Sexually Transmitted Infections: Epidemiology, Testing and Treatment for Adolescents 

Objectives

 Describe the scope and risk factors for sexually transmitted infections (STIs) in adolescents  Discuss the STIs affecting adolescents.

 Assess, treat, and prevent STIs in adolescent patients.



Adolescents Face Increased Risk for STIs

 Biological  Cognitive  Behavioral  Social/Institutional 

Biological Risk Factors: Females

Adolescent cervix Lack of immunity from prior infections Smaller introitus Lack of lubrication can lead to dry, traumatic sex 

Cognitive Risk Factors for STIs in Adolescents  Early adolescence: concrete thinking  Often unable to plan ahead for condoms  Serial monogamy in relationships leading to multiple partners  Personal fable  Unable to judge risk for STIs  “Other people get STIs” 



Behavioral Risk Factors

Intimate Partner Violence Age at First Intercourse Sexual Activity with New Partner Substance Use Multiple Sexual Partners

Behavioral Risk Factor: Older Partners

Predisposes adolescents to relationship power imbalance • Sexual negotiation more difficult • Increased risk of involuntary intercourse, lack of protective behavior, and exposure to STIs 

Men Who Have Sex With Men (MSM)

In 2013, MSM accounted for: • 75% of all primary and secondary syphilis cases An average of 4 in 10 MSM with syphilis are also infected with HIV. 

Women Who Have Sex with Women (WSW)  Adolescent WSW and females with both male and female partners might be at increased risk for STDs and HIV  Syphilis transmission, likely to occur during oral sex, between female sex partners may occur  C. trachomatis among WSW may be more common  HPV transmission can occur from skin-to-skin or skin to-mucosa contact during sex 

Risk Factor: Social/Institutional

Lack of Insurance/$ to Pay Lack of Transportation Concerns About Confidentiality Lack of Sex Ed Regarding Risk and Symptoms  Adolescent s Not Being Screened and Treated Stigma

STI Protective Factors

 Peer support for contraception and condoms  Communication with parents about sex  Connection to family  Connection to school and future success  Connection to community organizations 

Efficacy of Condoms in Preventing STIs

HIV Provide up to 85% reduction in transmission HPV GC, CT, and Trich HSV and Syphilis May prevent 70% of high- and low-risk infections in females When used consistently and correctly, reduce transmission risk Can prevent transmission when infected areas are covered  www.cdc.gov/condomeffectiveness/references.html

 STI Burden Why it matters

U.S. Preventive Services Task Force: High Priority Evidence Gaps  Why focus on STI care and treatment for adolescents and young adults?

 USPSTF 4th Annual Report identifies:  Long-term harms of HIV antiretroviral therapy  Interventions to prevent STIs in low-risk adolescents and high-risk adolescents  Effectiveness of screening strategies to identify high-risk adolescents 

CDC 2013 Report: STIs and Young People

Incidence ~20 Million new cases/year: 50% occur in people ages 15-24 Prevalence Total Infections: 110 Million Increased Risk  Cost # of new infections equal among young males (49%) and females (51%) Direct Medical costs: ~$16 billion/year



Half of New STIs: Ages 15-24

YRBS 2013 Condom Use

80,00%

% of HS Students Who Used a Condom at Last Intercourse

70,00% 60,00% 50,00% 40,00% 30,00% 20,00% 10,00% 0,00% 1991 1993 1995 1997 1999 High School Males 2001 2003 2005 2007 High School Females 2009 2011 2013 

YRBS 2013

Case: Erica

 Erica is a 16-year-old female who presents with dysuria.

 What is your initial differential diagnosis?

 What additional information do you need?



Prevention Counseling

AAP Patient-centered, age-appropriate anticipatory guidance; Integrate sex ed into clinical practice; can use educational materials; Prevention guidance, including abstinence, safer sexual practices, & condoms ACOG AAFP CDC* USPSTF* Counseling for all sexually active individuals High intensity behavioral counseling (HIBC) HIBC; interactive counseling approaches, i.e., client-centered STD/HIV prevention counseling; motivational interviewing; videos and large group presentations to provide information Intensive behavioral counseling for all sexually active adolescents and adults at hi-STI risk 

*Draft

Sexual History: The Five Ps  Partners  Gender(s), Number (three months, lifetime)  Prevention of pregnancy  Contraception, EC  Protection from STIs  Condom use  Practices  Types of sex: anal, vaginal, oral  Past history of STIs  www.stdhivtraining.net

Erica: Sexual History Results

 Several episodes of unprotected sex in the last few weeks with one male partner (her only lifetime)  Not on hormonal contraception but uses condoms most of the time  Engages in oral (giving and receiving) and vaginal sex  No known history of STIs 

History of Present Illness

 Onset and duration of symptoms  Description of symptoms  Associated symptoms  Nausea  Vomiting  Fever  Chills  Back pain  Sores, lumps, bumps 

Erica: History of Present Illness Results

 Erica tells you she has burning with urination and a “yellowish” discharge. She reports itchiness.

 She denies abdominal pain and fever and reports no bumps or lesions.

 What is the differential diagnosis?



Differential Diagnosis

Dysuria Urinary Tract Infection Genital Tract Infection • Cervicitis • Vaginitis Skin-Related Abnormalities/ mucosal perineal • Herpes • Trauma 

Case: Erica

 Do you need to perform a pelvic exam?

 Erica is symptomatic and sexually active.  A pelvic exam in this case is a diagnostic exam not an asymptomatic screening.

 If Erica had been asymptomatic, would you perform a speculum exam?



Summary Cervical Cytology Guidelines When to Begin Pelvic and Pap smears

Screening Date Organization Initial Screening Interval for Updated Under 30 American Congress of Obstetricians and Gynecologists (ACOG) Age 21, regardless of sexual initiation Every three years 2012 United States Preventive Services Task Force (USPTF) Age 21 or within three years of sexual initiation, whichever comes first At least every three years 2011 American Cancer Society (ACS)  Age 21 Every three years 2012

Differential Diagnosis

 You observe discharge in the vault but not in the os  You suspect vaginitis  What are the causes of vaginitis? 



Differential Diagnosis

Dysuria Genital Tract Infection Vaginitis Trichomoniasis Bacterial Vaginitis Candidal Vaginitis

 Erica: Case Continued Trich, BV, Candidal Vaginitis

Trichomoniasis

 Caused by infection with a protozoan parasite (

Trichomonas vaginalis)

 Most common curable STI  More women are infected than men  Prevalence  ~3.7 million people   Only 30% develop any symptoms Highest among blacks 

Trichomonads

Yeast buds Trichomonas* PMN PMN Trichomonas* Squamous epithelial cells

1. Trichomonas: bigger than PMNs 2. PMNs: dense nucleus; Trich: many small vacules 3. Trich: dead once viewed with microscopy — flagella rarely seen 

Trichomoniasis: Symptoms

Females: ~70% are asymptomatic

• Foul-smelling, frothy discharge • Greenish-yellow discharge • Vaginal itching, burning, redness • Dyspareunia • Dysuria • Soreness of the genitals

Males: Most are asymptomatic and often missed

 • Itching/irritation inside the penis • Burning after urination or ejaculation • Discharge from the penis

Routine Trichomoniasis Screening

AAP ACOG AAFP NOT routinely recommended for asymptomatic Consider screening ♀ if individual or population-based risk factors NOT routinely recommended Consider screening ♀ based on local prevalence CDC* NOT routinely recommended: HIV+ ♀ Consider screening persons receiving care in high-prevalence settings, i.e., STD clinics, correctional facilities or if high risk (e.g., multiple sex partners, or h/o STD) USPSTF  *Draft

Trichomoniasis

 Sequelae:  Pregnancy Complications • Preterm delivery; low birth weight  Can increase HIV risk Vaginitis Urethritis 

Bacterial Vaginosis

 Most common vaginal infection in women of childbearing age  Fewer than normal hydrogen peroxide-producing lactobacilli and greater prevalence of other types of bacteria in the vagina  Vaginal saline prep: normal (below); clue cells (above)

Bacterial Vaginosis

 Symptoms  Odorous discharge  Itching, burning, pain  Prevalence  21.2 million (29.2%) among ages 14 –49  Sequelae  Pregnancy complications; Pelvic Inflammatory Disease (PID)  Susceptibility to other STDs (HIV, HSV, CT/GC) 

Candidal Vaginitis

 What is it?

 Overgrowth of the yeast called

Candida

Description: yeast seen in 10% KOH wet mount 

Candidiasis Symptoms

Females Experience genital itching or burning, “cottage cheese-like” discharge Males Itchy penile rash 

Candidal Vaginitis

 Nearly 75% of females experience at least one “yeast infection” in their lifetime  Males rarely get genital candidiasis  Transmission  Most cases caused by person’s own

Candida

organisms  Less commonly passed through sexual intercourse 

Erica’s Cervix

 During the speculum exam you observe Erica’s cervix.  You suspect trichomonas.

 How do you definitively diagnose the causes of Erica’s vaginitis?



Evaluating Vaginitis

 Source: CA STD Training Center

Culture

• Sensitivity: 85%-90% • Specificity: 100%

Trichomonas Diagnosis

Antigen Detection

• Sensitivity: 83% • Specificity: 97%

Available test: OSOM Rapid Test DNA Probe

• Sensitivity: 60%-70% • Specificity: 100%

Available Test: Affirm ™ VP III Wet Mount

• Sensitivity: 60%-80% • Specificity: >97% No good test for males, so often untested 

Candida

Diagnosis

DNA Probe

• Sensitivity: 80% • Specificity: 98%

Wet Mount

• Sensitivity: 35%-45% • Specificity: 97%-99% 

Bacterial Vaginitis Diagnosis

Amsel’s Criteria Requires the presence of at least three of the following four criteria: Whiff test positive for fishy or musty odor when alkaline KOH solution added to smear Clue cells (bacteria attached to the borders of epithelial cells, >20% of epithelial cells) Vaginal pH >4.5

A homogenous noninflammato ry discharge 

Treatment

 Erica’s final diagnosis is vaginitis related to trichomoniasis.  How do you treat her? 

Trichomoniasis: Treatment

Recommended Regimen • Metronidazole 2 gm PO x 1 • Tinidazole 2 gm PO x 1 Alternative Treatment • Metronidazole 500 mg PO BID x 7 days Treatment Failure • Re-treat with metronidazole 500 mg PO BID x 7 days • If repeat failure, treat w/ tinidazole or metronidazole 2 gm PO x 5 days  Never use topicals

Trichomoniasis: Partner Management

 Sex partners of patients with

T. vaginalis

treated. should be  Patients should be instructed to avoid sex until they and their sex partners are cured.



How Would You Treat if Erica Was Diagnosed with BV?

Recommended Regimen • Metronidazole 500 mg PO x BID x 7 days • Metronidazole gel, 0.75%, 1 full applicator (5 g) PV OD x 5 days • Clindamycin cream, 2%, 1 full applicator (5 g) PV QHS x 7 days Alternative Treatment • Clindamycin 300 mg PO BID x 7 days • Clindamycin ovules 100 mg PV QHS x 3 days • Tinidazole 2g PO OD x 2 days • Tinidazole 1g PO OD x 5 days 

BV Diagnosis: Partner Management

 Clinical trials indicate that a female’s response to therapy and likelihood of relapse or recurrence are not affected by treatment of her sex partner(s).

 Routine treatment of sex partners is not recommended.



How Would You Treat if Erica Was Diagnosed with

Candida

?

Over-the-Counter Intravaginal Agents • Butoconazole 2% cream 5g PV x 3 days • Clotrimazole 1% cream 5g PV x 7–14 days • Clotrimazole 2% cream 5g PV x 3 days • Miconazole 2% 5g PV x 7days • Miconazole 4% cream 5g PV x 3 days • Miconazole 100mg vaginal suppository, one suppository for 7 days • Miconazole 200mg vaginal suppository, one suppository for 3 days • Miconazole 1200mg vaginal suppository, one suppository for 1 days • Tioconazole 6.5% ointment 5 g PV in a single application Prescription Intravaginal Agents • Butoconazole 2% cream (single dose bioadhesive product), 5 g PV x 1 day • Nystatin 100,000-unit vaginal tablet, one tablet for 14 days • Terconazole 0.4% 5g PV x 7 days • Terconazole 0.8% cream 5g PV x 3 days • Terconazole 80 mg vaginal suppository, one suppository for 3 days 



Treatment for

Candida

Oral Agent

Fluconazole 150 mg oral tablet, one tablet in single dose

Candida

: Partner Management

Not usually acquired through sexual intercourse.

Treatment of sex partners not recommended —may be considered in females who have recurrent infection. Minority of male sex partners might have balanitis —may benefit from treatment with topical antifungal agents. 

Additional Concerns

 Because she is a sexually active 16-year-old, she is also at risk for cervicitis

.

 What are the most common identifiable causes of cervicitis?

 Chlamydia  Gonorrhea 

 Erica: Case Continued Chlamydia and Gonorrhea

Chlamydia

Curable bacterial STI Most common reportable communicable disease Highest reported rates among adolescent and young adult females (Aged 15-24) Usually asymptomatic 

Chlamydia Symptoms

Females: Up to ~80-90% asymptomatic • Heavy or prolonged menses • Spotting • Dysmenorrhea • Dyspareunia • Vaginal discharge Males: Up to 90% asymptomatic • Penile discharge • Dysuria 

68% of All Chlamydia Cases Among 15- to 24-year-olds  CDC STD Surveillance Report 2013

Chlamydia —Rates by Race/Ethnicity, United States, 2009-2013  CDC STD Surveillance Report 2013

Sequelae Untreated Chlamydia: Females

Symptomatic PID occurs in 10-15% of women with untreated Chlamydia

Increased risk of HIV transmission



Sequelae Untreated Chlamydia: Males Epididymitis Reactive arthritis HIV transmission Proctitis



♀ Routine Annual Chlamydia Screening

AAP all sexually active ≤25 yrs ACOG all sexually active adolescents AAFP CDC* all sexually active <24 yrs all sexually active <25 yrs USPSTF all sexually active <24 yrs

*Draft



Chlamydia Screening: Males

Routine Screening NOT recommended for men Selective screening in high-prevalence populations should be  considered Correctional facilities STD clinics Adolescent-serving clinics MSM Multiple partners AAFP, CDC, USPSTF, AAP Recommendations

Gonorrhea

Curable bacterial STI Second most commonly reported disease Found in the cervix, uterus, fallopian tubes, and the urethra Can also be found in the mouth, throat, eyes, and anus 



Gonorrhea Symptoms

Females: ~50% are asymptomatic • Yellow or bloody vaginal discharge • Burning/painful urination • Bleeding with vaginal intercourse Males: Up to 50% asymptomatic • White, yellow/green pus from the penis with pain • Burning during urination • Swollen/painful testicles

Gonorrhea — Rates by Age and Sex, United States, 2013  CDC STD Surveillance Report 2013

Gonorrhea — Rates by Race/Ethnicity, United States, 2009 –2013  CDC STD Surveillance Report 2013

Clinical Manifestations: Male Genital Infection  Urethritis —Inflammation of urethra  purulent discharge  Epididymitis — Inflammation of the epididymis  Swollen testicle 

Clinical Manifestations: Female Genital Infection  Most infections asymptomatic  Urethritis —inflammation of the urethra  Cervicitis —inflammation of the cervix 

Sequelae of Untreated Gonorrhea

Females: Cramps and pain, vomiting, fever

Can lead to

• PID • Infertility • Ectopic pregnancy • HIV Males: Rare

Left untreated

• Prostate complications • Epididymis • HIV 

♀ Routine Gonorrhea Screening

AAP ACOG AAFP CDC USPSTF all sexually active ♀ <25 yrs all sexually active ♀ adolescents all sexually active ♀ <24 yrs all sexually active ♀ <25 yrs all sexually active ♀ <24 yrs 

♂ Routine Gonorrhea Screening

AAP AAFP CDC* USPSTF Consider screening AYA MSW on basis of individual and population based risk factors (persons of color, ↑ community prevalence) AYA MSM for rectal, oral, and urethral GC annually if receptive anal, oral or insertive intercourse. Screen Q3-6 mo if hi risk w/ multiple or anonymous partners, sex in with illicit drug use, or risky sex partners; GC-exposed Insufficient evidence to recommend for or against routine GC screening for in ♂ at ↑increased risk for infection MSM for rectal, oral, and urethral GC annually if receptive anal, oral, or insertive intercourse. Screen Q3-6 mo if hi risk w/ multiple partners or HIV+; GC-exposed Insufficient evidence to recommend for or against routine GC screening for in ♂ at ↑increased risk for infection  *Draft

USPSTF GC/CT Risk Factors

 Age   ♀ ages 15-24 years ♂ ages 20-24 years  New sex partner, >1 sex partner, or sex partner w/ STI infection; inconsistent condom use; H/O or coexisting STIs; and exchanging sex for money or drugs  Incarcerated populations, military recruits, and patients receiving care at public STI clinics  Racial/ethnic differences; blacks and Hispanics higher GC/CT rates vs. whites 

Case: Evaluating Cervicitis

 How do you evaluate Erica for cervicitis? 

Chlamydia/Gonorrhea Nucleic Acid Amplified Tests (NAAT) 

Females

: Self-collected vaginal swab is preferred • Urine samples are acceptable.

• Decreased performance compared with genital swabs 

Males

: Urine is the preferred specimen • Urethral swab samples are less sensitive than urine 

NAAT vs. Culture

 Schachter J,et al.

Sex Transm Dis

. 2008;35:637-42.

Chlamydia Diagnosis

Culture NAAT EIA Sensitivity: 70% Sensitivity: 85 –90% Specificity: 85 –95% Specificity: >98% Preferred Sensitivity: 50 –65% Specificity: >95% DFA Sensitivity: 65 –70% Specificity: 95% DNA Probe Sensitivity: 65 –70% Specificity: 95% 

Gonorrhea Diagnosis

Culture NAAT Sensitivity: 90% Specificity: 99% Sensitivity: 85 –90% Specificity: >98% Preferred  Typical Gram Stain Sensitivity: 80% Specificity: 98% 90% sensitive in symptomatic male; only 50% sensitive in females and in asymptomatic males DNA Probe Sensitivity: 35 –45% Specificity: 99%

How to Order Screen

 Non-genital GC/CT NAATs can be done by clinical laboratory with CLIA approval

Gen-Probe APTIMA testing

Pharyngeal Rectal Urine/Urethral

QUEST diagnostics test codes

70051X 16506X 13363X

LabCorp diagnostics test codes

188698 188672 183194 Relevant CPT Billing Codes: CT detection by NAAT: GC detection by NAAT: 87491 87591

Erica: Case Continued

 You collect a specimen and order a NAAT test for both gonorrhea and chlamydia.

 You administer a pregnancy test, which is negative.

 What else would you do?



Erica: Case Continued

 Because your exam was consistent for trichomoniasis and not cervicitis, you do not presumptively treat for gonorrhea and chlamydia.  In a week, labs confirm positive gonorrhea and negative chlamydia tests. 

Treatment for Uncomplicated Gonococcal Infections of the Cervix, Urethra, and Rectum Recommended Ceftriaxone 250 mg IM Once PLUS Azithromycin 1 g Orally Once

OR

Doxycycline 100 mg Orally Twice a day for 7 days Quinolones are no longer recommended in the United States for the treatment of gonorrhea and associated conditions, such as PID  www.cdc.gov/mmwr/preview/mmwrhtml/mm6131a3.htm?s_cid=mm6131a3_w

Treatment for Uncomplicated Gonococcal Infections of the Cervix, Urethra, and Rectum Alternative 1: If Ceftriaxone is not available Cefixime 400 mg Orally Once

PLUS

Azithromycin 1 g Orally Once

OR

Doxycycline 100 mg Orally Twice a day for 7 days

PLUS

Test of cure in 1 week  www.cdc.gov/mmwr/preview/mmwrhtml/mm6131a3.htm?s_cid=mm6131a3_w

Gonorrhea Treatment Options for Pharynx

Ceftriaxone 250 mg in a single intramuscular dose PLUS Azithromycin 1 g orally in a single dose OR Doxycycline 100 mg daily for 7 days As of 2007, quinolones are no longer recommended in the US for treatment of gonorrhea and associated conditions. 

Treatment for Uncomplicated Gonococcal Infections of Cervix, Urethra, Rectum, and Pharynx Alternative 2:

If patient is cephalosporin-allergic

Azithromycin Test of cure in 1 week 2 g PLUS Orally Once  www.cdc.gov/mmwr/preview/mmwrhtml/mm6131a3.htm?s_cid=mm6131a3_w

GC Follow-Up Testing

 Test of cure is

not

recommended if recommended regimen is administered  Test of cure

is

recommended if  Alternative regimen is administered  Symptoms persist after treatment and not from reinfection (prescription failure)  Test of cure by

N. gonorrhoeae

culture  Test isolated GC for antimicrobial susceptibility  If no cervical access, use NAAT • Most GC NAATs negative within a week of GC prescription  Repeat testing in 3 months regardless of prescription  www.cdc.gov/mmwr/preview/mmwrhtml/mm6131a3.htm?s_cid=mm6131a3_w

Positive Gonorrhea: When to Treat for Chlamydia

 If she had tested positive for chlamydia and gonorrhea  If she had been tested for chlamydia with a test other than a NAAT, and the chlamydia test was negative 

Chlamydia Treatment

 Recommended Regimens  Azithromycin 1 g PO single dose  Doxycycline 100 mg PO BID x 7 days  CDC STD Treatment Guidelines. 2010.

 STI Partner-Management Strategies

STI Partner-Management Strategies

Provider Referral Patient Referral Partners contacted by index patient’s provider or by a disease intervention specialist Index patient assumes primary responsibility to notify and refer his/her partners at risk Expedited Partner Therapy (EPT)  Providers (1) give patient medication intended for the partners (2) write partners’ prescriptions for medication

CDC Recommends EPT

 EPT: Delivery of medications or prescriptions by persons infected with an STD to their sex partners without clinical assessment of the partners.

 EPT laws vary by state:  Permitted in 35 states and the city of Baltimore, MD  Prohibited in 6 states (FL, KY, MI, OH, OK, WV)  www.cdc.gov/sTd/ept/legal/default.htm



Behaviors Affecting EPT Effectiveness

Patient-delivered specific Patient did not give Rx to any/all partners General noncompliance Partners noncompliant with Rx Patients did not contact partners Patients noncompliant with Rx Resumed sex <7 days after case and partner treatment Sex with new partner(s) 

EPT Barriers

 General theoretical liability issues  Rx without an exam  Medical records for treated partner?

 Legal issues with minors  Consent to care  Obligation to report sex in minors with older partners  Financial: who pays for partner Rx?

 Adverse drug effects  Partner may not seek complete STI assessment  Potential to miss partners’ other STIs, including HIV  Missed counseling opportunities for partners 

Repeat Testing After Treatment

 Pregnant females  Repeat testing, preferably by NAAT, 3 weeks after completion of recommended therapy  Non-pregnant females  Test of cure not recommended unless: • Compliance is in question, symptoms persist, or re infection is suspected  Repeat testing recommended 3-4 months after treatment • Especially adolescents; high prevalence of repeat infection 

What Is Next for STI Partner Strategies?

 Internet: Facilitating Partner Notification  MSM and in cases where no other identifying information is available  Many health departments now conduct formal internet partner notification (IPN)  Expedited Partner Therapy Legal/Policy Toolkit  Assist states interested in adopting EPT supportive laws  Assist states that have adopted EPT laws with addressing full implementation barriers  www.cdc.gov/std/ept/legal/LegalToolkit.htm



 Erica: Case Continued HIV Testing

HIV/AIDS

Incidence 1/3 of new infections in 2006 in people ages 13-29 Symptoms Infections in adolescents not usually symptomatic or diagnosed until 20s or 30s Some develop flu-like symptoms within a month or two of exposure to HIV 

HIV and MSM disparities

 MSM:  57% of the 1.1 million people with HIV  66% of all new HIV infections each year  91% of all HIV infections in young males, aged 13-19  Black MSM  2/3 of men with HIV aged 13-24  Largest increase in HIV infections 

HIV Awareness

 Proportion of people unaware of their HIV infection declined from 20% to 16%  As of 2009, 83 million adults aged 18-64 reported they had been HIV tested 

Routine HIV Screening

AAP ACOG AAFP CDC USPSTF Offer routine screening to all by age 16-18 yrs in health care settings when HIV prevalence > 0.1% Encourage routine HIV testing for all sexually active teens and those with other risk factors in low HIV prevalence areas Routine screen all sexually active adolescent ♀ Screen ages 18 to 65 yrs for HIV infection Screen younger adolescents and older adults at ↑ HIV risk Screen aged 13-64 in all health-care settings; Screen all high-risk persons at least annually, e.g., MSM; Screen all persons who seek STD diagnosis and treatment Screen age 15-65 yrs Screen younger adolescents and older adults at ↑ HIV risk Offer “reasonable approach” to screening intervals (1x for low risk; every 3 5 yrs for increased risk; annually for very high risk) 

CDC Backs New HIV Testing

 “Fourth generation” HIV test  More accurate diagnosis of acute HIV-1, established HIV-1, HIV-2  Distinguishes HIV-1 from HIV-2 antibodies  Detects HIV 3-4 weeks earlier, faster results  HIV-1 Western Blot no longer recommended  STI Quarterly Contraceptive Technology Update September 2014

HIV Positive Diagnosis

 Counseled regarding behavioral, psychosocial, and medical implications  Assess need for immediate care or support  Link patients to psychosocial and medical services  Partners (sexual and IDU) should be notified, either by the patient him/herself or by the provider, hospital, or state/local health department 



 Case Study: Justin Herpes and Syphilis

Case: Justin

 Justin is a 17-year-old male who presents with a painful sore “down there.” He noticed it five days ago. 

Sexual History

 During the sexual history, Justin discloses that he has had both male (1 lifetime) and female partners (3 lifetime).

 He is currently in a relationship with a female with whom he has vaginal and oral sex.  He uses condoms “almost all the time.”  He has no known history of STIs.



Physical Exam

 You do a genital exam and on the shaft of the penis, you observe several lesions.

What is your differential diagnosis? 

Differential Diagnosis

Herpes

Cluster of painful (sometimes) sores

Chancroid

Painful ulcer with sharp borders

 Genital Sores Trauma Syphilis

Solitary painless ulcer with indurated border

LGV

Painless papule, shallow erosion or ulcer

Genital Herpes Background

Caused by the herpes simplex viruses type 1 (HSV-1) and type 2 (HSV-2) Majority of genital and perirectal herpetic outbreaks caused by HSV-2 Estimated that one million new cases occur in the U.S. each year Over 80% new cases undiagnosed 

Adolescent Females and MSM

 While most recurrent outbreaks are due to HSV-2, HSV-1 is becoming more prominent as a cause of first episode of genital herpes 

Genital Herpes: Initial Visits to Physicians’ Offices, United States, 1966-2013  CDC STD Surveillance Report 2013

Herpes Simplex 2: Seroprevalence by Race, Sex, and Age Group  CDC STD Surveillance Report 2013

Genital Herpes: Symptoms

Most cases asymptomatic (up to 90%) Painful blisters/open sores in genital area May be preceded by a tingling or burning sensation in the legs, buttocks, or genital region Sores usually disappear within 2-3 weeks Virus remains in the body for life, causing outbreaks to recur occasionally 

Genital Herpes Types of Infection

 First clinical episode  Primary  Non-primary  Recurrent symptomatic infection  Asymptomatic infection 

Infection Type Lesions/ Symptoms

1 st Episode Primary Type 1 or 2 1 st Episode Non-primary Type 2 1 st Episode Recurrence Type 2 Symptomatic Recurrence Type 2 Infection Type 2 +/Sever, bilateral +/Moderate +/Mild +/Mild, unilateral – +/ – +/ – +/ –

Type Antibody at Presentation

HSV-1 HSV-2 – – + – + + +

Asymptomatic Viral Shedding

 Most HSV-2 is transmitted during asymptomatic shedding  Rates of asymptomatic shedding greater in HSV-2 than HSV-1  Rates of asymptomatic shedding are highest in new infections (<2 years) and gradually decrease over time  Asymptomatic shedding episodes are of shorter duration than shedding during clinical recurrences 

Genital Herpes Sequelae

 Aseptic meningitis  More common in primary infection  Generally no neurological sequelae  Rare complications include:  Stomatitis and pharyngitis  Radicular pain, sacral paresthesias  Transverse myelitis  Autonomic dysfunction  Psychological distress 

Painless Ulcer

 If Justin’s sore had been painless and solitary, what would the differential diagnosis be?



Syphilis

STI caused by the bacterium

Treponema pallidum

 Includes three stages: • Primary • Secondary • Late and Latent

Primary Syphilis: Signs and Symptoms

 One or more skin lesions called chancres at the site where the spirochete penetrated (2 weeks to 3 months after initial infection)  Large numbers of organisms are present in exudates of lesion and in lymph nodes and infiltration of ulcer with inflammatory cells  Highly infectious; diagnosis by dark field microscopy  Chancre heals within 2 months 

Secondary Syphilis: Signs and Symptoms

 Clinical signs of disseminated disease appear with prominent skin lesions (rash) dispersed over the entire body surface (occurs in 50% of cases) accompanied by flu-like symptoms (sore throat, fever, headache, etc.) and swollen lymph nodes  Maculopapular skin lesions that are most prominent on palms of the hands and soles of feet will occur in 80% of patients  Lesions called condylomas may occur on skin in moist areas (vagina and anus) 



Syphilis: Primary



Syphilis: Secondary

Primary and Secondary Syphilis: Rates by Age and Sex, United States, 2013  CDC STD Surveillance Report 2013

Primary and Secondary Syphilis by Race/Ethnicity and Sex  CDC STD Surveillance Report 2013

Primary and Secondary Syphilis: By Sex, Sexual Behavior, and Race/Ethnicity, United States, 2013  CDC STD Surveillance Report 2013

Sequelae

Chancre increases the risk of HIV • In recent outbreaks, rates of co-infection ranged from 20%– 70% 

Evaluating Genital Ulcers

 How do you evaluate the causes of Justin’s genital lesions?



Genital Herpes: Screening

Current CDC guidelines do not recommend universal screening with serology Consider testing if: Past inconclusive work up for genital lesions —negative herpes culture or NAAT Have a partner with genital HSV MSM Are HIV infected 

Routine Syphilis Screening

AAP ACOG AAFP CDC* USPSTF NOT routinely recommended MSM. Screen Q3-6 mo if hi risk; Consider if behaviors put them at higher risk; consult with LHD NOT recommended Screen based on local disease prevalence NOT recommended Screen persons at increased risk (MSM, CSW, exchange sex for drugs, correctional facilities) NOT recommended Screening in correctional facilities based local and institutional prevalence; MSM. Screen Q3-6 mo if hi risk w/ multiple partners or HIV+ NOT recommended Screen persons at increased risk (MSM, CSW, exchange sex for drugs, correctional facilities) *Draft 

HSV Diagnosis

Culture Sensitivity: 73% Specificity: 100% Culture requires a new lesion and high viral load Type Specific Serology Sensitivity: 80% 98% Specificity: >96% Most HSV-1 is not sexually transmitted PCR Sensitivity: 98% Specificity: 100% Sensitivity decreases as lesion heals 

Syphilis Diagnosis

Classical Testing 1 st Non treponemal - RPR - VDRL

2 nd

Treponemal test - TPPA - FTA Emerging Testing

1 st

Treponemal Test

2 nd

Non treponemal test 

Justin: Case Continued

 Results from the RPR negative and culture are positive for HSV-2  How do you treat?



HSV-2

Treatment for Acute First Episode Acyclovir 400 mg TID for 7 10 days Acyclovir 200 mg PO 5x/day for 7-10 days Famciclovir 250 mg PO TID for 7-10 days Valacyclovir 1 g PO BID 7 10 days  Simplest regimen preferred with adolescents

Suppressive Therapy

 Treatment with: 

Acyclovir

400 mg orally twice a day or 

Famiciclovir

250 mg orally twice a day or 

Valacyclovir



Valacyclovir

500 mg orally once a day or 1.0 g orally once a day 

Counseling: Treatment

 Suppressive therapy available and effective in preventing symptomatic recurrences  Episodic therapy sometimes useful in shortening duration of recurrent episodes  When and how to take antiviral medications  Recognition of prodromal symptoms to know when to begin episodic therapy 

Counseling: Transmission and Prevention

 Inform current and future sex partners about genital herpes diagnosis  Abstain from sexual activity with uninfected partners when lesions or prodrome present  Correct and consistent use of latex condoms might reduce the risk of HSV transmission  Valacyclovir suppressive therapy decreases HSV-2 transmission in heterosexual couples in which source partner has recurrent herpes 

If Justin Was Positive for Syphilis, How Would You Treat?

 Primary, Secondary, and Early Latent  Benzathine Penicillin G —2.4 million units IM x 1 dose 

What Other Tests Should You Order?

 HIV  What if Justin discloses to you sexual behavior with other males?



Chlamydia Testing for MSM Under 25

 Screen for urethral/rectal infection in males who in the past year have had:  Insertive anal intercourse  Receptive anal intercourse (NAAT of a rectal swab preferred)  Urine based NAAT is preferred  Rescreen for reinfection at 3 months  Screening for pharyngeal infection NOT RECOMMENDED  Marcell, A.V. and the Male Training Center for Family Planning and Reproductive Health. 2014.

Gonorrhea Testing for MSM

 Screen for urethral/rectal infection in sexually active MSM at least annually who have had:  Insertive anal intercourse  Receptive anal intercourse (NAAT rectal swab preferred)  Screen for pharyngeal infection in males who in past year have had:  Receptive oral intercourse (NAAT preferred)  Urine based NAAT is preferred  Rescreen for reinfection at 3 months  More frequent screening for MSM w/multiple or anonymous partners/illicit drug use  Marcell, A.V. and the Male Training Center for Family Planning and Reproductive Health. 2014.

Immunizations



Human papillomavirus (HPV4) vaccination

 Routine: ages 11-12; Catch-up: ages 13-21; Special populations: ages 22-26; ages 9-10 can be vaccinated 

Hepatitis B vaccination (HBV)

among persons aged <19 years and for all adults who are at risk or who request vaccination.

 Young MSM may require more thorough evaluation 

Hepatitis A (HAV)

among persons at risk  Marcell, A.V. and the Male Training Center for Family Planning and Reproductive Health. 2014.

Case Wrap-Up: Justin

 Genital lesions can be painful or painless  Painful: Chancroid  Sometimes painful: HSV  Painless: Syphilis, LGV  Patients with genital ulcers should be evaluated with: • • Serologic test for syphilis Diagnostic evaluation for HSV 

Go-to info sources: CDC!

 DSTDP: www.cdc.gov/std  Treatment guidelines  GC/CT lab guidelines  Surveillance stats (slides)  DHAP  Rapid tests  Surveillance stats (slides) 

Other STI screening guidelines

 CDC: www.cdc.gov/std/treatment  USPSTF: www.uspreventiveservicestaskforce.org/uspstopics.htm

 ACOG: www.acog.org/Resources-And-Publications 

Red Book STI Chapters  aapredbook.aappublications.org

Provider Resources: Sexually Transmitted Infections   National Chlamydia Coalition: ncc.prevent.org

U.S. Centers for Disease Control and Prevention  Statistics and Surveillance Reports: www.cdc.gov/std/stats/default.htm

 Expedited Partner Therapy: www.cdc.gov/STD/ept/default.htm

 Treatment Guidelines: www.cdc.gov/std/treatment/2010/default.htm

 American Social Health Association:  www.ashastd.org/std-sti/hpv.html

U.S. Department of Health and Human Services womenshealth.gov/faq/stdhpv.htm

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Provider Resources and Organizational Partners  www.advocatesforyouth.org

— Advocates for Youth  www.aap.org

— American Academy of Pediatricians  www.aclu.org/reproductive-freedom Union Reproductive Freedom Project American Civil Liberties  www.acog.org

— American College of Obstetricians and Gynecologists  www.arhp.org

— Association of Reproductive Health Professionals  www.cahl.org

— Center for Adolescent Health and the Law  www.glma.org

 Gay and Lesbian Medical Association

Provider Resources and Organizational Partners  www.guttmacher.org

— Guttmacher Institute  janefondacenter.emory.edu

University Jane Fonda Center at Emory  www.msm.edu

Morehouse School of Medicine  www.prochoiceny.org/projects-campaigns/torch.shtml

Pro-Choice New York Teen Outreach Reproductive Challenge (TORCH) NARAL  www.naspag.org

North American Society of Pediatric and Adolescent Gynecology  www.prh.org

— Physicians for Reproductive Health 

Provider Resources and Organizational Partners  www.siecus.org

— Sexuality Information and Education Council of the United States  www.adolescenthealth.org

— Society for Adolescent Health and Medicine  www.plannedparenthood.org

America Planned Parenthood Federation of  www.reproductiveaccess.org

Project Reproductive Health Access  www.spence-chapin.org

Spence-Chapin Adoption Services 

Please Complete Your Evaluations Now 