Sexually Transmitted Infections: Screening and Treatment Update Caroline Hacker, FNP-C and Christy Millican, FNP-C

Disclosures We have no disclosures or conflicts of interest!

Learning Objectives Review CDC guidelines about routine screening for STIs Get familiar with common clinical presentations Review CDC updates for treatment Discuss special circumstances and reasons to seek specialty consultation

Routine Screening Guidelines CDC ACOG AAP USPSTF HIV All adults and adolescents 13-64 at least once All sexually active adolescents All people at increased risk of transmission Gonorrhea Chlamydia Women: All sexually active women <25 years old yearly Men: consider screening in higher risk populations MSM: Yearly in all contact sites (rectal, oral, urine); every 3-6 months high risk **Start discussion about sexual activity 13-15 years old All women at increased risk of infection ages 15-65. Inconclusive evidence regarding men **Increased risk- sexually active, “high-risk” behaviors, high community prevalence Create a routine screening guideline for your clinic that is followed by all providers. Consider your population.

Pap Smears and Pelvic Exams ACOG recommends external genital exam only in patients younger than 21 years old, irrespective of sexual activity A pelvic examination always is an appropriate component of a comprehensive evaluation of any patient who reports or exhibits symptoms suggestive of female genital tract, pelvic, urologic, or rectal problems Routine cervical cancer screening (PAP) is not recommended until age 21, irrespective of sexual activity

Case Study 1: Vaginal itching and discharge A 15 year-old female Jane comes to clinic with a chief complaint of vaginal itching and discharge. It has been present for 2-3 weeks and she has also had some new breakthrough bleeding with her nexplanon she had placed last year. There is no particular odor; discharge is yellow. She is sexually active with one partner and believes they are monogamous. They use condoms sporadically. Denies pain with intercourse, fever, abdominal pain, nausea or vomiting.

Case Study 1: What to screen for? Based on this patient’s history, what would you screen for? How would you obtain these screenings? Chlamydia and gonorrhea screening by urine or vaginal swab (NAAT) Wet prep by molecular probe Screens for candida, bacterial vaginosis and trichomoniasis Is an internal pelvic exam necessary? Without pain with intercourse or other symptoms of pelvic inflammatory disease, initial pelvic exam is not necessary and patient can do a self swab for wet prep

Case Study 1: Results Results return to you the next day. She is positive for chlamydia; negative for gonorrhea, yeast, bacterial vaginosis and trichomonas Treatment recommendations: Azithromycin 1 g orally in a single dose Doxycycline 100 mg orally twice a day for 7 days Treatment can be sent to the pharmacy for patient pick up or patients can be brought back to clinic for observed therapy if there is concern for compliance

Chlamydia In men who have sex with men (MSM), always swab rectally and orally if concern for infection All sex partner should be treated; patients should abstain from sex for 7 days until all parties are treated Expedited partner therapy Patients should be re-screened in 4-12 weeks for test of re-infection. Screening sooner than 4 weeks may pick up bacteria that is still shedding

Chlamydia Statistics #6 in the nation in NC In 2017, 19,509 new cases in 15-24 year olds; disproportionally high African American burden https://www.cdc.gov/std/stats16/figures/3.htm

Case Study 2: Urethral discharge A 19 year-old male John comes to clinic with a chief complaint of some urethral discharge and burning with urination. This has been ongoing for about 1 week. The discharge is a yellowish-green. He denies fever, chills, testicular swelling or pain and rash. Sexual history reveals that he is sexually active with men and has had a new partner in the last month. They use condoms sporadically. They met on the grindr app; he believes this partner may have other partners as well. On physical exam there is no current urethral discharge, however, you do note an interesting rash on his palms and soles of feet. He is unsure how long that has been there and didn’t even really notice it prior to now.

John’s rash https://www.researchgate.net/figure/44630365_fig8_Figure-2-Palmar-and- plantar-rash-of-secondary-syphilisTypical-palmar-and-plantar-rash

Case Study 2: What to screen for? Given this patient’s medical and social history, what would you screen for? Chlamydia and gonorrhea by urine, oral and rectal swabs (NAAT) Patient can self-swab rectally Syphilis and HIV HIV can be HIV antibody by blood or rapid HIV by oral swab if this is available in clinic Counseling Open a conversation about safe sex and condom use Discuss increased risk of syphilis and HIV in this population Consider pre-exposure prophylaxis for HIV?

Case Study 2: Results John’s test results are positive for gonorrhea in the urine and oral swabs; negative for chlamydia. He is also unfortunately positive for syphilis; negative for HIV. What now? John has to return to clinic for treatment given his new diagnoses. In discussing the diagnoses with him, he does recall now having had a sore on his penis a few months ago https://www.cdc.gov/std/syphilis/images.htm

Gonorrhea Recommended treatment regimen: Ceftriaxone 250 mg IM in a single dose PLUS Azithromycin 1g orally in a single dose It is very important to treat with both agents in clinic- there is increasing resistance to treatment being seen Test of cure in 4-12 weeks- important considering resistance All sex partners need to be treated- no sex for 7 days after treatment for all partners If not already completed, all patients diagnosed with gonorrhea should be screened for chlamydia, HIV and syphilis as there is increased risk

Gonorrhea Statistics #6 in the nation in NC 2,768 new cases in 2017 among 15-24 year olds; disproportionally African American burden https://www.cdc.gov/std/stats16/figures/15.htm

Syphilis When reported to the CDC, they will make a home visit to help track epidemiology. Let your patient know! John’s rash in clinic is a hallmark sign of secondary syphilis. In retrospect, he also had the chancre present with primary syphilis infection Sexual transmission of T. pallidum is thought to occur only when mucocutaneous syphilitic lesions are present Consider referral to infectious disease specialist if available in the area Jarisch-Herxheimer Reaction Counsel patients about potential for fever, myalgias and headaches that can occur within 24 hours of treatment; more common during early syphilis Primary and Secondary Treatment: Benzathine penicillin G 2.4 million units IM in a single dose Titers must be followed over time for indication of treatment success and should decline fourfold (1:321:16). Testing should be completed at 6 and 12 months

Syphilis Statistics #9 in the nation in NC 250 new cases of syphilis in 2017 among 15-24 year olds; disproportionately African American burden https://www.cdc.gov/std/stats16/figures/32.htm

New HIV diagnosis In NC, 1015 new HIV diagnoses from 2015-2017 Counsel patient on importance of follow-up and lifetime care Provide emotional support Assess for acute medical needs Immediate referral to infectious disease for further workup and treatment

Pre-exposure Prophylaxis for HIV Given that John is sexually active with men, has now had gonorrhea and syphilis and isn’t always using condoms consistently, it is important to discuss ways to prevent HIV which include condom use, testing of partners and possibly pre-exposure prophylaxis  The pill (brand name Truvada) contains two medicines (tenofovir and emtricitabine) that are used in combination with other medicines to treat HIV. When someone is exposed to HIV through sex or injection drug use, these medicines can work to keep the virus from establishing a permanent infection. When taken consistently, PrEP has been shown to reduce the risk of HIV infection in people who are at high risk by up to 92%. PrEP is much less effective if it is not taken consistently. Patients must commit to taking medication consistently and following up every 3 months Consider referral to adolescent medicine or infectious disease for an older teen interested in this therapy if unable to prescribe in office

Case 3: Vulvar rash An 18 year-old female Sarah presents to clinic with a chief complaint of a rash on bilateral vulva. It is very painful and she has difficulty sitting down and urinating. She noticed some burning and tingling a few days ago and then the rash appeared. She has been sexually active in the past- about 3 months ago. She denies fever, chills or other vaginal discharge. On exam you find a significant rash of small lesions with ulcerated bases covering labia majora, minora and rectal area. Sarah has significant pain with your exam.

Common rash presentation http://www.webmd.com/sexual-conditions/ss/slideshow-std-pictures-and-facts

Case 3: What to test for? Based on clinical exam this rash is very suspicious for herpes simplex virus (HSV). Given its severity, it is reasonably likely that it may be HSV-1 vs. HSV-2. HSV-2 often causes smaller, more scattered lesions that can sometimes go unnoticed and therefore undiagnosed. HSV-1 initial outbreaks are often diffuse and very painful Testing: HSV-1 and HSV-2 by PCR of the lesions or culture of the lesions is best practice for testing Although serologic testing can be performed, it is not typically recommended. False negatives can be present in early infection. HSV-1 may be detected but is difficult to differentiate between exposure and oral lesions vs. vaginal lesions

Case 3: Treatment Cases are not tracked by the CDC Initial outbreaks Consider lidocaine gel for comfort Sitz baths Easiest regimens: Valacyclovir 1 g orally twice a day for 7–10 days Acyclovir 400 mg orally three times a day for 7–10 days Treatment can be extended if healing is incomplete at 10 days Provide emotional support and information about preventing spread to future partners given that HSV does not have a cure Always disclose previous HSV infections to care providers, especially to OB/GYN when pregnant Suppressive therapy Valacyclovir 1 g orally once a day Acyclovir 400 mg orally twice a day

Case 4: Vaginal discharge and odor A 14 year-old patient Emma comes to clinic with a chief complaint of vaginal discharge and odor. It has been ongoing for about 1 month and she describes it as a thin, watery discharge with a fishy odor that is particularly worse around her period. She occasionally has itching. She denies being sexually active. She is a dancer and stays in leotards frequently. She denies use of new soaps or detergents but does like to take bubble baths a few times a week. She denies bleeding between periods.

Case 4: What to test for? Wet prep by molecular probe Gram stain Screens for candida, bacterial vaginosis and trichomonas Gram stain Wet mount in office Would you elect to screen for chlamydia and gonorrhea given her report of no sexual activity ? Does she need a pelvic exam?

Case 4: Results Emma’s testing reveals bacterial vaginosis and candida. Trichomonas is negative Chlamydia and gonorrhea testing negative

Bacterial Vaginosis (BV) Characterized by fishy odor, watery discharge with ph >4.5 and clue cells Treatment is recommended for women with symptoms: Metronidazole 500 mg orally twice a day for 7 days Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days Tinidazole 2 g orally once daily for 2 days **Advise about disulfiram reaction with alcohol if using –azole therapy- no alcohol within 72 hours of last dose** No partner therapy necessary if sexually active During treatment, refrain from sexual activity Recurrence is very common if treatment not completed Limited evidence for role of probiotics Discuss with patient good vaginal hygiene practices: Avoid products with scents and dyes Avoid wearing tight clothing No douching The vagina is a self cleaning oven! Do not use soap on mucocutaneous surfaces- just water.

Vulvovaginal Candidiasis (VVC) Characterized by thick, white vaginal discharge, redness and itching Many OTC products are available, however, compliance is often poor and efficacy can be limited Treatment: Fluconazole 150 mg orally in a single dose (2 doses 3 days apart for severe symptoms) Clotrimazole 2% cream 5 g intravaginally daily for 3 days Recurrence: Retreat with 3 doses of fluconazole 150 mg (days 1, 3 and 7) Consider once weekly fluconazole 150 mg for >4 recurrences a year Consider rx for fluconazole 150 mg x 1 for patients who frequently get VVC after antibiotic therapy to prevent need for return visit

Trichomoniasis (Trich) Trichomoniasis is the most prevalent nonviral sexually transmitted infection in the United States, affecting an estimated 3.7 million persons T. vaginalis infection is associated with two- to threefold increased risk for HIV acquisition Characterized by diffuse, malodorous, yellow-green frothy discharge that likely will cause irritation Sensitivity of wet mount is low (51-65%)- therefore NAAT swab is preferred Treatment Metronidazole 2 g orally in a single dose OR Tinidazole 2 g orally in a single dose **Advise about disulfiram reaction with alcohol if using –azole therapy- no alcohol within 72 hours of last dose** Partners should also be treated and abstain from sex for 7 days after treatment to prevent reinfection Test for reinfection should be performed within 3 months (as soon as 2 weeks) Test for other STIs in patients positive for trich Can cause PID- consider internal pelvic exam and bimanual exam for patients who are positive and have dyspareunia, abdominal pain, cramping, fever etc.

Expedited Partner Therapy by State Per the NC Medical Board: Signed prescriptions of oral antibiotics of the appropriate quantity and strength sufficient to provide curative treatment for each partner named by the infected patient. Notation on the prescription should include the statement: “Expedited partner therapy.” https://www.cdc.gov/std/ept/legal/default.htm

Other considerations Always discuss contraception with patients who are sexually active and come in for STI testing Consider providing condoms in your office that are easily accessible for patients and can be taken discreetly if desired

Resources www.dontspreadit.com – Anonymous partner reporting https://www.cdc.gov/std/tg2015/default.htm - CDC treatment guidelines 2015 Can order hard copies of these materials to keep in clinic as well www.bedsider.org – great teen friendly information about contraception

References https://www.cdc.gov/std/tg2015/screening-recommendations.htm http://www.aafp.org/afp/2008/0315/p819.html http://pediatrics.aappublications.org/content/134/1/e302 https://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on- Gynecologic-Practice/Well-Woman-Visit https://www.cdc.gov/std/tg2015/default.htm https://www.cdc.gov/hiv/risk/prep/index.html http://epi.publichealth.nc.gov/cd/stds/figures/vol17no2.pdf https://www.cdc.gov/std/ept/legal/default.htm https://www.ncmedboard.org/resources-information/professional-resources/laws-rules- position-statements/position-statements/contact_with_patients_before_prescribing