Kees Rietmeijer, MD, PhD Denver Prevention Training Center 1

 Provide overview of the management of the most common STD syndromes: o Vaginal discharge o Male urethral discharge o Genital ulcer disease 2

3 New edition expected in 2014

 Express Visit o Eligible Asymptomatic Low-risk o Testing All Chlamydia NAAT Gonorrhea NAAT HIV Based on risk Syphilis: RPR  Comprehensive Exam o Eligible Symptomatic High-risk MSM Partner of STI Sex work o Testing Based on symptoms POCT All CT/GC NAAT RPR HIV 4

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 31 year old woman  Complains of abnormal, malodorous vaginal discharge since 10 days  Over the counter medications have been ineffective  Last sexual contact 3 days ago with new partner  2 partners in past 3 months  Otherwise no health problems 6

 What else do you want to know?  Only sex with men  Not aware of any partners’ symptoms  Inconsistent condom use  Previous STDs: o Chlamydia infection 2 years ago  No substance use or sex work  Never been tested for HIV 7

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12 NUGENT Score 0 NUGENT Score 10

 BV o Amsell Criteria Homogeneous, grey discharge Whiff Ph >4.5 Clue cells o Treatment Metronidazole/7d Tinidazole/7d  Partner management o Not recommended  Trichomoniasis o Motile trichomonads  Treatment o Metronidazole/single dose o Tinidazole/single dose  Partner management o Yes 13  Yeast o Hyphae o Spores  Treatment o Azoles Topical/5-7d Oral/single dose  Partner management o Not recommended

SensitivitySpecificity Wet prep55%–65%100% Culture75%100% POCT (OSOM)>83%>97% PCR (LDT)83-92%100% TMA AptimaTV100% ProbTec TVQ98.3% Briselden AM. J Clin Microbiol. 1994; Demeo LR. Am J Obstet Gynecol. 1996; Huppert JS. J Clin Microbiol. 2005; Nye MB. Am J Obstet Gynecol. 2009; Van Der Pol B. J Clin Microbiol Van Der Pol; Schwebke; Taylor: Posters STI & AIDS, 2013 Courtesy: Charlotte Gaydos. ISSTDR, Vienna; 2013.

 Chlamydia and gonorrhea NAAT (e.g., APTIMA or ProbeTec)  Syphilis: o Traditional algorithm: Non-trepenamal (RPR or VDRL) If + followed by treponemal test (TPPA/TPHA/FTA) o Reverse algorithm: Treponemal (EIA or rapid POC) If + followed by non-treponemal (RPR or VDRL)  HIV 15

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 24 year-old MSM  Urethral discharge since 3 days  Known HIV+  10+ partners in past 3 months  Last sex 2 days ago in bath house  Pt is “versatile”; i.e., engaging in both insertive and recepetive anal inntercourse 17

 Patient is in HIV care and had an undetectable viral load at last testing 2 months ago  Unprotected sex only with partners he knows are HIV+ as well  Has a history of multiple STDs, including syphilis and gonorrhea 18

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 Gonococcal Urethri t is  Treatment o Ceftriaxone + o Azithromycin or Doxycycline  Partners o <60 days o Evaluation and treatment o Expedited partner treatment (EPT)  Nongonococcal urethritis  Treatment o Azithromycin or Doxycycline  Partners o <60 days o Evaluation and treatment o EPT 22

Cause of Urethritis Among Males Denver Metro Health Clinic (N=7527)

Cause of Nongonococcal Urethritis Seattle, N = 606 Manhart et al. Clin Infect Dis 2013;56:934

Treatment Results C. trachomatis8690 M. genitalium4030 U. urealyticum7570 Clinical Cure8076 Azithromycin Doxycycline % % Manhart et al. Clin Infect Dis 2013;56:934

 Traditionally, clinical diagnosis established on basis of Gram-stained smear of urethral discharge at > 5 PMNs/HPF 26 However: Cut-off determined in pre-HAART era Low-level infections may be accompanied by low-level inflammatory response (especially for chlamydia) How does the Gram stain perform at different cut-off levels when using chlamydia NAAT as the gold standard?

27 Rietmeijer and Mettenbrink Sex Transm Dis 2012;39:18 N = 11,422 Gram Stains

 29 year-old woman  Very painful vulvar lesions, increasing in severity for past 4 days  Monogamous relationship with new partner since 3 months  Used condoms initially, but unprotected vaginal and oral sex after both partners tested negative for STD  No history of STDs  Partner not aware of symptoms and also negative STD history 28

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 Syphilis o Point of care History MSM Contact Darkfield RPR o Non-Point of care Treponemal test EIA TPPA FT-ABS o Treatment 2.4 MU LAB o Partner Management  Genital Herpes o Point of care History Contact Clinical presentation (Tzanck) o Non-Point of care Culture (PCR) o Treatment Acyclovir/Valacyclovir/ Famciclovir o Partner Management 33