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

Age at First
Intercourse
Sexual
Intimate
Activity
Partner
with New
Violence
Partner

Multiple
Substance
Sexual
Use
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 • 75% of all primary and

accounted for: 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 Concerns About

Lack of Insurance/ Transportation Confidentiality
$ to Pay

Lack of Sex Ed Adolescents

Regarding Risk and Not Being Stigma
Symptoms Screened
and Treated

 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 May prevent 70% of high- and low-

risk infections in females

When used consistently and

GC, CT, and Trich
correctly, reduce transmission risk

Can prevent transmission when

HSV and Syphilis
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 # of new infections equal among

Risk young males (49%) and females
(51%)

Direct Medical costs:

Cost
~$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 2001 2003 2005 2007 2009 2011 2013

High School Males High School Females



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

Patient-centered, age-appropriate anticipatory guidance;

Integrate sex ed into clinical practice; can use educational materials;
AAP
Prevention guidance, including abstinence, safer sexual practices, &
condoms

ACOG Counseling for all sexually active individuals

AAFP High intensity behavioral counseling (HIBC)

HIBC; interactive counseling approaches, i.e., client-centered STD/HIV

CDC* prevention counseling; motivational interviewing; videos and large
group presentations to provide information
Intensive behavioral counseling for all sexually active adolescents and
USPSTF* 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

Skin-Related
Urinary Tract Skin-Related
Urinary Tract Genital Tract Abnormalities/
Infection Genital Tract Abnormalities/
Infection Infection mucosal
Infection mucosal
perineal
perineal
• Cervicitis • Herpes
• Vaginitis • 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 Age 21, regardless of sexual
Every three years 2012
Gynecologists initiation
(ACOG)

United States Age 21 or within three years

At least every
Preventive Services of sexual initiation, 2011
three years
Task Force (USPTF) whichever comes first

American Cancer
Age 21 Every three years 2012
Society (ACS)


 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

Trichomoniasis

Bacterial
Vaginitis
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

1. Trichomonas: bigger than

PMN
PMNs
Yeast
2. PMNs: dense nucleus;
Trichomonas*
buds Trich: many small vacules
Trichomonas*
3. Trich: dead once viewed
Squamous with microscopy—flagella
PMN epithelial
cells rarely seen


 Trichomoniasis: Symptoms

• Foul-smelling, frothy discharge

• Greenish-yellow discharge
Females: ~70% • Vaginal itching, burning, redness
are asymptomatic • Dyspareunia
• Dysuria
• Soreness of the genitals

Males: Most are • Itching/irritation inside the penis

asymptomatic and • Burning after urination or ejaculation
often missed • Discharge from the penis 

 Routine Trichomoniasis Screening

NOT routinely recommended for asymptomatic

AAP
Consider screening ♀ if individual or population-based risk factors

NOT routinely recommended

ACOG
Consider screening ♀ based on local prevalence

AAFP

NOT routinely recommended: HIV+ ♀

Consider screening persons receiving care in high-prevalence
CDC*
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

Experience genital itching or burning,

Females “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

 Trichomonas Diagnosis

Culture Antigen DNA Probe Wet Mount

Detection
• Sensitivity: • Sensitivity: • Sensitivity: • Sensitivity:
85%-90% 83% 60%-70% 60%-80%
• Specificity: • Specificity: • Specificity: • Specificity:
100% 97% 100% >97%
Available test: Available Test: No good test
OSOM Rapid Test Affirm™ VP III
for males, so
often untested


 Candida Diagnosis

DNA Probe Wet Mount

• Sensitivity: 80% • Sensitivity: 35%-45%

• Specificity: 98% • Specificity: 97%-99%


 Bacterial Vaginitis Diagnosis

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

 Erica’s final diagnosis is

vaginitis related to
trichomoniasis.

 How do you treat her?


 Trichomoniasis: Treatment

Recommended Alternative Treatment

Regimen Treatment Failure
• Metronidazole • Metronidazole • Re-treat with
2 gm PO x 1 500 mg PO metronidazole
• Tinidazole BID x 7 days 500 mg PO
2 gm PO x 1 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 should be treated.

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

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
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

• Heavy or prolonged menses

Females: • Spotting
Up to ~80-90% • Dysmenorrhea
asymptomatic • Dyspareunia
• Vaginal discharge

Males:
• Penile discharge
Up to 90%
• Dysuria
asymptomatic

 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 all sexually active <24 yrs

CDC* all sexually active <25 yrs

USPSTF all sexually active <24 yrs

*Draft

 Chlamydia Screening: Males

Routine Screening NOT Correctional facilities

recommended for men
STD clinics

Selective screening in
high-prevalence Adolescent-serving clinics
populations should be
considered 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

• Yellow or bloody vaginal

Females: discharge
~50% are • Burning/painful urination
asymptomatic • Bleeding with vaginal
intercourse

• White, yellow/green pus from

Males:
Up to 50% the penis with pain
• Burning during urination
asymptomatic
• 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

• PID
Females: • Infertility
Cramps and Can • Ectopic
pain, vomiting, lead to
pregnancy
fever • HIV

• Prostate
Males: Left complications
Rare untreated • Epididymis
• HIV

 ♀ Routine Gonorrhea Screening

AAP all sexually active ♀ <25 yrs

ACOG all sexually active ♀ adolescents

AAFP all sexually active ♀ <24 yrs

CDC all sexually active ♀ <25 yrs

USPSTF all sexually active ♀ <24 yrs


 ♂ Routine Gonorrhea Screening

Consider screening AYA MSW on basis of individual and population based

risk factors (persons of color, ↑ community prevalence)
AAP 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

AAFP
♂ at ↑increased risk for infection

MSM for rectal, oral, and urethral GC annually if receptive anal, oral, or
CDC* 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

USPSTF
♂ 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 DFA DNA Probe

Sensitivity: Sensitivity: Sensitivity: Sensitivity: Sensitivity:

Sensitivity: Sensitivity: Sensitivity: Sensitivity: Sensitivity:
70% 85–90% 50–65% 65–70% 65–70%
70% 85–90% 50–65% 65–70% 65–70%
Specificity: Specificity: Specificity: Specificity: Specificity:
Specificity: Specificity: Specificity: Specificity: Specificity:
85–95% >98% >95% 95% 95%
85–95% >98%Preferred
>95% 95% 95%


 Gonorrhea Diagnosis

Culture NAAT Typical DNA

Gram Stain Probe
Sensitivity: Sensitivity: Sensitivity: Sensitivity:
Sensitivity: Sensitivity: Sensitivity: Sensitivity:
90% 85–90% 80% 35–45%
90% 85–90% 80% 35–45%
Specificity: Specificity: Specificity: Specificity:
Specificity: Specificity: Specificity: Specificity:
99% >98% 98% 99%
99% >98%
Preferred 98% 99%
90% sensitive in
symptomatic male;
only 50% sensitive
in females and in

asymptomatic males
 How to Order Screen

Non-genital GC/CT NAATs can be done by clinical laboratory

with CLIA approval

Gen-Probe QUEST LabCorp

APTIMA testing diagnostics test diagnostics test
codes codes
Pharyngeal 70051X 188698
Rectal 16506X 188672
Urine/Urethral 13363X 183194

Relevant CPT Billing Codes:

CT detection by NAAT: 87491
GC detection by NAAT: 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 1g Orally Once

OR
Twice a day for
Doxycycline 100 mg Orally
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 1g Orally Once
OR
Twice a day for
Doxycycline 100 mg Orally
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
Azithromycin 1 g orally in
Ceftriaxone a single dose OR
250 mg in a single PLUS Doxycycline 100 mg
intramuscular dose 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 2g Orally Once

PLUS
Test of cure in 1 week

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

Partners contacted by index patient’s

Provider
provider or by a disease intervention
Referral
specialist

Index patient assumes primary

Patient
responsibility to notify and refer his/her
Referral
partners at risk

Expedited Providers (1) give patient medication

Partner intended for the partners (2) write
Therapy (EPT) 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 did not give Rx to

Patient-delivered specific
any/all partners

Partners noncompliant with Rx

Patients did not contact partners
General noncompliance
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 Symptoms
1/3 of new infections in 2006 in Infections in adolescents not
people ages 13-29 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

Offer routine screening to all by age 16-18 yrs in health care settings when HIV
prevalence > 0.1%
AAP
Encourage routine HIV testing for all sexually active teens and those with other
risk factors in low HIV prevalence areas
ACOG Routine screen all sexually active adolescent ♀
Screen ages 18 to 65 yrs for HIV infection
AAFP
Screen younger adolescents and older adults at ↑ HIV risk
Screen aged 13-64 in all health-care settings;
CDC 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
USPSTF 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 Genital Sores Syphilis

Cluster of painful Solitary painless

(sometimes) sores ulcer with
indurated border

Chancroid LGV
Trauma
Painful ulcer with Painless papule, shallow
sharp borders 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


 Lesions/
Infection Type Type Antibody at Presentation
Symptoms
HSV-1 HSV-2
1st Episode
Primary +/Sever, bilateral – –
Type 1 or 2

1st Episode
Non-primary +/Moderate + –
Type 2

1st Episode
Recurrence +/Mild +/– +
Type 2

Symptomatic
Recurrence +/Mild, unilateral +/– +
Type 2

Asymptomatic


Infection – +/– +
Type 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

Past inconclusive work up for genital lesions—

Consider negative herpes culture or NAAT
testing if:
Have a partner with genital HSV

MSM

Are HIV infected


 Routine Syphilis Screening

NOT routinely recommended

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

*Draft

 HSV Diagnosis

Culture Type Specific PCR

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


 Syphilis Diagnosis

Classical Testing Emerging Testing

1
st 2nd 1st 2nd
Non- Treponemal Treponemal Non-
treponemal test Test treponemal test
- RPR - TPPA
- VDRL - FTA


 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

Famciclovir
Acyclovir 400 Acyclovir 200 Valacyclovir 1
250 mg PO
mg TID for 7- mg PO 5x/day g PO BID 7-10
TID for
10 days for 7-10 days days
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 500 mg orally once a day or
 Valacyclovir 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


Provider Resources and Organizational Partners
 www.advocatesforyouth.org—Advocates for Youth

 www.aap.org—American Academy of Pediatricians

 www.aclu.org/reproductive-freedom American Civil Liberties Union

Reproductive Freedom Project

 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 Jane Fonda Center at Emory University

 www.msm.edu Morehouse School of Medicine

 www.prochoiceny.org/projects-campaigns/torch.shtml NARAL Pro-

Choice New York Teen Outreach Reproductive Challenge (TORCH)

 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 Planned Parenthood Federation of

America

 www.reproductiveaccess.org Reproductive Health Access Project

 www.spence-chapin.org Spence-Chapin Adoption Services


 Please Complete Your Evaluations Now