1-7 days post exposure

Primary infection:
Itching and burning in the genital area, followed by an eruption of painful blisters which rupture to form shallow ulcers. Lesions are found on the vulva, vaginal walls or cervix in women and the glans, prepuce or penile shaft in men. Flu-like symptoms and painful enlargement of glands in the genital area may be present and, rarely, the victim may develop meningitis (headache, nausea, vomiting and neck stiffness). Lesions heal within 10-14 days following first exposure, but may recur.
Recurrent infection:
Approximately 80% of infected individuals develop recurrent lesions.
Recurrent infections tend to be milder and heal more quickly.
Eruptions are often preceded by a burning sensation in the genital area.
Recurrent lesions may be very small and go unnoticed.
Recurrences often follow specific triggers such as: emotional or physical stress, fever or stages of the menstrual cycle.

The clinical picture is very characteristic and laboratory confirmation is seldom needed.
Antibody tests can be done to determine whether an individual has been exposed to HSV2 (and is therefore at risk of shedding the virus).
Antibody tests are no good for diagnosing a current infection.
During an eruption, a swab of a lesion can be sent to the laboratory to look for the presence of the virus directly (either by culture or by microscopy of the cells from a lesion or PCR).

Unprotected sex: direct contact with mucosal lesions.
Infected persons may shed virus without having symptoms.
Mother to child: An infant may be infected with HSV when passing through the birth canal if the mother has genital herpes at the time of delivery.
The baby can develop a generalised herpes infection (but this is very rare).

Aciclovir (Zovirax) and Valaciclovir (Zelitrex) are drugs that can be used to treat HSV infections.
Medication needs to be started as early as possible after the onset of symptoms.
Use of these drugs during an eruption shortens the time to healing, but it does not prevent the virus from persisting in the body and it does not stop recurrences.

There is no vaccine available.
Regular condom usage substantially reduces the risk of transmitting genital herpes.
Condoms should be used even between attacks (as virus can be shed in the absence of clinically apparent lesions).
Continuous antiviral drug therapy may prevent clinical recurrences, but asymptomatic shedding of infectious virus can still occur.

2 weeks to 6 months

Pearly white papules develop on skin of the genital area: penis, pubis, scrotum and inner thighs in men and vulva, perineum and inner thighs in women. The number of lesions may vary from few to many. Lesions eventually disappear spontaneously, but this may take many months.

Clinical appearance is very typical.
Laboratory confirmation of the diagnosis is seldom done.

Skin-to-skin contact, sharing of towels.
Genital infection may be the result of sexual transmission.

The lesions tend to disappear spontaneously, but this may take months to years. Therapy is usually desired due to the unsightly nature of the lesions and concern about transmission of infection. Lesions respond well to treatment in healthy individuals, but may be refractory in immuno-compromised patients.
Destruction of individual lesions: cryotherapy, lasertherapy, curettage (pierce lesion and scrape out centre), podophyllin cream (not safe in pregnant women).
Other options: Cantharidin and Imiquimod

No specific measures other than avoiding contact with lesions. Condoms are unlikely to be protective.

6 weeks to six months

Many infections are asymptomatic.
Acute viral hepatitis: Anorexia, nausea, vomiting, pain in the upper abdomen and jaundice.
Most infections are self-limiting, but 5% of adults may become chronically infected with HBV.
These individuals can develop chronic liver disease or liver cancer, but usually only many years after infection.

Patients with acute viral hepatitis should have blood tests to identify the viral cause.

Close personal contact, in families, sharing razors, tooth-brushes, body fluids.
Sexual transmission.
HBV is 10 -100 fold more infectious than HIV.

During acute infection: no specific treatment.
Check the immune status of the sexual partner and other close contacts.
Immunise those who are not immune.
Follow patient up with further blood tests to confirm clearance of the infection.
Those who fail to clear HBV should be referred to a liver specialist for monitoring.

Effective vaccines are available to protect against Hepatitis B. The sex partner of an HBV infected person should be immunised.
Regular condom usage probably does reduce the risk of infection, but does not eliminate it.
Post exposure prophylaxis: If an individual is exposed to blood or body fluids of an HBV positive person, they should check their immunity to hepatitis B. If they are not immune, they should be given an injection of hepatitis B antibody by their doctor and start a course of HBV vaccination.

2-6 weeks post exposure, most individuals experience a febrile illness from which they recover, but they remain infectious life long thereafter.

Primary infection: fever, sweats, malaise, muscle pain, sore throat, headache and enlargement of lymph glands.
These symptoms tend to resolve spontaneously.
Asymptomatic infection: Infected patients feel well.
Late HIV infection: unexplained weight loss, chronic diarrhoea, increased susceptibility to normally harmless infections. Also may develop rare forms of cancer.

This requires laboratory tests that detect the presence of HIV antibodies in the patient’s blood (standard HIV test).
HIV antibody is present in a patient’s blood from about 4 weeks after exposure.
Less than 4 weeks after exposure, antibody tests may be negative (Window period).
Other tests can be used to detect infection before this:
P24 antigen is present in the blood about 3 weeks after infection
These days many laboratories use a p24 antigen/HIV antibody combination test to screen patients for HIV infection.
HIV PCR test: HIV DNA is present in the blood from about 2 weeks after infection. PCR test is used to determine whether a baby is infected with HIV.

NB If HIV tests are negative and a person has been recently exposed, a repeat HIV test should be taken 2-6 weeks later.

Infected persons are infectious life long from about 2 weeks after exposure. Virus is present in blood as well as in body fluids such as semen, vaginal secretions and breast milk. HIV is spread by sexual intercourse (vaginal, anal or oral sex), needle sharing in IV drug abuse, mother to child (during pregnancy, delivery and breast feeding) and needle stick injury.
The approximate risk per encounter/exposure:
Sex: 0.5% (maximum)
Needle sharing: 0.67%
Mother to child: 30% (if no prophylaxis is given)
Breastfeeding: 10% additional risk
Needle stick: 0.3%

See elsewhere for guidelines.

There is no vaccine. Regular condom use is protective.
Post exposure prophylaxis: If someone is exposed to HIV, infection may be prevented by immediately beginning a course of anti-retroviral drugs. Treatment should be started as soon as possible (probably ineffective if started >72 hours after exposure).
Recommended therapy (South Africa): Combivir (contains Zidovudine 300 mg PLUS Lamivudine 150 mg) given 12 hourly for 4 weeks.
Mother to child transmission during pregnancy and delivery can be reduced by treating the mother with anti-retroviral drugs during pregnancy and the infant after delivery (see PMCTC guidelines). To reduce the risk further, HIV-infected mothers should not breast feed their infants or should pasteurise their milk.

• A foul-smelling discharge (most noticeable after intercourse)
• Thin, vaginal discharge usually grey or white in colour, may be profuse

A doctor would examine a sample of vaginal fluid under a microscope to look for features associated with bacterial vaginosis (typically lots of bacteria sticking to epithelial cells). The doctor may also do some basic tests on the vaginal fluid, such as examining the pH (level of acidity).

Health experts are generally unsure about the role sexual activity plays in developing bacterial vaginosis. Changing or having many sexual partners may increase a woman’s chance of getting infected.

Bacterial vaginosis is treated with antibiotics. Generally, male sexual partners are not treated.

A monogamous sexual relationship and abstinence are the best preventative measures a woman can take, although given the uncertainty over the role of a sexually acquired pathogen, this may not be completely preventative

The symptoms develop about 1 week after exposure.

The typical presentation is of an ulcer in the genital area. This may start as a small bump, but develops into an ulcer after about a day. The ulcer could have any of the following characteristics:

• Ranges in size, up to 5cm across
• It is painful
• Has a base that is prone to bleeding if banged
• Has a base that is covered with a grey/yellowish material
• Has sharply defined, irregular/ragged borders

In men, the ulcer may occur on the foreskin, the shaft/head/opening of the penis or on the groove behind the head. Multiple ulcers can occur.
Lymph nodes in the groin may also become swollen, and may form abscesss, or ulcerate.

Chancroid may be suspected based on the nature of the ulcers, especially if multiple. A culture can be taken from the base of the ulcer to further determine the nature of the infection. However, since the organism is difficult to grow in the laboratory and takes time, this is seldom done in practice.

Chancroid is transmitted through sexual intercourse.

Genital ulcers, including chancroid, are usually treated with antibiotics. In South Africa, since the underlying cause of a genital ulcer is often not known, antibiotics to treat all the common causes of genital ulcers are usually prescribed. This is known as the syndromic approach. Large lymph nodes are drained either through local surgery or by using a needle.

Since chancroid is a bacterial infection that is spread through sexual contact, the best preventative measures one could take would be to either abstain from sex or to use protection when having intercourse. Having one sexual partner is the best ‘safe-sex’ option to have.

The incubation period for gonorrhoea is about 7 days, but may be as short as 2 days. In women, symptoms usually take a bit longer to develop, and may only become obvious after a couple of weeks.

Although men almost always complain of some symptoms of gonorrhoea, in women the infection may not have any symptoms. Women suffering from gonorrhoea may experience any of the following symptoms:

• Pain during intercourse
• Cloudy, yellowish vaginal discharge, which may have a foul odour
• Redness and swelling of the genitals
• Burning or itchy vaginal area
• Stomach pain

The typical symptoms in men are:

• Yellow, thick discharge from the penis
• Pain, swelling or tenderness in the scrotum and fever
• Painful or frequent urination or inability to urinate

A doctor would take a culture of discharge from the infected area. Under the microscope, you would see lots of white blood cells, as well as the organism (Neisseria gonorrhoeae). The organism can also be grown in the laboratory. However, in busy clinics this is often not done routinely.

Gonorrhoea is transmitted through unprotected sex. It can also be spread from mother to new-born during birth (this causes an eye infection in the new-born).

Treatment of patients with urethra or vaginal discharges usually consists of a combination of antibiotics to treat all the common causes of the urethral / vaginal discharge, since diagnostic tests are not always done, and since mixed infections are relatively common. This combination of antibiotics would include one active against Neisseria gonorrhoeae. Until recently this used to be ciprofloxacin; however there is now widespread bacterial resistance to this drug, and many centres advocate using a drug called ceftriaxone – which unfortunately has to be given as an injection. A follow-up visit 7 days after treatment can be done to assess whether the infection has responded to treatment.

Gonorrhoea is easily prevented because the bacteria that cause it can only survive under certain conditions. Preventative measures include:

• Always use condoms during vaginal, anal or oral sex. Female condoms, can also reduce the risk of transmission. Use of condoms will also help to prevent the spread of other STDs, including herpes, Chlamydia and HIV
• Ask to be tested for gonorrhoea during all routine visits
• If you are pregnant or planning to become pregnant, have yourself tested for gonorrhea

This ranges from about 1-6 weeks, but is 3 weeks on average.

• Small painless ulcer on genitalia
• Swollen groin lymph nodes on one or both sides
• Drainage from lymph nodes in groin
• Blood or pus from the rectum
• Swelling and redness of the skin in the groin area
• Tenesmus (pain while having a bowel movement)

Medical history of the patient is studied and a physical examination is performed. The exam may reveal:

• Swollen lymph nodes in the groin
• An ulcer on an affected person’s genitalia
• A perianal fistula (connection between the vagina and rectum) with drainage
• Drainage from lymph nodes in the groin
• A history of sexual contact with a person having lymphogranuloma venerum

As with other causes of genital ulcers, the causative organism is often not looked for, although a diagnosis of LGV (and thus Chlamydia trachomatis) may be suspected on the basis of the above clinical findings.

Chlamydia trachomatis is transmitted through sexual intercourse, both vaginal and anal.

Lymphogranuloma venereum is typically treated with antibiotics. In South Africa, since the underlying cause of a genital ulcer is often not known, antibiotics to treat all the common causes of genital ulcers are usually prescribed. This is known as the syndromic approach.

Safe sexual behaviour (i.e. using a condom) reduces risk but abstinence is the only certain way of preventing contracting and spreading a sexually transmitted disease.

The time between exposure and development of primary symptoms can rage from 9-90 days, but is about 3 weeks on average.

There are four stages of syphilis.

Primary Stage

• Painless genital ulcers, which normally resolve if untreated
• Swollen lymph nodes

Once the signs of primary syphilis settle, a period of weeks or months may pass before someone develops secondary syphilis. The features of secondary syphilis include:

• Generalised rash (can be whole body, but often palms and soles)
• Ulcers on mucous membranes (oral and genital)
• Hair loss
• Swollen lymph nodes
• Genital warts
• Headache
• Fever
• Fatigue
• Aches and pains
• Loss of appetite

Untreated, secondary syphilis will resolve spontaneously, and enter what is known as the latent stage. The latent stage is totally asymptomatic. Following the latent stage, some people (about 1/3) will develop tertiary syphilis.

Tertiary syphilis can affect the nervous system, heart and sometimes other organs.
Nervous System

• Personality changes
• Dementia
• Inflammation in the eyes
• Delusions
• Slurred speech
• Meningitis
• Changes in insight and judgement

Heart
The main effect is on the vessels leaving the heart (aorta), and on the valves in the heart. Swelling and dilatation of the vessels and valvular abnormalities are the commonly described problems

Other organs
Tertiary syphilis can result in areas of inflammation of various organs (such as the liver and testes), which may or may not cause that organ to function less efficiently depending on the degree of inflammation.

Blood tests can be done to detect substances produced by the body in reaction to the bacteria that cause syphilis. The older test is the VDRL test. Other blood tests may include RPR and FTA-ABS.

• Through sexual contact – this is the main route of transmission
• Blood transfusions (very rarely since blood is tested before being given)
• A mother can transmit it to her unborn children during pregnancy
• In very rare cases it can also be spread by kissing when the disease is in its second phase.

Every stage can be treated with an antibiotic which is usually given by injection. The drug most commonly used is penicillin. Prognosis during the early stages of the primary and secondary phase is excellent during treatment. However, the tissue damage that occurs during the tertiary phase cannot always be completely reversed.

Sex partners (of the preceding three months while in the primary phase; the preceding year when in the secondary phase) must be informed of the diagnosis so that they too can be tested.

• Correct use of condoms
• Staying in a monogamous relationship.
• It is essential to notify previous sex partners if you become aware that you have been infected with syphilis.

The incubation period may vary slightly depending on the organism (1-3 weeks), but is usually about 10 days (thus slightly longer than the incubation period for gonorrhoea).

Women with an early infection of chlamydia usually do not have any symptoms. In some cases, some of the following symptoms can be present:

• Vaginal discharge
• Itching in the genital area
• Mild pain and discomfort when urinating
• Cloudy urine
• Irregular menstrual bleeding
• Lower abdominal pain
• Fever
• General tiredness

In men:

• Frequent urge to urinate or a burning sensation when urinating
• Cloudy urine
• A whitish yellow discharge from the penis
• Redness or crusting at the tip of the penis

The urethral discharge can be difficult to distinguish from gonorrhoea clinically. The discharge in gonorrhoea is usually thicker and more purulent. If a sample of discharge is examined under a microscope, and Neisseria gonorrhoeae is not seen, then NGU would be suspected. The most reliable way of diagnosing the cause of NGU is by testing samples of discharge fluid to look for the DNA of organisms such as Chlamydia trachomatis. However, this is expensive, and is seldom done in routine clinical practice.

Non-gonoccal urethritis is only spread through sexual intercourse – vaginal and anal. It cannot be contracted though oral sex. It occurs more frequently amongst men than women, although it is possible that many women do not realise they have the infection as mentioned above

If a patient presents with a urethral or vaginal discharge, they are usually treated with combinations of antibiotics to treat the common causes of discharge – both gonorrhoea and the causes of NGU. This is done party because it is difficult and expensive to determine the causes of the discharge, and partly because mixed infections may occur. However, if a specific diagnosis is made (eg Chlamydia) by a laboratory test, the antibiotics to treat that organism would be chosen.

Spread of non-gonococcal urethritis can be prevented by limiting your number of sexual partners, using a condom, remaining in a monogamous relationship with a non-infected partner or by abstaining from sexual intercourse.

There is no specific incubation period, as many people may harbour the organisms for a long time before displaying any symptoms. Men are more likely to be asymptomatic than women.

Women:

• Vaginal itching
• Discomfort with intercourse
• Itching of the inner thighs
• Labial swelling or vulvar itching
• Greenish-yellow frothy or foamy vaginal discharge with a foul or strong smell

In men:

• Itching of urethra
• Burning after urination or ejaculation
• Slight discharge from urethra

In women, a physical exam would reveal red blotches on the vaginal wall or the cervix. A microscopic analysis (wet prep) would show the parasites in the vaginal fluids. Pap smears would also reveal the presence of the parasite. However, as with many other cases of vaginal discharge, investigations to determine the cause of the discharge are not always done, and the patient may be treated with a combination of antibiotics to cover all the common causes of discharge, including Trichomonas. Trichomoniasis is particularly difficult to diagnose in men. Men are treated if the infection was diagnosed in a known sexual partner. Men are also diagnosed if continued burning in the urethra persists despite treatment for gonorrhoea and Chlamydia.

Trichomoniasis can only be transmitted through penis-to-vagina intercourse since the Trichomonas vaginalis cannot survive in the mouth or rectum.

A healthy, monogamous sexual relationship with a known sexual partner will help reduce the likelihood of contracting any STI, including trichomoniasis. Condoms are the best and most reliable form of prevention available but abstinence is the best option to completely eliminate the chances of contracting an STI.

• Abnormal vaginal discharge
• Vaginal and labial itching
• Redness of the vulvar skin
• Inflammation of the vulvar skin
• Pain during intercourse
• Painful urination

Candidiasis is usually diagnosed by appearance of the symptoms. Tests to determine whether a yeast infection is present are performed by analysing some of the vulvar discharge under a microscope.

N/A

• Initially, the yeast infection should be treated by your GP. Treatment is possible by using vaginal creams like micanazole or clotrimazole.
• Medications for vaginal yeast infections are available in either vaginal cream/suppositories or oral preparations.
• The use of oral preparation should be avoided during pregnancy.

Prevention mainly revolves around being aware of some of the risk factors (mentioned above), and avoiding them if possible.
Foods like yoghurt and cranberry juice have been suggested to prevent the re-occurrence of yeast infections, although there is no good evidence that they are effective.
Wearing tight fitting undergarments has also been linked to candidiasis, although again, the evidence is not conclusive