Update in Genitourinary Medicine Mayur Chauhan

What’s New Changes in the provision of Sexual Health Services Changes in the provision of Sexual Health Services Epidemiology of STI Epidemiology of STI Microbiological and Virological Genital Sampling Microbiological and Virological Genital Sampling HIV and BBV infection HIV and BBV infection

Changes to Sexual Health Services Responsibility of commissioning of GUM and contraceptive services to Local authority Responsibility of commissioning of GUM and contraceptive services to Local authority Move towards integration of GUM and Contraceptive Services Move towards integration of GUM and Contraceptive Services Tendering of GUM and Contraceptive services to wide range of bidders including private Tendering of GUM and Contraceptive services to wide range of bidders including private Specialized commissioning of HIV services Specialized commissioning of HIV services CCG responsible for community gynaecology CCG responsible for community gynaecology

Integrated Model of GUM Services Integrated Model of GUM Services Core services Surveillance Screening Diagnosis & treatment Prevention of STI/HIV Partner notification Sexual health promotion Teaching and training Research Outreach services Vulval/genital dermatology Management of CIN Contraception Adolescent health care Sexual abuse services Erectile dysfunction Psychosexual services

National Standards

Epidemiology of STI

Risk factors for STIs Risk factors for STIs Younger age (especially <25 years) Younger age (especially <25 years) Sexual orientation Sexual orientation Ethnicity (for some STIs) Ethnicity (for some STIs) Living in inner city Living in inner city >2 partners in preceding 6 months >2 partners in preceding 6 months Use of non barrier contraception Use of non barrier contraception Partner with symptoms Partner with symptoms History of STI in the past History of STI in the past

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Chlamydia Epidemiology Epidemiology Chlamydia Screening Programme Chlamydia Screening Programme Dual Testing Dual Testing Swabbing for chlamydia Swabbing for chlamydia

Rate per 100,000 population of chlamydia cases by local authority of residence

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Systematic reviews show: median of 14% of women re-infected at repeat test [7] median of 11% of men infected at repeat test [8] [4] Woodhall STI 2012; [5] Turner STI 2012; [6] Rietmeijer STD 2002; [7] Hosenfeld STD 2009; [8] Fung STI 2007 Risk of re-infection following a positive chlamydia test

Re-testing for Chlamydia Infection National Chlamydia Screening Programme (NSCP) for England recommends that persons under the age of 25 years treated for chlamydia should be offered a repeat test for chlamydia three months after the completion of treatment. National Chlamydia Screening Programme (NSCP) for England recommends that persons under the age of 25 years treated for chlamydia should be offered a repeat test for chlamydia three months after the completion of treatment. BASHH also supports re-testing policy BASHH also supports re-testing policy

Chlamydia Screening Programme Dual Testing (chlamydia and gonorrhoea NAAT) in Newcastle and Northumberland. Dual Testing (chlamydia and gonorrhoea NAAT) in Newcastle and Northumberland. Six month pilot in other areas of NE looking at the benefit of dual testing Six month pilot in other areas of NE looking at the benefit of dual testing

What is the Optimal Swab Sample for Diagnosing Chlamydia? Self taken vulvo-vaginal swab Self taken vulvo-vaginal swab or or Clinician taken endocervical swab Clinician taken endocervical swab

Two Studies from Leeds Two Studies from Leeds Published in BMJ 2012:345; 2013 Published in BMJ 2012:345; 2013 Study population women Study population women Each had self taken V-V swab and endocervical swab. Each had self taken V-V swab and endocervical swab. Results analyzed into asymptomatic and symptomatic women for detection of chlamydia and gonorrhoea. Results analyzed into asymptomatic and symptomatic women for detection of chlamydia and gonorrhoea.

Results In asymptomatic women:- In asymptomatic women:- Self taken vulvovaginal swabs were significantly better at detecting chlamydia infection than clinician taken endocervical swabs (P < ) Self taken vulvovaginal swabs were significantly better at detecting chlamydia infection than clinician taken endocervical swabs (P < )

Results In symptomatic women:- In symptomatic women:- A self taken vulvovaginal swab before examination or a clinician taken vulvo-vaginal swab before speculum insertion is more sensitive in detecting chlamydia then clinician taken endocervical swab (p < ) A self taken vulvovaginal swab before examination or a clinician taken vulvo-vaginal swab before speculum insertion is more sensitive in detecting chlamydia then clinician taken endocervical swab (p < )

Results for Gonorrhoea testing In symptomatic and asymptomatic women:- In symptomatic and asymptomatic women:- Self taken Vulvovaginal swabs tested by NAAT were significantly more sensitive at detecting gonorrhoea than culture of urethral and endocervical samples taken by clinicians—culture missed almost one in five cases of gonorrhoea (p < 0.001). Self taken Vulvovaginal swabs tested by NAAT were significantly more sensitive at detecting gonorrhoea than culture of urethral and endocervical samples taken by clinicians—culture missed almost one in five cases of gonorrhoea (p < 0.001). Therefore best swab sample for detection of chlamydia and GC is a self taken vulvo- vaginal swab. Therefore best swab sample for detection of chlamydia and GC is a self taken vulvo- vaginal swab.

Take Home Message 1) Highest rates of chlamydia are in under 25 year old (M + F) 2) CSP having some impact in screening and diagnosing chlamydia infection 3) Best screening test in women is self taken or clinician taken vulvo-vaginal swab. 4) Recommend re-screening 3 months after treatment in under 25 year old men and women.

LGV – Lymphogranuloma Venerum

LGV in MSM Outbreak of LGV in N Europe since Dec 03 Chlamydia trachomatis serovariants L1–L3 are responsible. Clinical signs of anorectal syndrome or inguinal syndrome –Proctitis with inguinal lymphadenopathy –+/- fever Treat with 3 weeks of doxycycline

Gonorrhoea Epidemiology Epidemiology Dual Testing Dual Testing Antibiotic Resistance Antibiotic Resistance

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Rate per 100,000 population of gonorrhoea cases

GC Treatment Ceftriaxone + Azithromycin Spectinomycin Other antibiotics guided by sensitivities

Take Home Message 1) GC rates rising in both males and females 2) Screen multiple sites depending on sexual history 3) Refer to GUM for treatment and PN issues. 4) Need dual antibiotic treatments. 5) All patients should have TOC regardless of site of infection

Pubic Lice Prevalence decreasing Prevalence decreasing Related to shaving Related to shaving Treatments --- Permatherin lotion Treatments --- Permatherin lotion

HPV infection Epidemiology Epidemiology Treatments Treatments HPV vaccination HPV vaccination

Warts per population

Treatments and Management 1) Warticon now available 2) Aldara (imiquimod) 3) Ablative therapy (cryocautery, TCA (75% - 90%), hyfrecation, excision) 4) Combination of all above 5) Vaccination with HPV vaccine (under trial) 6) HIV positive ---- anal smears (In London)

HPV vaccination --- change from Cervarix to Gardasil In Australia --- immunization is provided to both boys and girls

Herpes Epidemiology Epidemiology Management Management Vaccine Vaccine Recurrent Herpes Recurrent Herpes

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Herpes rates per population in the North East

Herpes Management Diagnosis ---- PCR testing Diagnosis ---- PCR testing Treatments --- Acyclovir Treatments --- Acyclovir Vaccine Nil as yet Vaccine Nil as yet

Syphilis Epidemiology Epidemiology In UK the infection is endemic In UK the infection is endemic

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Rates of Syphilis per population

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Background 61.5% rise in the number of heterosexual patients diagnosed with syphilis in the North East of England between 2011 and 2012

Heterosexual Syphilis --- NCC Year 2012: 14 females and 14 males Year 2013: 4 females and 7 males Total : 39 patients

Mean age 2012 Female 23.5 years Male 29.7 years 2013 Female 21.6 years Male 26.2 years

Stage of syphilis : 23 primary, 8 secondary, 8 early latent 10 had documented positive microscopy findings 5 diagnosed with co-infection (4 cases of Chlamydia and 1 HSV) 30 patient treated with Benzathine penicillin, 7 treated with doxycycline, one not known

Mean Partners 6 months Females: 1.7 partners (30% casual, 70% regular) Males: 2.7 partners (56% casual, 44% regular)

Contact tracing for males 142 contacts (Nb. One contact reports having 100 contacts in previous 2 years) 22 traced 22 screened 120 untraceable (84.5%) 15/22 screened were positive for syphilis (68.1%)

Contact tracing for females 61 male contacts 25 traced 23 screened 36 untraced (59%) 16/23 screened were positive (69.5%)

Take Home Information Syphilis is ENDEMIC Syphilis is ENDEMIC Think Syphilis in differential diagnosis Think Syphilis in differential diagnosis Careful examination is important Careful examination is important Think testing for syphilis in MSM and Heterosexuals Think testing for syphilis in MSM and Heterosexuals Testing involves blood for syphilis serology Testing involves blood for syphilis serology Refer to GUM Refer to GUM

MSM epidemiology

STIs & HIV HIV is an STI HIV is an STI Some STIs increase risk of acquiring HIV Some STIs increase risk of acquiring HIV Some STIs increase shedding of HIV in infected individuals and therefore increase risk of transmitting HIV Some STIs increase shedding of HIV in infected individuals and therefore increase risk of transmitting HIV 54

Rates of HIV infection per population

57HIV in the United Kingdom: 2013 Annual new HIV and AIDS diagnoses and deaths: UK,

58HIV in the United Kingdom: 2013 Estimated number of people living with HIV : UK, 2012

Prevalence rates of HIV: United Kingdom, 2010 People with diagnosed or undiagnosed HIV infection/1000 population All1.5 Men2.0 Women0.9 MSM47 Black African47

61HIV in the United Kingdom: 2013 Mortality rates among people diagnosed with HIV: UK,

Remember: If your patient has ever had sex they are potentially at risk. For further advice or information Call Infectious Diseases (Ward 19OP RVI) 23110, ID office on 23382, or (on-call registrar) Or go to *British HIV Association (BHIVA) HIV testing guidelines: It is easy: NO NEED for pre-test counselling, just get consent and TEST FOR HIV THIVK. TEST. TAKE CONTROL Men who have sex with men Black African community HIV seroconversion (glandular fever-like symptoms) Unexplained bowel symptoms/weight loss Unexplained, persistent, severe dermatological conditions Blood dyscrasias, including persistent lymphopenia Recurrent infections (pneumonia, candidiasis) Viral hepatitis Cancers inc. lymphoma, lung, cervical, anal As recommended by BHIVA* Early diagnosis improves long-term outcome of HIV but 50% are still diagnosed late. YOU can help improve this by reducing missed opportunities for HIV testing:

66 PrEP ---- Pre Exposure Prophylaxsis

From April HIV self testing kits to be available to the general public. From April HIV self testing kits to be available to the general public.

Take Home Message Think HIV infection Think HIV infection Promote HIV testing Promote HIV testing Pre test --- just explain the reasons why you want to test. Pre test --- just explain the reasons why you want to test.

Take Home Message Early diagnosis is IMPORTANT (HIV treatments start early, decreased morbidity and mortality, decreased onward transmission, decreased risk of AIDS, partner notification more successful). Early diagnosis is IMPORTANT (HIV treatments start early, decreased morbidity and mortality, decreased onward transmission, decreased risk of AIDS, partner notification more successful).

Global Prevalence of Hepatitis B

NICE Guidance Promotion of Hep B and C testing Promotion of Hep B and C testing Treatment and Management of Hep B and C infection Treatment and Management of Hep B and C infection Hepatitis B Vaccination Hepatitis B Vaccination

RCGP / BASHH Document