Transcript Slide 27 - Physicians for Reproductive Health

Sexually Transmitted Infections:
Epidemiology, Testing and Treatment for
Adolescents

Objectives
 Describe the epidemiology, scope and risk factors for
sexually transmitted infections (STIs) in adolescents
 Discuss common STIs affecting adolescents
 Understand STI disparities and learn how to address
them in your practice
 Review screening and treatment guidelines to
assess, treat, and prevent STIs in adolescent
patients


Adolescent STI Burden
Why it matters
CDC STI Estimates

CDC 2013 Report: STIs and Young
People
Incidence
Prevalence
Increased
Risk
Cost

~20 million new cases/year:
50% occur in people ages 15–24
Total infections: 110 Million
# of new infections equal among
young males (49%) and females
(51%)
Direct medical costs:
~$16 billion/year
Adolescents Face Increased Risk for
STIs
 Biological
 Behavioral
 Social/Institutional


Who is Caring for Adolescents?
Clinical Care: Female Adolescents
Source: National Ambulatory Medical Care Survey, 2003–6

Hoover et al., J Adol Health, 2010
Case: Erica
 Erica is a 16-year-old
female who presents with
dysuria.
 What is your initial
differential diagnosis?
 What additional
information do you need?

Sexual History: The Five Ps
 Partners
 Gender(s), Number (three months, lifetime)
 Prevention of pregnancy
 Contraception, EC
 Protection from STIs
 Condom use
 Practices
 Types of sex: anal, vaginal, oral
 Past history of STIs

www.stdhivtraining.net
Erica: Sexual History Results
 Several episodes of unprotected sex in the last few
weeks with one male partner (her only lifetime)
 Not on hormonal contraception but uses condoms
most of the time
 Engages in oral (giving and receiving) and vaginal
sex
 No known history of STIs

Case: Erica
 Erica is a 16-year-old female
complaining of burning with
urination, yellowish discharge,
and vaginal itching. She denies
fevers, abdominal pain, and
bumps or other vulvar lesions.
 What is the differential
diagnosis?


Vaginitis
Trich, BV, Candida
Trichomoniasis and Other Vaginal Infections
Among Women—Initial Visits to Physicians’
Offices, United States, 1966–2013

CDC STD Surveillance Report 2014
Vaginitis Differential Diagnosis
Diagnosis
Bacterial Vaginosis
(Gardnerella vaginalis)
Trichomoniasis
(Trichomonas vaginalis)
Candida vaginitis
(Candida albicans)
Examination
- Thin, off-white discharge
with fishy odor
- No vaginal inflammation
Microbiology
Sequelae
Overgrowth of bacteria
species normally present
in vagina with anaerobic
bacteria
- Pregnancy complications;
Pelvic Inflammatory Disease
(PID)
- Susceptibility to other STDs
(HIV, HSV, CT/GC)

- Thin, yellow-green,
malodorous, frothy
discharge
-Vaginal inflammation
T vaginalis
is singlecelled,
flagellated,
anaerobic protozoan parasite.
Only protozoan that infects
genital tract.
-Pregnancy Complications
(pre-term delivery, low birth
weight)
-Increased HIV risk
*Women: Vaginitis
*Men: Urethritis
- Thick, “cottage cheese”
discharge
- Vaginal inflammation
Candida species are normal flora
of the skin and vagina.
VVC is caused by overgrowth of
C. albicans and other nonalbicans species.
-Pregnancy Complications (preterm delivery, low birth weight)
-Increased HIV risk
Trichomonas Vaginalis Testing
 Consider screening in high prevalence settings and
persons at high risk for infection
 Tests types
 Point of Care (POC)
 Clinical lab

CLIA – Waived, POC, Trichomonas Tests
 OSOM Trichomonas Rapid Test (Sekisui Diagnostics,
Framingham, MA)
• immunochromatographic capillary flow
dipstick technology
• test vaginal secretions
• self-testing may be an option
• sensitivity 82-95% / specificity 97–100%
 Results available in 10 minutes


Trichomonas NAATs
 APTIMA Trichomonas vaginalis assay (Hologic
Gen-Probe, San Diego, CA)
 FDA cleared for ♀ endocervical, vaginal, or urine
specimens
 Sensitivity = 95–100% / specificity = 95-100%
 Can test ♂ urine or urethral swabs if validated per CLIA
specification
 BD Probe Tec TV Qx Amplified DNA Assay
(Becton Dickinson, Franklin Lakes, NJ)
 FDA-cleared for ♀ endocervical, vaginal, or urine
specimens

Other Trichomonas Lab Tests
 Affirm VP III (Becton Dickinson, Sparks, MD)





nucleic acid probe-hybridization test
FDA-cleared to test vaginal secretions
evaluates for T. vaginalis, G. vaginalis, and C. albicans
results available within 45 minutes
sensitivity = 63% and specificity = 100%
 Culture
 vaginal secretions preferred ♀ specimen
 sensitivity = 75-96% / specificity up to 100%
 can test ♂ urethral swab, urine, or semen
 Wet prep exam of vaginal secretions
 sensitivity = 51-65%
 requires immediate evaluation of the specimens for optimal results

Erica: Diagnosis & Treatment
 POC test positive for trichomonas
 Diagnosis: Trichomoniasis
 How do you treat her?

Trichomonas Treatment
Recommended Regimen
 Metronidazole 2 g orally x 1
OR
 Tinidazole 2 g orally x 1
Alternative regimen
 Metronidazole 500 mg orally BID x 7 days

Persistent or Recurrent Trichomoniasis
 Common reason for treatment failure is reinfection
 treat all sex partners at the same time.
 If treatment failure, treat with metronidazole 500 mg
orally BID x 7 days
 If fails, treat with tinidazole or metronidazole 2 g
orally daily x 7 days
 If repeated treatment failures occur, call local health
department

Additional Concerns
 Because she is a sexually
active 16-year-old, she is
also at risk for cervicitis.
 What are the most
common identifiable
causes of cervicitis?
 Chlamydia
 Gonorrhea


Cervicitis
Chlamydia and Gonorrhea
Gonorrhea — Rates of Reported Cases by
Age and Sex, United States, 2014

CDC STD Surveillance Report 2014
Gonorrhea — Rates of Reported Cases by
Race/Ethnicity, United States, 2010–2014

CDC STD Surveillance Report 2014
Chlamydia — Rates of Reported Cases by
Age and Sex, United States, 2014

CDC STD Surveillance Report 2014
Chlamydia — Rates of Reported Cases by
Race/Ethnicity, United States, 2010–2014

CDC STD Surveillance Report 2014
STI Disparities: Meeting the Challenges
 Multiple factors contribute
to STI disparities in
African-Americans:
 Racial inequality
 High levels of uninsured
 Low educational
attainment
 High incarceration rates

 To address STI disparities,
involvement of affected
communities at all steps in
the process is required
Source: Valentine, J. “Addressing STD Disparities Among Adolescents”
Health Impact Pyramid with STI Prevention
Examples
Smallest
Impact
Behavioral counseling to
reduce STI/HIV
Counseling
& Education
Clinical
Interventions
Long-lasting
Protective Interventions
Changing the Context
To Make Individuals’ Default
Decisions Healthy
Largest
Impact

Socioeconomic Factors
Frieden T. AJPH 2010
STI Testing and Treatment
Immunization, male
circumcision
Ubiquitous condom
availability, alcohol tax
Decrease poverty &
inequality and improve
education & housing
Social Determinants Affecting Individual
Health
 Social environment can determine the availability of
healthy sexual partners
 Challenging economic circumstances can increase
risk for STIs if affordable quality health care is not
accessible
 Community mistrust/miscommunication between
providers and patients
 negatively affects health care-setting interactions & may lead
to barriers to care-seeking

Source: Valentine, J. “Addressing STD Disparities Among Adolescents”
Social/Institutional Risk Factors
Lack of
Insurance/$ to
Pay
Lack of
Transportation
Lack of Sex Ed
Regarding Risk
and Symptoms
Adolescent
s Not Being
Screened
and
Treated

Concerns About
Confidentiality
Stigma
STI Protective Factors
 Peer support for contraception and condoms
 Communication with parents about sex
 Connection to family
 Connection to school and future success
 Connection to community organizations

Cervicitis Differential Diagnosis
Diagnosis
Gonorrhea
Chlamydia
Examination
Women
Yellow or bloody vaginal
discharge, burning/painful
urination, bleeding with vaginal
Intercourse
Men
Women
Heavy or prolonged
menses, spotting,
dysmenorrhea, discharge,
dyspareunia
Men
Penile discharge, dysuria
White, yellow/green pus from the penis
with pain, burning during urination,
swollen/painful testicles
Preferred diagnostic test: Nucleic Acid Amplified Tests (NAAT)
Women – vaginal swab preferred
Men – urine acceptable
Diagnosis
**NAAT > DNA Probe > Culture**
Women
Cramps and pain, vomiting, fever  PID,
infertility, Ectopic pregnancy . HIV
Sequelae

Men
Rare  Prostate complications, epididymis, HIV
Women
- Symptomatic PID occurs in 10-15%
of women with untreated Chlamydia
- Increased risk of HIV transmission
Men
Epididymitis, reactive arthritis, HIV
transmission, proctitis
Screening:
Chlamydia & Gonorrhea
 Routine annual chlamydia and gonorrhea screening
for sexually active ♀<25 yrs
 Consider chlamydia screening for sexually active,
heterosexual, young ♂ in clinical settings with
chlamydia prevalence
 adolescent clinics, correctional facilities, STD clinics

https://www.cdc.gov/std/tg2015/chlamydia.htm
Chlamydia Treatment
 Rx not changed
 Effectiveness: azithromycin < doxycycline
 Data from several studies and meta-analysis
• Pooled cure rates: doxy=97.5% vs azithro=94.4%
• Conclusion: doxy marginally superior to azithro
 Doxycycline delayed release 200 mg tabs (Doryx)
  GI upset
 Qday x 7 days
 $

http://www.cdc.gov/std/tg2015/chlamydia.htm
Oropharyngeal Chlamydia
 Clinical significance unclear
 Routine oropharyngeal CT screening not
recommended
 Can be sexually transmitted to genital sites
 Treat oropharyngeal chlamydia with azithro or doxy

http://www.cdc.gov/std/tg2015/chlamydia.htm
Antibiotic-Resistant Gonorrhea

Gonorrhea Dual Therapy: Uncomplicated
Genital, Rectal, or Pharyngeal Infections
Ceftriaxone 250 mg IM
in a single dose
PLUS
Azithromycin
1 g orally
• Doxy no longer recommended as 2nd antimicrobial
for GC Rx
o substantially  prevalence of GC resistance to
tetracycline vs azithromycin

www.cdc.gov/std/tg2015/gonorrhea.htm
What Does Dual Therapy Mean?
Ceftriaxone and azithromycin administered
on same day
Preferably simultaneously and under direct
observation
Challenge if ceftriaxone IM in office and Rx for
azithro to fill in pharmacy
• must be given within 24 hr time period for
adequate treatment

Gonorrhea Treatment Alternatives 2015:
Anogenital Infections
ALTERNATIVE CEPHALOSPORINS:
Cefixime 400 mg orally once
PLUS
Dual treatment with azithromycin 1 g
OR
doxycycline 100 mg BID x 7 days
 Doxy removed as cotreatment

www.cdc.gov/std/tg2015/gonorrhea.htm
Gonorrhea Treatment Alternatives
Anogenital Infections
X
IN CASE OF SEVERE ALLERGY:
 Azithromycin 2 g orally once
(Caution: GI intolerance, emerging resistance)
Gentamicin 240 mg IM + azithromycin 2 g PO
OR
Gemifloxacin 320 mg orally + azithromycin 2 g PO

www.cdc.gov/std/tg2015/gonorrhea.htm
Alternative Urogenital GC Regimens
 Non-comparative randomized trial in adults with urethral
or cervical gonorrhea
1. Gentamicin 240 mg IM + azithromycin 2 g PO, or
2. Gemifloxacin 320 mg PO + azithromycin 2 g PO
 Rationale for regimens
 Additive effect between gentamicin and azithromycin (in vitro)
 Gemifloxacin more active against GC with known ciprofloxacin
resistance
Kirkcaldy, CID 2014
New Regimen Challenges
 Nausea common
 27% for gentamicin + AZ
 37% for gemifloxacin + AZ
 3% and 7% in each group vomited <1hr after administration
 Gemiflox no longer available
 FDA approved (6/15/2015) generic
 Updates on the availability can be found at:
www.cdc.gov/std/treatment/drugnotices/gemifloxacin.htm

GC Test of Cure
 Patients with pharyngeal GC treated with an
alternative regimen
 Obtain test of cure 14 days after treatment, using either
culture or NAAT
 Cases of suspected treatment failure
 Culture and simultaneous NAAT
 Call your local health department

Cephalosporin Treatment Failures
Oral cephalosporin treatment failures
reported worldwide
Japan, Hong Kong, England, Austria, Norway,
France, South Africa, and Canada
Ceftriaxone treatment failures in
pharyngeal gonorrhea and a few isolates
with high-level ceftriaxone resistance
reported

Unemo Eurosurveillance 2011 | Tapsall J Med Microbiol 2009 |
Ohnishi EID 2011 | Allen JAMA 2012
Suspected GC Treatment Failure After
Recommended Dual Therapy: What do I do?
REPORT: ECDOH STD program ASAP (within 24 hours)
CULTURE: if GC culture not available, call ECDOH
REPEAT TREATMENT: Gemifloxacin 320 mg + AZ 2g OR gentamicin
240 mg IM + AZ 2g
TREAT PARTNERS: Within 60 days with same regimen as
patient receives
TEST OF CURE (TOC): Patient returns in 7-14 days for TOC
culture and NAAT

• If reinfection suspected instead of treatment failure,
• repeat Tx with CTX 250mg + AZ 1g

Human Immunodeficiency Virus
HIV
HIV
Diagnosis
HIV
Examination
Infections in adolescents not usually symptomatic or diagnosed until 20s or
30s
Some develop flu-like symptoms within a month or two of exposure to HIV
“Fourth generation” HIV test
More accurate diagnosis of acute HIV-1, established HIV-1, HIV-2
Distinguishes HIV-1 from HIV-2 antibodies
Detects HIV 3-4 weeks earlier, faster results
Diagnosis
HIV-1 Western Blot no longer recommended
After a positive diagnosis
- Counseled regarding behavioral, psychosocial, and medical implications
- Assess need for immediate care or support
- Link patients to psychosocial and medical services
- Partners (sexual and IDU) should be notified, either by the patient
him/herself or by the provider, hospital, or state/local health department

HIV
Diagnosis
HIV
Screening
Screen aged 13-64 in all health-care settings;
Screen all high-risk persons at least annually, e.g., MSM;
Screen all persons who seek STD diagnosis and treatment
Disparities
MSM:
57% of the 1.1 million people with HIV
66% of all new HIV infections each year
91% of all HIV infections in young males, aged 13-19
Black MSM
2/3 of men with HIV aged 13-24
Largest increase in HIV infections

Pre-Exposure Prophylaxis (or PrEP)
 PrEP used to  HIV infection risk for people at  risk
  HIV risk from sex by > 90%
  HIV risk from injection drug use by > 70%.
 Daily Truvada® (tenofovir and emtricitabine)
 Indicated to prevent HIV infection for at risk ♂ or ♀
http://www.cdc.gov/hiv/pdf/PrEPguidelines2014.pdf
What’s the Evidence?
Study
Population
2500 MSM
iPrEX
Trial
TDF2
HIV+
Conversion
Overall 44% risk reduction
36/1224 in study group
Peru, Ecuador, Thailand, Brazil, S.
Africa, U.S.
Daily Truvada vs. Placebo
Partners
PrEP Trial
Efficacy
4758 heterosexual males and females
in sexual HIV discordant relationship
in Kenya and Uganda
50% reduction w/ >50% compliance
73% reduction w/>90% compliance
92% reduction if drug level detected in
blood
Overall 67% reduction with Tenofovir
75% reduction with Truvada
• Men: 84%
• Women: 66%
Truvada vs. Tenofovir vs. Placebo
Placebo stopped early b/c not as
effective
1219 heterosexual males and females
in Botswana
62% risk reduction
• Men: 80%
• Women: 49%
Truvada vs. placebo
84% adherence
Poor follow-up retention
No resistant organisms
detected
27 infected after
baseline in both tx
groups
No resistant organisms
detected
9/601 in study group
No resistant organisms
detected

Genital Sores
Genital Herpes—Initial Visits to Physicians’
Offices, United States, 1966–2013

CDC STD Surveillance Report 2014
Herpes Simplex Virus Type 2—Seroprevalence Among Non-Hispanic
Whites and Non-Hispanic Blacks by Sex and Age Group, National
Health and Nutrition Examination Survey, 1988–1994, 1999–2002,
2003–2006, and 2007–2010

CDC STD Surveillance Report 2014
Primary and Secondary Syphilis — Rates of Reported
Cases by Age and Sex, United States, 2014

CDC STD Surveillance Report 2014
Primary and Secondary Syphilis — Reported Cases* by
Sex, Sexual Behavior, and Race/Ethnicity, United States,
2014

CDC STD Surveillance Report 2014
Why do these Disparities Exist?
 Individual risk behaviors
 Higher # of lifetime sex partners
 Environmental, social and cultural factors
 Higher prevalence of STDs
 Difficulty accessing health care
 Homophobia and stigma
 Difficulty finding culturally-sensitive and appropriate care and
Tx

http://www.cdc.gov/std/stats14/std-trends-508.pdf
Differential Diagnosis
Herpes
Genital Sores
Solitary painless
ulcer with
indurated
border
Cluster of painful
(sometimes) sores
Chancroid
Painful ulcer with
sharp borders

Syphilis
Trauma
LGV
Painless papule,
shallow erosion or ulcer
Herpes and Syphilis
Diagnosis
Herpes Simplex Virus (HSV)
Syphilis
Examination
Types: First clinical episode (primary/nonprimary), recurrent symptomatic infection,
asymptomatic infection
- Mostly asymptomatic (90%)
- Painful blisters/open sores (can be preceded
by tingling/burning)
- Sores typically disappear in 2-3 weeks (virus
lies latent leading to future outbreaks)
3 Stages:
- Primary (9-90days): One or more skin
Tzanck smear: multinucleated giant cells
(insensitive)
Large numbers of organisms present in
exudates of lesion and in lymph nodes and
Laboratory
findings
lesions called chancres
- Secondary (6weeks-6months): Skin rash
and mucous membrane lesions, flu-like
symptoms
- Late/latent: symptoms disappear, internal
damage ensues
Highly infectious; diagnosis by dark field
microscopy
- Aseptic meningitis
More common in primary infection
Generally no neurological sequelae
Sequelae

- Rare complications include:
Stomatitis and pharyngitis
Radicular pain, sacral paresthesias
Transverse myelitis
Autonomic dysfunction
- Psychological distress
two- to five-fold increased risk of
acquiring HIV infection when syphilis is
present
Herpes and Syphilis
Diagnosis
Herpes Simplex Virus (HSV)
Syphilis
Screening
Current CDC guidelines do not recommend
universal screening with serology
NOT recommended
Consider testing if:
- Past inconclusive work up for genital
lesions—negative herpes culture or NAAT
-- Have a partner with genital HSV
-- MSM
-- Are HIV infected
Diagnosis
Culture: Specificity > sensitivity
•requires a new lesion and high viral load
Type-specific serology: Most HSV-1 is
not sexually transmitted
PCR: Sensitivity decreases as lesion
heals

Screening in correctional facilities based
facilities based local and institutional
institutional prevalence; MSM. Screen Q3Screen Q3-6 mo if hi risk w/ multiple
multiple partners or HIV+
Clasically:
1.) Non-treopnemal (RPR/VDRL)
THEN
2.) Treponemal (TPPA/FTA)
Emerging:
1.) Treponemal (TPPA.FTA)
THEN
2.) Non-treponemal (RPR/VDRL)
Herpes and Syphilis
Diagnosis
Herpes Simplex Virus (HSV)
Syphilis
Treatment
Acute therapy:
- Acyclovir 400 mg PO TID x 7-10 days
- Acyclovir 200 mg PO 5x/day x7-10 days
- Famciclovir 250 mg PO TID 7-10 days
- Valacyclovir 1 g PO BID x 7-10 days
Primary, Secondary, and Early Latent
Benzathine Penicillin G—2.4 million units
IM x 1 dose
Suppressive Therapy:
- Acyclovir 400 mg PO BID
- Famiciclovir 250 mg PO BID
- Valacyclovir 500 mg PO daily
- Valacyclovir 1.0 g PO daily
Alternative treatment:
Doxycycline 100 mg PO BID x 14 days
OR
Tetracycline 500 mg PO QID x 14 days
**Treatment can be extended if healing is
incomplete after 10 days of therapy.

Simplest regimen preferred with adolescents
Counseling: Transmission and
Prevention
 Inform current and future sex partners about genital herpes
diagnosis
 Abstain from sexual activity with uninfected partners when
lesions or prodrome present
 Most HSV-2 is transmitted during asymptomatic shedding,
which is highest in new infections (<2 years) and gradually
decrease over time
 Correct and consistent use of latex condoms might reduce the
risk of HSV transmission
 Valacyclovir suppressive therapy decreases HSV-2
transmission in heterosexual couples in which source partner
has recurrent herpes (Antiviral suppressive therapy
dramatically reduces, but does not eradicate shedding)


www.cdc.gov/std/tg2015/default.htm

2015 STD Treatment Guidelines
Special Populations
Men Who Have Sex With Men (MSM)
 CDC recommends at least yearly urethral and rectal
screening for MSMs who, in the last year, have
participated in:
 Insertive anal intercourse
 Receptive anal intercourse
 Receptive oral intercourse (GC only)
 Screening is recommended regardless of condom use
 For high risk sex behavior, should screen every 3-6
months

http://www.cdc.gov/std/tg2015/specialpops.htm#MSM
Women Who Have Sex with Women (WSW)
 Regardless of reported same-sex behavior, providers
should consider:
 Screening all females for chlamydia and gonorrhea as per
recommendations
 Offering routine cervical cancer screening and HPV vaccine
in accordance with current guidelines.

http://www.cdc.gov/std/tg2015/specialpops.htm#WSW
Transgender Males and Females
 Assess STD- and HIV-related risks based on current
anatomy and sexual behaviors
 diversity of transgender persons regarding surgical affirming
procedures, hormone use, and their patterns of sexual
behavior
 providers must remain aware of common STD Sx and
screen for STDs on basis of behavior and sexual practices

STI Partner Management Strategies
Provider
Referral
• Partners contacted by index
patient’s provider or by a disease
intervention specialist
Patient
Referral
• Index patient assumes primary
responsibility to notify and refer
his/her partners at risk
Expedited
Partner
Therapy
(EPT)

• Providers (1) give patient medication
intended for the partners (2) write
partners’ prescriptions for medication
CDC Recommends EPT
 EPT: Delivery of medications or prescriptions by
persons infected with an STD to their sex partners
without clinical assessment of the partners.
 EPT laws vary by state:
 Permitted in 40 states and Washington, D.C.
 Potentially Allowable in 8 states (AL, GA, DE, KS, OK, SD,
VA, NJ and Puerto Rico)
 Prohibited in 2 states (Kentucky & West Virginia)
 Heterosexual sex partners should be evaluated,
tested, and treated if:
 Had sexual contact with patient during or >60 days of
symptom onset/diagnosis of chlamydia or gonorrhea

https://www.cdc.gov/std/ept/legal/default.htm
Updated July 2016
Take Home Points
 Be aware of racial and ethnic disparities and practice
sensitive, culturally competent reproductive health
care
 Emphasize that your approach is nonjudgmental and
that you welcome future visits
 “I’m here for you, and I want you to feel comfortable
confiding in me. If you have something personal to
talk about, I’ll try to give you my best advice and
answer your questions”

Want to know more about STDs?
There’s an app for that.
CDC Treatment Guidelines
App for Apple and Android
http://www.cdc.gov/std/tg2015/
STD Clinical Consultation Network
(STDCCN)

8 Regional PTCs
Resources:
Sexually Transmitted Infections
 U.S. Centers for Disease Control and Prevention
 Statistics and Surveillance Reports: www.cdc.gov/std/stats/default.htm
 Expedited Partner Therapy: www.cdc.gov/STD/ept/default.htm
 CDC Treatment Guidelines:
http://www.cdc.gov/mmwr/pdf/rr/rr6403.pdf
 National Chlamydia Coalition: ncc.prevent.org
 American Social Health Association:
http://www.ashastd.org/std-sti/hpv.html
