Transcript Sexually Transmitted Infections

Sexually Transmitted Infections
Stacy Higgins, MD
Emory University School of Medicine
Most Common STIs
• Ulcerative Lesions
– Syphilis
– Genital Herpes
• Human Papilloma Virus
– Genital Warts
– Cervical Cancer
• Discharges
– Gonorrhea
– Chlamydia
History of Syphilis
• At the end of the 15th Century, syphilis arrived
in Western Europe
• “The French disease” or “The Disease of
Naples” since the first cases had developed in
that city during the French occupation
• People believed to have suffered from syphilis
The Tuskegee Study
The Tuskegee Study
• 1932: the USPHS enrolls 412 poor African
American men diagnosed with syphilis in Macon
County, Alabama
• Goal: follow the natural course of the disease
• Recruitment incentives:
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–
–
–
Free medical care
Free hot meals
A certificate signed by the Surgeon General
$50 dollar burial stipend
Tuskegee Study
• By 1943, penicillin was widely used to treat
syphilis, except among the men in the
Tuskegee study
• The study stopped in 1972, when a CDC staff
member blew the whistle
“He Who Knows Syphillis, Knows
Medicine”
Sir William Osler
Reported cases by stage of infection 1941–2005
Syphilis — Reported cases by stage of
infection: United States, 1941–2005
Primary and secondary syphilis rates by state, 2005
The total rate of primary and secondary syphilis for the United States and
outlying areas (Guam, P.R. and USVI) was 3 per 100,000. The Healthy People
2010 target is 0.2 case per 100,000 population.
Primary and secondary syphilis rates by race
and ethnicity
Clinical Manifestations
Primary syphilis:
CHANCRE
• single, painless, clean based ulcer with
induration
• painless regional lymphadenopathy (80%)
• incubation period of 3 to 90 days
• occur at site of innoculation
Secondary Syphilis
• 2w-6 mos after primary infection
• Primary chancre may or may not still be
present
• Skin rash
• Alopecia
• Mucosal lesions
• Generalized LAN
Syphilis- Latent stage
• Latent Syphilis: period from disappearance of
secondary symptoms until cure or tertiary
symptoms
– Early latent: within 1 year of infection
– Late latent: after 1 year of infection
Tertiary Syphilis
• Cardiovascular:
– syphilitic aortitis of ascending aorta
– aortic regurgitation
• Neurologic:
– asymptomatic
– aseptic meningitis
– paresis mimicking progressive dementia with
psychotic features
– tabes dorsalis
Treatment
Primary, secondary
and early latent (<1yr)
Late latent (>1y) or
latent of unknown
duration
Tertiary syphilis (not
neuro)
PCN 2.4 mu IM
Doxy 100mg PO BID x2w
Neurosyphillis
PCN G 3-4mu IV q4h for 1014d or
Procaine PCN 2.4mu IM
daily plus probenecid 500mg
PO QID x10-14d
Benzathine PCN 2.4mu IM
x3 doses weekly or
Doxy 100mg PO BID x4w
Benzathine PCN 2.4mu IM
x3 doses weekly or
Doxy 100mg PO BID x4w
Genital Herpes
Epidemiology
• Caused by HSV-1 or HSV-2
• Primary route of acquisition of HSV-2 is
through genital-genital sexual contact
• HSV-1 primarily acquired through oral-genital
contact
• Most cases subclinical
• Transmission primarily from subclinical
infection
Epidemiology
• 25% of the US population over 30yo has HSV-2
• One of the 3 most common STDs
• Genital Herpes:
– HSV-2: 80-90%,
– HSV-1: 10-20%
• Risk of infection correlates with the number of
lifetime sexual partners
Genital Herpes Simplex
Herpes: Initial Infection
• “Classic” presentation: macules and
papules that progress to vesicles, pustules
and ulcers
• Symptomatic cases sometimes severe with
prolonged, systemic manifestations
• Vesicles  painful ulcerations  crusting
Kimberlin and Rouse NEJM 350 (19): 1970, Figure 2 May 6, 2004
Herpes: Recurrent Infection
• May be symptomatic or more commonly
asymptomatic
• Prodrome may be present
• Duration of viral shedding is shorter and there
are fewer lesions present
• Recurrence rates decrease over time
Herpes and HIV
• High HIV titers found in genital herpes
ulcerations
• Plasma HIV viral load increases with HSV-2
infection reactivation in HIV-infected persons
Underdiagnosis of Genital Herpes
• 779 women attending STD clinic
• 372 genital herpes diagnosis
• Of the 372 diagnosed:
– 82 (22%) symptomatic
– 14 (4%) viral shedding without symptoms
– 60 (14%) history of symptoms
– 216 (58%) HSV-2 antibody without viral
shedding or history of symptoms
HSV: Diagnosis
• Tzanck smear
– multinucleated giant cells ~2/3rds of the time
when vesicles are present
– often negative at the stage of crusting
• Viral Culture
– becomes insensitive within days of onset
• Polymerase Chain Reaction
• Type-specific serum antibody assays
Therapy- Initial Episode
• Acyclovir 200mg 5x/day or 400mg TID x7-10d
• Valacyclovir 1000mg BID x7-10d
• Famciclovir 250mg TID x7-10d
• Increased rate of healing, but does not
prevent recurrences
HSV Recurrence
• Recurrence seen in ~50% of people with
symptomatic HSV within 6 months
• Recurrence in ~80% by one year
• Recurrence associated with stress, fever,
menstruation, and intercourse
Episodic Recurrence Therapy
• Acyclovir 400mg TID x5 days or 800mg TID
x2 days
• Valacyclovir 500mg BID for 3 days
• Famciclovir 125mg BID x5 days
• Only shortens duration if started within 24h
Suppressive Therapy
– Acyclovir ($1500) or valacyclovir ($2500) or
famciclovir ($2700)
– Offered to those with >6 recurrences/year or
severe outbreaks
– Can reduce frequency of symptoms by 85%
– Reduced frequency of subclinical viral shedding
– Reduces risk of transmission of HSV to uninfected
partners
Reducing Transmission
• Recommend consistent condom use
• Use of antiviral suppressive therapy to reduce
viral shedding
• Herpevac currently under study
Chlamydia
Chlamydia
• Nearly 1 million cases reported in 2005
• Infection caused by the intracellular parasite
Chlamydia trachomatis
• Asymptomatic infection with serious sequelae
Chlamydia — Rates: total and by sex
United States, 1986–2005
Chlamydia — Rates by region
United States, 1996–2005
Chlamydia — Rates by state
United States and outlying areas, 2005
Chlamydia — Rates by race/ethnicity
United States, 1996–2005
Clinical Manifestations- Males
• Males
– Can be asymptomatic
– Urethritis
– Epididymitis
– Proctitis
Urethritis
Epididymitis
• Inflammation of the epididymis
• In sexually active men etiology generally
gonorrhea or chlamydia
• Presents with pain and swelling in the
epididymis and scrotum
• May be preceded by urethral discharge,
dysuria, or urgency
Clinical Manifestations- Females
• Females
– Frequently asymptomatic
– Cervicitis
– Proctitis
– May present with sequelae
Chlamydia Cervicitis
Long-term Consequences
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•
•
•
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PID
Chronic pelvic pain
Ectopic pregnancy
Tubal-factor infertility
Pregnancy Outcomes
– Neonatal chlamydial infection
Chlamydia — Age- and sex-specific rates
United States, 2005
Screening
• Sexually active adolescent women should be
screened at least annually, even if symptoms
are not present
• Annual screening of all sexually active women
aged 20-25 years is also recommended
• Screening of older women should be done if
risk factors are present (e.g., those who have a
new sex partner and those with multiple sex
partners)
Nucleic Acid Amplification Tests
(NAATs)
• Specimens may be endocervical swabs, urethral
swabs from men, or urine from both men and
women
• Vaginal specimens have been used with
satisfactory performance
• Rectal and oropharyngeal specimens not
recommended
Sensitivity and Specificity
• Sensitivity of 96%
• Specificity of 98%
• Allows for detection of 20-30% more
infections than those detected by culture
• Cost-effective
Asymptomatic Screening
• Can use urine or vaginal swab
– Urine specimens must be FIRST CATCH
• Potentially avoid pelvic exam in asymptomatic
individuals
• Patient can collect specimen themselves
Treatment: Urethritis, MPC
• Single dose 1g azithromycin
• Doxycycline 100mg BID x7days
• Rescreening suggested by CDC 3-4 months
after treatment, especially in adolescents
• Treat for co-infection with GC
GONORRHEA
Gonorrhea — Rates: United States, 1941–2005
and the Healthy People 2010 target
Gonorrhea — Rates by region: United States 1996–
2005 and the Healthy People 2010 target
Gonorrhea — Rates by state: United States and
outlying areas, 2005
Gonorrhea — Age- and sex-specific rates: United
States, 2005
Gonorrhea- Clinical signs
• Urethritis
– Incubation: 1-14 d (usually 2-5 d)
– Sx: Dysuria and urethral discharge (5% asymptomatic)
• Asymptomatic or nonspecific in women until
complications develop
• Often co-infected with chlamydia- dual
therapy recommended
GC- Diagnosis
• Direct microscopy and culture
• Obtain specimens from all appropriate genital
and extra-genital sites
• NAATs
Gonorrhea Gram Stain
Gonorrhea- treatment
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Ceftriaxone 125mg IM x1
Doxycycline 100mg PO BID x7d
Ceftizoxime 500mg IM x1
Azithromycin 2g PO x1
Percent of Neisseria gonorrhoeae isolates with
resistance or intermediate resistance to ciprofloxacin,
1990–2005
Human Papilloma Virus
Papillomavirus
• Infect all vertebrate species
• More than 120 types found in humans
• Anogenital HPV infection the most common
STD
Human Papillomavirus (HPV)
• Highly prevalent
• Divided into low and high risk types
• Most HPV infections are asymptomatic,
unrecognized, or subclinical
• Risk Factors:
– Young age at 1st intercourse
– Multiple sexual partners
– History of STDs
– Tobacco use
Human Papilloma Virus (HPV)
• Most HPV infections are transient, with
median duration of 8 months
• Risk for persistent infection (>6 mos):
– Older age
– Infection with multiple types of HPV
– High risk type infection
– Duration of infection
Virology: HPV Types 6 and 11
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•
•
•
Prototypical low risk types
Primarily cause benign genital warts
Diagnosis of can be confirmed by biopsy
Depending on the size and anatomic location,
genital warts can be painful, friable, and
pruritic, although they are commonly
asymptomatic
"Cauliflower" condyloma
of the penis
Small papillomas
on penile shaft
Small papilloma
of the perineum
Verrucous vulvar warts
HPV Warts: Treatment
• Primary goal- removal of symptomatic warts
• Untreated, warts may resolve on their own,
remain unchanged, or increase in size or
number
• Available therapy for genital warts may
reduce, but probably do not eradicate,
infectivity
• Alternative to treatment: watch and wait
Role of HPV in Cervical Cancer
• Causal relationship identified
• Confers 85-90% of risk for cervical dysplasia
• HPV 16 most prevalent virus to infect the
uterine cervix
• Co-infection with 16 and any other high risk
type further increases the risk for
developing cervical cancer
Estimated Annual Burden of HPVRelated Diagnoses in the US
9,710 new cases of cervical cancer
330,000 new cases of high-grade
cervical dysplasia (CIN 2/3)2
1.4 million new cases of lowgrade cervical dysplasia (CIN
1)2
1 million new cases of
genital warts3
Cancer Types Attributable to HPV
Other Than Cervical Cancer1
100
Estimated percentage of cancer cases attributable to HPV
Estimated (%)
80
70
60
50
50
50
40
20
20
al
ni
le
ar
yn
ge
O
ro
ph
Cancer Type
Pe
l
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Va
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Vu
A
na
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0
1. González Intxaurraga MA, Stankovic R, Sorli R, Trevisan G. Acta Dermatovenerol. 2002;11:1–8.
Psychosocial Responses to
Anogenital Warts1
40
Causes of concern among men and women with anogenital warts (N=166)*
Reason for Concern (%)
35
30
25
20
15
10
5
0
Emotional/
Sexual
Cervical
Cancer
Recurrence Transmission
*Patients could report more than 1 reason for concern.
1. Maw RD, Reitano M, Roy M. Int J STD AIDS. 1998;9:571–578.
Pain
Treatment
Efficacy
HPV Burden in Cervical Cancer and
Other Anogenital Diseases
Prevalence of
HPV Type
HPV 16 and 18
100
90
80
70
60
50
40
30
20
10
0
1
2
Low-grade
cervical lesions
High-grade
cervical lesions
HPV 6 and 11
1,3,4
Cervical cancer
5
Genital warts
Information About HPV Vaccine
• Indicated in girls and women 9 to 26 years of age for
– the prevention of cervical cancer,
– precancerous or dysplastic lesions, and
– genital warts caused by HPV Types 6, 11, 16, and 18
• Not a substitute for routine pap smear screening
• Vaccination may not result in protection in all vaccine
recipients
• Not intended to be used for treatment
• HNot been shown to protect against diseases due to
non-vaccine HPV types
Vaccine Benefits
• Reduced need for medical care
• Decreased number of biopsies and invasive
procedures
• Save health care dollars
• Relieve anxiety
Vaccine Controversies
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•
•
•
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Age at vaccination
Vaccination of boys and girls
Cost ~$400
Recommendation vs Mandate
Effect on sexual behavior
The Beginning of the End for
Cervical Cancer?- Caveats
• Nearly 20 types of HPV associated with
cervical cancer
• Vaccination will not reverse infection or
cervical neoplasia once developed
• Duration of protection remains uncertain
• Need worldwide availability, where incidence
of cervical cancer much higher
Sexually Transmitted Infections:
Prevention Guidelines
Epidemiology
• Five of the top ten most reported diseases in
US in 1995 were STDs
• Incidence of STDs are ~15 million per year
• Women and infants bear a disproportionate
burden of STD-associated complications
Major Concepts
• Educate and counsel persons at risk on ways to
adopt safer sexual behavior
• Identify asymptomatic infected persons and
symptomatic persons unlikely to seek diagnostic
and treatment services
• Effective diagnosis and treatment
• Evaluation, treatment, and counseling of sex
partners
• Pre-exposure vaccination of persons at risk for
vaccine-preventable STDs
At-risk Persons
• Identification dependent on taking thorough
sexual history
• Educate on specific activities the patient can
take to avoid acquiring or transmitting an STD
• Encourage patients to adopt safer sexual
behaviors
Percentage of US High School Students
Who Have Had Sexual Intercourse1
Individuals Who Have Had
Sexual Intercourse (%)
70
2003 US Youth Risk Behavior Survey (N=15,214)
Female
60
Male
50
40
30
20
10
0
Grade 9
Grade 10
Grade 11
Grade 12
In addition, 7.4% of US adolescents reported sexual debut before 13 years of age.
By Grade 12, 20.3% of US adolescents reported ≥4 lifetime sexual partners.
1. Grunbaum JA, Kann L, Kinchen S, et al. MMWR. 2004;53(SS-2):1–96.
Preventing Transmission
• Abstinence from sexual intercourse (i.e., oral,
vaginal, or anal sex) is the best way to prevent
infection
• Long-term, mutually monogamous
relationship with an uninfected partner
• Counseling that encourages abstinence is
crucial for persons being treated for an STD or
whose partners are undergoing treatment
Condoms
• Prevent the sexual transmission of HIV
infection
• Can reduce the risk for other STDs (i.e.,
gonorrhea, chlamydia, and trichomonas)
• Less effective in preventing infections
transmitted by skin-to-skin contact (e.g.,
herpes, HPV, syphilis, and chancroid)
Instruct Proper Condom Use
• Use a new condom with each act of sexual
intercourse
• Carefully handle the condom to avoid damage
• Put the condom on after the penis is erect and
before any genital contact
• Use only water-based lubricants
• Ensure adequate lubrication
• Hold the condom firmly against the base of the
penis during withdrawal, and withdraw while the
penis is still erect
Spermicides
• Vaginal spermicides containing nonoxynol-9 are not
effective in preventing cervical gonorrhea, chlamydia,
or HIV infection
• Frequent use of spermicides containing N-9 has been
associated with genital lesions, which may be
associated with an increased risk of HIV transmission
• Condoms lubricated with spermicides are no more
effective than other lubricated condoms in
protecting against the transmission of HIV and other
STDs
ID and Treatment of Sex Partners
• Learn from persons seeking treatment for
STDs about their sexual partners
• Help to arrange for evaluation and treatment
of those partners
• Providers should encourage their patients to
make partners aware of potential STD risk and
urge them to seek diagnosis and treatment
Vaccines
• HPV Vaccine
• Herpevac
• Hepatitis B