AVD — Key Facts & Diagnosis

Clinical description

• Main symptoms: vaginal discharge with abnormal quantity/consistency/colour/odour. ± itching, soreness, swelling, dyspareunia, dysuria. ± lower abdominal/pelvic pain (if present, manage as LAP).
• Sexually transmitted causes: Trichomonas vaginalis, Neisseria gonorrhoea, Chlamydia trachomatis — can spread to upper genital tract causing PID.
• Non-sexually transmitted causes: Candida albicans, bacterial vaginosis (foul odour), genital schistosomiasis.
• Use sexual risk assessment to distinguish STI from non-STI causes. High STI risk: partner has STI symptoms and/or recent condomless sex with high-risk partner(s), or any sign of cervical infection.
• Routine syphilis screening is useful in women with AVD to diagnose asymptomatic syphilis.

Treatment

Always perform pelvic/abdominal palpation and speculum exam for women with AVD to rule out cervical cancer and PID. Follow LAP management if any tenderness is present.

High STI risk / cervicitis — standard treatment

• Ceftriaxone 500 mg IM stat.
• Azithromycin 1000 mg oral stat.
• Metronidazole 400 mg oral BD for 5 days.

Low STI risk / no cervicitis — standard treatment

• Metronidazole 400 mg oral BD for 5 days.
• If thick/cream discharge, burning/swelling: add clotrimazole 500 mg vaginal pessary stat.

Return if not resolved after 5 days. Add praziquantel 40 mg/kg if compatible with genital schistosomiasis.

Partner treatment

Partner treatment (asymptomatic)

• Low STI risk: no routine treatment for partners.
• High STI risk / cervicitis: ceftriaxone 500 mg IM stat + azithromycin 1000 mg oral stat + metronidazole 2000 mg oral stat.

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.