1. Sexually Transmitted Infections prevention, screening, treatment
J. Dennis Fortenberry MD MS
Section of Adolescent Medicine
Indiana University School of Medicine
School of Medicine . 1 1 1

2. Most people become sexually active during adolescence
Sexually Transmitted Infections Why STI are important in health care (especially for adolescents)
Most people become sexually active during adolescence
About 50% of new STI each year are in 15 – 24 year olds
With this very superficial look at STD epidemiology, let’s examine the more common syndromes. The most common status for people with STD is to be asymptomatic. But it may be useful to quickly review
Genital discharge / dysuria syndromes
genital ulcer / lymphadenopathy
and dermatologic syndromes
Sutton’s Law, attributed to the famous bank robber, Willie Sutton:
- Why do you rob banks?
- Because that’s where the money is.

3. Sexually Transmitted Infections U. S
Sexually Transmitted Infections U.S. Chlamydia Rates among women and men, by age - per 100,000 Population (2007)
Chlamydia rates show much the same thing. These rates translate to a disease prevalence in most areas of 8% to 15% among adolescent women.
Among adolescent men randomly selected from the general population, about 6% have chlamydia when screened by nucleic acid amplification tests.
1.1 million cases
Centers for Disease Control & Prevention, 2009

4. Sexually Transmitted Infections Indiana Chlamydia Rates among women and men - per 100,000 Population (2007)
Chlamydia rates show much the same thing. These rates translate to a disease prevalence in most areas of 8% to 15% among adolescent women.
Among adolescent men randomly selected from the general population, about 6% have chlamydia when screened by nucleic acid amplification tests.
Centers for Disease Control & Prevention, 2009

5. Sexually Transmitted Infections Prevention

6. Skills building and skills practice Empowerment
Sexually Transmitted Infections More successful approaches to STI prevention
Target behavior
Sexual behavior
Partner communication
Condom use
Screening and treatment
Education
Skills building and skills practice
Empowerment
Kirby DB et al. Sex and HIV education programs: their impact on sexual behaviors of young people throughout the world. Journal of Adolescent Health. 40(3):206-17, 2007

7. Sexually Transmitted Infections Less successful approaches to STI prevention Condyloma acuminata

8. Threats and fear Facts and data Silence Stigmatization Abstinence only
Sexually Transmitted Infections Less successful approaches to STI prevention
Threats and fear
Facts and data
Silence
Stigmatization
Abstinence only
Fortenberry et al. Relationships of stigma and shame to gonorrhea and human immunodeficiency virus screening. Am J Public Health, 92: , 2002.

9. Fails to account for method failure Non-developmental
Sexually Transmitted Infections Abstinence-only as an inadequate public health STI prevention strategy
Fails to account for method failure
Non-developmental
Withholding of health information
Heterosexual bias
Underhill K. Sexual abstinence-only programmes to prevent HIV infection in high income countries: Systematic review. Br J Med. 2007; 335:
Trenholm C, et al. Impact of 4 Title V Section 510 abstinence education programs-Final report. Mathematica Policy Research Inc. 2007
Santelli J, et al. Abstinence-only education policies and programs: a position paper of the Society for Adolescent Medicine. J. Adolesc Health; 38:83-87, 2006

10. Sexually Transmitted Infections Screening

11. Failure to recognize risk Stigma
Sexually Transmitted Infections Screening as an STI prevention strategy
Many STI asymptomatic
Chlamydia
Gonorrhea
HIV
Failure to recognize risk
Stigma
Centers for Disease Control & Prevention, 2006

12. Older non-pregnant women at increased risk
Sexually Transmitted Infections US Preventive Services Task Force Recommendations for Chlamydia screening
Older non-pregnant women at increased risk
All pregnant women at risk
No recommendations for screening of men
All sexually active women < 25 years
US Preventive Services Task Force. Annals of Internal Medicine, 2007; 147:
Rietmeijer K, et al. Chlamydia trachomatis positivity rates among men tested in selected venues in the United States: a review of the recent literature.
Sex Trans Dis. 35:S8 – S18, 2008

13. Older non-pregnant women at increased risk
Sexually Transmitted Infections US Preventive Services Task Force Recommendations for Chlamydia screening
Older non-pregnant women at increased risk
All pregnant women at risk
No recommendations for screening of men
All sexually active women < 25 years

14. Sexually Transmitted Infections Age at first coitus – Indianapolis
% with no
coital experience
Tu et al. unpublished data

15. Median age of 1st test = 15 years
Sexually Transmitted Infections Time from 1st coitus to 1st STI test by age at 1st coitus
Median age of 1st test = 15 years
Tu et al. Arch Pediatr Adolesc Med (in press)

16. Sexually Transmitted Infections Screening for Sexual Activity in Adolescents When, how and who, what
Any health maintenance visit age 10 and older
Any “appropriate” sick visit
After discussion of confidentiality
Parents etc out of room
How and who
“Do you have a boyfriend or girlfriend right now?” “Have you ever had sex with that person?” “Have you done anything sexual with that person?”
Yes No
Not really
What
Penile/vaginal
Oral/genital
Penile/anal
Ford CA, et al. Anticipatory guidance regarding sex: views of virginal female adolescents. J Adolesc Health 19: , 1996.
Reddy DM, et al. Effect of mandatory parental notification on adolescent girls' use of sexual health care services. JAMA. 288: , 2002.

17. Polymerase Chain Reaction (PCR) Ligase Chain Reaction (LCR)
Sexually Transmitted Infections Screening for Chlamydia (and Gonorrhea) Nucleic Acid Amplification Tests
Polymerase Chain Reaction (PCR)
Ligase Chain Reaction (LCR)
Strand Displacement Amplification (SDA)
Transcription-Mediated Amplification (TMA)
Hybrid Capture

18. High sensitivity and specificity Multiple tests on same sample
Sexually Transmitted Diseases Nucleic Acid Amplification Tests Advantages
High sensitivity and specificity
Multiple tests on same sample
Can be used in non-traditional venues
Variety of specimen types
Cervical/urethral
Urine
Vaginal: consider self-obtained
Cook RL, et al. Systematic review: noninvasive testing for Chlamydia trachomatis and Neisseria gonorrhoeae. Ann Int Med. 142(11):914-25, 2005

19. Sexually Transmitted Diseases Other screening tests to consider
Human immunodeficiency virus
Herpes simplex 2
Syphilis
Trichomonas
Centers for Disease Control and Prevention. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings.
MMWR 55(RR14):1-17, 2006.

20. Sexually Transmitted Diseases Other Prevention Strategies
Condom use
Immunization

21. Sexually Transmitted Infections Condom use for STI prevention
Consistent evidence for effectiveness
Chlamydia
Gonorrhea
Genital herpes
Human papillomaviruses
Syphilis
HIV
Efficacy for pregnancy prevention
Decline in use over time within relationships
Condom failure
Breakage
Slippage
Incorrect use
Holmes KK et al. Effectiveness of condoms in preventing sexually transmitted infections. Bulletin of the World Health Organization 82: , 2004
Fortenberry JD et al Condom use as a function of time in new and established adolescent sexual relationships. Am J Public Health 92: , 2002

22. Sexually Transmitted Infections Instructions for correct condom use
Open package near top
Check orientation but don’t unroll the condom
Unroll completely over erect penis
Check the tip
Lubricant
Practice

23. Sexually Transmitted Infections Immunization for STI Prevention
Hepatitis B
Human papillomavirus prevention
Quadrivalent vaccine (types 6, 11, 16, 18)
Women ages 9 – 26
FDA decision on indication for older women and for adolescent men expected within year

24. Sexually Transmitted Infections Diagnosis and Treatment

25. Sexually Transmitted Infections STI syndromes common in adolescence
Genital Discharge / Dysuria Syndromes
Genital Ulcer / Lymphadenopathy
Pelvic pain syndrome
Dermatologic Syndromes
With this very superficial look at STD epidemiology, let’s examine the more common syndromes. The most common status for people with STD is to be asymptomatic. But it may be useful to quickly review
Genital discharge / dysuria syndromes
genital ulcer / lymphadenopathy
and dermatologic syndromes
Shew ML, Fortenberry JD. Sexually Transmitted Diseases. in: Finberg L, Kleinman R (eds). Saunder’s Manual of Pediatric Practice. 3rd ed. (2007)

26. Sexually Transmitted Infections Diagnosis and Treatment Discharge syndromes

27. Sexually Transmitted Infections http://www.cdc.gov/std/default.htm
Sexually Transmitted Diseases
Treatment Guidelines – 2006
New guidelines will be released in early 2010

28. Sexually Transmitted Infections Gonococcal urethritis

29. Sexually Transmitted Infections Gonococcal cervicitis

30. Consider co-treatment
Sexually Transmitted Infections Principles of Chlamydia & Gonorrhea Treatment
Consider co-treatment
Don’t use quinolones for gonorrhea treatment unless sensitivity is known
Chlamydia
Doxycycline 100 mg BID x 7 days
Azithromycin 1 gram
Gonorrhea
Ceftriaxone 125 mg IM
Cefixime 400 mg orally

31. Sexually Transmitted Infections Criteria for BV Diagnosis
Characteristic white/gray discharge
Vaginal fluid pH > 4.5
Fishy amine odor after adding KOH
Presence of clue cells

32. Sexually Transmitted Infections Gram Stain - Normal Vaginal Epithelial Cell

33. Sexually Transmitted Infections Vaginal Gram Stain

34. Sexually Transmitted Infections Clue Cells

35. Reduction or absence of Lactobacillis species Gardnerella vaginalis
Sexually Transmitted Infections Bacteria associated with Bacterial Vaginosis
Reduction or absence of Lactobacillis species
Gardnerella vaginalis
Prevotella spp.
Atopobium vaginae
Leptotrichia aminonii
Bacterial vaginosis-associated bacterium (BVAB)
Fredericks et al. Molecular identification of bacteria associated with bacterial vaginosis. N Engl J Med. 353: , 2005.

36. Sexually Transmitted Infections Bacterial Vaginosis Treatment
Metronidazole gel, 0.75% 5 gram applicator daily for 5 days
Metronidazole 500 mg BID for 7 days
Clindamycin Cream, 2% 5 gram applicator daily for 7 days

37. Sexually Transmitted Infections Frothy Discharge Associated with Vaginal Trichomoniasis

38. Sexually Transmitted Infections Trichomonas Treatment
Metronidazole 2.0 grams orally
Metronidazole 500 mg orally BID for 7 days
Tinidazole 2.0 grams orally

39. Sexually Transmitted Infections Diagnosis and Treatment Genital ulcer syndromes

40. Sexually Transmitted Infections Primary syphilis-chancre

41. Sexually Transmitted Infections Primary syphilis - chancre

42. Sexually Transmitted Diseases Primary/Secondary Syphilis Treatment
Benzathine Penicillin G, 2.4 million units IM
Benzathine Penicillin G, 50,000 units/kg IM (children)

43. Sexually Transmitted Infections Primary herpes

44. Sexually Transmitted Infections Genital Herpes

45. Sexually Transmitted Infections Genital Herpes - First Episode
Acyclovir 400 mg TID for days
Famciclovir 250 mg TID for days
Valacyclovir 1000 mg BID for days

46. Sexually Transmitted Infections Genital Herpes Suppression
Acyclovir 400 mg BID
Famciclovir 250 mg BID
Valacyclovir mg QD

47. Sexually Transmitted Infections Diagnosis and Treatment Pelvic/Genital Pain

48. Sexually Transmitted Infections Diagnosis of Pelvic/Genital Pain
Pelvic inflammatory disease
Not pregnant
No evidence of other cause
Tenderness of pelvic structures
Epididymitis/orchitis
No evidence of testicular torsion

49. Sexually Transmitted Infections Treatment of Pelvic/Genital Pain
Pelvic inflammatory disease*
Ceftriaxone 250 mg IM plus
Doxycycline 100 mg BID for 14 days
Metronidazole 500 mg BID for 14 days
Epididymitis/orchitis
Doxycycline 100 mg BID for 10 days
* Several regimens are described in CDC treatment guidelines

50. Sexually Transmitted Infections Diagnosis and Treatment Dermatologic syndromes

51. Sexually Transmitted Infections Condyloma acuminata

52. Identifies most high-risk HPV types
Sexually Transmitted Infections Diagnosis of Human Papilloma Virus Infections
Hybrid Capture II
Identifies most high-risk HPV types
16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68
Identifies some low-risk HPV types
6, 11, 42, 43, 44

53. Sexually Transmitted Infections Genital Warts - Treatment
Imiquimod 5% Cream, 3 times weekly up to 16 weeks
Podofilox 0.5% solution or gel, twice daily for 3 consecutive days
Cryotherapy
Podophyllin or Trichloracetic acid

54. Sexually Transmitted Infections Secondary syphilis - condyloma lata

55. Secondary syphilis - papulosquamous rash

56. Sexually Transmitted Infections
The conundrum of STI prevention within the concept of sexual health
Prevention is mostly preparation
Diagnosis and treatment is prevention

57. Sexually Transmitted Infections Resources