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

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Presentation on theme: ". Sexually Transmitted Infections prevention, screening, treatment J. Dennis Fortenberry MD MS Section of Adolescent Medicine Indiana University School."— Presentation transcript:

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

2 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 Suttons Law, attributed to the famous bank robber, Willie Sutton: - Why do you rob banks? - Because thats where the money is.

3 Sexually Transmitted Infections U.S. Chlamydia Rates among women and men, by age - per 100,000 Population (2007) 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) Centers for Disease Control & Prevention, 2009

5 Sexually Transmitted Infections Prevention

6 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 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 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 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 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 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 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 Sexually Transmitted Infections Time from 1 st coitus to 1 st STI test by age at 1 st coitus Median age of 1 st 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 When –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: , Reddy DM, et al. Effect of mandatory parental notification on adolescent girls' use of sexual health care services. JAMA. 288: , 2002.

17 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 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 dont 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 Shew ML, Fortenberry JD. Sexually Transmitted Diseases. in: Finberg L, Kleinman R (eds). Saunders Manual of Pediatric Practice. 3rd ed. (2007)

26 Sexually Transmitted Infections Diagnosis and Treatment Discharge syndromes

27 Sexually Transmitted Infections 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 Sexually Transmitted Infections Principles of Chlamydia & Gonorrhea Treatment Consider co-treatment Dont 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 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

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 1000 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 –Ceftriaxone 250 mg IM plus – 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 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


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