1. Sexual Transmitted Infections in General Practice
Dr John McSorley

2. STIs in general practice
What are the sexually transmitted infections?
What is the epidemiology?
Why are STIs important?
What to look out for in general practice?
What is the patient experience in the GUM clinic
What is new?

3. Sexually transmitted infections
Bacterial Chlamydia / Gonorrhoea / Syphilis / Others
Viral HPV / Herpes /HIV / Hepatitis B/C ?A
Protozoa TV
Ectoparasites Lice/scabies

4. Number of diagnoses of chlamydia, England: 1995-2009
Diagnoses of chlamydia (from GUM and community based settings) increased by 8% from 2008 to 2009 (177,046 diagnoses in 2008 and 191,772 diagnoses in 2009). Data from community-based settings in 15 to 24 year olds were included from Chlamydia diagnoses in GUM clinics increased steadily every year until 2009 where the number of diagnoses in GUM dropped slightly. This likely reflects the high levels of testing and consequent diagnoses achieved by the roll-out of the National Chlamydia Screening Programme (NCSP) in community-based settings. 4

5. Age-specific distribution of the rate diagnosed with chlamydia at STI clinics, England: 2009
In women attending GUM clinics in 2009, 75% (35,700/47,530) of chlamydia diagnoses were in those aged under 25 years. Rates of diagnoses were highest in women aged 19 and men aged 21. 5

6. Uncomplicated Chlamydia NWLH 1997 to 2013

7. Number of diagnoses of genital warts (first, recurrent and re-registered episodes) by sex, GUM clinics, England and Wales*:
Between 1972 and 2009, the number of all genital warts diagnoses (first, recurrent and registered episodes) increased by 8- and 11-fold in men and women respectively. These rises may reflect increased incidence of infection, greater public awareness and/or improved detection rates. Although the number of genital warts diagnosed almost trebled (2.9-fold increase) in GUM clinics between 1977 and 1986, the following years saw a more gradual increase in diagnoses. This may be due to changes in sexual behaviour that coincided with the emergence of the HIV epidemic during the mid-eighties. Since 1994, numbers have continued to rise reaching 83,373 cases among men and 62,502 cases among women in 2009. 7

8. Number of diagnoses of genital herpes (first and recurrent episodes) by sex, GUM clinics, England and Wales*:
Between 1971 and 2009, the number of genital HSV diagnoses made at GUM clinics increased 7- and 31-fold in men and women respectively. This is reflected in the changing female to male ratio, from 0.3:1 in 1971 to 1.5:1 in The reason for the change in sex ratio is unclear. The number of diagnoses stabilised and fell briefly in the mid-eighties possibly due to changes in sexual behaviour following extensive media coverage of HIV and AIDS. Numbers of diagnoses have risen sharply in the last few years due to changes in sexual behaviour and an increasing use of highly sensitive diagnostic tests. 8

9. Numbers of diagnoses of syphilis (primary, secondary and early latent) by sex, GUM clinics, England, Wales and Scotland*:
Diagnoses of infectious syphilis made at GUM clinics in England, Scotland and Wales peaked towards the end of World War II, and then fell sharply in the late 1940s. New diagnoses among men rose steadily throughout the 1960s and 70s, while cases among women remained low. The male to female ratio of diagnoses peaked at 8:1 in 1983 in England and Wales and at 10:1 in 1984 in Scotland, suggesting that sex between men was the most common route of acquisition. Diagnoses in men declined in the early to mid-1980s, coinciding with emerging awareness of HIV, adoption of safer sex practices, and a parallel fall in HIV transmission among homosexual men. Since 2000, there has been a 7-fold increase in syphilis diagnoses among men and a two-fold increase among women in England and Wales. The latest increase having been primarily driven by sex among MSM. 9

10. Number of diagnoses of selected STIs and HIV in the UK, males: 2000-2009
Since 2000, numbers of diagnoses in GUM clinics of genital warts (first attack) and genital herpes (first attack) have risen considerably. Numbers of new diagnoses of gonorrhoea has decreased considerably with infectious syphilis diagnoses and new diagnoses of HIV levelling off. Uncomplicated chlamydia diagnoses rose sharply from , with a decline in GUM chlamydia diagnoses in This decline likely reflects the high volume of testing achieved in community-based settings by the National Chlamydia Screening Programme in 2009. 10

11. Uncomplicated N. gonorrhoea at NWLH 1997 to 2013

12. Incidence Chlamydia commonest (75% under 25s) Warts
Herpes (Ratio F:M 0.3:1 to 1.5:1)
Gonorrhoea greatly decreased but…
Syphilis (since 2000, 7 fold increase in men and doubling in women)
HIV levelling off (or not)

13. Why are STIs important? ½ billion new curable STIs each year worldwide
STIs (not HIV) 2nd most common cause of healthy life lost in women (15-49) worldwide
US: 8 million cases/yr direct cost $8.7 billion/yr
Costs of the complications (PID, ectopic pregnancy,infertility) £100s millions
Physical and psychological morbidity e.g. herpes
10-40% untreated CT develop PID
Post infection tubal damage c40% infertility
Preventable: STI care Vaccinations

14. Why are STIs important?
Aversely affect Pregnancy: Ectopic Pregnancy x6-10 more likely if prev PID, c50% EP attributable to prev STI. <35% pregnancy with untreated GC results in abortion, prem delivery
ASYMPTOMATIC c70% in UK
GP/PN will see several cases of people with STIs in a week
Failure to suspect & diagnose is a disservice
Best way to reduce STIs is by population screening

15. What/who should you be looking out for in general practice?
Very frequently asymptomatic
Symptoms dysuria, vaginal or urethral discharge, pelvic pain, genital lumps, bumps
Index of suspicion
Sexually active, change of partners, multiple partners, unfaithful partner

16. High index of suspicion
Young people
5% of under 25yr old each year every year
Emergency contraception
Pre termination
Men (<45) with urinary syndromes STI, STI, STI, STI, STI not UTI
Epididymo-orchitis CT x10 more likley
GUM

17. STI screening in MSM: NWLH 1997 to 2013

18. Some principles to remember about STIs
More than one infection
More than one person and partner -the index and the contact - hence partner notification
Education and prevention both primary and secondary
Avoid sex until both (or all) parties are treated

19. Some common examples Case 1
A 19 year old girl requests an IUD for emergency contraception
She had unprotected sex 4 days ago
What questions would you like to ask?

20. Case 1 contd. How many partners has she had in last 3-6 mths
Any previous STIs?
Does her partner have any symptoms?
Has she had other unprotected sex?
She has had 2 partners in past 3 months
What would be your next step?

21. History, management At risk of chlamydia (>5%)
At risk of PID with IUD insertion
Consider (referral for) STI screen
Perform chlamydia test (swab or urine)
Consider prophylaxis with Azithromycin 1 gram
Advise no sex until result available

22. Result of swab
Chlamydia test positive
What do you do next?

23. Chlamydia test is positive (case 1)
Refer her and her partner to GUM clinic
Full STI screen
Treatment
Partner notification
Or Treat yourself
If GUM attendance not possible
Doxycycline 100mgs po bd for 7 /7, or azithromycin 1 gram PO, or erythromycin 500mgs po bd for 10/7
No sex until she and partner are treated

24. Chlamydial infection Rarely symptomatic 50-90% women no symptoms
Vaginal discharge, cervicitis uncommon
Rarely presents with PID, Reiters syndrome or reactive arthritis
Diagnosed using DNA test on swab (endocervical, vulval,vaginal, urine)

25. Clinical features in Chlamydial infection

26. Know your local GUM clinic Routine tests
All patients tested for chlamydia, gonorrhoea, syphilis and HIV (Brent Hep B core)
‘Pee and go’ NAAT testing (DNA testing for chlamydia/gonorrhoea)
Additional tests for Hepatitis B, trichomonas, herpes , other conditions eg hepatitis C,LGV

27. Special considerations in GUM clinics
Focus on young people
Normalisation and early HIV testing (POCT testing)
Frequent STI screens for gay men

28. Patients journey in GUM clinic
Asymptomatic
Nurse
Rapid history
Urine NAAT,blood syphilis, HIV +/-Hepatitis B
Not examined
No news good news
Symptomatic
Doctor
Full history
+/- examined Dr/nurse
Tests swabs/other relevant tests Herpes,other sites
Treatment
Follow up

29. Case 2 34 year old married man returns from business trip to India
Noticed a sore on his penis 2 weeks ago
It is not painful but it is not getting better
What further information would you like?

30. Case 2 Sexual history Any sex with men? Past history of STIs
Drug/allergy history
General medical history

31. Case 2 History Unprotected sex with 2 sex workers in Delhi 6 weeks ago
Sex with his wife on number of occasions since his return
He took antibiotics from his dentist for 5 days 3 weeks ago
What action would you take at this stage?

32. Case 2 assessment Examine his genitalia Findings are:
Superficial ulcer sub preputial area and shotty nodes in the groin

33. Case 2 management Is this a drug reaction? Is this an STI?
What would you recommend?

34. Case 2 management Refer to GUM clinic for full STI screen
Tests for syphilis serology, swab for PCR, full STI screen including HIV and Hepatitis B
Results show Syphilis EIA positive, raised RPR 1/64 consistent with primary syphilis

35. Case 2 management
Treated with 1 injection of benzathine penicillin I/M 2.4 mega units
Wife also needs testing and ?epidemiological treatment
Advise repeat HIV test after 3 months
Consider hepatitis B vaccination

36. Syphilis

37. Syphilis Infectious syphilis more common in past 10 years.
Secondary syphilis may present with a rash
There have been >10 local scattered epidemics amongst heterosexuals in UK
Endemic again in gay men
Foreign travel history is important
Always consider the possibility of associated HIV

38. Case 3 26 year old 20 weeks pregnant , first pregnancy
Married for 2 years
Vulval discharge and itching for weeks, ?smelly
Slight external dysuria
Thrush treatment from the pharmacy but it doesn’t seem to have helped

39. Case 3 She is very worried this will affect her baby
Sex only with her husband who is a travelling salesman
He has been avoiding sex with her lately and keeps telling her she needs to have a check up in the local clinic
She didn’t see why she needed to go to a clinic and decided to come to you her GP

40. Case 3 contd Is this thrush? Is this something else? Refer to GUM
Triaged
Vaginal slides Trichomonas Vaginalis
She is very embarrassed (and angry) to hear that this is an STI but relieved it will not affect her baby
Treated Metronidazole 2 grams PO Stat

41. Trichomoniasis

42. Trichomonas vaginalis
Rarely causes symptoms in men
Typically a frothy fishy smelling discharge.
Similar to Bacterial vaginosis discharge
Diagnosed on wet mount microscopy
Not a serious infection
Marker for other STIs
Single dose treatment Metronidazole 2 grams
Treat partner

43. Case 4
Your practice nurse has been doing a study with the local GUM clinic screening under 25s routinely for chlamydia and gonorrhoea using urine testing.
A 21 year old Afrocaribean male was found to have gonorrhoea and was recalled you are asked to see him.
What do you do

44. Case 4
Sexual history 3 partners in past 6 weeks all unprotected. No regular girlfriend
He has no discharge or dysuria
No previous STIs
Otherwise well and not taking any medication
What do you do?

45. Case 4 Refer to GUM clinic for full STI screen treatment and
partner notification
In GUM clinic
Urethral swab for microscopy, GC culture and sensitivity
Treatment
Ceftriaxone 500mgs IM stat with treatment for chlamydia
Cefixime 400mgs po stat if refuses injection

46. Gonorrhoea 40% women and 10% men are asymptomatic
Vaginal discharge and cervicitis are not common presenting symptoms in women.
Urethral discharge and dysuria are common in men
Multi drug resistant GC coming!!!!

47. Gonorrhoea

48. Gonorrhoea Disseminated

49. Gonorrhoea
Commoner in black population locally (x 10) although most cases in UK in caucasians
x5-6 in MSM

50. Herpes First episode genital herpes Recurrent genital herpes
Common presentation
Young woman presents with ‘cuts’or sores on the vulva
Possibly in a stable relationship

51. Herpes

52. Patients with Herpes
Primary genital herpes can frequently be diagnosed as patient enters the room
Severe discomfort walking, sitting down uncomfortable, may have severe dysuria, may complain of discharge, may be crying
May be febrile

53. Primary herpes

54. Genital herpes
Primary herpes blisters ulcers, may be confluent, may be associated vulval oedema and tender lymphadenopathy.
Easy to diagnose clinically
Confirmed by a swab for herpes virus PCR

55. Genital herpes Treatment
Acyclovir 200mgs po 5/day for 5 days or 400mgs tds for 5 days
Advice re PU in bath, handwashing
Pain relief, lignocaine gel
In depth discussion re infectivity, recurrences, partner, childbirth
Reassurance that first attack always the worst

56. Genital herpes 1/3 will get no more attacks
1/3 will get 2-3 attacks per year
1/3 will get frequent/severe attacks and may require suppressive therapy for a year or more

57. Genital herpes in pregnancy
Main problem is primary herpes.
May cause miscarriage due to febrile illness in first trimester
Primary herpes in last trimester may be associated with neonatal herpes
Indication for Caesarian section if Primary or first episode herpes occurs within 6 weeks of delivery

58. Warts Warts are often discovered incidentally during examinations
They are sexually transmitted ,- human papilloma virus (HPV)
The HPV types which cause warts are not oncogenic.
Oncogenic HIV subtypes 16/18.
The subtypes commonly causing warts are 6/11

59. Warts

60. warts, meatal

61. Warts and abnormal smears
We are commonly asked whether warts have caused an abnormal cervical smear
Reassure that the HPV subtype that causes warts does not cause pre cancerous changes on a smear.
Also oncogenic HPV causes anogenital cancer but is much rarer that cervical cancer except in MSM / HIV +ve

62. Warts treatment
Podophyllotoxin
Cryotherapy
Imiquimod
No treatment

63. Lice and Scabies Pubic itch Visible ‘crabs’ in pubic hair.
Visible nits in pubic hair
Sexually transmitted (close body contact)
Treat with Malathion 0.5% apply to hair and leave overnight
Repeat after 3-5 days
Full STI screen

64. Lice

65. Scabies Generalised itch Worse at night
Specifically finger toe webs, wrists, skin creases, pubic area. May cause papules on penis
Treatment Permethrin cream. Malathion 0.5% aqueous lotion
Apply and leave overnight for 12 hours
Wash clothes and bedding in >50 degrees
Sexual and household contacts tretaed

66. Scabies

67. HIV diagnoses in general practice
Majority asymptomatic
Late diagnosis a problem
In GP consider testing:
All new registrations at your practice
Flu like illness
Skin conditions eg shingles, recurrent folliculitis, molluscum contagiosum on the face, KS
Haematological conditions, neutropaenia, thrombocytopaenia

68. Rash of HIV seroconversion

69. Shingles think HIV

70. HIV Normalise the HIV test Important clinical investigation
In depth counselling not necessary
If positive contact the GUM clinic (if we don’t contact you first)

71. Conclusions STIs are common
High index suspicion especially amongst young people, gay men
Screening with self taken swabs/urines very easy with DNA tests
Normalise HIV testing
Doing more screening will drive down the incidence of new disease