Sexually Transmitted Diseases (STDs) Among Inmates Stephen Tabet, MD, MPH University of Washington Harborview Medical Center Northwest AETC

Patient Presentation 28 year old Hispanic male presents to clinic complaining of rectal discharge and difficulty defacating for the last 3 days. You review his chart and note he has never been into clinic and has no known illnesses or past medical history. What questions would you like to ask him? What would you do next before calling the provider on call?

Patient Presentation The patient denies any blood in this stool, fever, chills, etc. The patient reports being married and adamantly denies having sex since prior to incarceration 8 months ago. He denies any previous STDs

Patient Presentation His provider sees him the next morning and anoscopy is difficult secondary to patient’s rectal pain, but it shows yellow discharge. What should be done next?

Patient Presentation The patient tests HIV-negative and RPR non-reactive. Urethral GC and CT are both negative. Rectal testing is positive for GC by culture and negative for CT. What is this patient’s diagnosis and what would you use to treat him?

Proctitis Definition: Inflammation of the rectum which begins at the anorectal line with normal mucosa above 15 cm. Diagnosis: Symptoms include constipation, tenesmus, rectal pain, hematochezia, and a mucopurulent rectal d/c. Clinical findings range from normal mucosa w/ mucopus to diffuse inflammation w/ friability. Usually see PMNs on Gram stain.

Proctitis Etiology: Gonorrhea Chlamydia HSV-1 or HSV-2 Syphilis (rarely)

2002 CDC STD Treatment Guidelines Uncomplicated Gonorrhea Including Proctitis . Cefixime 400 mg PO once, directly observed Ceftriaxone 125 mg (or 250 mg) IM once Ciprofloxacin 500 mg PO once, directly observed Ofloxacin 400 mg PO once or levofloxacin 250 mg PO once, directly observed Plus Azithromycin or doxycycline for presumptive chlamydial infection HHH-1127 3/20/1998

Patient Presentation The patient is treated with cefixime 400 po and azithromycin 1 gram po. After much discussion, he reports that having had receptive anal sex with another inmate, but pleads with you not to report it. What would you do next? Report it?

Patient Presentation A patient is in clinic reporting that he has been raped. What would you do? What are your legal obligations in working up this patient?

Patient Presentation 43 year old patient transferred from a county jail 3 days prior is in clinic with an itchy rash of the hands PMH significant for COPD and eczema

Patient Presentation What’s the diagnosis? How do you treat it? How do you treat his cell mate, if at all?

Patient Presentation 38 year old male with schizophrenia reports having a sore penis for a while. He thinks he may have gotten his skin caught in his zipper. What would you do next? What history would you obtain before calling his provider?

Patient Presentation What should you do? Tell him that it’s a circumcision scar and not to worry about it. Tell him you suspect he has a sexually transmitted disease and set him up an appointment to get evaluated. Have him kite his provider

Patient Presentation The ulcer is negative for HSV by DFA and culture. RPR is 1:16 with positive FTA-ABS The patient is treated with benzathine penicillin G 2.4 mU IM X 1 What else, if anything, should be done?

Most genital ulcers likely to be Herpes Simplex Virus (HSV)

Herpes HIV+ Patient

Patient Presentation A inmate is in clinic reporting ‘testicle problems’ and wants to be examined by a female nurse. You review his chart and note he has been in clinic with the same complaint several times before, but has yet to be examined. What would you do next?

Hernia Scrotal hernia located within the scrotum is usually an indirect inguinal hernia . It comes through the external inguinal ring. The examining fingers could not get above it in the scrotum An incarcerated hernia can be a medical emergency

Patient Presentation 28 y.o. female inmate has increased, malodorous vaginal discharge, mild vulvar pruritis for about a week What would you do next?

Patient Presentation Incarcerated for the past 3 ½ years No conjugal visits Monogamous w/ female partner for 1 year

1998 CDC STD Treatment Guidelines Trichomoniasis Metronidazole 2.0 PO, single dose Metronidazole 500 mg BID x 7 d Metronidazole is safe at all stages of pregnancy Vaginal therapy is ineffective Treat sex partner(s): male and female HHH-1130 3/20/1998

Continue to stress that metronidazole vaginal gel is not effective 2001 CDC STD Treatment Guidelines DRAFT: CHANGES EXPECTED Trichomoniasis Continue to stress that metronidazole vaginal gel is not effective Tinidazole effective, but available only at compounding pharmacies HHH-1130 3/20/1998

Patient Presentation 36 yo man is in sick call for evaluation of headache and a rash. One day prior he noted sudden appearance of a diffuse maculopapular rash involving the palms of the hands and the soles of the feet.

Patient Presentation Denies recent high-risk sexual behavior RPR +1:128; TPPA + Rash resolved after treatment with 3 weekly injections of benzathine penicillin

Primary and secondary syphilis — Counties with rates above and below the Healthy People year 2010 objective:US, 2000

Patient Presentation 32 year old male presents 10 days after being incarcerated with one week of fatigue, night sweats, sore throat, and rash Examination shows a healthy appearing male with T 38.9 C, a rash and 1/2 – 1 cm bilateral occipital, cervical and axillary lymphadenopathy

Patient Presentation At this point, without any laboratory data, what is your differential diagnosis?

Differential Diagnosis Anthrax Secondary syphilis ‘Flu’ or non-specific viral syndrome Drug Reaction Epstein-Barr virus (EBV) mononucleosis Primary cytomegalovirus (CMV) infection Toxoplasmosis Primary herpes simplex virus infection Rubella

Patient Presentation Patient reports being in a heterosexual monogamous relationship for the past 3 years He denies sex with men, but does report ‘occasional’ heroin IVDU for the past 8 yrs Acute HIV seroconversion is suspected HIV antibody test is ordered and returns negative by ELISA and WB

Patient Presentation What would you do next? 1) Don’t overly alarm him. Tell him that while he currently tested HIV-negative, he still needs follow up HIV testing in another month. 2) Tell him you suspect he is in the very early stages of HIV infection and is very infectious. Then repeat HIV Ab. 3) Tell him you suspect he is in the very early stages of HIV infection and is very infectious. Then do an HIV RNA (viral load).

Patient Presentation Laboratory data HIV RNA by PCR 1.8 million copies/ml CD4+ T-cells 640 /microliter platelet count 104,000/microliter Rash, sore throat, and fatigue all resolve within 1 week. Night sweats persist for 4 weeks.