HIV & Hepatitis B Integration

Clinical description

All STI patients have biological evidence for recent unprotected sex with a partner at high HIV risk. STIs increase HIV transmission/acquisition risk up to 5-fold. About 16% of STI patients in Malawi in 2023 were HIV positive; about 1% with a negative rapid test may have acute HIV in the window period.

HIV status ascertainment

• Routinely ascertain HIV and ART status for all STI index patients and partners.
• Never tested or tested negative in the past: offer new HIV test (routine opt-out strategy). Do not use coercion — emphasise STI will be treated regardless of HIV testing.

Referral by HIV status

• Known positive: reinforce ART adherence or refer for re-initiation if not on ART.
• New positive: active referral for ART initiation.
• New negative: explain and offer/refer for PrEP, VMMC, consistent condom use. Schedule VMMC appointment in 2 weeks when STI has healed.

Prevention

Hepatitis B in STI patients

• HBV is mostly transmitted during childbirth and early childhood; sexual transmission accounts for 15–30%.
• Risk of chronic infection: 90% when infected at birth, 30% under five, 5% as older child/adult.
• 25% of people with chronic HBV develop cirrhosis and liver cancer. 65% have no symptoms.
• Almost all under 22-year-olds in Malawi have completed HBV infant vaccination (started 2002) and don't need routine testing.
• Offer routine HBV testing (HBsAg rapid test) to all STI patients born before 2002 who have not completed HBV vaccination.
• HBsAg positive: refer for clinical assessment. HBsAg negative: offer HBV vaccination (3 doses) for high-risk groups.

Hepatitis C

HCV is mainly transmitted through blood products and needles; sexual transmission is rare. HCV prevalence in Malawi is thought to be low except in people who inject drugs. Routine HCV testing for STI patients is not indicated.