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VIRAL STDs: Genital Herpes and Warts

VIRAL STDs: Genital Herpes and Warts. Burning questions. Jeffrey D. Klausner, MD, MPH Professor of Medicine and Public Health Attending Physician Ronald Reagan Medical Center Program in Global Health for World Health and Division of Infectious Diseases David Geffen School of Medicine

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VIRAL STDs: Genital Herpes and Warts

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  1. VIRAL STDs:Genital Herpes and Warts Burning questions Jeffrey D. Klausner, MD, MPH Professor of Medicine and Public Health Attending Physician Ronald Reagan Medical Center Program in Global Health for World Health and Division of Infectious Diseases David Geffen School of Medicine Department of Epidemiology Karin and Jonathan Fielding School of Public Health UCLA AAHIVU August 2014

  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 STD Guidelines group • Dr. Klausner is a board member of YTH, Inc, non-profit • Dr. Klausner is medical advisor for Healthvana.com • In the past 12 months, Dr. Klausner has received: • Travel support for meeting coordination and speaking from Standard Diagnostics, Inc. • Research funding or donated supplies from the NIH, CDC, Hologic, Inc., Alere, Inc., Chembio, Inc. Cepheid, Standard Diagnostics, Inc., and MedMira, Inc. JDKlausner@mednet.ucla.edu

  3. Many sexually transmitted infections • Bacteria • Chlamydia trachomatis • Neisseria gonorrhoeae • Treponema pallidum • Mycoplasma genitalium • Ureaplasma urealyticum • Haemophilus ducreyi • Shigella spp. • Salmonella spp. • Protozoa • Trichomonas vaginalis • Giardia lamblia • Entamoeba histolytica • Viruses • Human papillomaviruses (> 120 types) • Herpes simplex virus 1 and 2 • Kaposi’s Sarcoma-associated virus (Human herpes virus 8) • Human immunodeficiency virus • Human T-cell lymphotropic virus 1 and 2 • Cytomegalovirus • Ebstein-Barr virus • Hepatitis A, B and C

  4. STIs in the United States • Over 20 million new cases per year • 50% in those < age 25 years • 110 million prevalent STIs • > $16 billion dollars annually in direct medical costs http://www.cdc.gov/std/stats/STI-Estimates-Fact-Sheet-Feb-2013.pdf

  5. Sexually Transmitted Diseases • Urethritis • Cervicitis • Vaginitis • Vaginosis • Balanitis • Warts • Genital ulcer disease • Pelvic inflammatory disease • Proctitis • Pharyngitis • Skin rashes • Tubo-ovarian abscess • Hepatitis • Epididymitis • Arthritis • Conjunctivitis • Meningitis • Cancer • Infertility • AIDS

  6. Today’s talk • Genital herpes • Genital warts

  7. Case • 35 y transwoman presents with sores on her “thing” • She noticed them about 2 days ago. They are painful. She is HIV-infected on ART and is followed regularly

  8. 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” 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

  9. Progression of Herpes Lesions

  10. Detection of herpes infection

  11. Typical and atypical herpes manifestations in men Grouped vesicles

  12. Typical and atypical herpes manifestations in female

  13. Key counseling messages in genital herpes 1. Herpes is common: 1 in 6 2. Infection is often asymptomatic 3. Transmission is sexual and 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

  14. 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.

  15. Treatment of primary genital herpes Initial episode acyclovir 400 mg tid x 7-10 d #30 ($35.49) famciclovir 250 mg tid x 7-10 d #30 ($187.99) valacyclovir 1 gm bid x 5-10 d #20 ($243.19) Nilsen et al., Lancet, 1982; Wald et al., AAC, 1994; Loveless et al, ICAAC, 1995 Fife et al., STD, 1997.

  16. Treatment of recurrent genital herpes Recurrent episode acyclovir 400 mg tid x 5-7 d #15 ($20.79) acyclovir 800 tid x 2 d #6 ($17.79) valacyclovir 500 mg bid x 3-7 d #6 ($44.19) famciclovir 1 gm bid x 1 d #4 ($51.89) Reichman et al, JAMA, 1984 ; Wald et al, CID, 2002 ; Leone et al, CID, 2002

  17. Suppression of genital herpes Suppressive therapy acyclovir 400 mg bid #60 ($64.99) famciclovir 250 mg bid #60 ($369.99) valacyclovir 500 mg or 1.0 gm qd #30 ($364.29) Straus et al., JAMA, 1988; Mertz et al., Arch Intern Med, 1997; Patel et al., GU Med, 1997; Shacker et al., Ann Intern Med, 1998

  18. 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.

  19. Suppressive Therapy Reduces Transmission • 743 source partners received valacyclovir • 741 received placebo • Daily valacyclovir reduced incidence of symptomatic genital HSV-2 infection in partner by 77% • acquisition of any HSV-2 infection by 50% Corey L et al. NEJM, 2004.

  20. 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. On physical exam you see multiple warty lesions

  21. Exophytic lesions condylomata acuminata HPV warts condylomata latasyphilis

  22. 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

  23. Provider-applied treatment for external genital warts MedicationCure rate Cryotherapy liquid nitrogen 50% TCA/BCA 80-90% 50% Surgical excision 50% Patient applied podofilox 70% Patient applied imiquimod 70%

  24. HPV and immunization • 2392 women allocated to HPV-16 vaccine or placebo • 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 • Cervarix (HPV 16, 18) FDA-approved • HPV immunization recommended in 11 & 12 year old boys and girls, and approved for ages 9-26 years.

  25. HPV and anal cancer • Anal cancer rates in gay men about 35-50/ 100,000 per year • Increased in HIV-infected, 50-100/100,000 per year • Anal PAP smear screening may detect early disease • No evidence routine anal PAP screening reduces disease incidence • Current screening recommendations vary, no national recommendations

  26. Me JDKlausner@mednet.ucla.edu CDC www.cdc.gov/std Current STD Management Textbook Sources for more STD information

  27. Thank you

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