Debbie Richmond NP-C ACRN AAHIVS Wayne State University LGV and HCV Clusters in PLWH: The Nurse’s Role in Identifying and Managing Emerging Issues Debbie Richmond NP-C ACRN AAHIVS Wayne State University HIV/AIDS Program June 1, 2018

Our Programs WSUPG Adult Infectious Disease Clinic ~2000 HIV infected patients Horizons Project: HIV care for youth ~280 HIV infected patients age 14 to 24 As well as youth needing PEP and/or PrEP Detroit Public Health STD Clinic Offering STD and HIV testing; PrEP and PEP MATEC Michigan

Nurses Roles in Outbreaks Severe Acute Respiratory Syndrome-SARS Swine-origin influenza A Middle East respiratory syndrome-MERS Norovirus-camp nurses; school nurses Ebola Zika Measles-school nurse teams The topic I was asked to speak on was the role of the nurse in outbreaks. I have been working on 2 outbreaks that happened within our patient population LGV and HCV So I attempted to do some literature review of nurses in other outbreaks…

Closer to home… HIV Hepatitis STDs Our roles in these outbreaks is more familiar to some of us…

Nurses with different roles… Medical assistants, RN,BSN,MSN,NP,DNP… public health nurses non public health Inpatient Clinic care nurses Home care nurses School nurses

How does it affect us… Minimal literature found on how does identifying and managing an outbreak affect nurses. Lack of knowledge Fear Stress Preparedness Resources

First Case: Genital Ulcer Male in late 40’s; MSM and HIV positive for more than 15 years; HIV RNA PCR <20 on HIV meds Presented with non healing penile ulcer Tests were negative for Herpes and Syphilis Developed large right inguinal lymph node Physician colleague suggested a swab of the ulcer for Ct and the probable diagnosis of LGV Swab was positive for Ct but we did not have access to confirmatory tests Symptoms resolved on doxy 100 mg BID for 21 days

What did I do about this… This was a different STD than we usually see I did some reading and wanted to know if it would fall under health department and partner notification I called my networks and found that we have an STD epidemiologist and that LGV is reportable and partners are to be notified.

Then what happened… Another patient of mine came in with same symptoms-he reported a partner at another hospital with symptoms of probable proctitis that can happen with LGV And another patient with a lingering ulcer-that we swabbed and was positive for Ct Then we were on Michigan alert and conference calls with the CDC

Outline CDC 2015 LGV Overview and Guidelines Testing for LGV Treatment of LGV LGV Patient Cases Review Genital syndrome Proctitis syndrome Hepatitis C outbreak in MSM / non IVDU

Epidemiology LGV prevalence is not known in the U.S. Not reportable in all states Literature review includes sources from: United Kingdom Netherlands Spain Hungary New Zealand Canada

Eurosurveillance 2003-2015 2003 – 1 case reported 2004 – 28 cases reported 2005 – 220 cases reported….. 2014 – 679 cases reported Positive chlamydia samples from HIV infected MSM patients in the UK are tested for LGV and they have identified that approximately 25% of them have asymptomatic LGV Eurosurveillance, Volume 20, Issue 48, 03 December 2015

CDC: LGV Genital Symptoms Lymphogranuloma venereum (LGV) is caused by C. trachomatis (Ct)serovars L1, L2, or L3 self-limited painless genital ulcer or papule tender inguinal and/or femoral lymphadenopathy that is typically unilateral www.cdc.gov/std/tg2015

CDC: LGV Rectal Symptoms proctitis / proctocolitis can mimic inflammatory bowel disease mucoid and/or bloody rectal discharge anal pain constipation tenesmus fever www.cdc.gov/std/tg2015

Untreated and Chronic LGV If not treated early: can be an invasive, systemic infection leading to chronic colorectal fistulas and strictures reactive arthropathy has also been reported www.cdc.gov/std/tg2015

Routine Clinical GC/CT NAAT Testing Anal swab for GC/Ct Use the endocervical swab, insert past the sphincter and apply gentle pressure into the crevices of the rectum Throat swab for GC/Ct Gentle swabbing of oropharynx, tonsils, uvula and crevices Urine for GC/Ct Have patient give first voided 10 cc of urine *Penile ulcer swab for Ct in suspect case* GC is Neisseria gonorrhea; Ct is chlamydia trachomatis NAAT testing is the DNA testing of the organism-not a culture We use the pink swab from the BD ProbeTec collection kit for endocervical specimens. It may mistake oral Neisseria of other species for Neisseria gonorrhea but this is not relevant to the Chlamydia outbreak

CDC LGV Diagnostic PCR Report There is no licensed LGV test for clinical use PCR-based DNA sequencing can be used to differentiate LGV from non-LGV C. trachomatis Currently available at the CDC lab Results take 10-14 days Results are intended for outbreak investigation and for research purposes only www.cdc.gov/std/tg2015

Example of CDC LGV PCR test result “Specimen Process: Qiagen DNA mini kit protocol Diagnostic Assay: Real-time Multiplex PCR for LGV Results: The specimen tested positive for LGV C. trachomatis “ For questions regarding specimen collection, transport, storage and lab testing-contact – Dr. Cheng-Yen Chen at cyc1@cdc.gov This is what the test result looks like when you get it back from the CDC.

Process of LGV Confirmatory Testing Screening of the patient: risk factors and symptoms Routine NAAT swab of penile ulcer or anus If the NAAT is positive for Chlamydia per the clinic or hospital lab: Fill out 2 page CDC form “CDC Specimen Submission Form” Have your lab send the “remnant” of the sample along with the CDC form to the CDC via your State lab

CDC Guidelines for LGV Treatment Persons with a clinical syndrome consistent with LGV, including proctocolitis or genital ulcer disease with lymphadenopathy, should be presumptively treated for LGV. Recommended Regimen Doxycycline 100 mg orally twice a day for 21 days www.cdc.gov/std/tg2015 Sexually Transmitted Diseases. 44(4):245-248, April 2017 Recent article in April 2017 STD journal confirms this treatment as 97% effective

CDC Guidelines for Partners Management of Sex Partners Sexual contact with a patient who has LGV within the previous 60 days should tested for urethral, cervical, or rectal chlamydial infection depending on anatomic site of exposure. Treat presumptively with a Chlamydia regimen (azithromycin 1 g orally single dose or doxycycline 100 mg orally twice a day for 7 days). www.cdc.gov/std/tg2015

LGV Case Classification Confirmed Case A probable case with laboratory confirmation LGV‐specific PCR Probable Case One or more of the following: 1) Patient with one or more signs or symptoms compatible with LGV and other causes of LGV‐like symptoms (e.g. syphilis, gonorrhea, HSV) ruled out AND a positive C. trachomatis from culture or NAAT from a body site associated with symptoms 2) Sexual partner of a probable or confirmed case AND a positive C. trachomatis result by culture or NAAT Suspect Case Both of the following: 1) A clinically compatible case as defined by one or more signs or symptoms compatible with LGV 2) A sexual partner of a probable or confirmed case

Our LGV Cases as of 4-23-18 32 confirmed cases with positive LGV PCR at CDC 30 with proctitis 1 with penile ulcer. 1 with both penile ulcer and proctitis. 9 probable cases = early in the outbreak 3 with penile ulcers 6 with proctitis Plus 3 repeat confirmed LGV cases with proctitis -1 reports not taking his original dose of doxy

Asymptomatic Proctitis Case 25 year old sexual contact named by our first case DIS worker had some difficulty finding and getting him in for care Asymptomatic- he was seen in the STD clinic and given their standard and complete testing that included HIV testing Anal swab positive for Ct and confirmed as LGV Treated with doxycycline HIV test came back positive and he has been engaged in the HIV clinic

Symptomatic LGV Proctitis Male in late 40’s; MSM and HIV + for many years; HIV RNA undetectable on treatment Presented in the ER last year with c/o rectal bleeding Referred to surgeon with c/o pain with bowel movements Anal ‘Exam Under Anesthesia’ and biopsy Another surgery clinic appointment Abd/pelvic Ct scan suggests cancer Colonoscopy with several biopsies Follow up visit with surgeon = 15 lb weight loss Patient comes for routine HIV clinic visit and the doctor evaluates patient for probable LGV diagnosis

PrEP Patient Reported by Detroit Health Dept STD clinic colleague in February 2017 36 year old male presented with anal pain HIV negative On PrEP Reports 15 male partners in the past 2 months Anal swab positive for Ct Confirmed positive for LGV by the CDC Also with anal GC

Proctitis Diagnostics ~6 patients had abd/pelvic CT scans Examples of actual results: “diffuse thickening of the wall of the rectum with perirectal mildly enlarged lymph nodes suggestive of proctitis” “Anal rectal cancer with regional and retroperitoneal metastatic involvement; moderate fecal stasis”

Colonoscopy and Biopsy 5 patients had a colonoscopy Ulcerated anal mass Rectal ulcers 1 patient had sigmoidoscopy Proctitis Biopsies Adenoma Colonic mucosa Inflammation

Examples of Proctitis Symptoms 54 year old called and came to clinic with report of “hemorrhoids” flaring along with constipation 25 year old reported “worsening” of his chronic anal warts 26 year old reports worsening constipation, anal pressure and feeling like he needs to move his bowels every 30 minutes-making it difficult to work at his job-he was miserable!

MMWR Notes from the Field Cluster of Lymphogranuloma Venereum Cases Among Men Who Have Sex with Men — Michigan, August 2015–April 2016 MMWR Morb Mortal Wkly Rep 2016;65:920–921

Additional testing for patients being evaluated for LGV Other STDs need to be checked Syphilis serology sequence GC/Ct NAAT of other exposed sites Herpes PCR on all ulcers Hepatitis screening, including annual/PRN Hepatitis C HIV testing (prefer 4th generation test) and HIV prevention counseling Always perform if HIV negative or unknown HIV status Offer PrEP if HIV negative as they may be at high risk Repeat HIV testing per protocol

Concomitant STIs and Connections New HIV infection Hepatitis C Syphilis Gonorrhea Herpes Social media Jack’d Grindr

Hepatitis C infections in MSM ~5 of our patients with LGV also tested positive for Hepatitis C We began to notice other new Hepatitis C infections in our MSM/non IVDU patients so we reported these to the state viral hepatitis team At least 30 cases of HCV in MSM have been reported in the SE Michigan cluster, with 10 of them studied to be linked

Poster presented at 2016 STD Prevention Conference Cluster of Sexually Transmitted Hepatitis C Virus Among the MSM Population in Southeast Michigan Jenny Gubler, MS1, Sandra Johnson, BS2 and Joseph Coyle, MPH1, 1Commumicable Disease Division, Michigan Department of Health and Human Service, Lansing, MI, 2STD Surveillance and Intervention, Michigan Department of Health and Human Service, Detroit, MI The samples are being sent to the CDC for molecular analysis

Coinfected LGV and HCV 32 year old MSM patient July 2015: AST = 304 and ALT = 333 October 2015 AST = 39 and ALT = 49 December 2015: he came in with symptoms of proctitis Hepatitis C test was positive Anal LGV test was positive

Interesting HCV Case Routine visit in March 2017 LFTs elevated; AST=368 and ALT=366 RPR elevated up to 1:32 Hepatitis C antibody negative Last tested HCV negative 8 months earlier When he came in for syphilis treatment one week later, we ordered hepatitis C as PCR viral load and it was positive at 529,862

HCV/HIV/MSM Recent count in our clinic is ~ 32 patients We are working to treat and cure these patients My next goal is to review the cases and assess who has been treated To look at who has achieved 12 week SVR To look at who is lost to follow up

This is the CDC recommended testing sequence for identifying HCV infection; For persons who might have been exposed or immunocompromised-test for HCV RNA-viral load.

Our Roles Student We may be an expert in our current role But I encourage you to be open to always knowing there is something new to learn everyday. We need to remain aware of the bigger picture Our patients are our teachers.

Clinician: Using your expertise, training and knowledge base Curiosity Documentation And if a signal of outbreak or something happening beyond your patient-be open to seeing the forest, not just the tree

Advocate Our patients and their communities need a voice Sometimes we are the only ones that can speak up for them If we see something like an outbreak or an issue that is affecting their community we may be the best or the only people that can bring it to light

Collaborator: ‘play well with others’ Networking; stepping outside the box! Look where I stepped...health dept, CDC!! All in an effort to meet the needs of our patients and their community

Educator Here I am again. I have presented this information several times. Each time someone comes up and may state they have seen a possible LGV case but was not aware of how to make the diagnoses. But the most rewarding is to hear my patients report that they share this information about health to their peers. THAT is what it is all about to me. And where I see my main role in these outbreaks

Contacts and Thanks! CDC Staff-partially listed in the MMWR article Michigan Department of Health and Human Services STD and Hepatitis Divisions Surveillance Disease Intervention Specialists Detroit Public Health STD Clinic WSU Adult Infectious Disease Clinic and Adolescent HIV Clinic colleagues drichmond@med.wayne.edu