ARI — Key Facts & Diagnosis

Clinical description

• Main symptoms: anorectal pain, itching, discharge, bleeding, sensation of rectal fullness, tenesmus, constipation, mucus streaking of stools. Can also be asymptomatic.
• Transmission by receptive anal sex. Most STIs causing GUD and MUDS can also cause ARI: N. gonorrhoea, C. trachomatis, HSV-2, LGV, syphilis, M. genitalium.
• Consider non-STI causes: haemorrhoids, fissures, inflammatory bowel disease, amoebiasis.

Treatment

Treat if anal discharge is seen in a patient with receptive anal sex in the last 6 months. Examine for skin lesions and ulcers. Add empirical rectal schistosomiasis treatment if compatible.

Standard — no anal pain, no blistering rash

• Ceftriaxone 500 mg IM stat.
• Azithromycin 1 g oral single dose stat.
• Benzathine penicillin 2.4 mega units IM stat.

Standard — anal pain ± blistering rash

• As above, plus acyclovir 800 mg oral TDS for 2 days. (First/severe episode: acyclovir 400 mg oral TDS for 10 days.)

Return if not resolved after 5 days. If not improved: azithromycin 1000 mg oral stat then 500 mg OD until healed + doxycycline 100 mg oral BD for 14 days.

Partner treatment

Partner treatment (asymptomatic)

• Ceftriaxone 500 mg IM stat + azithromycin 1000 mg oral stat + benzathine penicillin 2.4 mega units IM stat. Omit acyclovir for asymptomatic partners.

At every visit

HIV & ART status

• Ascertain HIV + ART status from health passport or self-report.
• Offer new HIV test for all unless previously diagnosed. Do not use coercion.
• New positive: active referral for ART initiation.
• New negative: refer/offer PrEP, VMMC, consistent condom use.
• Known positive: reinforce ART adherence or refer for re-initiation.

Hepatitis B

• Offer HBV rapid test for all patients born before 2002.
• HBsAg negative: refer for HBV vaccination unless previously completed 3 doses.
• HBsAg positive: refer for clinical and treatment assessment.

Syphilis screening

• Offer syphilis rapid test for concurrent asymptomatic syphilis (except in GUD/ARI where it does not influence treatment decisions).

Risk reduction & condoms

• Risk reduction counselling. Promote and dispense condoms.
• Promote VMMC for all non-circumcised men. Schedule appointment in 2 weeks.