Understanding Sexually Transmitted Diseases: Focus on HIV and Genital Herpes

1. Doc, I Have This Drip ….

2. Sexually Transmitted Diseases and HIV Ronald D. Wilcox MD FAAP Project Director/Principal Investigator, Delta AIDS Education & Training Center Louisiana State University Health Sciences Center Depts. of Internal Medicine and Pediatrics Section of Infectious Diseases

3. www.deltaaetc.org 504-903-0788 LPS Coordinator: Dana Gray

4. ARS • This presentation will be using an audience response system to better involve the audience and help us determine your learning needs.

5. Disclaimers • The presenter does not have any financial interests or affiliations that will influence the presentation • The presenter does not have any personal experience with these diseases so please do not ask • The presentation has a number of very graphic slides - You Have Been Warned!

6. Question • Please describe your profession • 1. Infectious disease or STD specialist • 2. Primary care physician or Nurse Practitioner • 3. Nurse or Health Educator • 4. Case Manager / Social Worker / Other • 5. Person who was wandering by and came in to feel like they are a part of a crowd

7. Question • How familiar are you with the CDC STD Guidelines from May, 2006? • 1. I have read them thoroughly • 2. I have looked over the charts and read some of the text • 3. I am somewhat familiar with them • 4. I know they are out there • 5. What are STDs and who is the CDC?

8. Genital Ulcer Diseases • Initial work-up • Serologic testing for syphilis • Diagnostic evaluation for herpes simplex – culture or antigen testing • Depending on area, culture for H. ducreyi

9. Question • What is the most common cause of genital ulcer disease in the United States? • 1. Treponema pallidum • 2. Herpes simplex virus – 1 • 3. Herpes simplex virus – 2 • 4. Haemophilus ducreyi • 5. Chlamydia sp.

10. Herpes Simplex • Two serotypes: HSV-1 and HSV-2 • HSV-1 cause of up to 30% of primary herpes genitalis • Most common cause of genital ulcers in the USA • Most HSV-2 infected patients are unaware of status • Diagnosis: • clinical diagnosis should be confirmed by laboratory testing, either DFA or viral culture • PCR usually reserved for use in diagnosis of CNS infections • Tzanck preps insensitive and non-specific • Type-specific antibodies form within weeks

11. Herpes Simplex – Primary Infection

12. 2006 CDC STD Treatment GuidelinesPrimary Genital Herpes • Recommended Regimens (7-10 day duration): • Acyclovir 400 mg po tid OR 200 mg po 5x/day OR • Famciclovir 250 mg po tid OR • Valacyclovir 1 gm po bid

13. Recurrent Herpes Simplex

14. Herpes Simplex

15. Herpetic Whitlow

16. 2006 CDC STD Treatment Guidelines Recurrent Genital Herpes • Recommended Regimens: • Acyclovir 400 mg po tid OR 800 mg po bid x 5 days OR 800 mg po tid x 3 days OR • Famciclovir 125 mg po bid x 5 days OR 1000 mg po daily x 1 day OR • Valacyclovir 500 mg po bid x 3 days OR 1 gm po daily x 5 days

17. 2006 CDC STD Treatment Guidelines Suppression of Genital Herpes • Recommended Regimens: • Acyclovir 400 mg po bid OR • Famciclovir 250 mg po bid OR • Valacyclovir 500 - 1000 mg po daily

18. Herpes simplex • Higher doses of acyclovir may be required for oral HSV or HSV proctitis, ie 400 mg po five times daily • Suppressive dosing is used when recurrences occur > 6 episodes per year • Severe disease may require IV therapy at 5-10 mg/kg q8 (based on ideal body weight) for 2-7 days

19. Herpes simplex • Counseling • Two main goals: • Help pts cope with the infection • Prevent sexual and perinatal passage • Important to stress that transmission still can occur even when asymptomatic due to shedding – more frequent in HSV-2 and in the first 12 months after infection • Latex condoms may decrease transmission • Risk for neonatal HSV should be explained to all patients, including men. Women who do not have HSV-2 should avoid sex with men with HSV in the third trimester

20. Effect of HSV by HIV • Lesions may be prolonged or more severe • May have atypical appearance • Acyclovir-resistance is more common in HIV-infected persons and should be tested for if no response to therapy – also resistant to valacyclovir and possibly famciclovir • Use valacyclovir in those with CD4 < 200 very cautiously

21. Question • Should all HIV+ patients be placed on acyclovir if they have a history of HSV infection? • 1. Yes, they all should • 2. Yes, if they have at least 2 episodes per year • 3. Yes, if they have at least 6 episodes per year • 4. No, they only need treatment when they have an outbreak

22. Effect of HSV on HIV • Increased viral load with each outbreak • Resetting the HIV viral load baseline higher after the outbreak heals

23. 2006 CDC STD Treatment Guidelines Episodic Genital Herpes in Persons with HIV Infection • Recommended Regimens: • Acyclovir 400 mg po tid x 5-10 days OR • Famciclovir 500 mg po bid x 5-10 days OR • Valacyclovir 1 gm po bid x 5-10 days

24. 2006 CDC STD Treatment Guidelines Suppression of Genital Herpes in HIV-Infected Persons • Recommended Regimens: • Acyclovir 400-800 mg po bid - tid OR • Famciclovir 500 mg po bid OR • Valacyclovir 500 mg po bid

25. Herpes simplex • In pregnancy: • 30-50% passage to infant in mothers who get primary infection near time of delivery; < 1% passage for asymptomatic mothers or those who get infection during first trimester • Delivery by c-section if mother has visible lesions reduces risk of transmission

26. Neonatal Herpes • Localized: • Skin, Eyes, Mouth • CNS infection • Disseminated • Tx: Acyclovir 20 mg/kg/dose q8 for 14-21 days

27. Question • Which bacterial organism is associated with painful genital ulcerations and tender regional LAD? 1.Staphylococcus aureus 2. Haemophilus ducreyi 3. Treponema pallidum 4. Calymmatobacterium granulomatis

28. Chancroid • Causative organism: Haemophilus ducreyi • In US occurs in discrete outbreaks • Diagnosis is usually clinical • One or more painful genital ulcers • Clinical presentation, appearance, and possible presence of regional tender lymphadenopathy • No evidence of T. pallidum infection by serology or dark-field microscopy • Test for HSV from the ulcer is negative • 10% are co-infected with T. pallidum or HSV

29. Chancroid

30. Chancroid

31. Chancroid Lymphadenopathy

32. 2006 CDC STD Treatment GuidelinesChancroid • Recommended Regimens • Azithromycin 1 gm orally in a single dose OR • Ceftriaxone 250 mg IM in a single dose OR • Ciprofloxacin 500 mg po bid x 3 days OR • Erythromycin base 500 mg po tid x 7 days

33. Chancroid • Patients who are HIV + or uncircumcised do not respond to treatment as well as usual or may require longer courses of antibiotics • Ulcers should resolve usually within 7 days but may take over 2 weeks for large ulcers or for uncircumcised men • Sexual partners need examination & treatment • Some experts recommend erythromycin if HIV+

34. Granuloma inguinale(Donovanosis) • Causative agent: intracellular Calymmatobacterium granulomatis • Painless, progressive ulcerative lesions without suppurative regional lymphadenopathy • Ulcers highly vascular (“beefy red”) and bleed easily • Diagnosis by biopsy • Tx: recommended doxycycline or tmp/smx bid for at least three weeks

35. Lymphogranuloma venereum • Causative agent: Chlamydia trachomatis serovars L1, L2, or L3 • Most common presentation tender inguinal/femoral LAD commonly unilateral • May cause proctocolitis or inflame perirectal or perianal lymphatic tissue • Diagnosis: clinical suspicion, epidemiologic information, and exclusion of other etiologies along with serology • Tx: Recommended: Doxycycline 100 mg po bid x 21 days (Alternative erythromycin base 500 mg po QID x 21 days) • No change in therapy if HIV+

36. Question • Which of the following is/are non-treponemal screening tests for syphilis? • 1. VDRL • 2. RPR (rapid plasma reagin) • 3. FTA-ABS • 4. 1 & 2 • 5. All of the above

37. Syphilis • Causative organism: Treponema pallidum • Diagnostic testing: • Darkfield examinations or Direct flourescent antibodies of tissue • Nontreponemal tests – quantitative • VDRL • RPR (rapid plasma reagin) • Treponemal test • FTA-ABS • TP-PA (particle agglutination)

39. Primary Syphilis Incubation period 10-90 days (mean 3 weeks) Chancre: Painless, indurated, with sharp, raised border Non-treponemal tests + in only 50%

40. Secondary Syphilis 3-6 weeks after appearance of the chancre Generalized bilaterally symmetrical maculopapular rash, involving palms & soles Patchy alopecia common Generalized LAD in 75% (esp epitrochlear) Condyloma lata Dry rash minimally contagious, wet areas highly contagious

41. Condyloma lata

42. 2006 CDC STD Treatment GuidelinesSyphilis – Primary & Secondary • Recommended Regimen: • Benzathine Penicillin G (Bicillin L-A) 50,000 units/kg IM in a single dose, up to the adult dose of 2.4 million units • 15% failure rate

43. Latent Syphilis • Clinically silent stages: • Early – between primary & secondary • Late or unknown duration – after secondary • Diagnosed by serology • Need evaluation for presence of aortitis, gumma, iritis, and uveitis

44. 2006 CDC STD Treatment GuidelinesLatent Syphilis • Recommended Regimens: • Early Latent • Benzathine Penicillin G 50,000 units/kg up to 2.4 million units in a single dose • Late Latent • Benzathine Penicillin G 50,000 units/kg up to 2.4 million units weekly for three doses

45. Tertiary Syphilis Gummas – destructive lesions of skin or bones Aortic anheurysms Aortic Insufficiency Non-treponemal tests 70% sens

46. 2006 CDC STD Treatment GuidelinesTertiary Syphilis • Recommended Regimen: • Benzathine Penicillin G (Bicillin L-A) 2.4 million units IM weekly for three doses

47. 2006 CDC STD Treatment Guidelines Syphilis – Special Circumstances • Penicillin Allergy • Primary or Secondary • Doxycycline 100 mg po bid x 14 days OR • Tetracycline 500 mg po qid x 14 days OR • Desensitization to Penicillin if pregnant • Alternatives: Ceftriaxone 1 gm daily x 8-10 days OR Azithromycin 2 gms po x 1 * • Latent and Tertiary • Same as above but for 28 days

48. Neurosyphilis • Lymphocytic meningitis – manifestation of primary or secondary syphilis or later as meningovascular syphilis • CVA in a young patient • Dementia secondary to General Paresis • Tabes dorsalis – stabbing pains due to posterior column disease • CSF: + VDRL (low sens) or elevated WBC or elevated protein • Some experts recommend FTA-ABS for CSF – has high sensitivity but low specificity

49. 2006 CDC STD Treatment Guidelines Neurosyphilis • Recommended Regimen: • Aqueous Crystalline Penicillin G 3-4 million units every 4 hours (total 18-24 million units/day) or by continuous infusion • Alternative Regimen: • Procaine Penicillin 2.4 million units IM daily PLUSProbenecid 500 mg po qid x 10-14 days • Possibly: Ceftriaxone 2 gm daily x 10-14 days

50. Early Congenital Syphilis • Osteochondritis (55%) • Snuffles • Rash (40%) • Anemia (30%) • Hepatosplenomegaly (20%) • Jaundice (20%) • Neurologic Signs (20%) • Pseudoparalysis of an extremity • Lymphadenopathy (5%) • Mucous patches (5%)