1. Sexually Transmitted Diseases

2. Epidemiological Assumptions Upon Successful Prevention of STDs Prob. of PID in women would reduce from 20% to 4% by Rx of CT; from 20% to 6% by Rx of GC In the absence of Rx, 50% of pregnant women with P&S syphilis would have delivered a child with congenital syphilis Each STD case treated prevents 0.5 cases of that STD in the population by interrupting transmission About 1 case of HIV is averted for ever 5000 cases of CT treated, 8000 cases of GC treated, or 250 cases of syphilis treated About 3 cases of HIV would be averted for each 10,000 people who received HIV counseling and testing Chesson et al. Formulas for estimating the costs averted by STI prevention programs in the U.S. Cost Effectiveness and Resource Allocation 2008; 6:10

3. Chlamydia (Chlamydia trachomatis ) The most commonly reported nationally notifiable disease 1,422,976 cases reported in the US, 2012 Estimated 2.8 million infections occur each year CT prevalence among 14 to 24-year-olds is nearly 3x that of 25-39 yrs Estimated that 1 in 15 sexually active females aged 14-19 years has chlamydia In ND, CT rates are more than 10x higher among AI than rates in whites

4. Immunobiology of Chlamydia Whether Sx or not, untreated CT can ascend to the upper genital tract Pelvic Inflammatory Disease Fibrosis, scarring and loss of tubal function Infertility, ectopic pregnancy and chronic pelvic pain CT is the leading preventable cause of tubal factor infertility

5. 5 Swollen or Tender Testicles (Epididymitis) Source: Health Awareness Connection, http://www.healthac.org/images.html

6. 6 Chlamydial Symptoms in Women: Cervicitis Normal Cervix Chlamydia Cervicitis

7. Pelvic Inflammatory Disease (PID) 7 Source: Cincinnati STD/HIV Prevention Training Center

8. PID Approx. 750,000 PID diagnosed in US each year PID – 10% to 20% of untreated CT infections in females will result in PID ◦ Ectopic Pregnancy (6%) ◦ Infertility (10-15%) ◦ Chronic pelvic pain (18%) The younger the pt, the greater the chance of re-infection ◦ 2x the odds for ectopic pregnancy ◦ 4x the odds for PID

9. Chlamydia Screening Recommendations All sexually active women under age 26 should be screened once a year Women age 26 and older with one or more of the following: a)Multiple or new sex partner in last 60 days b)PID or other sequelae c)Positive for CT in last 12 months Anyone testing positive for CT should be re-tested in 3 months

10. Screening Males for Chlamydia Routine CT screening of males not recommended ◦ Feasibility, impact, cost-effectiveness in preventing sequelae in females Male partners of females infected with CT should be top priority Consider targeted screening in high prevalence settings such as corrections

11. Chlamydia Treatment Guidelines Azithromycin 1 g orally in a single dose OR Doxycycline 100 mg orally twice a day for 7 days * Need to abstain from all sexual activity for 7 days after completion of therapy*

12. PID Treatment Guidelines Ceftriaxone 250 mg IM in a single dose & Doxycycline 100 mg orally twice a day for 14 days WITH or WITHOUT Metronidazole 500 mg orally twice a day for 14 days

13. Gonorrhea Caused by the bacteria, Neisseria gonorrhoeae (NG) or Gonococcal (GC) Incubation period: 1- 14 days Duration: Unknown Highly transmissible Asymptomatic infections

14. Gonorrhea Screening Guidelines Base screening on high morbidity areas among high-risk populations Age groups 15-24 years

15. Risk of Sequelae Following GC Infection Pelvic Inflammatory Disease (PID) Ectopic Pregnancy Infertility Disseminated Gonococcal Infection

16. 16 Gonorrhea Symptoms in Men: Discharge from the Penis Source: CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides

17. Gonorrhea Treatment Guidelines Ceftriaxone 250 mg IM in a single dose & Azithromycin 1 g orally in a single dose OR Doxycycline 100 mg orally twice a day for 7 days

18. Prevent Re-Infection CDC recommended re-screening 3 months after treatment Treating partners of infected females with CT/GC is critical Dual therapy for GC cases regardless if CT is ruled out (2010 STD Guidelines) Test of Cure Recommended Only in Pregnant Women

19. Syphilis: Treponema pallidum PrimarySecondary Occurs after incubation Occurs in every case Usually one or more chancres at the site of exposure Most infectious stage of syphilis Occurs any time after the eruption of the primary chancre (usually 4 – 6 weeks up to one year) The “great imitator” – rashes of different varieties, often on palms and soles

20. Syphilis: Treponema pallidum Tertiary Other characteristics Late manifestations of syphilis Can involve any part of the body Can occur during primary or secondary syphilis Gummatous lesions Latency – periods between stages in which the person has no symptoms or signs of syphilis Neurosyphilis Congenital syphilis

21. 21 Primary syphilis-chancre

22. 22 Primary syphilis - chancre

23. 23 Secondary syphilis - papulosquamous rash

24. Traditional Syphilis Screening Algorithm Presumptive diagnosis ◦ Non-treponemal tests: RPR and VDRL  Both are usually quantified  Titer correlates with disease activity Confirmed diagnosis ◦ Treponemal tests: TP-PA and FTA-ABS

25. Syphilis Screening Recommendations Pregnant females Partner(s) exposed to a positive syphilis case Blood donors MSM ◦ Screen CT, GC and syphilis at 3 – 6 mo intervals if reporting multiple and anonymous sex partners HIV+ individuals should be tested once a year

26. Reverse Sequence Syphilis Screening EIA/CIA are treponemal antibody tests ◦ Automated, low cost in high volume settings, less occupational hazard, no false negs All reactive EIA/CIA must be reflexively tested with a quantitative RPR to detect active infection Discordant results (EIA+/RPR-) must be confirmed w/ a second treponemal test TP-PA www.cdc.gov/std/default.htm

27. HIV/AIDS and STDs Individuals who are infected with STDs are at least 2-5x more likely to acquire HIV infection ◦ Genital ulcers create a portal of entry for HIV ◦ Inflammation resulting from STDs increase conc. of cells in genital secretion that serve as targets for HIV (e.g., CD4+ cells) People with STDs > 2x as likely to have HIV in genital secretions; the median conc. of HIV in semen is 10x higher in men infected with GC and HIV than in men only infected with HIV STD treatment reduces an individual's ability to transmit HIV HIV testing should always be recommended for individuals who are diagnosed with or suspected to have an STD.

28. PARTNER SERVICES

29. ND Partner Services CT ◦ Under 14 ◦ Diagnosed with PID ◦ Pregnant Gonorrhea ◦ All Cases HIV ◦ All Cases  Interviews conducted by ND Field Staff

30. Interview Period Guidelines Gonorrhea and Chlamydia Symptomatic: 60 days prior to the onset of symptoms through the date of adequate treatment Asymptomatic: 60 days prior to the initial positive test through the date of adequate treatment Syphilis: Depends on Stage and Symptoms

31. Information Gathered During An Interview Number/Foundation ◦ # Lifetime Partners ◦ Sex Behavior: Sex with Men, Women, IDU, etc. Name ◦ Name for each partner, including screen names Exposure ◦ First & Last Sexual Contact, Frequency, Type of Sex Locating ◦ How to find partners Clustering: Suspect Cases Description: Detailed Description of Partners

32. STD Interview Format Intro: Confidentiality Assessment: Concerns, Social History, Medical History, Disease Comprehension Intervention: Partners, Risk Reduction Conclusion: Risk Reduction Plan, Commitments

33. Expedited Partner Therapy (EPT) Treatment of partners without an intervening personal assessment by a health-care provider Accepted method of treatment of CT and GC infections in ND as of January 2009 ◦ GC Treatment is Cefixime (Not Effective for Pharyngeal Infections) Guidelines for medical providers, website, EPT toolkit under development