncrc!!a and Curvcd gram
mnrphntypcs BactcrIndcs spp. varIab!c rnds
mnrphntypcs
O 4 (3O/oif) O(O/oif) O
1 3 (5-3O/oif) 1 (1/oif) 1 oi 2
2 2 (1-4/oif) 2 (1-4/oif) 3 oi 4
3 1 (1/oif) 3 (5-3O/oif)
4 O (O/oif) 4 (3O/oif)
a
Moipholypes aie scoied as lhe aveiage nunlei seen pei oiI inneision fieId(oif). Nole
lhal Iess veighl is given lo cuived Cian - vaiialIe iods. TolaI scoie IaclolaciIIi C.
vaginaIis and acleiiodes spp. cuived iods.
O no noipholypes piesenl
1 1noipholypes piesenl
2 1 lo 4 noipholypes piesenl
3 5 lo 3O noipholypes piesenl
4 3O oi noie noipholypes piesenl.
Inleipielalion of Nugenl scoie
O-3 noinaI, nevei lieal
4-6 inleinediale, decide on synplons foi liealnenl
7-1O Tieal
ig c ran sainc tagina| sncar sncing a ncrna|
|cra c |accaci||i
ig ran sainc tagina| sncar in ica|
c|c cc||
ig g ran sainc tagina| sncar sncing |argc ran
ncgaitc rcs ci|incs n|icris
sc nf gram staIn fnr dIagnnsIs nf ccrvIca! InfcctInn
1. The Cian slain nelhod in fenaIe does nol piovide concIusive evidence of lhe
piesence of ConococcaI infeclion. Iiesence of gian negalive dipIococci indicales
infeclion lul lheii alsence does nol iuIe oul infeclion.
2. The cosls associaled vilh lhe nelhod, incIuding lhe cosl of nainlaining
nicioscopes, oulveigh lhe lenefils in leins of inpioved quaIily of caie.
ig n ran sain sncar
ranncgaitc i|ccccci c Neisseiia gonoiihoeae
RapId P!asma RcagIn (RPR) tcst fnr 5yphI!Is
The cuiienl nonlieponenaI lesls foi syphiIis aie VeneieaI Disease Reseaich Laloialoiy
(VDRL) and iapid pIasna ieagin (RIR) lesl. RIR lesl is nosl suilalIe foi lhe piinaiy
heaIlh caie sel-up.
Bnx A. Prnccdurc nf RPR tcst
Prnccdurc nf RPR tcst
Infoin aloul lhe infeclion and lhe pioceduie foi diagnosis
Seek consenl
Use a sleiiIe needIe and syiinge. Diav 5 nI of lIood fion a vein. Iul in a
pIain lesl lule
Lel lhe lesl lule sland foi 2O ninules lo aIIov seiun lo sepaiale(Oi cenliifuge
35 ninules al 2OOO3OOO ipn). In lhe sepaialed sanpIe, seiun viII le on
lop.
Use sanpIing pipelle lo liansfei lhe seiun. Take caie nol lo incIude any ied
lIood ceIIs fion lhe Iovei pail of lhe sepaialed sanpIe.
HoId lhe pipelle veilicaIIy ovei a lesl caid ciicIe. Squeeze leal lo aIIov one
diop (5O I) of seiun lo faII onlo a ciicIe. Spiead lhe diop lo fiII lhe ciicIe
using a loolhpick oi olhei cIean spieadei.
Impnrtant: ctcra| san|cs na c cnc cn cnc cs car c carc| nc c ccnaninac nc
rcnaining cs circ|cs sc nc i an srcacr cr cacn san|c arc|| |ac|
cacn san|c in a |icn nanc cr nncr
Allach dispensing needIe lo a syiinge. Shake anligen. Diav up enough
anligen foi lhe nunlei of lesls done (one diop pei lesl).
HoIding lhe syiinge veilicaIIy, aIIov exaclIy one diop of anligen lo faII onlo
each lesl sanpIe. Do nol slii.
Rolale lhe lesl caid snoolhIy on lhe paIn of lhe hand foi 8 ninules (oi iolale
on a nechanicaI iolaloi.)
IntcrprctIng rcsu!ts
Aflei 8 ninules iolalion, inspecl lhe caid in good Iighl. Tuin oi liIl lhe caid lo see
vhelhei lheie is cIunping (ieaclive iesuIl). Tesl caids incIude negalive and
posilive conlioI ciicIes foi conpaiison.
LxanpIe lesl caid
1. Non-ieaclive (no cIunping oi onIy sIighl ioughness): Negalive foi
syphiIis
2. Reaclive (highIy visilIe cIunping): Iosilive foi syphiIis
3. WeakIy ieaclive (nininaI cIunping): Iosilive foi syphiIis
Nntc ca| rcacitc can a|sc c ncrc inc| gran|ac an iic| c scc nan nis
i||sraicn
Make suie anligen vas iefiigeialed (nol fiozen) and has nol expiied.
If RPR pnsItIvc
Lnquiie if lhe vonan and hei pailnei have ieceived piopei liealnenl.
If nol, lieal vonan and pailnei foi syphiIis vilh lenzalhine peniciIIin.
Tieal nevloin vilh lenzalhine peniciIIin.
IoIIov-up nevloin in 2 veeks.
CounseI on safei sex.
igi Tcs scrn is nic in anigcn an
nc car is |acc cn arcriac rcacr
ig caing rcs|s cr ni|c
scra sncing rcacitc an ncn rcacitc
san|cs Tnc rcscncc c sna|| c |argc
|ccc|ac c|ns inicacs rcaciti ncrcas
nc c|ning cr a tcr s|ign rcgnncss
inicacs ncnrcaciti
Cnrrc!atInn and cnnfIrmatInn nf tcst rcsu!ts
SyphiIis lesls delecl anlilodies, vhich aie evidence of cuiienl oi pasl infeclion.
SyphiIis lesls aie nol needed lo diagnose CIienls vilh genilaI uIceis (vho shouId
le nanaged using IIovchail).
Non-lieponenaI lesls (such as RIR and VDRL) aie lhe piefeiied lesls foi scieening.
These lesls delecl aInosl aII cases of eaiIy syphiIis, lul faIse posilives aie possilIe.
RIR can le peifoined vilhoul a nicioscope.
TieponenaI lesls, such as Tieponena paIIidun haenaggIulinalion lesl (TIHA),
fIuoiescenl Tieponena anlilody alsoiplion lesl (ITA-Als), niciohaenaggIulinalion
assay foi anlilodies lo Trccncna a||in(MHA-TI), if avaiIalIe, can le used lo confiin
non-lieponenaI lesl iesuIls.
uanlilalive RIR lilies can heIp evaIuale lhe iesponse lo liealnenl.
The foIIoving lalIe can le used lo inleipiel syphiIis lesl iesuIls.
Nntc ncrc aiicna| css arc nc atai|a|c a|| |icns in rcacitc cr snc| c
rcac
Bnx A. IntcrprctIng scrn!ngIca! tcst rcsu!ts
RIR RIR lilie TIHA
Aclive infeclion 1:8
Lalenl syphiIis Oflen 1:4
IaIse posilive UsuaIIy 1:4 -
SuccessfuI liealnenl oi - 2 lilies deciease (e.g. fion 1:16 lo 1:4)
ANNEXRE 2
CONDOM AND IT5 PROPER 5AGE TECHNIE
Condon is one of lhe laiiiei nelhods of conliaceplion. They aie nade ly using eilhei
Ialex oi poIyuielhane, vhich cannol le penelialed ly spein, STIs oi HIV, so il piovides
duaI pioleclion, heIps in avoiding unvanled piegnancies and gives pioleclion againsl
STIs. Theiefoie pionolion of lhe use of condons and ieady accessiliIily of condons is
inpoilanl foi lhe conlioI of STIs and HIV. Managenenl of STIs incIudes counseIing on
pievenlive neasuies and use of condons. AII heaIlh faciIilies pioviding STI seivices
nusl aIvays have in slock lhe essenliaI diugs and condons. The necessily of using
condons nusl le expIained lo lhe CIienls aIong vilh lhe advice on lhe liealnenl
scheduIe and inpoilanl foi conpIiance of lhe fuII couise of nedicines piesciiled.
Gcncra! InstructInns fnr Cnndnm sc
Rcmcmbcr
The condon does nol incIude speinicide. If you vanl addilionaI pioleclion, you
nusl add youi ovn speinicide.
ecause il is nade fion poIyuielhane, you can use oiI-lased Iuliicanls vilh lhe
condon.
Use a nev condon each line you have sex.
Use a condon onIy once.
Ioi lesl iesuIls, sloie condons in a cooI, diy pIace.
Do nol use a condon lhal nay le oId oi danaged.
Dn nnt usc a cnndnm If
The package is lioken.
The condon is liillIe oi diied oul.
The coIoi is uneven oi has changed.
The condon is unusuaIIy slicky.
Ma!c Cnndnm
Mosl naIe condons aie nade of Ialex, vhiIe sone aie nade of poIyuielhane. MaIe
condons aie of lvo lypes: Non Iuliicaled and Iuliicaled.
Bnx A2. Hn tn usc a ma!c cnndnm
5tcp Opcn Pacagc
Use a nev condon each line you have sex
Check lhal il has nol expiied and lhal lhe packaging
has no hoIes ly piessing lhe pack lelveen youi fingeis
Iush condon lo one side of package lo aIIov ioon lo
leai open olhei side
Renove condon caiefuIIy
DO NOT use fingei naiIs, leelh oi shaip oljecls lo
open package oi ienove condon
5tcp2 Put It nn
Squeeze cIosed lop end of condon lo nake suie no
aii is inside (can nake il lieak)
IIace condon ovei lop of eiecl penis
Wilh olhei hand, unioII condon genlIy dovn lhe fuII
Ienglh of youi penis (one hand sliII squeezing lop end)
5tcp DurIng scx
Make suie condon slays in pIace
If il cones off, vilhdiav youi penis and pul on a nev
condon lefoie inleicouise conlinues
Once spein has leen ieIeased i nlo condon
(ejacuIalion), vilhdiav lhe eiecl penis and HOLD lhe
condon in pIace on penis
5tcp DIspnsc nf cnndnm
Renove condon ONL vhen penis is fuIIy vilhdiavn
Keep lolh penis and condon cIeai fion conlacl vilh
youi pailneis lody
Knol lhe end of lhe used condon
IIace in lissue oi lag lefoie lhioving il in dusllin
DO NOT fIush condons dovn lhe loiIel. Il viII lIock
lhe syslen
Fcma!c Cnndnm
IenaIe condons aie nade of poIyuielhane. One advanlage of il ovei lhe naIe condon
is lhal ils size and shape enalIe il lo covei lhe videi suiface aiea incIuding sone of lhe
exleinaI genilaIia, lhus il nay offei addilionaI pioleclion againsl infeclions lhal can le
liansnilled ly conlacl vilh skin noinaIIy nol coveied ly a naIe condon. Hovevei,
lhe fenaIe condon is expensive. Il is fieeIy avaiIalIe in open naikel lul nol yel incIuded
in lhe NalionaI faniIy WeIfaie piogian.
Bnx A2.2 Hn tn usc a fcma!c cnndnm
Bcfnrc Intcrcnursc 5tcp Opcn Pacagc
Renove lhe fenaIe condon fion lhe package, and iul il
lelveen lvo fingeis lo le suie lhe Iuliicanl is evenIy spiead
inside lhe shealh. If you need noie Iuliicalion, squeeze lvo
diops of lhe exlia Iuliicanl incIuded in lhe package inlo
lhe condon shealh.
5tcp 2 Put It In
The cIosed end of lhe fenaIe condon viII go inside youi
vagina. Squeeze lhe innei iing lelveen youi lhunl and
niddIe fingei.
5tcp Assurc rIght pnsItInn
Inseil lhe iing inlo youi vagina. Using youi index fingei,
push lhe shealh aII lhe vay inlo youi vagina as fai as il viII
go. Il is in lhe iighl pIace vhen you cannol feeI il. Do nol
voiiy, il canl go loo fai.Ncc Tnc |ricaicn cn nc cna|c
ccncn i|| nac i s|icr sc ac cr inc c inscr i
DurIng scx 5tcp
The iing al lhe open end of lhe fenaIe condon shouId slay
oulside youi vagina and iesl againsl youi Ialia (lhe oulei
Iip of lhe vagina). e suie lhe condon is nol lvisled.
Once you legin lo engage in inleicouise, you nay have lo
guide lhe penis inlo lhe fenaIe condon. If you do nol, le
avaie lhal lhe penis couId enlei lhe vagina oulside of lhe
condons shealh. If lhis happens, you viII nol le piolecled.
Aftcr Intcrcnursc 5tcp DIspnsc nf cnndnm
ou can safeIy ienove lhe fenaIe condon al any line aflei
inleicouise. If you aie Iying dovn, ienove lhe condon
lefoie you sland lo avoid spiIIage.
Thiov lhe fenaIe condon avay. Do nol ieuse il.
DurIng Intcrcnursc rcmcmbcr tn rcmnvc and Inscrt a nc fcma!c cnndnm If ccncn
ris cr cars ring inscricn cr cars ring inscricn cr sc nc ccr ring is snc insic nc
cnis cncrs csic nc ccn nc ccncn ncncs insic nc tagina cr c natc sc again
ANNEXRE
5TI C!InIc 5ctup
A. Intcrna! structurc
The inleinaI sliucluie of lhe cIinic shouId piovide physicaI piivacy, audiloiy piivacy
and confidenliaIily foi CIienl inleivievs and infoinalion in lhe foIIoving aieas:
Wailing and iegislialion aiea
ConsuIlalion and exaninalion ioon, vilh dooi
Laloialoiy aiea (if feasilIe) and
CounseIing ioon, vilh dooi.
AII aieas shouId have adequale Iighling and venliIalion.
B. 5taffIng
Slaffing shouId le adequale foi lhe foIIoving cIinic funclions lo le caiiied oul in a lineIy
nannei, vilhoul excessive vailing lines:
CIinic adninislialion, CIienl iegislialion, iecoid-keeping and iepoiling
SexuaI and iepioduclive heaIlh hisloiy-laking, cIinicaI exaninalion and CIienl
nanagenenl, incIuding counseIing and educalion
Laloialoiy-lased diagnoslic lesling (vheie appIicalIe)
Mainlenance of cIinicaI slandaids foi STI nanagenenl and
Iiocuienenl and nainlenance of cIinic suppIies.
AII cIinic slaff posilions shouId le fiIIed al aII line vilh appiopiialeIy liained peisonneI.
Nev slaff shouId le liained in eIenenls of STI Case nanagenenl.
C. EuIpmcnt and Drugs
Lquipnenl shouId le nainlained in good voiking oidei.
Lquipnenl shouId le nainlained ly:
Wiping / dusling daiIy vilh cIean cIolh
Covei vilh pioleclive coveiing
Condons, diugs and olhei suppIies shouId aIvays le in slock in lhe cIinic. AvaiIaliIily
of lIislei pack of diugs coIoui coded foi diffeienl syndiones nay le consideied.
D. CnnrdInatInn bctccn c!InIc staff and nutrcach scrvIccs (hcrcvcr
app!Icab!c)
CIose coIIaloialion and connunicalion lelveen lhe cIinic and oulieach slaff viII heIp
in idenlifying and addiessing piolIens and ienoving nisundeislandings lelveen lhe
cIinic and connunily in a lineIy nannei.
ReguIaiIy scheduIed neelings shouId le heId vilh cIinic slaff, piojecl oulieach
slaff and peei educalois lo discuss
- CIinic aclivilies
- Connunily needs and conceins
- Ways of pionoling lhe cIinic
- IoIIov-up of cases in lhe connunily and
- The ongoing piocess of cooidinalion.
Oulieach voikei shouId le encouiaged lo iepoil lack lo cIinic slaff on issues such
as connunily peiceplion of lhe cIinic, liealnenl conpIiance, side effecls of
nedicalions, elc.
A connunily noniloiing syslen shouId le in pIace.
CIinic slaff shouId pailicipale in oulieach visils on a ieguIai lasis.
E. C!Icnt frIcnd!y cnvIrnnmcnt
Iive conponenls of a cIinic enviionnenl lhal aie acceplalIe lo CIienls and pionole
liusl vilhin lhe connunily aie:
RespeclfuI allilude of slaff
Convenienl Iocalion and cIinic opening houis
ConfidenliaIily
Anonynily and
Righl of iefusaI of seivices.
ConfidenliaIily shouId le ensuied al aII lines. This nusl le conlinuaIIy ieinfoiced vilh
lhe slaff.
CIinics shouId have a confidenliaIily poIicy lhal is enfoiced and connunicaled lo
lhe CIienls and connunily.
CIienls shouId le infoined aloul hov lheii nedicaI infoinalion is handIed, and
vhen and hov such dala nay le used foi evaIualion puiposes.
AII slaff shouId ieceive liaining in lhe confidenliaIily poIicies of lhe cIinic.
AII slaff shouId sign a confidenliaIily agieenenl.
Anonynily can le pieseived ly aIIoving CIienls lo piovide idenlifying infoinalion,
such as a voiking nane, age, dale of liilh, elc., inslead of lheii officiaI liilh nane. Il
is nol necessaiy lo ask foi idenlificalion papeis. A iegislialion nunlei can le assigned
lo each CIienl as his/hei idenlifying infoinalion. S/he shouId le insliucled lo keep lhis
lo ensuie conlinuily of seivice in lhe cIinic.
AII CIienls have a iighl lo iefuse seivices, even vhen lhe cIinic slaff nay lhink lhey aie
in lhe CIienls lesl inleiesl. CIienls shouId nol le foiced inlo allending lhe cIinic oi
ieceiving liealnenl. If lhe CIienl sliII iefuses liealnenl aflei expIoiing and discussing
lhe ieasons foi iesisling exaninalion oi liealnenl, lhe cIinician nusl iespecl lhe CIienls
choice. Il is possilIe lhal lhe CIienl viII aIIov exaninalion on a sulsequenl visil aflei a
liusl in lhe cIinics slaff is eslalIished.
ANNEXRE
LI5T OF DRG5
Drugs tn bc stnccd at 5TI C!InIcs
AII cIinics nusl nainlain adequale slock of diugs iequiied foi liealnenl of STIs as pei
lhe slandaid piolocoI. IoIIoving is lhe invenloiy of essenliaI STI liealnenl diugs. They
shouId le sloied in a secuie Iocalion and used lefoie lheii expiiy dale.
1. Inj. enzalhene IeniciIIin 24 Iakhs unil viaI
2. Inj. Cefliiaxone (25O ng & 1 gn)
3. Tal. Azilhionycin (1g)
4. Tal. Cefixine (4OOng)
5. Tal. IIuconazoIe (15O ng)
6. Tal. SecnidazoIe (5OO ng)
7. Tal MelionidazoIe (4OO ng)
8. Tal. Liylhoionycin (5OO ng) lase/sleaiale
9. Cap. DoxycycIine (1OO ng)
1O. Cap. AcycIovii (4OO ng)
11. CIoliinazoIe VaginaI pessaiy (5OO ng)
12. IodophyIIin lincluie 2O
13. Ieinelhiin ciean (5) and (1)
ANNEXRE
DI5INFECTION AND NIER5AL PRECATION5
The leins slandaid piecaulions and addilionaI (liansnission-lased) piecaulions have
iepIaced pievious leins such as univeisaI lIood and lody fIuid piecaulions, univeisaI
piecaulions and laiiiei nuising.
Slandaid piecaulions iequiie lhal heaIlh caie voikeis assune lhal lhe lIood and lody
sulslances of aII palienls aie polenliaI souices of infeclion, iegaidIess of lhe diagnosis
oi piesuned infeclious slalus.
AddilionaI (liansnission-lased) piecaulions aie needed foi diseases liansnilled ly
aii, diopIels and conlacl.
A nunlei of RTIs can le spiead fion palienl lo heaIlh caie piovidei oi lo olhei palienls
if lasic piecaulions aie nol foIIoved. Hepalilis and C viiuses and HIV aie incuialIe
infeclions lhal aie easiIy liansnilled ly ieuse of conlaninaled shaips. ecause RTIs aie
oflen asynplonalic, il is nol possilIe lo knov vhich palienls have an infeclion. Ioi lhis
ieason, slandaid piecaulions shouId le foIIoved ly aII lhe heaIlh caie voikeis.
5tandard prccautInns
Slandaid piecaulions incIude lhe foIIoving-
1. Hand vashing and anlisepsis (hand hygiene)
2. Use of peisonaI pioleclive equipnenl vhen handIing lIood, lody sulslances,
excielions and secielions
3. Appiopiiale handIing of palienl equipnenl and soiIed Iinen
4. Iievenlion of needIe-slick/shaip injuiies
5. Managenenl of heaIlh caie vasle
. Hand ashIng and antIscpsIs (hand hygIcnc)
Hand vashing lieaks lhe chain of infeclion liansnission and ieduces peisonlo-peison
liansnission. Il is lhe nosl inpoilanl vay lo kiII geins on lhe skin. ou need lo vash
youi hands even noie lhoioughIy and foi a Iongei line in lhe foIIoving silualions:
lefoie and aflei heIping soneone give liilh
lefoie and aflei louching a vound oi lioken skin
lefoie and aflei giving an injeclion, oi culling oi pieicing a lody pail
aflei louching lIood, uiine, slooI, nucus, oi fIuid fion lhe vagina and
aflei ienoving gIoves
lelveen conlacl vilh diffeienl palienls
The hands nusl le vashed foi a nininun of 1O-15 seconds, counl lo 3O as you sciul
youi hands aII ovei vilh lhe soapy Ialhei. Use soap oi olhei disinfeclanl lo ienove diil
and geins. Use a liush oi sofl slick lo cIean undei youi naiIs, lhen iinse, using iunning
valei. Do nol ieuse lhe sane valei. Inneision of hands in lovIs of anliseplics is nol
ieconnended. Connon loveIs nusl nol le used as lhey faciIilale liansnission of
infeclion. If lheie is no cIean diy loveI, il is lesl lo aii-diy hands.
FIgAa Hand ashIng Prnccdurcs
Source : cr| ca|n rganiaicn cgicna| icc cr cscrn aciic ncrin gic|incs
cr naicna| rcarcncss ani|a agc
Hand vashing is lhe sinpIesl and nosl cosl-effeclive vay of pievenling
lhe liansnission of infeclion
The hands nusl le vashed foi a nininun of 1O-15 seconds vilh soap oi
olhei disinfeclanl
Connon loveIs nusl nol le used as lhey faciIilale liansnission of infeclion
2. sc nf pcrsnna! prntcctIvc cuIpmcnt hcn hand!Ing b!nnd, bndy substanccs,
cxcrctInns and sccrctInns
Using peisonaI pioleclive equipnenl offeis pioleclion ly heIping lo pievenl nicio-
oiganisns fion-
Conlaninalion of hands, eyes, cIolhing, haii
eing liansnilled lo olhei palienls and slaff
IeisonaI pioleclive equipnenl incIudes:
CIoves
Masks
Apions
Covns
caps/haii coveis
G!nvcs
Use of gIoves (cIean, non-sleiiIe) oi a piece of pIaslic foi handIing diily landages,
cIolhs, lIood, vonil oi slooI.
DisposalIe gIoves shouId nol le ieused
CIoves nusl le changed nol onIy lelveen conlacls vilh diffeienl palienls lul
lelveen lasks/ pioceduies on lhe sane palienl lo pievenl cioss-conlaninalion
lelveen diffeienl lody siles.
IeisonaI pioleclive equipnenl nusl le used effecliveIy, coiieclIy and al aII
lines vheie lheie is conlacl vilh palienls lIood, lody fIuids, excielions and
secielions nay occui
. ApprnprIatc hand!Ing nf patIcnt cuIpmcnt and snI!cd !Incn
Lnsuie lhal aII ieusalIe equipnenl is cIeaned and iepiocessed appiopiialeIy lefoie
leing used on anolhei palienl.
Keep ledding and cIolhing cIean. This heIps in keeping sick peopIe confoilalIe and
heIps in pievenling skin piolIens. HandIe cIolhing and/ oi sheels caiefuIIy, vhich aie
slained vilh lIood, uiine, slooI oi olhei lody fIuids. Sepaiale fion olhei Iaundiy foi
vashing. Diy Iaundiy lhoioughIy in lhe sun if possilIe oi iion aflei diying.
. PrcvcntInn nf nccd!cstIcsharp InurIcs
AII lhe used disposalIe syiinges and needIes, scaIpeI lIades and olhei shaip ilens
shouId le pIaced in a puncluie iesislanl conlainei having a piopei Iid. These conlaineis
nusl le Iocaled cIose lo lhe aiea. Nevei iecap oi lend needIes.
. Managcmcnt nf hca!thcarc astc
DaiIy coIIeclion of vasle nusl le encouiaged and uncoIIecled, Iong sloied vasle oi
vasle vilhin lhe pienises nusl le avoided. The lio-nedicaI vasle shouId le segiegaled
inlo conlaineis/lags al lhe poinl of ils geneialion inlo coIoui coded conlaineis/lags.
TalIe 12a gives lhe coIoui, coding, lype of conlaineis used and nuIlipIe liealnenl
oplions foi disposaI of lhe lio-nedicaI vasle.
Tab!c Aa Managcmcnt nf hca!th carc astc
cc ria| snc| c cnc in a sccrc arca ria| snc| c c nccrs cc an a |cas
nccrs actc nc grcnacr a|c
ncnica| rcancn sing a |cas nccn|cric sc|icn cr an cncr cincn cncnica|
rcagcn ns c cnsrc na cncnica| rcancn cnsrcs isinccicn
nrcing ns c scn sc as c rctcn nancric sc c snar asc
Slandaid piecaulions iequiie lhal heaIlh caie voikeis assune lhal lhe lIood and lody
sulslances of aII palienls aie polenliaI souices of infeclion, iegaidIess of lhe diagnosis
oi piesuned infeclious slalus. AddilionaI (liansnission-lased) piecaulions aie needed
foi diseases liansnilled ly aii, diopIels and conlacl. A nunlei of RTIs can le spiead
fion palienl lo heaIlh caie piovidei oi lo olhei palienls if lasic piecaulions aie nol
foIIoved. Hepalilis and C viiuses and HIV aie incuialIe infeclions lhal aie easiIy
liansnilled ly ieuse of conlaninaled shaips. ecause RTIs aie oflen asynplonalic, il
is nol possilIe lo knov vhich palienls have an infeclion. Ioi lhis ieason, slandaid
piecaulions shouId le foIIoved ly aII lhe heaIlh caie voikeis.
DIsInfcctInn nf Instrumcnts
Disinfecl oi sleiiIize equipnenl and insliunenls. Insliunenls nusl fiisl le vashed
and lhen disinfecled if lhey aie lo le used lo:
cul oi pieice skin
give an injeclion
cul lhe coid duiing chiIdliilh
exanine lhe vagina, especiaIIy duiing oi aflei chiIdliilh, a niscaiiiage, oi an
induced aloilion
peifoin any liansceivicaI pioceduie.
HIgh!cvc! dIsInfcctInn thrcc stcps
CIeaning insliunenls and equipnenl lo gel iid of neaiIy aII lhe geins is caIIed high-
IeveI disinfeclion. The foIIoving pioceduies couId le foIIoved lo achieve il:
1. 5naIng: Soak insliunenls foi 1O ninules in O.5 soIulion of lIeach (chIoiine).
Soaking insliunenls in lIeach soIulion viII heIp piolecl you fion infeclion vhen
cIeaning lhen. If you do nol have lIeach, soak youi insliunenls in valei.
2. WashIng: Wash aII insliunenls vilh soapy valei and a liush unliI each one Iooks
veiy cIean, and iinse lhen vilh cIean valei. e caiefuI nol lo cul youiseIf on shaip
edges oi poinls. Weai gIoves vhen vashing insliunenls if possilIe, use heavy
gIoves.
3. DIsInfcctIng: Slean oi loiI lhe insliunenls foi 2O ninules.
To slean lhen, you need a pol vilh a Iid. The valei does nol need lo covei
lhe insliunenls, lul use enough valei lo keep slean coning oul of lhe sides
of lhe Iid foi 2O ninules. Do nol oveiIoad vilh insliunenls. No insliunenls
shouId pioliude alove lhe iin of lhe pol.
To loiI lhen, you do nol need lo fiII lhe vhoIe pol vilh valei. ul you shouId
nake suie lhe valei coveis aII lhe insliunenls in lhe pol foi lhe enliie line.
Iul a Iid on lhe pol.
Ioi lolh sleaning and loiIing, slail lining lhe 2O ninules aflei lhe valei
vilh lhe insliunenls is fuIIy loiIing. Do nol add any nev insliunenl lo lhe
pol once you legin lo counl.
TalIe shovs hov lo nake a disinfeclion soIulion of O.5, 1 and 2 avaiIalIe
chIoiine
Tab!c Ab Hypnch!nrItc sn!utInn nf 0. and 2 avaI!ab!c ch!nrInc
Note: |cacn sc|icn cccncs nsa|c rai| ncncc i nccs c c rcsn| rcarc ai| cr
cnangc cn cccning ir ri n|crinc |cacn can c ccrrcsitc rccc nca| insrncns
ncrcgn| rinsing ncn in acr acr scaing cr nincs
C!canIng nf thc Hcath Ccntcrs
Ialienl caie aieas nusl le cIeaned ly vel nopping. OnIy diy sveeping is nol
ieconnended. Any aieas visilIy conlaninaled vilh lIood oi lody fIuids shouId le
cIeaned innedialeIy vilh deleigenl and valei.
Tab!c Ac Cnmmnn dIsInfcctants uscd fnr cnvIrnnmcnta!
c!canIng In hca!th ccntcrs
Note: ncra| ccrgcn an arn acr sc|icn snc| c sc cr a|| rcinc an gcncra|
c|caning ncn a isinccan is rcirc cr sracc c|caning cg acr si||agc cr ccnaninaicn
in |cc cr c |is nc nanacrcs rcccnncnaicn cr sc an cccaicna| nca|n an
sac insrcicn snc| c c||cc
ANNEXRE
MONTHL REPORT FORMAT
( NalionaI AIDS ConlioI Iiogianne)
Repoiling Monlh :
Nane of Cenlie :
Nane of Iock :
Nane of Disliicl :
Nane & Ihone No. of Officei In Chaige :
Labnratnry C!InIca! DIagnnsIs
Typc nf DIscascs
Agc Grnup 5cx
Labnratnry Tcsts Nns. Tcstcd Nns. Fnund
PnsItIvc
1. SyphiIis Daik IieId Micioscopy
SeioIogy -VDRL/RIR
TolaI
2. Conoiihoea Diiecl Sneai (Cianss Slain)
CuIluie
3. ChIanydia LLISA Anlilody
4. Chancioid Cians / CIensa Slaning
5. Tiichononasis Diiecl vel nounl
6. Candiadiasis (CandidaaIlicons) KOH vel nounl
7. acleiiaI Vaginosis Wel nounl piepaialion foi cIue ceIIs
8. Olheis (specify)
DctaI!s nf Cnndnm DIstrIbutInn, Partncr Trcatmcnt and Cnunsc!Ing 5crvIccs
DctaI!s Ma!c Fcma!c Tnta!
1. Nunlei of condons disliiluled
2. Nunlei of fenaIe condons disliiluled
3. Nunlei of pailneis nanaged
4. Nunlei of palienls iefeiied lo ICTC
5tatus nf AvaI!abI!Ity nf McdIcIncs and Cnnsumab!cs (5tnc DctaI!s)
DctaI!s Whcthcr avaI!ab!c In adcuatc If nn, LIst thc nncs nnt
uantIty fnr thc ncxt avaI!ab!c In adcuatc
thrcc mnnths uantIty
cs Nn
1. ConsunalIes
2. Medicines foi
Tiealing STD
3. MaIe Condons
4. IenaIe Condons
ANNEXRE 7
REFERENCE5 AND 5ORCE
We gialefuIIy acknovIedge lhe use of naleiiaI lhal has leen adapled fion lhe foIIoving
souices:
5nurcc Pub!IcatInn car
WoiId HeaIlh Oiganisalion STI/RTI Managenenl in Repioduclive
HeaIlh Caie Sellings: A Iockel Cuide
foi LssenliaI Iiaclice 2OO1
WoiId HeaIlh Oiganisalion CuideIines foi lhe Managenenl of
SexuaIIy Tiansnilled Infeclions 2OO3
WoiId HeaIlh Oiganisalion SexuaIIy Tiansnilled and Olhei
Repioduclive Tiacl Infeclions
A Cuide lo essenliaI Iiaclice 2OO5
WoiId HeaIlh Oiganisalion Diafl CIolaI Slialegy foi lhe
Iievenlion and ConlioI of SexuaIIy
Tiansnilled infeclions 2OO5
WoiId HeaIlh Oiganisalion IiaclicaI guideIines foi Infeclion
ConlioI in HeaIlh Caie IaciIiles,
SLARO, Nev DeIhi 1999
Cenlie foi Disease ConlioI CuideIines foi Tiealnenl of STDs 2OO2
CIinicaI Lffecliveness Cioup UK NalionaI CuideIines on STIs 2OO2
IopuIalion Seivices InleinalionaI IIovchails foi STIs in MaIes 2OO4
IaniIy HeaIlh InleinalionaI Handlook foi design and
nanagenenl of piogians 2OO5
Indian CounciI of MedicaI CuideIines foi Managenenl of
Reseaich Repioduclive Tiacl Infeclions:
Ioi MedicaI Officeis al IHCs 1996
NalionaI AIDS ConlioI SexuaIIy Tiansnilled Infeclions-
Oiganisalion Tiealnenl CuideIines Diafl
NalionaI AIDS IIovchails on lhe Syndionic
ConlioI Oiganisalion Managenenl of SexuaIIy Tiansnilled
Infeclions 2OO4
Uniled Nalions IopuIalion Iund Refeience MaleiiaI on Case
Managenenl of RTIs/STIs in IHC
Sellings foi MedicaI Officeis 2OO4
Ialhfindei InleinalionaI Conpiehensive Repioduclive HeaIlh
and IaniIy IIanning Tiaining
CuiiicuIun (ModuIe 12) 2OOO
Lngendei HeaIlh SexuaIIy Tiansnilled Infeclions
OnIine ninicouise 2OO6
We gialefuIIy acknovIedge lhe use of picluies fion lhe foIIoving souices:
1. Depl of Skin & VeneieaI diseases, Loknanya TiIak MedicaI CoIIege and Sion HospilaI, Sion , Munlai
2. Depl of Skin & VeneieaI diseases, Selh C S MedicaI CoIIege and KLM HospilaI, IaieI, Munlai
3. haialiya Vidya havans Svani Iiakashananda Ayuiveda Reseaich Cenlie (SIARC), }uhu,
Munlai
ANNEXRE
CnnrdInatIng nIt at NatInna! InstItutc fnr Rcscarch In
RcprnductIvc Hca!th, MumbaI
Di. Chandei Iuii, Diiecloi
Di. Sanjay Chauhan, Depuly Diiecloi
Di. eena }oshi, Reseaich Officei
Di. Ragini KuIkaini, Reseaich Officei
Di. KanaI Hazaii, Depuly Diiecloi
Di. Rajashiee Manjiekai, Iiojecl Reseaich Officei
CORE GROP MEMBER5
Depailnenl of MaleinaI HeaIlh, Minisliy of HeaIlh and IaniIy WeIfaie, Coveinnenl
of India
Di. V.K. Manchanda, Depuly Diiecloi CeneiaI (ieliied)
Di. (Mis) I. I. Kaui, Depuly Connissionei
Di. Hinanshu hushan, Assislanl Connissionei
Di. (Mis) Manisha MaIholia, Assislanl Connissionei
NatInna! AID5 Cnntrn! OrganIsatInn
Di. }olna Sokhey, AddilionaI Iiojecl Diiecloi
Di. Ajay Kheia, }oinl Diiecloi (SuiveiIIance)
Di. Vinod Khuiana, ConsuIlanl & Iiogianne Officei
Wnr!d Hca!th OrganIsatInn, IndIa OffIcc
Di. Aivind Malhui, Cooidinaloi, IaniIy & Connunily HeaIlh
nItcd NatInns Pnpu!atInn Fund
Di. Dinesh AgaivaI, TechnicaI Advisoi (Repioduclive HeaIlh)
Iiof (Ms) Sajida Ahned
Iiof & Head, Depailnenl of Connunily Medicine,
MedicaI CoIIege, Cuvahali, Assan
Di (Ms) Rekha Davei
Iiof. & Head, Depl. of OCN, Cianl MedicaI
CoIIege & }.}. HospilaI, ycuIIa, Munlai
Di. (Mis) AIka Cogale
ConsuIlanl MiciolioIogisl (UNAIDS) 12, Sahyog
Hsg Sociely, Mahin, Munlai
Di. R.R. Cangakhedkai
Depuly Diiecloi, NalionaI AIDS Reseaich Inslilule,
ICMR, MIDC , hosaii, Iune
Di. S. D. Cupla
Diiecloi, InleinalionaI Inslilule of HeaIlh
Managenenl & Reseaich, Sanganei, }aipui
Di. }ayashiee }oshi
Depuly Diiecloi, haialiya Vidya havans SIARC,
VilhaInagai, }uhu, Munlai
Di. Suiindei }aisvaI
Iiofessoi, Tala Inslilule of SociaI Sciences, Deonai,
Munlai
Di. Hena }eiajani
Iiofessoi and Head, Depl. of Skin and VD, LTMC &
LTM CeneiaI HospilaI, Sion, Munlai
Di. H. K. Kai
Iiofessoi and Head, Depailnenl of DeinaloIogy
and VeneioIogy, R.M.L. HospilaI, Nev DeIhi
Di. Usha Kiishna
ConsuIling CynecoIogisl, CIinic foi Wonen, Ciigaon,
Munlai
Di. SuniI Khapaide
Diiecloi, Inslilule of IaniIy WeIfaie Reseaich &
Tiaining, Khelvadi, Munlai
Di. Uday Khopkai
Iiofesssoi and Head, Depailnenl of Skin and VD,
Selh C.S. MedicaI CoIIege, IaieI, Munlai
Di. Renuka KuIkaini
Iiofessoi, Depl of CIinicaI IainacoIogyTNMC &
L Naii hospilaI, Munlai
Di. (Mis) Meenakshi Malhui
Iiof and Head, Depailnenl of MiciolioIogy, LTMC
& LTM CeneiaI HospilaI, Sion, Munlai
LI5T OF CONTRIBTER5
Di. }ayanli Mania
Assislanl Diiecloi, NalionaI Inslilule foi Reseaich
in Repioduclive HeaIlh, (ICMR), IaieI, Munlai
Di. . N. MaIi
SRO, NalionaI Inslilule foi Reseaich in Repioduclive
HeaIlh, (ICMR), IaieI, Munlai
Di. Deoki Nandan
IiincipaI & Dean of HospilaI, S. N. MedicaI CoIIege,
Agia
Suig. Cdi (Di.) Shankai Naiayan
SpeciaIisl in NeonaloIogy, Depl. of IaedialiicsINHS
Ashvini, CoIala, Munlai
Di. I. Iadnanalan
Diiecloi, RCH Iiojecl, Covl.of TaniI Nadu, DMS
Idg, Anna SaIai, Chennai
Di. Deepak Raul
Iiof. and Head, Depl. of LpidenioIogy, AII India
Inslilule of Hygiene & IulIic HeaIlh, KoIkala
Di. Ioujdai Ran
Iiofessoi, InleinalionaI Inslilule foi IopuIalion
Sciences, Deonai, Munlai
Di. }ayanli Shaslii
Iiofessoi, Depl of MiciolioIogy, TNMC & L Naii
HospilaI, Munlai CenliaI, Munlai
Di. Sudha SaIhan
Iiof and Head, Depl. of OCNV.M. MedicaI
CoIIege, Safdaijung HospilaI, DeIhi
Di. Usha Saiiya
ConsuIlanl CynaecoIogisl and CylophalhoIogisl,
AIless Cana HospilaI, Munlai
Di. N. Usnan
Iiofessoi of DeinaloIogy & STDInslilule of
VeneioIogy, Chennai
Di. KaushaI Veina
Depl. of Skin and VeneieaI Diseases, AII India
Inslilule of MedicaI Sciences, Ansaii Nagai, DeIhi
Di. Teodoia LIviia Wi
Diiecloi, STI Capacily Tiaining, IaniIy HeaIlh
InleinalionaI, Munlai
Di. Sanjay odpey
Iiof & Head, Depl of Iievenlive & SociaI Medicine,
Covl. MedicaI CoIIege, Nagpui
Nanes in aIphalelicaI oidei
IkfgjIkdfjg
Matcrna! Hca!th DIvIsInn
MInIstry nf Hca!th and FamI!y Wc!farc
Gnvcrnmcnt nf IndIa
August 2007
NATIONAL GUIDELINE5 ON
PREVENTION, MANAGEMENT AND CONTROL OF
REPRODUCTIVE TRACT INFECTION5
INCLUDING
5EXUALLY TRAN5MITTED INFECTION5

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