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Sexually Transmitted Diseases

Sexually Transmitted Diseases. Jeffrey D. Klausner, MD, MPH Professor of Medicine and Public Health Attending Physician Ronald Reagan Medical Center Center for World Health and Division of Infectious Diseases David Geffen School of Medicine Department of Epidemiology

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Sexually Transmitted Diseases

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  1. Sexually Transmitted Diseases Jeffrey D. Klausner, MD, MPH Professor of Medicine and Public Health Attending Physician Ronald Reagan Medical Center Center for World Health and Division of Infectious Diseases David Geffen School of Medicine Department of Epidemiology Karin and Jonathan Fielding School of Public Health African-American HIV University MRL 1-441 August 13, 2013

  2. Disclosures • Dr. Klausner is a faculty member of the University of California Los Angeles • Dr. Klausner is a guest researcher with the US CDC Mycotics Diseases Branch • Dr. Klausner is a member of the WHO Congenital Syphilis Elimination advisory group • Dr. Klausner is medical director, APLA Health and Wellness Center • Dr. Klausner is a board member of Isis-Inc. • In the past 36 months, Dr. Klausner has received: • Travel support for meeting attendance from WHO, London School of Hygiene and Tropical Medicine and Council of Scientific Industrial Research, South Africa • Research grant funding, supplies or unrestricted gifts from the NIH, CDC, California HIV Research Program, Hologic Gen-Probe, Inc., Gilead Sciences, Inc., Cepheid, Inc., APLA, Public Health Foundation Enterprises, American Jewish World Service and Qpid.me JDKlausner@mednet.ucla.edu

  3. Why do we care about STDs? • Cause up to 40% of infertility • Tubal damage, chronic pelvic pain, ectopic pregnancy • May result in fetal loss, preterm birth, stillbirth and infant infections • ↑ increase risk and spread of HIV-infection • MSM with rectal gonorrhea have 6x increased risk of HIV in next year • MSM with syphilis have 4-5x increased risk of HIV in next year

  4. STD Prevention Strategy 2013 • Screen, Treat, Treat, Screen • SyndromicManagement • Education, condom promotion, vaccination (HPV, HBV)

  5. Case 17 year old female uses SexInfo text message service (Text “SexInfo” to 61827) and comes in for a check-up. She has one regular partner for 6 months and has no symptoms. What screening tests are appropriate?

  6. Recommended STD screening tests in sexually active women, US Preventive Services Task Force • All sexually active women younger than 25 years including adolescents • Chlamydia • HIV • If at high risk • Gonorrhea • Syphilis • If age > 20 or sexually active > 3 years • Pap smear (HPV)

  7. Recommended STD screening tests in sexually active women, US Preventive Services Task Force • High-risk characteristics • having multiple current partners • having a new partner • using condoms inconsistently • having sex while under the influence of alcohol or drugs • having sex in exchange for money or drugs • African-American

  8. Chlamydia trachomatis • Lives inside other cells • Infects certain genital skin cells • Changes life cycle over time

  9. Uncomplicated chlamydialinfection • azithromycin 1 gm orally onceORdoxycycline 100 mg orally twice daily for 7 days • Partner treatment • Re-testing at 3 months Female cervix, 10x

  10. Chlamydia trachomatisin gay and other men who have sex with men • 15-20% of urethritis • Prevalence in those w/ history of receptive anal intercourse in past 6 months: 5-10% • Common etiology of proctitis • Sexually active MSM who practice receptive anal intercourse should be screened every 3-6 months

  11. Rectal Chlamydia and Gonorrhea Positivity Transwomen or MSM, Low Income Countries Prabawanti C et al. AIDS Behav 2011; Sanders EJ et al. STI, 2010; Vuylsteke B et al STI 2012.

  12. Rectal STD screening is accurate and easy Nucleic acid amplification tests (NAATs) are 2.5 times more accurate than culture Variety of NAAT manufacturers Swabs may be self-collected Schachter, STD 2008; Soni, STD 2011

  13. Rectal Gonorrhea, San Francisco Mean positivity 7.0% (n=488+)

  14. Case • 28 year old male c/o discharge from his penis for a few days and yellow stains in his underwear. • It burns when he urinates. • He denies any recent sexual partners but does say that he received oral sex about a week ago.

  15. Differential diagnosis of urethritis • Infectious Neisseria gonorrhoeae Chlamydia trachomatis Mycoplasmagenitalium Trichomonasvaginalis Herpes simplex virus 1 and 2 Oral flora---streptococci, anaerobes, haemophilus species • Non-infectious Trauma--physical or chemical (drugs), post-catheterization or sex-play related Autoimmune--Reiter’s syndrome

  16. Uncomplicated gonococcal infection Neisseria gonorrhoeae Urethra Cervix Pharynx Rectum Gram-negative intracellular diplococci Gram stain of urethral discharge, 1000x

  17. Nucleic acid amplification tests (NAATs) PCR, SDA, TMA sensitivity 95% specificity >99.5% -- NAATs FDA-cleared in urethra, cervix, urine, vagina, self-obtained vaginal Verified in pharynx and rectum Gram stain sensitivity 92% specificity 90% Culture sensitivity 95% specificity 99% Diagnosis of gonorrhea

  18. Treatment of gonorrhea 1) Ceftriaxone 250 mg injection Plus chlamydia treatment if not ruled out 2) Partner treatment—evaluation/ patient-delivered therapy 3) Repeat testing in 3 months.

  19. Case • 32 y female seen w/ new vaginal discharge • Reports no new sex partners, monogamous for > 5 years

  20. Differential diagnosis of vaginal discharge • Infectious Vaginitis Trichomonasvaginalis Bacterial vaginosis Candida albicans(yeast) Cervicitis Neisseria gonorrhoeae Chlamydia trachomatis Herpes simplex virus 1 and 2 • Non-infectious Mechanical, chemical or allergic irritation

  21. Work-up of vaginal discharge • Sexual history • Speculum examination: vaginitis vs. cervicitis • Vaginal fluid analysis • pH, microscopy, KOH, whiff test • Gonorrhea and chlamydia testing, if at risk • New sex partner, young, partner w/ other partners

  22. Trichomoniasis Trichomonasvaginalis Vagina Cervix Urethra

  23. OSOM Trich Rapid test sensitivity 90-95% specificity 92.5-100% PCR, TMA High sensitivity and specificity Wet mount sensitivity 40-80% specificity 90% Culture (TV inpouch) sensitivity 95% specificity 99% Diagnosis of trichomoniasis

  24. Treatment of trichomoniasis MetronidazoleCure rate 2 gm po x 1 95% 500 mg po bid x 5-7 95% Partner management—Treat partners

  25. Case 22 year old sexually active women c/o new bumps on her vagina. She reports a new partner over the past 3 months with rare condom use.

  26. Exophytic lesions condylomataacuminata HPV warts condylomatalatasyphilis

  27. External genital warts • Human papilloma virus, types 6, 11 • Vagina, cervix, penis, urethra, anus/rectum • Diagnosis by visual inspection—80% accurate • Up to 70% sexually active adults exposed to HPV

  28. Provider-applied treatment for external genital warts MedicationCure rate Cryotherapy liquid nitrogen 50% Podophyllin resin 10-25% 50% TCA/BCA 80-90% 50% Surgical excision 50%

  29. Patient-applied treatment for external genital warts MedicationCure rate Podofilox 0.5% x 4 weeks 70% bid x 3 days, rest x 4 days Imiquimod 5% x 12- 16 weeks 70% qhs 3x/ week

  30. External genital warts and cervical cancer screening • Women with external genital warts should undergo regular Pap screening as recommended for women without genital warts • Genital warts are not an indication for a change in the frequency of Pap test or for cervical colposcopy • No recommendations for sex partner management • No role for HPV typing in evaluation of genital warts in men or women

  31. HPV and immunization • 2392 women allocated to HPV-16 virus-like particle or placebo and followed for 7 months • 0% HPV incidence vs. 3.8 per 100 person-years Koutsky L et al. NEJM, November 2002 • Gardasil (HPV 6,11,16,18) FDA-approved June 2006 • HPV immunization recommended in 11 & 12 year old boys and girls, and approved for ages 9-26 years.

  32. HPV and anal cancer • Anal cancer rates in gay men about 50/ 100,000 • Increased in HIV-infected • Anal PAP smear screening might detect early disease • No evidence routine anal PAP screening reduces disease incidence • Current screening recommendations vary, no national recommendations

  33. Case • 35 y transgender (M F) presents with sores on her “thing” • She noticed them about 2 days ago. They don’t hurt. She is HIV-infected on HAART and is followed regularly

  34. Genital herpes Prevalence of HSV-2 type-specific antibody in U.S., 2005-2008 Human herpes simplex virus type-1 and -2 Mostly asymptomatic, “unrecognized” 1 Penis,Cervix, Urethra, Anus, Rectum, Vagina 16.1%HSV-2 Includes all races, both genders, aged 12 years and older NHANES, 2005-2008, CDC STD Division

  35. Diagnosis of genital herpes Culture PCR sensitivity 70-90% 90% specificity 100% 100% Type-specific serology: EIA, Wb, immunoblot sensitivity 80-90% specificity 90-95% Ashley RL, Derm Clinic, 1998

  36. Typical and atypical herpes manifestations in men Grouped vesicles

  37. Typical and atypical herpes manifestations in women

  38. Key counseling messages in genital herpes 1. Herpes is common: 1 in 6 2. Infection is often asymptomatic 3. Transmission is sexual but often when partners are asymptomatic 4. Spread can be reduced with symptom recognition, avoidance of sex when symptomatic, condom use and suppressive therapy 5. Tell partners: most will cope

  39. Treatment of Genital Herpes Famciclovir [Famvir] 500 mg 250 mg 125 mg Valacyclovir [Valtrex] 1 g 500 mg Acyclovir [Zovirax] 800 mg 600 mg 200 mg Valtrex and Zoviraxare registered trademarks of GlaxoSmithKline.

  40. Treatment of primary genital herpes Initial episode acyclovir 400 mg tid x 7-10 d #30 ($5.10) famciclovir 250 mg tid x 7-10 d #30 valacyclovir1 gm bid x 5-10 d #20

  41. Treatment of recurrent genital herpes Repeat episode acyclovir 400 mg tid x 5-7 d #15 acyclovir 800 tid x 2 d #6 valacyclovir500 mg bid x 3-7 d #6 famciclovir 1 gm bid x 1 d #4

  42. Suppression of genital herpes Suppressive therapy acyclovir 400 mg bid #60 ($10.20) famciclovir250 mg bid #60 valacyclovir500 mg or 1.0 gm qd #30

  43. Suppressive Therapy Reduces Transmission • 743 source partners received valacyclovir; 741 received placebo over 8 months. • Daily valacyclovir reduced incidence • acquisition of symptomatic genital HSV-2 infection by 77%, 2.3% vs. 0.5% • acquisition of any HSV-2 infection by 50% , 3.8% vs 1.9% Corey L et al. NEJM, 2004.

  44. Condoms Reduce HSV Transmission • 528 monogamous couples discordant for HSV-2 infection were followed for 18 months. • Condom use during more than 25% of sex acts was associated with 92% reduction in HSV-2 acquisition for women • 1862 persons in HSV-2 vaccine study followed for 18 months. • Condom use during more than 65% of sex acts was associated with a 34% reduction in HSV-2 acquisition in women, 41% reduction in men, and 58% in gay men. Wald A et al. JAMA 2001;285:3100-3106; Wald A et al. CDC STD Prevention Confcerence 2002, B9E, A.40.

  45. Case • 30 year old man c/o rash, swollen glands, fever • What additional history? • What tests? • Treatment?

  46. Trends in syphilis by sex, age and race/ethnicity, US CDC STD Surveillance, 2010

  47. Syphilis Louisiana was #1 in 2011 (Georgia #3)

  48. Primary syphilis—chancres

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