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Sexually transmitted infections
consultation. Particularly awkward pitfalls to avoid
include taking a menstrual and obstetric history from
a trans woman and forgetting to record the cervical
smear test history in a trans man. Collect detailed
information on hormonal treatment and surgery to
date so that you are appropriately prepared for the
examination and genital site sampling. Remember
that a speculum examination may be more difficult
for transgender people who have a vagina or a
neovagina. Screen for IPV, general threats of violence
and harassment, sex work, group sex, the use of sex
toys as well as drug and alcohol misuse, including
‘chem- sex’. Viral hepatitis screening and vaccination
against HAV, HBV and HPV will be indicated based
on the aforementioned risk behaviours.
Sex workers
Sex workers are at higher risk of STI and also for
physical violence from clients as well as IPV, so screen
for these specifically. Depending on their place of
work (sauna, flat, street) they may also have issues
with drug and alcohol dependence. Take a thorough
history of services offered as it may dictate the
anatomical sites to be screened. Vaccination against
HAV and HBV is indicated as in MSM. Support to
enable better negotiation around ‘safe sex’ should
also be provided.
HIV prophylaxis
Strong evidence indicates that when taken correctly
daily or on demand, pre- exposure prophylaxis (PrEP)
is highly effective at reducing HIV transmission
and is recommended for HIV prevention in those
deemed at risk. This includes, but is not limited to,
MSM, sex workers and other cis and trans people
based on risk assessment. Post- exposure prophylaxis
(PEP) is also available for those presenting within
72 hours of a high- risk HIV exposure, although the
evidence base for efficacy is less robust.
Young and other vulnerable people
Bacterial STI and unplanned pregnancies are both
more common in young people, so longer consultations
are required in order to gather additional information
and provide education and support on ‘safe- sex’ and
initiating contraception. Recognizing child sexual
exploitation (CSE) is of particular concern in the
sexual health setting and an appropriate proforma
(e.g. Spotting the Signs1) should be used to identify
coercion, grooming, abuse and non- consensual sex
in those under 18 years. Ensure the patient is aware
that if serious concerns are raised these are likely
to be discussed with the child safeguarding team.
Vulnerable adults include those with mental health
disorders and learning disabilities. Consultations will
be longer and information gathering will be more
challenging. Screen for signs of abuse as you would
with young people.
Female genital mutilation (FGM)
Female genital mutilation is the deliberate cutting
and altering of the female genitalia without medical
need and is carried out on young females between
infancy and age 15. It is illegal in the UK and should
be screened for in consultations with people assigned
female at birth. If FGM has occurred, record when
and where it was performed, the patient’s attitude
towards FGM and if you have any safeguarding
concerns for children in the family. FGM performed
under the age of 18 is a matter for the police as well
as the child safeguarding team.
Genital examination
Prior to performing the genital examination, it is
essential that you take time to explain to the patient
what will happen and in doing so you are also gaining
consent to proceed. Familiarize yourself with your
environment and equipment and develop a reliable
routine. A fluent and systematic approach will instil
confidence in you and the patient. A chaperone
should be offered for every examination and gloves
should be worn throughout. In cases of sexual assault
and child sexual exploitation, it is imperative that
forensic and genital examination is carried out by
specially trained personnel. You must not interrupt
the chain of evidence so always seek advice before
proceeding. In the course of your examination you
may find evidence of FGM and this should always
be documented.
General examination of the pubic area and
groin
The patient is best examined in the lithotomy
position, exposed from umbilicus to knees. Start
by inspecting the skin of the supra- pubic, pubic,
inguinal, perineal and perianal areas. Palpate the
inguinal area and note the size, shape, contour,
firmness, mobility and tenderness of any swellings
you find. In males inspect the skin of the scrotum
and the dorsal and ventral surfaces of the penis and
in females the labia majora and minora.
Note if pubic hair is shaved or waxed and the
presence of any folliculitis. In a patient presenting
with genital itch, examine the pubic hair closely for
the ectoparasite Phthirus pubis (and its eggs) which
causes ‘crabs’.
Look at the skin creases for evidence of fungal
and bacterial intertrigo. Tinea cruris gives rise to an
erythematous rash with a well- defined border. In
cutaneous candidiasis the border is poorly defined
with satellite lesions surrounding it.
Tiny dark- red papules of angiokeratoma (Fig.
18.1), or round, firm, whitish nodules of sebaceous
cysts may be seen on the scrotum or the vulva.
Both are harmless and the patient can be reassured.
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Multiple small yellow- white papules may be seen on
the underside of the penis or the inner vulva. These
are ectopic sebaceous glands (Fordyce’s spots) (Fig.
18.2) that do not require treatment.
An inflamed, red and thickened (lichenified)
scrotum or vulva with added excoriations is typical
of lichen simplex and suggests an underlying chronic
skin condition such as atopic eczema or a contact
dermatitis.
Itchy pink or hyperpigmented nodules on the
genitals are typical of scabies. The itch tends to be
worse at night. Excluding the face and neck, other
lesions can be found on the abdomen, the axilla, the
Figure 18.1 Angiokeratoma.
elbows, wrists and hands where classical interdigital
linear burrows are seen.
Lichen sclerosus (LS) is an inflammatory skin
condition of unknown aetiology that can affect any
part of the skin, but is most often symptomatic at the
genitals. LS affects both sexes, although the distribution
differs; in males it typically presents on the glans,
meatus, frenulum and prepuce whilst in females on
the vulval and perianal skin leading to a ‘figure of eight’
distribution (Fig. 18.3). Active LS causes erythema,
which in turn leads to thinning, tightening and
hypopigmentation of the skin (sclerosis). Telangiectasia
(owing to friable bloods vessels), fissures and blisters
can also be seen. The chronic inflammatory process
(particularly if untreated) can lead to squamous cell
carcinoma in a small proportion of cases.
You may find pigmented naevi and non- pigmented
groin and anal skin tags which can be confused with
genital warts (condylomata acuminata).
Genital warts are benign epithelial skin tumours
predominately caused by HPV types 6 and 11.
They appear on the genital skin as single or multiple
broad- based or pedunculated growths with a
cauliflower- like appearance. They are usually soft to
touch but also karatinized and can arise anywhere
on the anogenital skin, inside the urethral meatus,
the vagina, the cervix and inside the anus (Fig. 18.4).
Genital molluscum are benign epithelial skin
eruptions caused by the Molluscum contagiosum
virus. They typically appear in the pubic area as
pearly, pink or yellow dome- shaped papules with a
central umbilicus and are smooth to touch.
Both warts and molluscum are sexually transmitted.
Occasionally they can appear sore and inflamed,
particularly if they have been manipulated.
Painful anogenital sores are most commonly
caused by herpes simplex virus (HSV), but other
causes of genital ulceration should be considered
and guided by the sexual history. In primary herpes
the characteristic shallow ulcers are preceded by a
crop of blisters, although it is typical for the patient
to present after they have broken (Fig. 18.5). They
Figure 18.2 Fordyce spots.
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Figure 18.3 Lichen sclerosus.
Figure 18.5 Genital herpes.
Tropically acquired causes of genital ulceration
include chancroid and donovanosis, but these infections
are becoming exceedingly rare in the countries in
which they were once endemic. Lymphogranuloma
venereum is another cause of genital ulceration that
has become more common in MSM in recent years;
however, it is more likely to present with proctitis.
Other causes of genial ulcer include trauma, fixed
drug reactions, dermatitis and Behcet’s disease.
A groin swelling is likely to be inguinal
lymphadenopathy. Anal, penile and vulval carcinoma
may metastasize to the inguinal lymph nodes giving
rise to hard, irregular and fixed lymphadenopathy.
Inguinal lymphadenopathy may also be part of a
generalized disorder, such as lymphoma, secondary
syphilis, infectious mononucleosis or HIV infection.
Figure 18.4 Genital warts.
may experience intense dysuria owing to infection
of the urethral mucosa and develop painful inguinal
lymphadenopathy and a flu- like illness that correlates
with seroconversion. Owing to nerve invasion that
establishes viral latency, paraesthesia of the skin of the
genitals, buttocks and lower limbs is not uncommon.
Recurrences tend to be less severe and can present
atypically as itchy spots or fissures so always take a
detailed history of previous similar episodes.
A solitary painless genital ulcer should lead to
suspicion of syphilis, particularly if the patient is
in a high- risk group (e.g. MSM or a sex- worker).
The primary syphilitic chancre is typically hard
(indurated) with a clear serous fluid oozing from its
base and regional lymphadenopathy that is painless
and rubbery. The coronal sulcus of the penis is the
most common site (Fig. 18.6).
Male genital examination
Palpate the scrotal contents by anchoring each testis
between the fingers and smoothing the fingertips
over surface noting the size (they should be roughly
equal) and any tenderness or masses. Next palpate the
epididymis (a soft structure that runs alongside the
testis) and the tubular structure of the vas deferens
within the spermatic cord as it passes through the
neck of the scrotum. Examine the patient standing
to check for hernias.
A varicocele is a tortuous dilatation of the veins
contained within the spermatic cord (known as
the pampiniform plexus) and it feels like a ‘bag of
worms’ in the scrotum. A hydrocele is a painless
fluctuant scrotal swelling that can be demonstrated
by transillumination. Small, firm lumps within
the epididymis are harmless cysts. A sudden onset
of severe pain in the scrotum is concerning for a
testicular torsion or a strangulated inguinal hernia.
Urgent ultrasonography and surgical review
are recommended if in doubt. A painless, hard
enlargement of a testis must be considered malignant
and should also be investigated without delay.
If the patient presents with penile lump or
curvature, on palpation you may find a hard,
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fibrotic mass within the shaft which is typical of
Peyronie’s disease. Occasionally (following rigorous
sexual activity) a boggy tender swelling known as a
lymphocele can form just proximal to the neck of
the glans. The patient can be reassured that it will
settle spontaneously.
Retract the prepuce (if present) to reveal the subprepuce, coronal sulcus, glans penis, external urethral
meatus and frenulum. Inspect inside the meatus and
swab any discharge present before carefully drawing
the prepuce forwards.
Smegma is greyish- white cheesy material arising
from Tyson’s glands (which lie either side of the
frenulum) and may accumulate under the prepuce
if unwashed. Tiny regular papules arranged in rows
around the coronal sulcus are coronal papillae (pearly
penile papules), which may be mistaken for warts.
Phimosis is the inability fully to retract the
prepuce, which may be a late complication of lichen
sclerosus. Phimosis may predispose to recurrent
episodes of infection of the glans (balanitis), the
prepuce (posthitis) or both (balanoposthitis) which
is often fungal in aetiology and also seen in poorly
controlled diabetes. Always perform a urinalysis.
A paraphimosis is painful swelling of a trapped
retracted prepuce and may need urological
intervention.
Female genital examination
Carefully inspect the skin of the intralabial folds, the
clitoral hood and clitoris. Part the labia to expose the
vestibule and the opening of the vagina (introitus)
and note the presence of any discharge.
Vulval papillae appear as small, smooth finger- like
projections at the vestibule of the vagina; often they
are confused with genital warts. A Bartholin’s cyst or
a tender abscess can be found at the inferior aspect
of the labia either side of the vaginal opening. It may
result from gonococcal or chlamydial infection, and
purulent discharge may be observed from Bartholin’s
duct, which is between the upper two- thirds and
lower one- third of the labia.
If visualization of the vagina and cervix is required,
use your non- dominant hand to anchor the labia
away from the vestibule and using your dominant
hand place a lubricated speculum into the introitus.
Gently insert it into the vagina and advance slowly.
When fully inserted, open the speculum to reveal
the cervix and fix it in place. Inspect the vaginal
walls and the cervix. Samples of discharge can be
taken from the lateral wall and posterior fornix of
the vagina as well as the cervical opening (os).
Nabothian follicles appear as yellow cysts on the
cervix, which may have prominent vessels on their
surface but are normal. A cervical ectropion (ectopic
columnar epithelium) may be visible surrounding the
cervical os, which is also normal. Purulent discharge
and friability of the cervical os can be a sign of
mucopurulent cervicitis. A retained foreign body,
such as a tampon, causes a very offensive odour; if not
removed, may, rarely, lead to toxic shock syndrome.
A bimanual examination (BME) is indicated in
cases of suspected PID or other pelvic pathology.
Insert two fingers of the dominant hand into the
vagina to palpate the cervix. Use the non- dominant
hand to apply pressure on the lower abdomen
enabling you to palpate the uterus and each adnexa
Figure 18.6 Primary syphilis.
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between the fingers. Note the approximate size of
the uterus and any abnormal masses. Pain elicited
on palpation of the cervix is known as cervical
excitation tenderness and this may co-exist with
uterine and adnexal tenderness. All are positive
findings suggestive of PID.
Proctoscopy
If the patient presents with symptoms suggestive of
proctitis or has lumps and ulceration extending into
the anal canal, then proctoscopy is indicated. The
patient should be in the left lateral position with knees
drawn up to chest. Place a lubricated proctoscope at
the anal verge and apply gentle pressure onto the
external anal sphincter, allowing it to open. Slowly
advance the proctoscope into the anal canal and
rectum. Remove the obturator to allow examination
of the rectal mucosa. Proctitis appears as purulent
discharge with friable mucosa. Ulceration may also
be seen. Samples can be taken from the rectal wall
before carefully removing the proctoscope.
Anal itch (pruritus ani) may be secondary to
rectal discharge, anal warts, hemorrhoids, perianal
dermatitis or poor anal hygiene. If the itch is worse
at night, then threadworm infestation should be
considered. Both primary syphilis and genital herpes
can present with anal fissures. Flat warty lesions of
condylomata lata can be confused with anal warts
but, in fact, are the highly infectious lesions of
secondary syphilis (Fig. 18.7).
General examination
A widespread maculopapular rash should raise
suspicion for HIV seroconversion or secondary
syphilis. Other signs of secondary syphilis include a
palmoplantar rash, patchy alopecia of the scalp and
erythematous lesions of the oral mucosa known as
mucous patches. In cases of suspected secondary
or late syphilis, then a dedicated cardiovascular
and neurological examination may be indicated
according to symptomatology.
Dermatological conditions (e.g. atopic eczema,
seborrheic dermatitis, psoriasis and lichen planus)
can all affect the genital skin and, in some cases, may
be the only presentation of it. If you find evidence
of these in the genitals make sure to examine the
remaining skin, nails, scalp and oral cavity for other
features to support your diagnosis.
Testing
A combination of nucleic acid amplification tests
(NAAT), serology, microscopy and culture is used
to screen for and diagnose STI. Point-of-care tests
(POCT) (e.g. for HIV, Trichomonas vaginalis (TV)
and syphilis) are particularly useful in outreach and
resource poor settings.
Asymptomatic
The NAAT performed on urine and self- taken swabs
Figure 18.7 Condylomata lata.
Table 18.1 Site-specific screening using NG/CT NAAT according to gender and sexual behaviour
Urine Oropharynx + rectum Vulvovaginal
Cis MSM All All
Trans men and women All Sex worker If a vagina present
Cis women Sex worker All
Cis men (heterosexual) All
from the oropharynx, vulvovagina and rectum are
According to sexual risk
Age <25 years
According to sexual risk
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validated to detect Neisseria gonorrhoea (NG) and
Chlamydia trachomatis serovars D- K (CT) with a
high sensitivity and specificity. See Table 18.1 for
guidance on site-specific testing according to gender
and sexual behaviour. It is important to note that all
sexually active MSM should be tested at three sites,
regardless of sexual roles and practices.
Alongside NG/CT NAAT, serological tests are
the main screening method for diagnosing HIV
and syphilis and should be offered to all those who
attend sexual health services or request a sexual
health screen.
Syphilis is caused by the spirochete bacterium
Treponema pallidum (TP). Specific serological
tests for treponemes are used as screening tools to
diagnose syphilis. False- positive results can occur
occasionally, so a positive result on one specific test
(e.g. treponemal enzyme immunoassay (EIA)) is
always repeated on another (e.g. Treponema pallidum
particle agglutination (TPPA)). Non- specific tests
(e.g. the anticardiolipin antibody also known as the
Venereal Disease Research Laboratories (VDRL)
and the rapid plasma reagin (RPR)) are used to
quantify the degree of treponemal disease activity.
The VDRL and RPR are expressed as a titre (e.g. 1:4,
1:8, etc.); following treatment a two- fold reduction
in titre is considered an adequate response. Specific
tests for syphilis will remain positive lifelong. Past
infection with endemic treponematoses, such as
yaws, bejel and pinta, may also result in positive
specific serological tests for syphilis and it is custom
to treat presumptively.
Additional serological tests to screen for HAV, HBV
and HCV are offered to MSM, sex workers, people
living with HIV (PLWH) and others according to
endemic risk, lifestyle and sexual practices.
An understanding of testing window periods is
useful. GC/CT NAAT can reliably exude infection
2 weeks after exposure. The combined fourth
generation HIV antigen/antibody test will reliably
exclude HIV 45 days following exposure. HIV
POCT, as well as hepatitis B and C antibodies, may
take up to 90 days.
Symptomatic
Urethral discharge should be investigated with
Gram- stain microscopy and the patient should not
have passed urine for at least 2 hours. A sample is
taken from the urethra using a plastic loop or swab
and smeared onto a microscope slide ready for
staining.
A short history of continuous thick yellow
urethral discharge following recent condomless
sex is typical of gonococcal urethritis (GU). This
diagnosis is strongly supported by the presence of
polymorphonucleocytes (PML) with Gram- negative
intracellular diplococci (GNID) on microscopy
(Fig. 18.8) and ultimately confirmed with positive
NAAT and culture for NG. Culture is also used for
antimicrobial sensitivity testing of NG diagnosed
by NAAT. Symptomatic NG proctitis and cervicitis
may also be diagnosed on microscopy, albeit with
lower sensitivity.
Lower genital NG infections may be complicated by
epididymo- orchitis, PID and disseminated infection
involving the skin and joints. Autoinoculation to the
eye can give rise to gonococcal conjunctivitis (an
ophthalmic emergency).
A cloudy grey- white discharge would imply nongonococcal urethritis (NGU); for a list of causes see
Box 18.1. The diagnosis of NGU is confirmed by
greater than 5 PML per high power field (×1000)
on microscopy of urethral smear. Urine NG/CT
and mycoplasma genitalium (MGen) NAAT are
performed in the first instance, whereas persistent
NGU may require additional NAAT for TV. NGU
can be complicated by epididymo- orchitis, PID and
sexually acquired reactive arthritis (SARA) which, in
addition to urethritis, classically gives rise to bilateral
kerato- conjunctivitis and oligoarthritis. Circinate
balanitis is a cutaneous manifestation of SARA that
appears on the glans penis as erythematous eroded
Figure 18.8 Gram- negative intracellular diplococci.
Box 18.1
Sexually transmitted infection (STI)
Causes of non- gonococcal urethritis
Chlamydia trachomatis D- K serovars (∼30%)
Mycoplasma genitalium (∼30%)
Trichomonas vaginalis
Ureaplasma urealyticum
Herpes simplex virus
Intrameatal warts
Meatal chancre
Non- STI
Bacterial urinary tract infection
Adenoviruses
Candidiasis
Urethral stricture
Chemical irritation
Foreign body
Trauma
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lesions that coalesce with a slightly raised and
polycyclic edge.
Epididymo- orchitis is a clinical diagnosis characterized by acute onset of pain in the scrotum with
tenderness of the testes and epididymis on examination. In sexually active men under the age of 35
the most likely cause is STI. Gram stain of a urethral smear may be normal, show NGU or GU. In
older men, a bacterial urinary tract infection is a
more common cause. The diagnosis is supported by
positive urine dip for leukocytes, blood and nitrites;
a urine culture should be performed in addition to
urine NG/CT NAAT.
Vaginal discharge should be investigated with two
forms of microscopy. A sample taken from the vaginal
wall using a cotton tip is smeared onto a microscope
slide for Gram- staining. A second sample taken from
the posterior fornix using a plastic loop is mixed into
a drop of saline on a microscope slide, known as a
wet preparation. Vaginal discharge may also be pH
tested using litmus paper. STI is a common cause
of vaginal discharge so perform vulvovaginal swab
(VVS) NG/CT NAAT in all cases.
Bacterial vaginosis (BV), which is an imbalance
of the normal vaginal microflora, presents as an
offensive classically ‘fishy’ off- white discharge with
no inflammatory symptoms. It may arise following a
change in sexual partner or unprotected sex, but it is
not considered to be an STI.
The diagnosis is confirmed by the absence of
lactobacilli and the presence of mixed flora and ‘clue
cells’ (Hay- Ison criteria) on Gram- stain microscopy
of vaginal smear. ‘Clue cells’ are vaginal epithelial
cells covered with Gardnerella vaginalis, which
are Gram- variable but mainly Gram- negative
coccobacilli. The vaginal pH is typically elevated
more than 4.5.
A thick white, yellow or green ‘cottage- cheese’
like discharge associated with vulval irritation is
suggestive of vulvovaginal candidiasis (VVC) which
is not an STI. External or false dysuria may occur
when urine makes contact with inflamed vulva,
so be wary of confusing this presentation with a
urinary tract infection, particularly because it can be
triggered and indeed worsened by a course of broadspectrum antibiotics. The diagnosis is confirmed by
the presence of fungal spores and hyphae on Gramstain microscopy of vaginal smear. In recurrent
infections, culture of candida species may be useful
in identifying intrinsic and acquired anti- fungal
resistance.
Infection with TV may give rise to a fishy, frothy
yellow- green discharge which can be intensely itchy
and sore. The diagnosis is confirmed by the direct
visualization of jerky motile trichomonads under
light- field illumination (Fig. 18.9). The sensitivity of
microscopy for detecting TV is variable, so consider
performing VVS TV NAAT if there is vulval
inflammation with an offensive discharge and no
cause found on microscopy.
Abnormal vaginal bleeding, deep dyspareunia
and LAP should be investigated as per vaginal
discharge, but additional examination of the cervix
and pelvic organs is required. With clinical features
of mucopurulent cervicitis or PID on examination,
then endocervical Gram- stain microscopy is
indicated. Mucopurulent cervicitis has a similar
infective aetiology to urethritis and is investigated
accordingly. PID is an ascending infection of the
pelvic organs and usually the result of bacterial STI;
however, bacterial vaginosis and anaerobic infections
are implicated. The diagnosis should be considered
in any sexually active women with recent onset
LAP and a positive BME in whom no other cause is
found. The absence of endocervical or vaginal PMN
on microscopy has good negative predictive value
for diagnosing PID; however, their presence is nonspecific. Right upper quadrant pain in association
with PID is known as Fitzhugh- Curtis syndrome and
is caused by perihepatic inflammation.
Infectious proctitis should be suspected in any
patient with a history of receptive anal intercourse;
typical symptoms and inflamed rectal mucosa are
noted on proctoscopy. Microscopy of rectal smear
should be performed and greater than 5 PML ×1000
is supportive of the diagnosis. Rectal NG/CT NAAT
Figure 18.9 Trichomonas vaginalis.
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should be performed in all cases. MSM and other
people based on risk assessment should have additional rectal swab NAAT for CT serovars 1–3 also
known as lymphogranuloma venereum (LGV) and
HSV 1 and 2, particularly if ulcers are seen. Rarely,
LGV may progress to colitis or mimic inflammatory
bowel disease in presentation.
HSV 1 and 2 NAAT should be performed on all
cases of genital ulcers. Where a genital syphilitic
chancre is suspected, either by history or appearance,
then a sample of serious fluid should be removed
from the ulcer base with a cover slip. The diagnosis
is confirmed by direct visualization of the motile
spirochete under dark- ground microscopy (DGM)
(Fig. 18.10). Ulcer swabs for TP NAAT can be
performed (where available) and may be useful in
cases where DGM is negative or not possible (e.g.
a chancre in the oral cavity). Contemporaneous
syphilis serology should always be performed at the
time of presentation and may be negative early in
the disease (Table 18.2).
thrush may rarely occur in the context of the acute
severe viraemia and associated CD4 T- lymphocyte
(CD4) decline. HIV seroconversion can also be very
mild or asymptomatic. Anyone presenting with rash
and fever should be tested for HIV, particularly if
having recently engaged in high- risk sexual activity
or IVDU. The differential diagnosis would also
include viral hepatitis, cytomegalovirus (CMV),
Epstein- Barr virus (EBV), secondary syphilis and
drug reactions. If HIV is diagnosed during the
primary illness and it is acceptable to the patient,
then rapid initiation of ART is appropriate and will
have the benefit of reducing the viral reservoir and
be associated with a significant decline in onward
transmission.
Following seroconversion, the immune system
attempts to control HIV and, in doing so, brings the
level of HIV- RNA in the blood (known as the viral
load) down to a set point. The CD4 count partially
recovers and also stabilizes to a baseline level that
is typically within the normal range. A period of
clinical latency ensues and the CD4 count decline
correlates with advancing immunosuppression (Fig.
HIV infection
18.11).
In the UK routine screening for HIV is recom-
The spread of HIV infection and the emergence of
the acquired immune deficiency syndrome (AIDS)
in the early 1980s resulted in a dramatic fall in life
expectancy across the world. Increased access to
HIV testing and the development and uptake of
combined antiretroviral therapy (ART) mean that
people living with HIV (PLWH), if treated early, will
have a normal life expectancy and cannot transmit
the virus. Nevertheless, a significant proportion
remains at risk of the infective and non- infective
complications, especially if they are undiagnosed and
develop late- stage infection, or once diagnosed are
unable to access or adhere to ART.
Primary HIV infection may present with a
seroconversion illness that is non- specific and can
feature any of fever, headache, myalgia, malaise,
diarrhea, lymphadenopathy, pharyngitis and a
widespread erythematous, maculopapular rash. Night
sweats, weight loss, meningism, neuropathy and oral
mended in the following circumstances:
1. MSM, female partners of MSM, people who
inject drugs, sex workers, trans women, people
from countries with a high seroprevalence
(>1%) and their sexual contacts.
2. Anyone accessing health services for sexual
health, addiction and substance misuse,
antenatal care, termination of pregnancy and
the management of hepatitis B and C, TB and
lymphoma.
3. Anyone accessing health care settings in areas
where the prevalence is high (2–5 per 1000) or
extremely high HIV (>5 per 1000).
4. Anyone presenting with symptoms or signs of
an indicator condition which be AIDS- defining
or non- AIDS- defining but associated with an
undiagnosed HIV prevalence of more than 1 per
1000. (Tables 18.3 and 18.4).
5. The sexual partners of those diagnosed with
HIV.
When assessing all PLWH, gather information
on current symptoms and past medical history,
including any infections or cancers and treatment
given. If HIV has been newly diagnosed, then a
detailed social history is required to ascertain if
sexual partners and/or children are also at risk which
would necessitate further contact tracing and testing.
If a patient is already known to have HIV, then
gather information on the latest CD4 count and
HIV viral load and record the current ART regimen
and any prophylactic antimicrobials. It is prudent
to find out the centre the patient attended for HIV
care so that outstanding information can be obtained
at the earliest convenience. An assessment of sexual
Figure 18.10 Treponema pallidum.
wellbeing, relationships and the psychological impact
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18
Sexually transmitted infections
Table 18.2 Investigations and diagnoses in symptomatic patients
Syndrome Features Near patient test results Presumptive diagnosis Laboratory tests
Urethral discharge Thick
Yellow
Cloudy grey- white Urethral Gram stain: >5 PML Non- gonococcal
Tender testis or
epididymis
Vaginal discharge Thin
Abnormal vaginal
bleeding
Pain
±positive BME
Anorectal symptoms Purulent
Genital ulcers Painful
BME, Bimanual examination; CT, chlamydia trachomatis; GNID, gram negative intracellular diplococci; HSV, herpes simplex virus; LGV, lymphogranuloma venereum;
MGen, mycoplasma genitalium; NAAT, nucleic acid amplification test; NG, neisseria gonorrhea; PML, polymorphonucleocyte; TP, treponema pallidum TV, trichomonas
vaginalis; VVS, vulvulo-vaginal swab.
Age <35 years
Urethral discharge
Age >35 years
Urinary symptoms
Fishy odour pH:
>4.5
Frothy
Yellow green
Fishy odour
Inflammation
Thick cheesy
White
Inflammation
Purulent
Inflamed friable
cervix
Inflamed friable
Rectum
Multiple
Shallow
Painless
Solitary
Indurated
Urethral Gram stain: GNID Gonococcal urethritis Urine NG/CT NAAT
Urethral NG culture
Urine NG/CT, MGen,
urethritis
Urethral Gram stain: Normal Epididymo- orchitis Urine NG/CT, MGen
Urethral Gram stain: >5 PML
Urethral Gram stain: GNID Gonococcal
Epididymo- orchitis
Urinalysis: normal UTI epididymo- orchitis Urine NG/CT NAAT
Urinalysis: leucocytes, blood,
nitrites
Vaginal Gram stain: Clue cells, no
lactobacilli
Wet prep: negative
Wet prep: Motile trichomonads
Vaginal Gram stain: PML/normal
Vaginal Gram stain: Spores and
hyphae
Wet prep: negative
Vaginal Gram stain:
PML/clue cells, no lactobacilli/
normal
Wet prep: negative
Endocervical Gram stain: GNID Gonococcal cervicitis
Rectal Gram stain: >5 PML Proctitis Rectal NG/CT, LGV,
Rectal Gram stain: GNID Gonococcal proctitis Rectal GC/CT NAAT
N/A Genital herpes Ulcer HSV 1+2 NAAT
Ulcer fluid dark ground: Motile
spirochetes
Bacterial vaginosis (BV) VVS NG/CT NAAT
Trichomonas vaginalis
(TV)
Vulvovaginal
candidiasis (VVC)
Mucopurulent cervicitis
±PID
±
PID
Primary syphilis Ulcer TP NAAT
TV NAAT
NAAT
Urine NG/CT NAAT
Urethral NG culture
Urine culture
VVS NG/CT, TV NAAT
VVS NG/CT NAAT
±Yeast culture
Endocervical NG/CT,
MGen NAAT
Endocervical NG/CT
NAAT
NG culture
HSV, MGen NAAT
NG culture
of living with HIV is appropriate in all situations.
Complete your assessment with a systematic
review and examination looking for features of
immunosuppression and indicator conditions.
Persistent lymphadenopathy may be the only
positive finding in early asymptomatic infection and
the CD4 count is expected to be above 500 cells/
mm3.
As the CD4 count falls below normal, mild
symptoms and signs of immune activation and
immunosuppression may appear. These include
repeated upper respiratory tract infections (e.g.
sinusitis, otitis media, tonsillitis and pharyngitis),
oral ulcers, herpes zoster (shingles) and seborrheic
dermatitis.
As the CD4 count falls below 350 cells/mm3 and
the HIV viral load rises, the patient’s health will
begin to deteriorate. Oral candidiasis presents with
a painful mouth and examination reveals white
plaques on the tongue and palate over inflamed
and bleeding mucosa (Fig. 18.12). Oral hairy
leucoplakia may also be seen on the lateral border
SECTION THREE
Weeks Years
CD4
+
T lymphocyte count (cells/mm
3
)
HIV RNA copies per ml plasma
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Sexually transmitted infections
399
Primary
1200
infection
1100
1000
900
800
700
600
500
400
300
100
0
03691212345678910 11
Figure 18.11 The natural history of HIV infection.
Table 18.3 AIDS- defining indicator conditions in people
living with HIV
Category AIDS- defining condition
Neoplasms Cervical cancer, non- Hodgkin lymphoma,
Kaposi’s sarcoma
Bacterial
infections
Mycobacterium tuberculosis, pulmonary or
extrapulmonary
Mycobacterium avium complex/Mycobacterium
kansasii, Mycobacterium, other species
or unidentified species, disseminated or
extrapulmonary
Pneumonia, recurrent (two or more episodes in
12 months) Salmonella septicaemia, recurrent
Viral
infections
Cytomegalovirus retinitis
Cytomegalovirus, other (except liver, spleen,
glands)
Herpes simplex, ulcer(s) >1 month/bronchitis/
pneumonitis
Progressive multifocal leukoencephalopathy
Parasitic
infections
Cerebral toxoplasmosis
Cryptosporidiosis diarrhoea >1 month
Isosporiasis >1 month
Atypical disseminated leishmaniasis
Reactivation of American trypanosomiasis
(meningoencephalitis or myocarditis)
Fungal
infections
Pneumocystis carinii pneumonia
Candidiasis, oesophageal, bronchial/tracheal/
pulmonary
Cryptococcosis, extrapulmonary
Histoplasmosis, disseminated/extrapulmonary
Coccidioidomycosis, disseminated/
extrapulmonary
Penicilliosis, disseminated
Source: BHIVA/BASHH/BIA Adult HIV Testing Guidelines 2020.
Acute HIV syndrome
wide dissemination of virus
seeding of lymphoid organs
Clinical latency
Death
Opportunistic
diseases
Constitutional
symptoms
7
10
6
10
5
10
4
10
3
10
2
10
Table 18.4 Non- AIDS- defining HIV indicator conditions
(associated with an undiagnosed HIV prevalence
of >1 per 1000)
Category Condition
Hematological Unexplained leukocytopenia/
thrombocytopenia lasting >4 weeks
Neoplasm Malignant lymphoma, anal cancer/
dysplasia, cervical dysplasia, primary
lung cancer
Neurological Peripheral neuropathy, mononeuritis,
Guillain- Barré syndrome, subcortical
dementia, multiple sclerosis- like
disease
Dermatological Seborrheic dermatitis/exanthema,
severe or atypical psoriasis
Renal Unexplained chronic renal
impairment
Gastro- intestinal Unexplained weight loss, unexplained
chronic diarrhea
Infective Community- acquired pneumonia,
herpes zoster (shingles), hepatitis
B or C (acute of chronic), hepatitis
A, unexplained oral candidiasis,
candidaemia, STI, mononucleosislike illness, visceral leishmaniasis,
invasive pneumococcal disease
Other Unexplained lymphadenopathy,
unexplained fever, oral hairy
leukoplakia
Source: BHIVA/BASHH/BIA Adult HIV Testing Guidelines 2020.
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