General Session Prevention and Treatment of HPV and Other Common STDs Clare Hawkins, MD Clinician, Legacy Community Health Services FQHC Faculty Member, Houston Methodist Family Medicine Residency Lead Physician – Texas, Aspire Health Care: Palliative Care Baytown, Texas Educational Objectives By completing this educational activity, the participant should be better able to: 1. Discuss the most common sexually transmitted diseases seen in the primary care setting. 2. Discuss prevention of HPV and other common STDs. 3. Implement a management strategy of a patient with an STD. 4. Become familiar with the various pharmacological treatments available. Speaker Disclosure Dr. Hawkins has disclosed that he has no actual or potential conflict of interest in relation to this topic. 8 Speaker Disclosure
Sexually Transmitted
Diseases
 Dr. Hawkins has disclosed that he has no
actual or potential conflict of interest in
relation to this topic.
Clare Hawkins MD MSc FAAFP
CFW April 2016
First Case
Educational Objectives
 Your 17 yo F patient is going to college and
asks about birth control
 You think to explain about barrier
contraception
By completing this educational activity, the
participant should be better able to:
1. Discuss the most common sexually transmitted
diseases seen in the primary care setting
2. Discuss prevention of HPV and other common
STDs
3. Implement a management strategy of a patient
with an STD
4. Become familiar with the various
pharmacological treatments available
Polling Slide 1
What is the most prevalent STD?
Most Common STD: HPV
 What is the chance she will get a STI while on
campus?
 What is the chance she will already have one?
 Why do we even let our children out of the
house?
1.
2.
3.
4.
HIV
HSV
HPV
HIN (Heck if I know)
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HPV – 100 subtypes 40 are genital
16 & 18 oncogenic, 6 & 11 genital warts
34,788 new HPV-associated cancers (09)
355,000 new cases of anogenital warts were
associated with HPV infection (09)
Common: most people get it some time in their
life asymptomatic
1
HPV Facts
HPV Causal for Cancer
 Most spontaneous clear, but remote
neoplasms may develop
 No way to ascertain latency status
 Anogenital area (bathing suit area) but
also oropharynx
 Transmission anogenital, genital-genital,
oral
 Condoms, limiting sex partners helpful
 Persistent infection
with oncogenic types
of HPV has a causal
role in;
 Nearly all cervical
cancers
 In many vulvar
 Vaginal cancer
 Penile cancer
 Anal cancer
 Propharyngeal
cancers
Forman D, de Martel C, Lacey CJ, et al. Global burden of human papillomavirus and related diseases. Vaccine 2012;30(Suppl 5):F12–23.
Polling Slide 2
Your 25 yo patient is concerned about
HPV vaccination, he has sex with other
men, insertive and receptive
1. It is too late to administer HPV vaccine
2. You can begin a 3 vaccine series regardless of if
he has had warts
3. You should begin vaccination only if he hasn’t
had warts
4. He is too old
HPV (Cancer) Vaccination
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F (9) 12-26
M (9) 12-21 (MSM 26)
3 doses within 6 months
Vaccinate even if already abn PAP or genital wart
Promote as “cancer prevention”
Have office-systems to track vaccination
Not licensed for pregnant women
Cervical Cancer Screening
Anal Cancer Screening
 Only Screening approved by systematic
evidence
 Starting age 21, every 3 years
 >=30 pap every 3, or co-testing for HPV
every 5
 Continue to test those who have had HPV
vaccine
 Insufficient evidence for Anal Pap
 Some clinical centers perform anal cytology to screen
for anal cancer among high-risk populations
 Then high-resolution anoscopy (HRA) for those with
abnormal cytologic results
 Persons with HIV infection
 MSM
 History of receptive anal intercourse
 Oncogenic HPV tests are not clinically useful for anal
cancer screening among MSM because of a high
prevalence of anal HPV infection
2
Treatments
 Imiquimod – self-administered 3.75, 5%
cream
 Podofilox – self-administered, .5% soln or gel
 Podophyllin resin 10%–25% - no longer
recommended
 Sinecatechins
 Trichloroacetic Acid TCA or BCA
 External, vaginal, cervical
 Cryotherapy exp urethral, vaginal, cervical
3. Implement a Management
Strategy of a Patient with an STD
 Diagnosis
 Treatment
 Health Education/Coaching
 Contact Tracing
 Reporting
Key Messages for Persons with
Anogenital Warts
1. If untreated, may
resolve, or proliferate
2. No need for extra Pap
3. Timing of HPV
acquisition cannot be
determined. Sex
partners can share HPV
though warts only for
one
4. Common/benign but
significant psychosocial
5. Treatment does not cure,
therefore they may return
within 3m
6. Test for other STD, and be
aware of transmission risk
7. Condoms may lower
transmission risk
8. HPV Vaccine can prevent
most genital warts, but if
given after they are present,
will not reduce wart burden
4. Become Familiar with the various
pharmacological treatments
available
 Guidelines from CDC
 Accessible, current and timely
Urethritis and Cervicitis
 Chlamydia
 Urethritis
 Nongonococcal Urethritis
 Cervicitis
3
Polling Slide 3
Chlamydia screening is indicated for
women under age 25
1. Regardless of whether they are having
sexual intercourse
2. Using urine chlamydia NAAT test
3. Using vaginal or cervical NAAT test
4. Using only cervical NAAT test
Chlamydia Testing
 TEST: High index of suspicion for those with symptoms
 Spotting, Dysuria, Urethral or Vaginal Discharge
 If abdominal pain (F), consider PID
 If saddle pain or testicle pain consider epididymitis
or prostatitis
 NAAT (DNA)
 First Morning Urine (M)
 Self Collected Vaginal Swab (F)
 Physician Collected Vaginal or Cervical Specimens
 Oropharyngeal Swabs or Rectal (not FDA
approved)
 Anal Cytological Specimens not as sensitive but
approved
Pregnancy & Neonatal
Chlamydia Screening
 Pregnancy
 Test of cure 3-4 weeks later
 Test of persistent cure 3 months later
 Third trimester re-testing, advised for pregnant
women < 25 years
 Neonatal (trans-cervical spread to eye, rectum
and oropharynx for up to 3 yrs)
 Conjunctivitis, (7-28 days) (erythro prophylaxis?)
 Pneumonia (1-3 months) afebrile pneumonia,
staccato cough and hyperinflation
 Non-Culture testing from everted lid DFA
 USPSTF
Treatment
Polling Slide 4
Expedited Partner Therapy – EPT
 Directly observed single dose treatment
 Azithromycin – 1 gm po
 Expedited Partner Therapy: (EPT)
 Give a written prescription to your patient to
treat their partner
 Partners accompanying patient to follow-up
appt
 MSM advised to have in person visit for testing
 Asymptomatic Women < 25 who are sexually
active
 Other “High Risk”
 New Sexual Partner in last 6 months?
1. Is legal in Texas
2. Should be issued together with patient education
regarding drug and risks
3. Is appropriate if patient’s partner unlikely to come
in for evaluation
4. Can be used for contacts < 6 months in past or
beyond if no other source of infection
5. All of the above
4
Chlamydia Treatment
 Azithromycin – 1 g po single dose or
 Doxycycline – 100 mg bid 7 d
 Alternate Regimens
 Erythromycin – base 500 mg qid 7 d
 Erythromycin ethylsuccinate – 800 mg orally
qid 7 d
 Levofloxacin – 500 mg daily 7 d
 Ofloxacin – 300 mg bid 7 d
Gonococcal Infections
 Gonorrhea is the second most commonly
reported communicable disease
 820,000 new N. gonorrhoeae infections
occur each year
 Very symptomatic in M, less so in F,
therefore leads to PID
 Emerging resistance
Gonorrhoeae Testing
Gonorrhoeae Screening
 TEST: High index of suspicion for those with symptoms
 Annually Women < 25
 High Risk
 Those who have a new sex partner
 More than one sex partner
 A sex partner with concurrent partners
 A sex partner who has an STI
 Exchanging sex for money or drugs
 Inconsistent condom use in those not mutually
monogamous
 How would you ask about this?
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Urethral or Vaginal Discharge
If abdominal pain (F), consider PID
If saddle pain or testicle pain, consider epididymitis or prostatitis
Fitz Hugh Curtis, perihepatitis
Petechial or pustular acral skin lesions,
Asymmetric polyarthralgia, tenosynovitis, or oligoarticular septic
arthritis
 NAAT (DNA)
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First Morning Urine (M)
Self-Collected Vaginal Swab (F)
Physician Collected Vaginal or Cervical Specimens
Oropharyngeal Swabs or Rectal (not FDA approved)
Anal Cytological Specimens not as sensitive but approved
Gonorrhoeae Risk Groups
 Concentrated in specific geographic
locations and communities.
 Subgroups of MSM are at high risk
 Ask public health authorities in community for
guidance about local high-risk groups
 A recent travel history with sexual contacts
outside of US
GC Testing
 NAAT (More Sensitive)
 Urethral, Cervical, Vaginal
 Oropharyngeal, Rectal, Conjunctival (not FDA
approved) read product insert, caution with
other pharyngeal neisseria sp.
 Culture (Fastidious)
 Urethral, Cervical
 Less Sensitive, More Specific and allows
Sensitivity testing
 Gram Stain
 Sens/Spec for symptomatic discharge, but not
to r/o for screening
5
GC Treatment cx, Urethra, Pharynx
 Ceftriaxone 250 mg IM in a single dose and
Azithromycin 1g orally in a single dose
 If ceftriaxone is not available:
 Cefixime 400 mg orally in a single dose and
Azithromycin 1 g orally in a single dose
Treatment of Contacts
 Treat sexual
contact within the
60 days preceding
onset of sx or dx
 EPT, public health,
bring partner in
 Inspot.org
Treatment: GC Resistance
 Co-treatment for (relatively asymptomatic)
Chlamydia, even if chlamydia test negative
because decreased antimicrobial resistance
 Ceftriaxone 250 IM plus Azithromycin 1 g (or
Doxycycline)
 Cefixime 400 po no longer recommended as firstline due to resistance
 Gemifloxacin 320 mg plus oral Azithromycin 2 g
was associated with cure rates of 99.5% , (8%
vomiting)
 Direct observed treatment, and remain abstinent 7
days
Vaginal Discharge
 History:
 Sexual behaviors and
practices
 Gender of sex partners
 Menses
 Vaginal hygiene practices
(e.g., douching)
 Self-treatment with
medications should be
elicited
 Since most yeast vaginitis is
self treated
Vaginal Discharge: Testing
Not transmitted sexually but is in DDx for discharge
pH (> 4.5 in BV or Trich)
KOH test for hyphae
Microscopic examination of fresh samples of the
discharge: Clue cells or trichomonads
 High Specificity, 50% Sensitivity
 NAAT (trich) higher sensitivity but expensive
 DNA probe for G. vaginalis available
but uncertain performance
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Vaginal Discharge: BV
Replacement of N flora with;
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Prevotella sp.
Mobiluncus sp.
G. vaginalis
Ureaplasma
Mycoplasma,
Numerous fastidious or
uncultivated anaerobes
Associated With;
 Multiple male or female
partners
 A new sex partner
 Douching
 Lack of condom use
 Lack of vaginal lactobacilli
 (Women who have never
been sexually active are
rarely affected)
6
BV Complications & Treatment
 HIV Acquisition
 HIV Transmission to M
 (But partner treatment not
recommended)
 Acquisition of GC,
Chlamydia, HSV-2
 Preterm Labor
 Gyn Surgery complications
 Recurrent BV
 Metronidazole 500 mg bid 7d
 Metronidazole gel 0.75% one
full applicator (5 g) daily x 5
days
 (Disulfiram reaction 72 h)
 Clindamycin 2% one app (5g)
daily x 7 d
 No studies support the
addition lactobacillus
intravaginally or probiotic as
an adjunctive or replacement
therapy in women with BV
Recurrent BV
1. Metronidazole or tinidazole 500 mg twice daily for 7
days) followed by intravaginal boric acid 600 mg
daily for 21 days and then suppressive 0.75%
metronidazole gel twice weekly for 4–6 months
2. Monthly oral metronidazole 2 g administered with
fluconazole 150 mg has also been evaluated as
suppressive therapy; this regimen reduced the
incidence of BV and promoted colonization with
normal vaginal flora
1. Reichman O, Akins R, Sobel JD. Boric acid addition to suppressive antimicrobial therapy for recurrent bacterial vaginosis.
Sex Transm Dis 2009;36:732–4.
2. McClelland RS, Richardson BA, Hassan WM, et al. Improvement of vaginal health for Kenyan women at risk for acquisition
of human immunodeficiency virus type 1: results of a randomized trial. J Infect Dis 2008;197:1361–8
Vaginal Discharge: Trich
 Most common non-viral STD 3.7
million
 13% BF
 1.8% of non-Hispanic white women
 >11% of women aged ≥40 years
 High prevalence in STD clinic patients
 26% of symptomatic F
 6.5% asymptomatic F
 9%–32% of incarcerated women
 2%–9% of incarcerated men)
 Prevalence in MSM is low
 53% of HIV infected women and
associated with PID
Trich
Testing
 Wet Prep:
 Inexpensive, rapid
 55% sensitive
 NAAT
 95% sensitive and specific but $
 17% reinfection rate
 Therefore retest 2-12 weeks
Vaginal Discharge: Yeast
Not a Sexually Transmitted Disease
75% of women develop Vaginal yeast infections
90% Candida Albicans
Candida glabrata, Candida parapsilosis and
Saccharomyces cerevisiae are responsible for up to 33
percent of recurrent infections
 73% of women self-treat
 OTC 1,3,7 day topical imidazole or single dose rx
fluconazole
 Infected women have
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 Metronidazole or tindazole 2 g single dose
 Metronidazole 500 bid 7 d
 Treat sex partners
 Recurrent: (ddx contact derm, HSV, Vaginismus)
 Infected men have symptoms of
 Urethritis, epididymitis, or prostatitis
 Vaginal discharge that might be diffuse, malodorous,
or yellow-green
 With or without vulvar irritation.
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(Inverse relationship to vaginal burning risk)
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Fluconazole 100-200 mg weekly
Consider Diabetes testing (and HIV?)
15 percent of women in a study who had irritant dermatitis, their selftreatment played a role in the perpetuation of their symptoms
Am Fam Physician. 2001 Feb 15;63(4):697-703.
7
PID
 Spectrum: endometritis, salpingitis, tuboovarian abscess, and pelvic peritonitis
 GC, Chlamydia 50%
 Normal Vaginal Flora
 BV association, but not reduced by
treating
 Cytomegalovirus (CMV), M. hominis, U.
urealyticum, and M. genitalium
PID Treatment IV
 Cefotetan 2 g IV every 12 hours
PLUS
 Doxycycline 100 mg orally or IV every 12 hours
OR
 Cefoxitin 2 g IV every 6 hours
PLUS
 Doxycycline 100 mg orally or IV every 12 hours
OR
 Clindamycin 900 mg IV every 8 hours
PLUS
 Gentamicin loading dose IV or IM (2 mg/kg), followed by a
maintenance dose (1.5 mg/kg) every 8 hours. Single daily
dosing (3–5 mg/kg) can be substituted.
Epididymitis
 Testicular/ scrotal pain r/o torsion
 <35 yo Chlamydia/ GC
 Coexists with urethritis
 Insertive MSM partner highest risk
 >35 yo Enteric Organisms more likely
(bladder outlet obstruction
 Chronic > 6 wks sx granulomatous disease
i.e., TB
PID
 Clinical diagnosis of symptomatic PID has a PPV
for salpingitis of 65%–90% compared with
laparoscopy
 Low threshold for diagnosis (any of cervical
motion tenderness, uterine or adnexal
tenderness)
 Asymptomatic, or abnormal bleeding,
dyspareunia, and vaginal discharge)
 Even women with mild or asymptomatic PID
might be at risk for infertility
PID Treatment PO
 Ceftriaxone 250 mg IM in a single dose PLUS Doxycycline 100 mg
orally twice a day for 14 days
WITH* or WITHOUT Metronidazole 500 mg orally twice a day for 14 days
 Cefoxitin 2 g IM in a single dose and Probenecid, 1 g orally
administered concurrently in a single dose PLUS Doxycycline 100
mg orally twice a day for 14 days
WITH or WITHOUT Metronidazole 500 mg orally twice a day for 14 days
Other parenteral third-generation cephalosporin (e.g., ceftizoxime or
cefotaxime)
 PLUS Doxycycline 100 mg orally twice a day for 14 days
WITH* or WITHOUT Metronidazole 500 mg orally twice a day for 14 days
 Sex Partners should be evaluated, tested, and presumptively treated
for chlamydia and gonorrhea, regardless of the etiology of PID
HIV Prevalence
1,218,400 persons aged 13 years and older
are living with HIV infection
156,300 (12.8%) who are unaware of their
infection
Number living with HIV increased but new
HIV infections stable.
8
HIV Epidemiology
 44,073 people were diagnosed with HIV
2014
 New Dx declined by 19% from 2005 to 2014
 1.2 million persons living HIV in US 2011
 14% were living with undiagnosed infection
 62% of new HIV infection in US in 2011 were
men who have sex with men
 32% develop AIDs within 12 months of dx
HIV Screening
 CDC recommends HIV screening for patients aged
13–64 years in all health-care settings
 Opt-out testing preferred
 Consent is part of consent for general medical care
and separate consent not recommended
 Provide preventive counseling but don’t require it
 HIV 1 & 2 antibody, antigen or RNA then
confirmatory (HIV-2 antibody differentiation assay,
Western blot or IFA)
 POC testing 30 minutes, less able to detect early
infection
HIV Epidemiology Incarcerated
 Since epidemic began 92,613 persons with AIDS that were
infected through heterosexual sex, have died, including an
estimated 4,550 in 2012
 New HIV infections among women are primarily attributed to
heterosexual contact (84% in 2010) or injection drug use (16% in
2010
 Incarcerated Men 5 x the general population to
have HIV
 AA-Males 5 times as likely as white men, 2x
Hispanic/Latino men
 AA-Females 2 x as likely to be pos HIV as white or
Hispanic/Latino women
 9/10j inmates are released in under 72 hours,
making HIV testing/ treatment difficult
 Inmates reluctant to disclose risk behaviors
Source: CDC. Estimated HIV incidence among adults and adolescents in the United States, 2007–2010. HIV
HIV Epidemiology Reservoir
 18.1% of US adults and adolescents living with
HIV infection in 2009 were unaware of their HIV
infection
 Spread by anal or vaginal sex or by sharing
drug-use equipment with an infected person
 New infections are increasing among young
men who have sex with men, especially
young, black men men who have sex with
men
HIV Epidemiology: Age
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>55 are ¼ one-quarter of Americans living with HIV in 2012.
More likely to be diagnosed late in disease course
20 to 24 99% survived more than 12 months
50 to 54, 89%
55 to 59 86%
60 to 64, 82%
> 65
73%
Less likely to discuss sex with their physicians
ED meds facilitate sex for older men otherwise incapable
of SI.
9
HIV Epidemiology Gender
 Women were 23% of those living with HIV infection in 2011
 2010, the estimated number of new HIV infections among MSM
was 29,800, a significant 12% increase from 2008
 MSM are 4% of the M pop in US
 MSM were 78% of new HIV among M & 63% of all new infections
 MSM accounted for 54% of all people living with HIV infection in
2011
 The greatest number of new HIV infections (4,800) among MSM
occurred in young black/African American MSM aged 13–24
 Young black MSM accounted for 45% of new HIV infections
among black MSM and 55% of new HIV infections among young
MSM overall
 Texas 18,000/104,300 unaware of their infection
 Texas Males MSM > 13 yo unaware 12,110/62,400 (19.4% )
HIV Epidemiology Sex-Work
HIV
 Use of sexual activity for income or employment or for nonmonetary items, such as food, drugs, or shelter (“survival”
sex)
 Crosses many socioeconomic groups
 High-end escorts
 People who work in massage parlors
 Adult film industry
 Exotic dancers
 State-regulated prostitutes (in Nevada)
 Street-based men, women, and transgender people who
participate in survival sex
 Drug and alcohol abuse co-exist
 11 yrs between HIV and AIDS if not treated
 As of 2011, approximately 16% of the
estimated 1.2 million persons with HIV
infection in the United States are unaware
of their infection
 Acute HIV asymptomatic 50-90% of the
time
 Important to dx early
http://www.cdc.gov/hiv/
Acute HIV
 50-90% are asymptomatic during acute
infection
 Tests are often negative during this phase
 Repeat test 30-60 days
Genital, Anal or Perianal Ulcers
 Genital HSV, most common
 Syphilis, if unsure, treat as presumptive dx
 Chancroid Haemophilus ducreyi (sporadic
outbreaks Africa/Caribbean)
 Azithromycin 1 g orally in a single dose
 Ceftriaxone 250 mg IM in a single dose
 Ciprofloxacin 500 mg bid 3 d
 Erythromycin base 500 mg tid 7 d
 Granuloma Inguinale (Donovanosis)
 Lymphogranuloma Venereum
10
Herpes Simplex Virus, (HSV)
HSV 1 & II (50 million HSV II in the US)
Most HSV-2 are undiagnosed
Many have mild or unrecognized infections
BUT will shed virus intermittently in the anogenital area
Most genital herpes infections are transmitted by persons
Management of genital HSV should address the chronic
nature of the disease rather than focusing solely on acute
episodes
 Management of discordant partners
 Suppressive therapy in HSV positive individual to
reduce transmission
 Barrier
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HSV Counseling
 Natural hx
 Recurrences and
 Asymptomatic viral
shedding
 Suppressive rx
 Episodic rx
 Informing current partners
 Informing future partners
 Risk of neonatal infection
 Increased HIV transmission
risk
 Culture of vesicles specific but not sensitive
 NAAT becoming more available
 PCR is the test of choice for diagnosing HSV
infections affecting the central nervous system and
systemic infections
 Cytologic detection of cellular changes associated
with HSV infection is an insensitive and nonspecific
method of diagnosing genital lesions (i.e., Tzanck
preparation) and therefore should not be relied on
 Screening not indicated
HSV Treatment Acute
 HSV-2 viral shedding more
than HSV-1 and most in first
year after acquisition
 Avoid contact if prodromal
 Daily suppression partly
effective to reduce
transmission unless coinfection
 Type-specific couple testing
HSV Treatment Episodic Recipes
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HSV Testing
Acyclovir 400 mg tid or 800 bid or 800 tid for 5 d
Acyclovir 800 mg tid 2 d
Valacyclovir 500 mg bid 3 days
Valacyclovir 1 g daily 5 days
Famciclovir 125 mg bid 5 d
Famciclovir 1 gram orally twice daily for 1 day
Famciclovir 500 mg once, followed by 250 mg
bid 2 d
Acyclovir 400 mg tid 7-10 d
Acyclovir 200 mg 5 x / d 7-10 d
Valacyclovir 1 g bid 7–10 d
Famciclovir 250 mg tid 7–10 d
May extend treatment if resolution not
apparent
Episodic HSV with HIV Co-infection
 Acyclovir 400 mg tid 5-10 d
 Valacyclovir 1 g bid 5-10 d
 Famciclovir 500 mg bid 5–10 days
11
HSV Suppressive
 Non-HIV
 Acyclovir 400–800 bid-tid
 Valacyclovir 500 mg bid
 Famciclovir 500 mg bid
Syphilis
 Treponema pallidum
 Multiple manifestations
 Most frequently detected in primary care with
screening/ serology
 Increased incidence related to HIV
 Epidemic in some populations
 Sexual transmission only when mucocutaneous
syphilitic lesions present
 Uncommon after the first year of infection
Syphilis
Syphilis Testing: 2 Tests Required
 Primary (i.e., ulcers or chancre at the infection
site)
 Secondary (i.e., manifestations that include, but
are not limited to, skin rash, mucocutaneous
lesions, and lymphadenopathy)
 Tertiary (i.e., cardiac, gummatous lesions, tabes
dorsalis, and general paresis)
 Latent lacking clinical manifestations, detected
by serologic testing
 Early (one year), or late latent
 Nontreponemal test: VDRL or RPR
 False Positives common:
Positive RPR
Syphilis Treatment
 4x change, from 1:16 to 1:4 or from 1:8 to 1:32,
shows a significant difference between two
nontreponemal test results (same test, same lab)
 15%–25% of patients treated during the primary
stage revert to being serologically nonreactive after
2–3 years
 Neurosyphilis: depends on a combination of CSF
tests (CSF cell count or protein & reactive CSF-VDRL)
in the presence of reactive serologic test results and
neurologic signs and symptoms (csf VDRL not
sensitive)
 Adult Treatment
 Benzathine penicillin G 2.4 million units IM in a single
dose
 Child Treatment
 Benzathine penicillin G 50,000 units/kg IM, up to the
adult dose of 2.4 million units in a single dose
 Early Latent Syphilis
 Benzathine penicillin G 2.4 million units IM in a single
dose
 Late Latent Syphilis or Latent Syphilis of Unknown Duration
 Benzathine penicillin G 7.2 million units total,
administered as 3 doses of 2.4 million units IM each at
1-week intervals
 HIV, autoimmune conditions, immunizations,
pregnancy, injection-drug use, and older age
 Treponemal test: FTA-ABS, TP-PA, or EIA
 Fluorescent treponemal antibody absorbed
 T. pallidum passive particle agglutination assay,
 Immunoblots, or rapid treponemal assays also
available
 DFA
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More Penicillin!!
Hepatitis
 Tertiary Syphilis with Normal CSF Examination
 A: Fecal Oral, vaccinate
 B: Very infectious, percutaneous or infectious
 Benzathine penicillin G 7.2 million units total,
administered as 3 doses of 2.4 million units IM each at
1-week intervals
 1000x HIV, 1% hepatic failure
 Reservoir is those who are persistent HBSag pos
 Neurosyphilis and Ocular Syphilis
 90% of infants become chronic carriers, 30% children
 Identify through testing high risk groups, including pregnant
 Immunize at birth preventing vertical transmission
 Aqueous crystalline penicillin G 18–24 million units per
day, administered as 3–4 million units IV every 4 hours
or continuous infusion, for 10–14 days
 Procaine penicillin G 2.4 million units IM once
daily & Probenecid 500 mg orally four times a
day, both for 10–14 days
 Vaccination
 IDU, MSM, and adults with multiple sex partners), and all adults
seeking protection from HBV infection
 PEP: HBIG and HB vaccine
 C: Not usually sexually acquired
Proctocolitis
 Inflammation of rectum with tenesmus or rectal
discharge
 GC, Chlamydia, LGV serovars, T pallidum, HSV
 Recent onset among persons who have recently
practiced receptive anal intercourse is usually
sexually acquired
 Presumptive therapy should be initiated while
awaiting results of laboratory tests
 Ceftriaxone 250 im and Doxycycline 100 bid 7d
Sexually Transmitted Diseases Treatment Guidelines 2015, CDC, Pg. 96. MMWR, June 5, 2015, Vol. 64, No. 3
Prevention
 Abstinence
 Male Condoms
 Pre-Exposure Vaccination
 Pre-exposure vaccination is one of the most
effective methods for preventing transmission
of human papillomavirus (HPV),up to age 26
 HAV, and HBV
 Pre-Exposure Prophylaxis
Other Prevention Strategies
Male Circumcision
Emergency Contraception
Post-exposure Prophylaxis for HIV and STD
Antiretroviral Treatment of Persons with HIV
Infection to Prevent HIV Infection in Partners
 HSV Treatment of Persons with HIV and HSV
Infections to Prevent HIV Infection in Uninfected
Partners
 Retesting after 3 months
 Partner Services: Expedited Partner Therapy




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Pregnancy Screening
 HIV, Hep B, GC, Syphilis, Chlamydia , <25
years (twice)
 HCV if high risk (Injection Drug User IDU)
 No evidence for
 HSV, Trich, BV
Prevention: 5 Strategies
1. Accurate risk assessment and education and
counseling of persons at risk on ways to avoid STDs
through changes in sexual behaviors and use of
recommended prevention services;
2. Pre-exposure vaccination
3. Identification of asymptomatically infected persons
and persons with symptoms associated with STDs;
4. Effective diagnosis, treatment, counseling, and follow
up of infected persons
5. Evaluation, treatment, and counseling of sex partners
of persons who are infected with an STD.
Sexual History Taking: Rapport
1. Partners
 Open-ended questions
 “Tell me about any new sex partners you’ve had
since your last visit,”
 “What has your experience with using condoms
been like?”);
 Understandable, nonjudgmental language
 “Are your sex partners men, women, or both?”
 “Have you ever had a sore or scab on your penis?
 Normalizing language
 “Some of my patients have difficulty using a condom
with every sex act. How is it for you?”
 “Do you have sex with men, women, or both?”
 “In the past 2 months, how many partners have
you had sex with?”
 “In the past 12 months, how many partners have
you had sex with?”
 “Is it possible that any of your sex partners in the
past 12 months had sex with someone else while
they were still in a sexual relationship with you?”
2. Practices
“To understand your risks for STDs, I need to understand the
kind of sex you have had recently.”
 “Have you had vaginal sex, meaning ‘penis in vagina sex’?”
 If yes, “Do you use condoms: never, sometimes, or always?”
 “Have you had anal sex, meaning ‘penis in rectum/ anus
sex’?”
 If yes, “Do you use condoms: never, sometimes, or always?”
 “Have you had oral sex, meaning ‘mouth on penis/
vagina’?”
 For condom answers:
If “never”: “Why don’t you use condoms?”
If “sometimes”: “In what situations (or with whom) do you
use condoms?”
3. Prevention of pregnancy
4. Protection from STDs
 “What are you doing to prevent
pregnancy?”
 “What do you do to protect yourself from
STDs and HIV?”
14
5. Past History of STDs
“Have you ever had an STD?”
“Have any of your partners had an STD?”
Additional questions to identify HIV and viral
hepatitis risk include:
“Have you or any of your partners ever injected drugs?”
“Have your or any of your partners exchanged money or
drugs for sex?”
“Is there anything else about your sexual practices that I
need to know about?”
15
Medication Index
Prevention and Treatment of HPV and Other Common STDs
The following medications were discussed in this presentation. The table below lists the generic and trade name(s) of these medications. Generic Name
Acyclovir
Azithromycin
Benzathine Penicillin
Bivalent HPV Vaccine
Cefixime
Cefotetan
Cefoxitin
Ceftriaxone
Clindamycin
Disulfiram
Doxycycline
Erthromycin
Erthromycin Ethylsuccinate
Famciclovir
Fluconazole
Gemifloxacin
Gentamicin
Imiquimod
Levofloxacin
Metronidazole
Ofloxacin
Podofilox
Podophyllin
Probenecid
Quadrivalent HPV Vaccine
Sinecatechins
Tinidazole
Valacyclovir
Trade Name
Zovirax
Zithromax, Zmax
Bicilin, Permapen
Cervarix
Suprax
Cefotan
Mefoxin
Rocephin
Cleocin, Clindesse, Clindets, Evoclin
Antabuse
Acticlate, Doryx, Doxteric, Doxy, Monodox, Oracea, Vibramycin
Ery‐Tab, Eryc, Erythrocin, PCE
E.E.S., Eryped
Famvir
Diflucan
Factive
None
Aldara, Zyclara
Levaquin
Flagyl, Metrogerl‐Vaginal, Nevessa, Vandazole
None
Condylox
Podocon‐25
Probalan
Gardasil
Veregen
Tindamax
Valtrex
Notes