RTIs, STIs and HIV in Adolescents

Definition

Reproductive Tract Infections (RTIs)

Are defined as any infections of the reproductive system. They include Sexually Transmitted Infections (STIs) and other infections of the reproductive track that are not caused by sexual contact. These other infections may be the result of overgrowth of the bacteria and other organisms that normally live in the vagina. RTIs also include infections that result from inadequate infection prevention practices by individuals. Although RTIs affect both women and men, research shows that women are more susceptible to infection and often less likely to seek treatment than men. In addition, complications can be more serious in women and infections can be transmitted to the offspring of pregnant women.

Sexually Transmitted Infection (STIs)

STI is an infection one can get by having intimate sexual contact with someone who already has the infection. STIs can be caused by viruses, bacteria, and parasites. Many STIs have mild or no symptoms. So one can have an STI and not even know about it. Most STIs can be found by simple tests, but routine testing is not widespread. Thus, many cases of STIs go undiagnosed and untreated, which can lead to serious health problems— particularly for women.

What are Reproductive Tract Infections (RTIs)

RTI refers to three different types of infections which affect reproductive tract:

• Overgrowth of organisms normally present in the vagina.
• Infection introduced during medical procedures
• Sexually transmitted infections due to organism transmitted through sexual activity.

RTIs include all infections of the reproductive tract, whether transmitted sexually or not, for example, Bacterial Vaginosis or Candidiasis which are caused by a disturbance in the equilibrium of the vaginal flora or Pelvic Inflammatory Disease caused by iatrogenic infection (infections introduced or contacted at a health facility during a clinical procedure). These are examples of reproductive tract infections that have not been sexually transmitted. On the other hand, pathogens like which are

commonly transmitted by sexual contact (Human Immune Deficiency Virus, Hepatitis -B, C, D, etc.) do not always or at all cause an infection of the reproductive tract.

RTIs can also be iatrogenic infections (e.g., infections introduced to the reproductive tract by use of unclean hands and instruments during delivery, IUD insertion, abortion or medical and surgical procedures, etc.)

What are Sexually Transmitted Infections (STIs)?

Sexually Transmitted Infections (STIs) refer to infections transmitted from one person to another primarily by sexual contact. Some STIs can be transmitted by exposure to contaminated blood, and from a mother to her unborn child.

STIs are among the most common illnesses in the world, and have far- reaching health, social and economic consequences for millions of men, women and infants.

In addition to their sheer magnitude, the incidence and prevalence of STIs among adolescents is increasing in both developed and devloping countries. This is a major public health problem for two reasons:

• STIs result in serious negative medical and psycho-social effects in the infected individual. In case of infected females, there is the added risk of infection and illness in the unborn child.
• STIs, especially those with genital ulcers, facilitate the transmission of HIV between sexual partners. The prevention and treatment of STIs therefore needs to be a key component of a strategy to prevent the transmission of HIV.

The four most prevalent STIs are chlamydial infection, gonorrhoea, syphilis and trichomoniasis. These STIs can be prevented and cured provided that adequate antibiotics are availale and standardised treatment protocols are employed.

Symptoms of RTIs/STIs

Some of the symptoms in an adolescent who seeks advice either from a health centre could be:

• For both adolescent boys and girls:
  • Genital ulcers (sores)
  • Burning sensation while passing urine - Swelling in the groin
  • Itching in the genital region
  • Pain during sexual intercourse
• For adolescent girls:
• Unusual vaginal discharge
• Pain in lower abdomen
• Change in menstrual flow
• For adolescent boys:
• Discharge from the penis

Factors responsible for RTI/STI among adolescents

• Adolescents are anxious to do experiments oblivious of any chances of diseases and as such indulge in unsafe sexual practices
• More prone towards risk taking behaviour or take risk as a mode of thrill and adventure
• Vaginal and cervical epithelium in adolescents is immature
• Lack of adequate and appropriate health services
• Poor reproductive hygiene practices
• Unsafe delivery and abortion

Why adolescent boys and girls more prone to STIs?

In today’s world, adolescents face heightened risks of exposure to STIs. In many societies, sexual activity begins during adolescence, either within the context of marriage or - increasingly - before marriage occurs.

Sexual relations during adolescence are often unplanned and sporadic, and sometimes the result of pressure, coercion or force. Adolescents start sexual activity before they have:

• Experience and skills in self-protection.
• Adequate information about STIs and how to avoid contracting these infections.
• Access to preventive services and protective supplies (such as condoms).

Adolescent girls are thought to be more susceptible to STIs than adult women because of both biological and social reasons:

Adolescent boys in many cultures feel they have to prove themselves sexually; to indicate this graduation to adulthood. Studies confirm that adolescent boys and young men often have high rates of STIs, and that they frequently ignore such infections, or rely on self-treatment.

In addition to increasing the risk of STIs, unprotected sexual activity increases the risk of other reproductive health problems such as too early, unwanted pregnancy and unsafe abortion.

Factors that increase risk of RTIs

• Poor general health
• Poor genital hygiene
• Poor menstrual hygiene in girls
• Unhygienic practices by services providers during delivery, abortion or IUD insertion.

Factors that increase risk of STIs

• History of unprotected sexual activity in the recent past
• Having sex with partner having sore on the genital region or urethral or vaginal discharge
• Multiple sexual partners

Consequences of STIs among adolescents

The consequences of STIs contracted during adolescence are more severe than in adults. This is especially true in the case of female adolescents.

Consequences of STIs for adolescents

• Pelvic inflammatory disease (PID): Chlamydia infection during adolescence is more likely to result in (PID) and its complication (such as infertility);
• Cancer of the cervix: exposure to infection (such as Chlamydia and Human Papilloma virus) during adolescence is more likely to result in cancer of the cervix;
• Tertiary Syphilis: Heart and brain damage as a long-term consequence of an untreated Syphilis infection;
• Stigma and embarrassment associated with STIs can impair psychological development and attitudes towards sexuality later in life
• 8-10 times more risk of HIV
• Bad outcomes of pregnancy

Prevention of RTIs/STIs

• Maintaining proper genital hygiene is important. Girls should also maintain good menstrual hygiene.
• Practicing responsible sexual behaviour. Being faithful to one partner.
• Practicing safe sex
• Avoiding sexual contact, if either of the partner has an STI
• By not neglecting any unusual discharge
• Ensuring complete treatment of self and sexual partner (partner treatment)
• Opting for institutional delivery or home delivery by a trained birth attendant
• Availing safe abortion services

Main factors that hinder a prompt and correct diagnosis of STIs/RTIs in adolescents

Main factors that hinder a prompt and correct diagnosis of STIs in adolescents

Adolescents often lack information about the services that are available. For example, they may not know of existing services, where and when they are provided or how much they cost. Even if they have this information, they are often reluctant to seek help for diagnosis and treatment because of embarrassment, because they do not want to be seen by people they may know, and because of fear of negative reactions from health-care workers.

In many countries adolescents with STIs go to traditional healers or buy remedies from street vendors. This is likely to result in improperly and inadequately treated infections. The symptoms and signs of some STIs disappear without treatment; in these situations, adolescents may believe that the disease has resolved spontaneously when in fact it has not done so.

STIs may be asymptomatic, especially in young women. Adolescents may not be aware of the differences between normal and abnormal conditions (such as normal and abnormal genital discharges), and hence do not seek help. Asymptomatic and mildly symptomatic STIs are likely to be missed when health-care providers apply the syndromic approach for diagnosis and management. Symptomatic STIs may also be missed if health-care providers do not have adequate skills to undertake a clinical examination or to elicit the needed information from adolescents who are not fully knowledgeable about their bodies.

Main factors that could hinder the effective management of STIs in adolescents

As indicated above, adolescents may be reluctant to use services due to factors such as inadequate information, difficulties in accessing services, and lack of money to pay for them. They often tend to self-mediate when they believe that they have exposed themselves to the risk of an STI.

Adolescents often have difficulty in complying with treatment because it may be lengthy (e.g. in the case of chlamydia) or painful (e.g. in the case of venereal warts), and sometimes they need to conceal medication so that the STI is not revealed to others. In many places, medicines for the treatment of STIs can be bought at pharmacies, without a prescription, they can also be bought from vendors in a market. It is therefore important for the health-care worker to ascertain if the adolescent has tried/taken any medication for the STI, before coming for help.

HIV /AIDS

HIV stands for : Human Immunodeficiency Virus

AIDS stands for

Acquired : Not genetically inherited but get it from some body

Immuno-deficiency : Inadequancy of the body’s main defence mechanism to fight external disease producing organisms

Syndrome : A group of disease or symptoms

AIDS results from infection with HIV, which stands for human immuno-deficiency virus. HIV gradually destroys the body’s capacity to fight off infections by destroying the immune system. As a result a routine infection can turn life threatening, as the body is not able to produce antibodies to protect against them. The HIV infected person becomes more susceptible to a variety of infections known as opportunistic infections like tuberculosis.

Transmission of HIV

• Different forms of sexual contract including unprotected anal, vaginal or oral sex.
• From an infected mother to her child (MTCT) during pregnancy, delivery, or breastfeeding.
• Sharing of infected syringes and needles contaminated with infected blood and other body fluids, such as                  injectibe drug users, use of contaminated skin-cutting tools, needle stick injuries in health care settings.
• Transfusion of infected/unsafe blood or blood products.

The most common route of transmission in our country is through the sexual route and about 85% of cases have acquired HIV through this mechanism. However, in north eastern India, the epidemic is mainly among intravenous drug users.

Diagnosing HIV infection

It is not possible to tell whether or not a person has HIV/AIDS by the way he or she looks and acts.

Sometimes, it is possible to suspect this infection from the presence of certain symptoms either in isolation or in combination. However, these cannot be relied upon solely for the diagnosis, as they are usually nonspecific and common to other illnesses as well.

Signs and Symptoms of AIDS

Some of the salient features of AIDS besides signs and symptoms of specific opportunistic infection:

• An unexplained loss of weight lasting at least one month
• Diarrhoea lasting for more than 1 month
• Intermittent or constant fever for more than 1 month
• A cough that persists for more than one month
• Enlarged glands (lymph nodes) in the neck, armpits, or groin

Only a laboratory test can confirm the presence of HIV

Knowing one’s HIV status enables an individual to make informed decisions about treatment and care and learn how to avoid passing the infection on to others. Many people infected with HIV have no symptoms, and, therefore, there is no way of knowing with certainty that the person is not infected unless he or she has repeatedly tested negative for the virus - and has not engaged in any risky behaviour between tests.

ELISA test is the most common screening test used for initial testing. Whenever, this screening test is positive, a confirmatory test is done. The Western blot is used to confirm screening tests results. Both these tests detect the presence of antibodies against HIV.

Sometimes it is possible to test negative in the very early stages of HIV infection. This period is called the ‘window period’. This is because the test is looking for antibodies that have not yet developed. In this case the test should be repeated after a duration of three months.

Maintaining confidentiality of test results is of utmost importance because disclosure of a person’s status may be detrimental not only for the individual concerned but also for the people around him such as their family members. They may be alienated or stigmatised due to the lack of accurate information as well as the prevailing myths and misconceptions about the infection in the society.

Testing must always be voluntary and with informed consent of the client. Pre and post-test counselling are an integral part of testing. Such voluntary counselling and testing services are now available free of cost at many government health facilities.

Integrated Counselling and Testing Centre (ICTC)

HIV voluntary Counselling and Testing (ICTC) has shown a positive role in both HIV prevention and as an entry point to care. It providers people with an opportunity to learn and accept their HIV resostatus in a confidential environment. ICTC is a relatively cost-effective intervention in preventing HIV transmission. Improving information to advocate the benefits of ICTC and raising community awareness will contribute greatly to promote utilization of this service. HIV testing services address multiple needs and rights of individuals at risk or already infected so that effective counselling, condom supplies and peer and community support are also available. Such efforts to reduce stigma and discrimination will normalize community perceptions of HIV infection and AIDS, and make counselling services available to all who seek them, regardless of their willingness to be tested.

Counselling guidelines clearly state that no HIV testing is to be undertaken without pretest and post test counselling. Therefore, counselling services have to be improved bearing this issue in mind. Voluntary HIV counselling and testing is the process by which an individual undergoes counselling enabling him or her to make an informed choice about being tested for HIV. This decision must be the choice of the individual and he or she must be assured that the process will be confidential. However, in concurrence with the Supreme Court decision, Partner notification is necessary and this makes it imperative for the attending physician to disclose the HIV status to the spouse or sexual partner of the person. Inspite of this all efforts must be made to counsel the person for disclosure of HIV status to the spouse or sexual partner.

Benefits of ICTC

The potential benefits of ICTC are:

• Improved health status through good nutritional advice.
• Earlier access to care and treatment
• Prevention of HIV related illness Emotional support
• Better ability to cope with HIV related anxiety
• Awareness of safer options for reproduction and infant feeding. Motivation to initiate or maintain safer sexual practices.
• Motivation for drug related behaviour
• Safer blood donation

Management of HIV in young people

Management of HIV in young people includes a range of services that provide (a) care, (b) treatment, (c) Support, (d) positive prevention for young people living with HIV, and (e) counseling, which is an integral part of all these services.

The aim of services is to help young PLHIV (People living with HIV) to:

• Stay healthy and live positively
• Adhere to care and treatment
• Understand the benefits of disclosing HIV status to family, sexual partner(s), close friends
• Cope with stigma and discrimination towards themselves and their loved ones

Care

Management of HIV is based on medical and psychosocial care in a healthcare setting. The ten principles  can be used in managing many diseases, including HIV.

General principles of good chronic care

• Develop a treatment partnership with your patient
• Focus on your patients concerns and priorities.
• Use the 5As –Assess, Advise, Agree, Assist, Arrange
• Support the patients education and self management
• Organize proactive follow-up
• Involve expert patients, peer educators and support staff in your health facility
• Link the patient to community –based resources and support
• Use written information –registers, treatment plans, patient calendars, treatment cards, to document, monitor, and remind
• Work as a clinical team (and hold team meetings).Each team must include a district ART clinician
• Assure continuity of care

Treatment

Treatment includes antiretroviral therapy, prevention, treatment and care of opportunistic infections and STIs. Treatment also includes management of other chronic conditions (e.g. cancers, depression). There are distinct groups of HIV-infected adolescents who may require ART, but have different needs because of their infection history. For adolescents who were infected around birth and have survived into adolescence, HIV disease may develop as rapid progression or slow progression. In rapid progression, they may have begun ART during childhood and are likely to have had experience with different treatments. These adolescents may face challenges relating disclosure of HIV status, developmental delays, and transition of care from paediatric to adult care, and choice of appropriate ART regimens and adherence. Adolescents who were infected around birth with slow progression of HIV disease may present for the first time to ART services during adolescence; their treatment and care needs are similar to those who become infected during adolescence. ART is a lifelong treatment and this creates a challenge for adherence.

Support

Support deals with the emotional, spiritual and material support for young PLHIV, which is often provided by peers, family and community.

• Support may be connected to ART and care
• Support is about assisting young PLHIV to cope with the impact of HIV on their lives on every aspect of life
• Support includes all measures that alleviate the impact of HIV on the young PLHIV, their family and their community.

Positive Prevention

Positive prevention for young people includes all strategies that increase the self esteem and confidence of young PLHIV, with the aim of protecting their own health and avoid passing the infection to others.

An important part of positive prevention is counseling, with the aim of

• Supporting positive living (emotional, psychological and physical), which can help PLHIV to live healthily and take responsibly for their health.
• Assisting PLHIV to learn how to enjoy a healthy sexual life, without fear of infecting their loved ones.
• Involving PLHIV and associations of PLHIV in community activities

Counseling

Counseling of young PLHIV concentrates on the emotional, behavioural, and social issues that relate to living with HIV. Counseling often begins with an HIV test result; however, counseling is an essential part of HIV management and care and is much more than explaining to a young PLHIV his/her test result.

Sources :

1. Rashtriya Kishor Swasthya Karyakram - Resource Book by Ministry of Health and Family Welfare
2. Rashtriya Kishor Swasthya Karyakram - Facilitator Guide by Ministry of Health and Family Welfare