In women, Neisseria gonorrhea and Chlamydia trachomatis may cause cervicitis. The complications of untreated cervicitis include pelvic inflammatory disease (PID) and tubo-ovarian abscess. If untreated, these infections can lead to scarring of the fallopian tubes, which increases the risk of ectopic pregnancy. Aggressive surveillance and treatment of STIs is thus important not only for decreasing HIV transmission, but also for reducing pregnancy-related deaths.

Because STIs are often asymptomatic (particularly in women), ZL medical staff improve case detection by relying not only on self-reported symptoms, but also on algorithms incorporating context-specific epidemiological risk factors elucidated through local research.^143–145 Risk assessment algorithms are useful as a screening tool and are especially helpful in settings where confirmatory testing is not available. As may be true in many resource-poor settings, the risk factors elucidated by ZL (as outlined in Protocol 2.5) are tied not only to a woman’s age and number of sexual partners but also to economic stressors. The risk factors included in Protocol 2.5 are specific to women in rural Haiti; other settings should rely on risk factors for cervical infection specific to that context. Note that, in the absence of laboratory testing, ZL staff recommend that all pregnant women receive empiric treatment for chlamydia and gonorrhea.

Per Protocol 2.6, all women presenting with lower abdominal pain should undergo a pregnancy test, a speculum exam with cervical gram stain or DNA probe to assess for cervicitis, and a bimanual exam to assess for PID, tubo-ovarian abscess, or ectopic pregnancy.¹⁴⁶ Women with symptoms of vaginal discharge should receive empiric treatment for STIs per Protocol 2.7. However, the majority of women with STIs are asymptomatic; thus, as mentioned, screening should extend beyond the syndromic approach.

Men complaining of urethral discharge or dysuria should be carefully examined for evidence of discharge; swabs should be obtained for gram stain or PCR testing (where available). Active tracing of the patient’s social contacts and treatment of sexual partners should be provided as a routine part of care. The most common pathogens causing male urethral discharge in Haiti are Neisseria gonorrhea and Chlamydia trachomatis. Because chlamydia and gonorrhea may be asymptomatic in women, once a man is diagnosed with an STI, his partner(s) should receive empiric treatment for the infection. Protocol 2.8 gives the recommended course of management of urethral discharge.

Regardless of whether or not the patient complains of such symptoms, it is important to routinely question all women presenting for care whether or not they are experiencing vaginal discharge or vulval itching or burning. If symptomatic, the patient should be evaluated for vaginitis, which is caused by bacterial vaginosis, trichomoniasis, and candidiasis. Diagnosis of vaginitis is made based on exam findings, wet mount and gram stain microscopy, and pH and KOH tests per Protocol 2.7; empiric treatment can also be considered without a pelvic exam or in the absence of laboratory evaluations.

In pregnant women, bacterial vaginosis has been associated with increased risk of preterm labor, premature rupture of membranes, late miscarriages, and MTCT of HIV. Treatment of asymptomatic vaginal infections during pregnancy has been shown to reduce preterm delivery by 50 percent.¹⁴⁷ All pregnant women, whether symptomatic or asymptomatic, should thus be screened for vaginal infections and treated as necessary early during the second trimester.

The diagnosis and treatment of genital ulcers is of particular importance for decreasing the risk of HIV transmission between discordant partners. While some genital ulcers present with pain, others are relatively asymptomatic. As a routine part of the medical history, the practitioner should ask every patient if he or she has noticed bumps, sores, or ulcers on the genitalia. Worldwide, the causative organisms for genital ulcers vary greatly. In Haiti, the most common cause of a painless genital ulcer is syphilis.

Chancroid is another common form of genital ulcers. Unlike syphilis, chancroid presents with painful single or multiple ulcers and, often, enlarged inguinal nodes. Herpes simplex virus (HSV) can also present as painful ulcers, appearing as multiple, small vesicular lesions. There is no cure for HSV. Patients, especially HIV-infected patients suffering from chronic herpes outbreaks, should be offered acyclovir for symptom relief and suppressive therapy. Granuloma inguinale (also called donovanosis) presents as large, painless, nodular and spreading ulcers not associated with lymphadenopathy. Lastly, lymphogranuloma venereum (LGV) causes a painless ulcer at the genital site of inoculation and then spreads, involving the inguinal or perirectal lymph nodes (so-called “tropical bubo”); such nodes are tender and may eventually suppurate. If buboes are present, they should be drained by needle aspiration through healthy skin. If suppuration occurs, TB should be ruled out by performing AFB analysis on the purulent discharge. Long-term sequelae of LGV include rectovaginal fistula, proctocolitis, and elephantiasis of the genitals due to lymphatic obstruction. Decisions regarding treatment for syphilis, chancroid, granuloma inguinale, or LGV should be made based on local epidemiology per Protocol 2.9.

All patients who present for VCT, pregnancy testing, or STI screening should receive a serologic test for syphilis. While false-positives are not uncommon, in resource-poor settings where syphilis is endemic and access to confirmatory testing is limited, all patients who have a positive serologic test should be treated for latent disease.