STI management ⚠️

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

• Offer treatment as soon as possible to prevent complications and stop spread

• If person has symptoms and/or syndromes likely to be caused by an STI, or has put themself at risk — treat straight away — do not wait for laboratory or POC Test results
• See individual protocols
• Genital ulcers and lumps
• Discharge from penis and dysuria (pain passing urine)
• Testicular Pain
• Vaginal discharge
• Pelvic inflammatory disease

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

Positive pathology results

Chlamydia

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

Do

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

Follow-up

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

Pregnancy considerations

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

Gonorrhoea

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

Do

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

Follow-up

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

Pregnancy considerations

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

Genital herpes

• See Genital ulcers and lumps 

Donovanosis

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

Do

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

Follow-up

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

Pregnancy considerations

• Medical consult

Syphilis

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

Primary syphilis

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

Secondary syphilis

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

Tertiary syphilis

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

Do

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

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

Follow-up

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

Pregnancy considerations 

Medical consult — this is an STI emergency

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

Trichomonas

Do

• Give metronidazole oral — adult 2g, single dose

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

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

Follow-up

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

Pregnancy considerations

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

Mycoplasma genitalium

• Treatment varies — medical consult or contact sexual health unit

HIV

Do

• Follow advice from sexual health unit and local protocols where appropriate
• Aim to start treatment early
• Continued involvement of primary care services is important. Usually involves
• Managing and monitoring antiretroviral medicines
• Contact tracing and management of contacts
• STI and safer sex education

Pregnancy considerations

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

Non STI results

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

Contact tracing

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

Ask

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

Asking about partners

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

Do

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

Follow-up of partners

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

Education

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

STI education

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

Safer sex education

• If person has safer sex — less chance of an STI
• Make sure they know what this means — don’t just think they will know
• Safer sex is
• Using a condom properly every time
• OR having sex with just 1 partner after both have ‘clear’ STI check-up

Condom education

• Only contraceptive method that protects against most STIs
• Show them how to use a condom
• Offer condoms to take away. Talk about where they can get more

Supporting resources

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