Sexual Transmitted Infections in General Practice Dr John McSorley

STIs in general practice What are the sexually transmitted infections? What is the epidemiology? Why are STIs important? What to look out for in general practice? What is the patient experience in the GUM clinic What is new?

Sexually transmitted infections Bacterial Chlamydia / Gonorrhoea / Syphilis / Others Viral HPV / Herpes /HIV / Hepatitis B/C ?A Protozoa TV Ectoparasites Lice/scabies

Number of diagnoses of chlamydia, England: 1995-2009 Diagnoses of chlamydia (from GUM and community based settings) increased by 8% from 2008 to 2009 (177,046 diagnoses in 2008 and 191,772 diagnoses in 2009). Data from community-based settings in 15 to 24 year olds were included from 2008. Chlamydia diagnoses in GUM clinics increased steadily every year until 2009 where the number of diagnoses in GUM dropped slightly. This likely reflects the high levels of testing and consequent diagnoses achieved by the roll-out of the National Chlamydia Screening Programme (NCSP) in community-based settings. 4

Age-specific distribution of the rate diagnosed with chlamydia at STI clinics, England: 2009   In women attending GUM clinics in 2009, 75% (35,700/47,530) of chlamydia diagnoses were in those aged under 25 years. Rates of diagnoses were highest in women aged 19 and men aged 21. 5

Uncomplicated Chlamydia NWLH 1997 to 2013

Number of diagnoses of genital warts (first, recurrent and re-registered episodes) by sex, GUM clinics, England and Wales*: 1972 - 2009   Between 1972 and 2009, the number of all genital warts diagnoses (first, recurrent and registered episodes) increased by 8- and 11-fold in men and women respectively. These rises may reflect increased incidence of infection, greater public awareness and/or improved detection rates. Although the number of genital warts diagnosed almost trebled (2.9-fold increase) in GUM clinics between 1977 and 1986, the following years saw a more gradual increase in diagnoses. This may be due to changes in sexual behaviour that coincided with the emergence of the HIV epidemic during the mid-eighties. Since 1994, numbers have continued to rise reaching 83,373 cases among men and 62,502 cases among women in 2009. 7

Number of diagnoses of genital herpes (first and recurrent episodes) by sex, GUM clinics, England and Wales*: 1971 - 2009   Between 1971 and 2009, the number of genital HSV diagnoses made at GUM clinics increased 7- and 31-fold in men and women respectively. This is reflected in the changing female to male ratio, from 0.3:1 in 1971 to 1.5:1 in 2009. The reason for the change in sex ratio is unclear. The number of diagnoses stabilised and fell briefly in the mid-eighties possibly due to changes in sexual behaviour following extensive media coverage of HIV and AIDS. Numbers of diagnoses have risen sharply in the last few years due to changes in sexual behaviour and an increasing use of highly sensitive diagnostic tests. 8

Numbers of diagnoses of syphilis (primary, secondary and early latent) by sex, GUM clinics, England, Wales and Scotland*: 1931 - 2009   Diagnoses of infectious syphilis made at GUM clinics in England, Scotland and Wales peaked towards the end of World War II, and then fell sharply in the late 1940s. New diagnoses among men rose steadily throughout the 1960s and 70s, while cases among women remained low. The male to female ratio of diagnoses peaked at 8:1 in 1983 in England and Wales and at 10:1 in 1984 in Scotland, suggesting that sex between men was the most common route of acquisition. Diagnoses in men declined in the early to mid-1980s, coinciding with emerging awareness of HIV, adoption of safer sex practices, and a parallel fall in HIV transmission among homosexual men. Since 2000, there has been a 7-fold increase in syphilis diagnoses among men and a two-fold increase among women in England and Wales. The latest increase having been primarily driven by sex among MSM. 9

Number of diagnoses of selected STIs and HIV in the UK, males: 2000-2009   Since 2000, numbers of diagnoses in GUM clinics of genital warts (first attack) and genital herpes (first attack) have risen considerably. Numbers of new diagnoses of gonorrhoea has decreased considerably with infectious syphilis diagnoses and new diagnoses of HIV levelling off. Uncomplicated chlamydia diagnoses rose sharply from 2000-2008, with a decline in GUM chlamydia diagnoses in 2009. This decline likely reflects the high volume of testing achieved in community-based settings by the National Chlamydia Screening Programme in 2009. 10

Uncomplicated N. gonorrhoea at NWLH 1997 to 2013

Incidence Chlamydia commonest (75% under 25s) Warts Herpes (Ratio F:M 0.3:1 to 1.5:1) Gonorrhoea greatly decreased but… Syphilis (since 2000, 7 fold increase in men and doubling in women) HIV levelling off (or not)

Why are STIs important? ½ billion new curable STIs each year worldwide STIs (not HIV) 2nd most common cause of healthy life lost in women (15-49) worldwide US: 8 million cases/yr direct cost $8.7 billion/yr Costs of the complications (PID, ectopic pregnancy,infertility) £100s millions Physical and psychological morbidity e.g. herpes 10-40% untreated CT develop PID Post infection tubal damage c40% infertility Preventable: STI care Vaccinations

Why are STIs important? Aversely affect Pregnancy: Ectopic Pregnancy x6-10 more likely if prev PID, c50% EP attributable to prev STI. <35% pregnancy with untreated GC results in abortion, prem delivery ASYMPTOMATIC c70% in UK GP/PN will see several cases of people with STIs in a week Failure to suspect & diagnose is a disservice Best way to reduce STIs is by population screening

What/who should you be looking out for in general practice? Very frequently asymptomatic Symptoms dysuria, vaginal or urethral discharge, pelvic pain, genital lumps, bumps Index of suspicion Sexually active, change of partners, multiple partners, unfaithful partner

High index of suspicion Young people 5% of under 25yr old each year every year Emergency contraception Pre termination Men (<45) with urinary syndromes STI, STI, STI, STI, STI not UTI Epididymo-orchitis CT x10 more likley GUM

STI screening in MSM: NWLH 1997 to 2013

Some principles to remember about STIs More than one infection More than one person and partner -the index and the contact - hence partner notification Education and prevention both primary and secondary Avoid sex until both (or all) parties are treated

Some common examples Case 1 A 19 year old girl requests an IUD for emergency contraception She had unprotected sex 4 days ago What questions would you like to ask?

Case 1 contd. How many partners has she had in last 3-6 mths Any previous STIs? Does her partner have any symptoms? Has she had other unprotected sex? She has had 2 partners in past 3 months What would be your next step?

History, management At risk of chlamydia (>5%) At risk of PID with IUD insertion Consider (referral for) STI screen Perform chlamydia test (swab or urine) Consider prophylaxis with Azithromycin 1 gram Advise no sex until result available

Result of swab Chlamydia test positive What do you do next?

Chlamydia test is positive (case 1) Refer her and her partner to GUM clinic Full STI screen Treatment Partner notification Or Treat yourself If GUM attendance not possible Doxycycline 100mgs po bd for 7 /7, or azithromycin 1 gram PO, or erythromycin 500mgs po bd for 10/7 No sex until she and partner are treated

Chlamydial infection Rarely symptomatic 50-90% women no symptoms Vaginal discharge, cervicitis uncommon Rarely presents with PID, Reiters syndrome or reactive arthritis Diagnosed using DNA test on swab (endocervical, vulval,vaginal, urine)

Clinical features in Chlamydial infection

Know your local GUM clinic Routine tests All patients tested for chlamydia, gonorrhoea, syphilis and HIV (Brent Hep B core) ‘Pee and go’ NAAT testing (DNA testing for chlamydia/gonorrhoea) Additional tests for Hepatitis B, trichomonas, herpes , other conditions eg hepatitis C,LGV

Special considerations in GUM clinics Focus on young people Normalisation and early HIV testing (POCT testing) Frequent STI screens for gay men

Patients journey in GUM clinic Asymptomatic Nurse Rapid history Urine NAAT,blood syphilis, HIV +/-Hepatitis B Not examined No news good news Symptomatic Doctor Full history +/- examined Dr/nurse Tests swabs/other relevant tests Herpes,other sites Treatment Follow up

Case 2 34 year old married man returns from business trip to India Noticed a sore on his penis 2 weeks ago It is not painful but it is not getting better What further information would you like?

Case 2 Sexual history Any sex with men? Past history of STIs Drug/allergy history General medical history

Case 2 History Unprotected sex with 2 sex workers in Delhi 6 weeks ago Sex with his wife on number of occasions since his return He took antibiotics from his dentist for 5 days 3 weeks ago What action would you take at this stage?

Case 2 assessment Examine his genitalia Findings are: Superficial ulcer sub preputial area and shotty nodes in the groin

Case 2 management Is this a drug reaction? Is this an STI? What would you recommend?

Case 2 management Refer to GUM clinic for full STI screen Tests for syphilis serology, swab for PCR, full STI screen including HIV and Hepatitis B Results show Syphilis EIA positive, raised RPR 1/64 consistent with primary syphilis

Case 2 management Treated with 1 injection of benzathine penicillin I/M 2.4 mega units Wife also needs testing and ?epidemiological treatment Advise repeat HIV test after 3 months Consider hepatitis B vaccination

Syphilis

Syphilis Infectious syphilis more common in past 10 years. Secondary syphilis may present with a rash There have been >10 local scattered epidemics amongst heterosexuals in UK Endemic again in gay men Foreign travel history is important Always consider the possibility of associated HIV

Case 3 26 year old 20 weeks pregnant , first pregnancy Married for 2 years Vulval discharge and itching for weeks, ?smelly Slight external dysuria Thrush treatment from the pharmacy but it doesn’t seem to have helped

Case 3 She is very worried this will affect her baby Sex only with her husband who is a travelling salesman He has been avoiding sex with her lately and keeps telling her she needs to have a check up in the local clinic She didn’t see why she needed to go to a clinic and decided to come to you her GP

Case 3 contd Is this thrush? Is this something else? Refer to GUM Triaged Vaginal slides Trichomonas Vaginalis She is very embarrassed (and angry) to hear that this is an STI but relieved it will not affect her baby Treated Metronidazole 2 grams PO Stat

Trichomoniasis

Trichomonas vaginalis Rarely causes symptoms in men Typically a frothy fishy smelling discharge. Similar to Bacterial vaginosis discharge Diagnosed on wet mount microscopy Not a serious infection Marker for other STIs Single dose treatment Metronidazole 2 grams Treat partner

Case 4 Your practice nurse has been doing a study with the local GUM clinic screening under 25s routinely for chlamydia and gonorrhoea using urine testing. A 21 year old Afrocaribean male was found to have gonorrhoea and was recalled you are asked to see him. What do you do

Case 4 Sexual history 3 partners in past 6 weeks all unprotected. No regular girlfriend He has no discharge or dysuria No previous STIs Otherwise well and not taking any medication What do you do?

Case 4 Refer to GUM clinic for full STI screen treatment and partner notification In GUM clinic Urethral swab for microscopy, GC culture and sensitivity Treatment Ceftriaxone 500mgs IM stat with treatment for chlamydia Cefixime 400mgs po stat if refuses injection

Gonorrhoea 40% women and 10% men are asymptomatic Vaginal discharge and cervicitis are not common presenting symptoms in women. Urethral discharge and dysuria are common in men Multi drug resistant GC coming!!!!

Gonorrhoea

Gonorrhoea Disseminated

Gonorrhoea Commoner in black population locally (x 10) although most cases in UK in caucasians x5-6 in MSM

Herpes First episode genital herpes Recurrent genital herpes Common presentation Young woman presents with ‘cuts’or sores on the vulva Possibly in a stable relationship

Herpes

Patients with Herpes Primary genital herpes can frequently be diagnosed as patient enters the room Severe discomfort walking, sitting down uncomfortable, may have severe dysuria, may complain of discharge, may be crying May be febrile

Primary herpes

Genital herpes Primary herpes blisters ulcers, may be confluent, may be associated vulval oedema and tender lymphadenopathy. Easy to diagnose clinically Confirmed by a swab for herpes virus PCR

Genital herpes Treatment Acyclovir 200mgs po 5/day for 5 days or 400mgs tds for 5 days Advice re PU in bath, handwashing Pain relief, lignocaine gel In depth discussion re infectivity, recurrences, partner, childbirth Reassurance that first attack always the worst

Genital herpes 1/3 will get no more attacks 1/3 will get 2-3 attacks per year 1/3 will get frequent/severe attacks and may require suppressive therapy for a year or more

Genital herpes in pregnancy Main problem is primary herpes. May cause miscarriage due to febrile illness in first trimester Primary herpes in last trimester may be associated with neonatal herpes Indication for Caesarian section if Primary or first episode herpes occurs within 6 weeks of delivery

Warts Warts are often discovered incidentally during examinations They are sexually transmitted ,- human papilloma virus (HPV) The HPV types which cause warts are not oncogenic. Oncogenic HIV subtypes 16/18. The subtypes commonly causing warts are 6/11

Warts

warts, meatal

Warts and abnormal smears We are commonly asked whether warts have caused an abnormal cervical smear Reassure that the HPV subtype that causes warts does not cause pre cancerous changes on a smear. Also oncogenic HPV causes anogenital cancer but is much rarer that cervical cancer except in MSM / HIV +ve

Warts treatment Podophyllotoxin Cryotherapy Imiquimod No treatment

Lice and Scabies Pubic itch Visible ‘crabs’ in pubic hair. Visible nits in pubic hair Sexually transmitted (close body contact) Treat with Malathion 0.5% apply to hair and leave overnight Repeat after 3-5 days Full STI screen

Lice

Scabies Generalised itch Worse at night Specifically finger toe webs, wrists, skin creases, pubic area. May cause papules on penis Treatment Permethrin cream. Malathion 0.5% aqueous lotion Apply and leave overnight for 12 hours Wash clothes and bedding in >50 degrees Sexual and household contacts tretaed

Scabies

HIV diagnoses in general practice Majority asymptomatic Late diagnosis a problem In GP consider testing: All new registrations at your practice Flu like illness Skin conditions eg shingles, recurrent folliculitis, molluscum contagiosum on the face, KS Haematological conditions, neutropaenia, thrombocytopaenia

Rash of HIV seroconversion

Shingles think HIV

HIV Normalise the HIV test Important clinical investigation In depth counselling not necessary If positive contact the GUM clinic (if we don’t contact you first)

Conclusions STIs are common High index suspicion especially amongst young people, gay men Screening with self taken swabs/urines very easy with DNA tests Normalise HIV testing Doing more screening will drive down the incidence of new disease