1. Update on STIs Catherine M. Bettcher, M.D.
CME Director & Assistant Professor,
Department of Family Medicine
University of Michigan

3. Learning Objectives
Apply evidence-based recommendations to the diagnosis and treatment of Trichomoniasis, Chlamydia and gonorrhea
Implement strategies to prevent HPV infection
Discuss special situations that may arise with screening/treatment of adolescents

4. Patient Case:
29 y/o female presents with increased vaginal discharge but no odor, itching, pain
Has had 2 sexual partners in the past year
Had a normal Pap smear 4 years ago
Uses OCP for contraception, no condoms

5. Patient Case: Wet prep: > 10 WBCs/HPF
No clue cells, yeast hyphae, motile Trich
Elevated pH of 5.0

6. Trichomoniasis
Most common non-viral STI. Prevalence rates 10x higher in AAs compared to non-Hispanic whites.
CDC recommends screening HIV-infected females annually and suggests that screening can be considered in females at high risk of infection.

7. Trichomoniasis: Diagnosis
NAAT
Collect vaginal, endocervical, or urine specimens from women
Prefer urethral swabs in men
Culture
Antigen-detection, point-of-care test
Wet prep microscopy
60-70% sensitivity
Do not diagnose Trich based on Pap smear due to poor sensitivity and specificity.

8. Trichomoniasis: Treatment
Tinidazole is associated with fewer GI effects but increased cost.

9. Trichomoniasis: Follow-up
Retest females 3 months after treatment
Routine screening not recommended
CDC recommends annual screening in all HIV-infected women
AAP recommends consideration of screening in high- risk females

10. Chlamydia
Most common reportable infectious disease in the U.S. Most infections are asymptomatic; this may lead to PID and complications such as ectopic pregnancy, infertility and chronic pelvic pain. Chlamydial infections are 10 times more prevalent than gonococcal infections in women aged 18 to 26 years.

11. Chlamydia
Minorities are disproportionally affected.

12. Chlamydia Screening: How Successful Are We?
In 2009, ACOG changed guidelines for Pap smears
Study compared data from 3,500 females aged before and after the change
National Commission on Prevention Priorities ranked Chlamydia screening of young women as 1 of 10 most beneficial and cost-effective preventative services but also among the most underutilized.
CDC recommends annual Chlamydia screening of MSM.

13. Chlamydia: Diagnosis NAAT Culture
Endocervical or vaginal swabs, or first catch urine in women
Urethral swab or first catch urine in men
Culture
Endocervical swab in women
Urethral swab in men

14. Chlamydia: Treatment

15. Gonorrhea
(gram neg diplococci) More than 95% of women with gonorrhea have no symptoms. Gonorrhea is more likely than Chlamydia to be symptomatic in men. Infection may lead to urethritis and epididymitis. Infection may facilitate HIV transmission. Gonococcal infection is concentrated in specific geographic locations and communities.

16. Gonorrhea: Diagnosis NAAT Culture
Endocervical or vaginal swabs, or first catch urine in women
Urethral swab or first catch urine in men
Culture
Endocervical swab in women
Urethral swab in men
Women can self collect vaginal specimens. Rectal and pharyngeal swabs can be collected, although these collection sites have not been approved by the FDA.

17. Gonorrhea: Treatment

18. Gonorrhea: Treatment
Patients should abstain from sex until they and their sex partners have completed treatment and no longer have symptoms.

19. Chlamydia and Gonorrhea: Follow-up
No routine test of cure 3-4 weeks after treatment
Retest patients 3 months after treatment
Consider Expedited Partner Therapy (EPT) for sex partners
Sex partners of infected individuals during the 60 days before the diagnosis should be tested and treated.
For gonorrhea, EPT with cefixime and azithromycin can be considered. EPT is not recommended for men who have sex with men.

20. Gonorrhea: Suspected Treatment Failure
Consider failure in the following situations
No resolution of symptoms in 3-5 days after treatment, and no sex during this period
Positive test of cure and no sex following treatment
Send culture with simultaneous NAAT
Retreat with recommended regimen

21. Human papillomavirus (HPV)
Usually resolves spontaneously with no health problems
Can lead to genital warts and precancers/cancers of cervix, anus, penis, vulva, vagina, head and neck
Cannot determine which infections will resolve and which will progress
Does not interfere with pregnancy

22. That’s 1 case every 20 minutes
Every year in the United States 27,000 people are diagnosed with a cancer caused by HPV
Here’s another way to think about the number of cases of HPV cancers in the United States annually.
That’s 1 case every 20 minutes

23. Cancers Caused by HPV, U.S.
Cancer site
Average number of cancers per year probably caused by HPV
% per year
Male
Female
Both Sexes
Anus
1,400
2,600
4,000
91%
Cervix
10,400
Oropharynx
7,200
1,800
9,000
72%
Penis
700
63%
Vagina
600
75%
Vulva
2,200
69%
TOTAL
9,300
17,600
26,900
Here you can see the distribution of HPV cancers at the various anatomic sites, with about 9,300 HPV cancers occurring in men, and 17,600 HPV cancers occurring in women, in the US, annually.
CDC, United States Cancer Statistics (USCS),

24. Oral Human Papillomavirus Infection: Differences in Prevalence Between Sexes and Concordance With Genital Human Papillomavirus Infection, NHANES 2011 to 2014

25. Protection Against HPV

27. Administration of HPV Vaccine
Routinely give at age years
Recommended through age 26 for females and through age 21 for males not previously vaccinated
Two doses of HPV vaccine are recommended for those who start the series before their 15th birthday. The second dose should be given 6 to 12 months after the first dose. Vaccination is recommended through age 26 for gay, bisexual, transgender, and men who have sex with men, and HIV infected persons.

28. HPV Vaccine Comparison
This chart demonstrates the HPV types included in each vaccine. The bivalent vaccine targets cancer causing HPV types 16 and 18, which cause approximately 66% of cervical cancers. Quadrivalent vaccine, targets types 16 and 18, as well as types 6 and 11 that can cause genital warts. The 9-valent HPV vaccine, targets the same 4 types as the quadrivalent and 5 additional cancer causing types the cause approximately 15% of cervical cancers.
No clinical trial data are currently available to demonstrate efficacy for prevention of oropharyngeal or penile cancers. However, because many of these are attributable to HPV16, the HPV vaccine is likely to offer protection against these cancers as well.
These Genital warts ~66% of ~15% of
HPV Types Cervical Cervical
Cause: Cancers Cancers

29. Impact of HPV Vaccination
In countries with >50% coverage among year olds
Prevalence of HPV 16/18 decreased 68%
Anogenital warts decreased by 61%
Evidence of herd effects

30. Your preteen needs three vaccines today to protect against meningitis, HPV cancers, and pertussis.
This sounds like “Your preteen needs three vaccines today to protect against meningitis, HPV cancers, and pertussis.”
I want to point out a few things on this slide. The word “today” is especially important because it conveys to the parent that you are recommending that all of these vaccines be given today, not another day. The order of the vaccine-preventable diseases is also important. We want to sandwich HPV cancers between meningitis, because that one really scares parents, and pertussis, because most parents are going to get that vaccine for their child. So meningococcal 1st, HPV cancer 2nd, pertussis 3rd.

31. Adolescents

32. Adolescent Confidentiality: Michigan Law
A parent or legal guardian must provide consent on behalf of a minor (under age 18) before health care services are provided.
Exceptions to the parental consent rules:
Emergency care
Care for emancipated minors
By court order, marriage, military active duty
Specific healthcare services related to:
Sexual health
Mental health
Substance use treatment

33. Adolescent Confidentiality: Michigan Law
Patients ages 12 and up have a right to the following WITHOUT parental consent or knowledge:
Pregnancy testing and prenatal care
Birth control information and contraceptives
Testing and treatment for sexually transmitted infections

34. Adolescent Confidentiality: Michigan Law
Healthcare providers must breach the minor’s confidentiality and tell the parent if:
There is suspicion of abuse by an adult
The minor is a risk to themselves or someone else
The minor is under age 12 and has been sexually active
Provider may choose (but is not obligated) to tell the parents about any care provided to the minor patient

35. Adolescent Visits
Discuss the expectation that some time will be spent with the teen alone
Inform adolescent patients and their parents about their rights and limitations regarding confidentiality laws and procedures
By law, I have to keep anything you tell me confidential unless I’m concerned about your safety or someone else’s safety. Then, the law sometimes requires me to notify others.

36. Adolescent Confidentiality Caveats
Explanation of benefit (EOB) or medical bill might disclose tests and treatments for STDs
Encourage teens to discuss care with families
Teens can pay out of pocket
Refer teens to clinics where confidential care is free or based on a sliding scale
Consider making STI screening “routine”

37. Screening Recommendations: Draft
Co-testing nearly doubles the number of follow up tests and does not lead to increased detection of CIN-3 and cervical cancer compared hrHPV testing alone.

38. Screening Recommendations
Highest infection rates occur in women aged 20 to 24 years. Risk factors: new or multiple sex partners, a sex partner with concurrent partners, sex partner with STI, inconsistent condom use in non-monogamous relationships, previous or concurrent STI, exchanging sex for money or drugs.

39. Screening Recommendations

40. Primary Prevention
Administer HPV vaccine to females and males aged 11 to 12 years
Give the hep B vaccine if not previously vaccinated
Offer the hep A vaccine if not previously vaccinated
Counsel about sexual behaviors and educate about prevention
Counseling can reduce risky sexual behaviors and increase the likelihood of condom use. Interventions range from 30 min to 2 hrs—interventions of lesser intensity are also effective. Behavioral counseling about sex does not increase sexual activity among adolescents.

41. Questions

42. Conclusions Use NAAT for diagnosis
Rescreen men and women with chlamydia or gonorrhea in 3 months
Rescreen women with trichomoniasis in 3 months
Promote HPV vaccination
Seek opportunities to screen adolescents appropriately

43. References
Expedited Partner Therapy (EPT) for Chlamydia and Gonorrhea: Guidance for Health Care Providers. Michigan Department of Health and Human Services.
Hauk L. CDC releases 2015 guidelines on the treatment of sexually transmitted diseases. Am Fam Phys. 2016;93(2):
Lee KC et al. Sexually transmitted infections: recommendations from the U.S. Preventive Services Task Force. Amer Fam Phys. Dec 2016;94(11):
Murray PJ. Screening for nonviral sexually transmitted infections in adolescents and young adults. Pediatrics. July 2014;134(1):e302–e311.
Ursu A, Sen A, Ruffin M. Impact of cervical cancer screening guidelines on screening for Chlamydia. Ann Fam Med. 2015;13(4):
Workowski KA. Centers for Disease Control and Prevention sexually transmitted diseases treatment guidelines. Clin Inf Dis. 2015;61:S759-S762.
Workowski KA, Bolan GA. Sexually transmitted diseases treatment guidelines, MMWR Recommendations and Reports. 2015;64(3):1-137.