Review of NACO guidelines on STI and RTI

Disclaimer: This post is for academic purposes only. Please read the original document if you intend to use them for clinical purposes.

This document provides summary of the “National Technical Guidelines on STI (Sexually Transmitted Infections) and RTI (Reproductive Tract Infections),” published in 2024 by NACO (National AIDS and STD Control Programme), MOHFW (Ministry of Health & Family Welfare), GOI (Government of India).

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Key Concepts:

• STI (Sexually Transmitted Infections): infections that primarily spread through sexual contact. They can also be transmitted from an infected mother to her infant (vertical transmission) during pregnancy and childbirth, and through blood products and tissue transfer. A majority of STI cases are asymptomatic, meaning the absence of symptoms does not rule out infection. An asymptomatic infection can still be transmitted to sexual partners and lead to complications. The term ‘STI’ is preferred over ‘STD’ (Sexually Transmitted Diseases) to indicate that infections do not always result in symptomatic disease.
• RTI (Reproductive Tract Infections): any infection of the reproductive tract. In women, this includes infections of the vagina, cervix, uterus, fallopian tubes, and/or ovaries, and may also involve external genitalia. In men, it may involve the testes, epididymis, and/or prostate, as well as external genitalia. While some RTI are caused like STI, others can result from an overgrowth of normal organisms (e.g., bacterial vaginosis) or improper medical procedures like catheterization, termination of pregnancy, or IUD insertion. Practices such as vaginal douching, multiple sexual partners, and inconsistent condom use are also linked to increased RTI risk.
• It is highlighted that Not all RTIs are sexually transmitted, and not all STIsare located in the reproductive tract.
• More than 30 microorganisms are associated with various STI and RTI, with many others exclusively with RTI. These infections significantly increase the risk of acquiring and transmitting HIV, and are responsible for serious sexual and reproductive morbidity (including infertility), adverse pregnancy outcomes, and various cancers. They can manifest differently in People Living with HIV (PLHIV) and may lead to increased morbidity and infectiousness in this population.

Trends in India:

India shows significant heterogeneity in STI/RTI statistics. There has been a decline in the burden of STI/RTI with a shift from bacterial and ulcerative infections to chronic viral STI (like genital herpes, HPV) in the 21st century. While earlier studies (post-2005) reported a significant decrease in STI rates, current programmatic data indicate increasing trends of RPR seropositivity in DSRC(Designated STI/RTI Clinics). According to NFHS-5, 5% of women and 2.1% of men (15-49 years) self-reported an STI in the last 12 months, rising to 12.3% for females and 9.3% for males when including genital discharge/sore or ulcer.

Services delivery in India:

Services are delivered through a network under the National AIDS and STD Control Programme (NACP) and National Health Mission (NHM).

• Designated STI/RTI Clinics (DSRC), also known as ‘Suraksha Clinic,’ are primarily located in DH (District hospitals) and MC (Medical colleges). They serve general, high-risk, and vulnerable populations and act as referral units.
• Services are also provided at SDH (Sub-district Hospitals), CHCs (Community Health Centres), PHCs (Primary Health Centres), and SCc (Sub-centres) under NHM.
• High-Risk Groups (HRGs), including FSW (Female Sex Workers), MSM (Men who have Sex with Men), PWID (People who Inject Drugs), TG (Transgender), and populations in P&OCS (Prison and other Closed Settings), as well as bridge populations (migrants, transportation workers), receive services through TI (Targeted Interventions).
• Screening for STI/RTI is also provisioned at ART Centres for PLHIV.
• The Sampoorna Suraksha Strategy (SSS) includes STI/RTI services for ‘at-risk‘ populations and One Stop Centres (OSC).
• The Link Worker Scheme (LWS) covers HRGs, bridge populations, PLHIV, and their partners in rural areas, mainly through referrals.
• The syndromic approach is the backbone of STI/RTI services in India, ensuring prompt treatment alongside diagnostic facilities.
• STI color-coded kits are distributed under NACP to streamline diagnosis and management of common STI/RTI, consisting of pre-packaged, color-coded medications for specific syndromes.
• A network of STI laboratories under NACP supports etiological diagnosis, syndromic validation, gonococcal antimicrobial susceptibility surveillance, and quality assurance. This network includes Regional STI training, RSTRRLs (Research and Reference Laboratories) linked to SRCs (State Reference Centers) and DSRCs.

NACP-V Strategy:

Goal 3 of NACP-V aims to intensify efforts for dual elimination of vertical transmission of HIV & syphilis, while Goal 4 specifically targets universal access to quality STI and RTI services for at-risk and vulnerable populations. Proposed strategies under NACP-V include:

• Strengthening strategic information via monitoring, surveillance, and research.
• Maintaining and augmenting the role of DSRCs for new initiatives.
• Developing integrated communication strategies for HIV and STI prevention, testing, and treatment
• Dovetailing HIV and Syphilis dual testing, including Dual Rapid Diagnostic Test kits (Dual RDT).
• Promoting active case findings through social network and partner testing.
• Improving collaboration with NHM to scale up services and linkages to quality diagnostics.
• Strengthening private sector engagement.
• Periodically updating STI and RTI management guidelines.
• Augmenting laboratory capacities.
• Strengthening supply chain management for STI/RTI commodities.

Factors Contributing to spread:

They include:

• Biological factors: Age (young women more vulnerable due to immature vaginal/cervical tissue), sex (women have larger mucosal surface exposure, uncircumcised men more vulnerable), and immune status (compromised immunity, like in HIV, increases vulnerability).
• Behavioral factors: Inconsistent/no condom use, frequent change of sexual partners, multiple partners, sex with casual partners/sex workers, transactional sex, sex in exchange for drugs, group sex, and blood transfusion.
• Social factors: Women’s limited power in sexual practices, economic dependency, sexual violence, early marriage, and high-risk practices in certain populations (adolescents, transactional sex, migrants, MSM, H/TG, drug users, P&OCS).
• Healthcare system factors: Lack of access to services, lack of awareness, associated stigma, and iatrogenic infections due to untrained providers or unsafe procedures.

Approaches to STI and RTI Management:

Three main approaches used are:

1. Traditional Clinical approach: Relies on clinical experience to identify signs/symptoms of a specific STI and its treatment.
2. SCM (Syndromic Case Management) approach: Based on identifying a syndrome (a set of correlated signs/symptoms) and treating for the most common organisms responsible for that syndrome. It’s fast, effective for selective syndromes, relatively inexpensive, and easy to learn and integrate into public health systems. However, it may lead to overtreatment in asymptomatic patients or those with only one STI causing a syndrome.
3. Laboratory-assisted approach: Based on laboratory identification of organisms and subsequent treatment.

The Syndromic Case Management (SCM) is the cornerstone of STI/RTI services in India, often enhanced with on-site diagnostics (Enhanced Syndromic Case Management or ESCM). The guidelines detail common STI/RTI syndromes, their causative agents, clinical presentations, examination findings, laboratory investigations, and treatment options.

Management Aspects:

• History Taking: Emphasizes open, respectful, non-judgmental, and culturally sensitive communication, ensuring privacy and confidentiality. It involves asking about current symptoms, HIV/STI-related risk behaviors, past STI history, and medical/obstetric/menstrual history. Special consideration is given to transgender/intersex persons based on their current anatomy and sexual behaviors.
• Clinical Examination: Crucial for diagnosis, focusing on the anogenital area but also including general examination for other STI manifestations. It requires informed verbal consent and, preferably, the presence of a chaperone. Specific guidance is provided for examining female, male, and transgender clients, with detailed anatomical considerations for those who have undergone gender-affirmative surgeries.
• STI Color-Coded Kits: Pre-packaged medications aligned with specific syndromes (e.g., Kit 1 for Urethral Discharge/Vaginal Discharge, Kit 3 for Genital Ulcer Disease for Syphilis/Chancroid) are used for streamlined management.
• PT (Presumptive Treatment): One-time treatment for assumed infection in high-risk individuals, especially for asymptomatic infections. It is provided to HRGs during their first clinic visit and if they miss routine check-ups for six or more consecutive months, specifically for gonorrhoea and chlamydia using Kit 1.
• Partner Notification and Management: A crucial component of comprehensive case management, involving informing sexual contacts of potential risk, screening them, and providing treatment. Various approaches like patient referral, provider referral, and contract/conditional referral are described.
• Sexual Health Education and Risk Reduction Counselling: Essential components provided in a nonjudgmental, empathetic manner, tailored to the client’s culture, language, gender identity, sexual orientation, age, and developmental level. This includes safer sex practices, STI/HIV screening importance, and vaccination benefits.
• Primary Prevention Methods: Include vaccination (HPV, HAV, HBV), consistent and correct condom use (external and internal), HIV Pre-Exposure Prophylaxis (PrEP), and HIV Post-Exposure Prophylaxis (PEP). Doxy-PEP (Doxycycline Post-Exposure Prophylaxis) is also discussed for bacterial STI prevention, particularly for MSM and transgender women with a history of STI.

STI and RTI among Special Populations

The guidelines provide specific considerations for:

• Pregnant and Breastfeeding Women: STI/RTI are major causes of maternal/perinatal morbidity and mortality. Universal screening for syphilis is emphasized, with immediate on-spot BPG dose for reactive cases. Acyclovir is safe for genital herpes treatment in pregnancy, and suppressive therapy is recommended from 36th week. Certain drugs (Doxycycline, Ofloxacin, Quinolones, Secnidazole, Tinidazole, oral Fluconazole, Lindane, Ivermectin) are contraindicated or not recommended in pregnancy/breastfeeding.
• Infants: STI/RTI can be transmitted vertically (e.g., congenital syphilis, neonatal herpes, chlamydial, gonococcal infections) or through sexual abuse. Detailed protocols for congenital syphilis assessment and management, including curative and prophylactic treatments with penicillin, are provided.
• Children, Adolescents and Youth Populations: STI/RTI can be acquired transplacentally, intrapartum, post-natally, or through sexual abuse/unsafe practices. Physiological susceptibility in adolescent girls (cervical ectopy) is noted. Comprehensive, non-judgmental assessment and primary prevention strategies like vaccination, counseling, and integrated sexuality education are crucial.
• Key and other Vulnerable Populations (sex workers, MSM, H/TG, PWID): Have higher HIV/STI burden due to sexual networks, behaviors (e.g., anal sex, transactional sex, substance use). Management includes symptomatic treatment and regular screening/presumptive treatment for asymptomatic infections. Rectal and pharyngeal testing for gonorrhea/chlamydia is highlighted.
• BP (Bridge Population) & P&OCS (Population in Prisons and other Closed Settings): At high risk due to mobility, separation from partners, and limited healthcare access. Regular medical check-ups (bi-annually/annually for BP, annually for P&OCS) and screening are recommended.
• PLHIV (People Living with HIV): STI/RTI co-infections pose significant risks due to immune dysregulation and can accelerate disease progression. STI/RTI presentation can be unusual or severe in PLHIV [94]. Regular screening (annually for sexually active PLHIV, every 6 months for key populations PLHIV) and partner management are vital. Specific considerations for syphilis, herpes, chancroid, LGV, donovanosis, urethritis, cervicitis, BV, trichomoniasis, VVC, PID, epididymitis, pediculosis pubis, scabies, and HPV in PLHIV are detailed.

Management of Sexual Violence

Sexual violence causes significant physical and psychological harm, affecting women, girls, boys, and sexual minorities. The Indian Penal Code was amended in 2013 (and incorporated into Bharat Nyaya Sanhita, 2023) to broaden the definition of rape to include all forms of sexual violence and mandates treatment by healthcare facilities. Health professionals have a dual role: providing medical and psychological support, and assisting in medico-legal proceedings by collecting evidence while maintaining sensitivity and privacy. Post-assault examination is crucial for identifying/preventing STI, with prophylaxis recommended for common infections (Chancroid, Gonorrhea, Chlamydia, T. vaginalis, BV) and HIV/Hepatitis B PEP. The POCSO Act (Protection of Children from Sexual Harassment Act, 2012) mandates reporting child sexual abuse and defines sexual assault in children.

Laboratory Diagnosis:

This chapter details the importance of laboratory testing for screening, confirmatory diagnosis, syndromic management validation, antimicrobial susceptibility determination, and surveillance. It covers diagnostic methods for Gonorrhea (microscopy, culture, NAAT), Chlamydial infections (NAAT, serology, tissue culture), Syphilis (Non-treponemal and treponemal tests, algorithms), HSV infection (virological tests, serological tests), Chancroid (microscopy, culture), LGV (molecular testing, NAAT), Granuloma inguinale (visualization of Donovan bodies), Trichomoniasis (wet mount, NAAT), Bacterial Vaginosis (Amsel criteria, Nugent’s score), Vulvo-vaginal candidiasis (microscopy, culture), genital Mycoplasmas (NAAT), HPV infection (visual inspection, biopsy, molecular detection), and viral hepatitis (serology for HAV, HBV, HCV, HDV). It also highlights the importance and limitations of Point-of-Care Testing (PoCT) for increasing access to timely diagnosis in resource-limited settings.

Conclusion:

The guidelines comprehensively address STI (Sexually Transmitted Infections) and RTI (Reproductive Tract Infections), which pose a significant challenge to sexual and reproductive health and well-being. Their primary goal is to prevent, manage, and control STI and RTI to avert HIV transmission and ensure sound sexual-reproductive health. The document emphasizes providing universal access to quality STI and RTI services to at-risk and vulnerable populations across the country.

_{Citation: National Technical Guidelines on Sexually Transmitted Infections and Reproductive Tract Infections (2024). National AIDS Control Organization, Ministry of Health and Family Welfare, Government of India.}