1. Infectious Disease Division
Sexually Transmitted Infections and 2010 CDC STD Treatment Guidelines April 11, HIV/STD/TB/Hepatitis Symposium Bismarck ND
David McNamara, M.D.
Infectious Disease Division
Gundersen Lutheran
La Crosse WI

2. Disclosures No commercial disclosures
Dakota AIDS Education & Training Center

3. Learning Objective
At the end of the presentation, participants should be familiar with basics of:
Common Sexually Transmitted Infections
2010 CDC STD Treatment Guidelines
Common presentations of HIV
HIV Screening

4. What is Your Professional Discipline?
Nurse
Physician
Public Health (RN, Epidemiologist)
Allied Health
Laboratory
Social Worker
Other

5. Overview Sexually Transmitted Infections Case # 1 Case # 2 Case # 3
Summary

6. Sexually Transmitted Infections
Common
Wide variety of pathogens can be transmitted sexually
Often transmit more efficiently male→female than female→male
Sequelae
Direct effect of pathogen on body
Infertility, ectopic pregnancy, cancer, transmission to fetus

7. Some (not all) Pathogens Transmitted Sexually
T. pallidum (Syphilis)
Neisseria gonorrhoeae
Chlamydia trachomatis
Ureaplasma urealyticum
Mycoplasma genitalium
Haemophilus ducreyi (Chancroid)
Chlamydia trachomatis L1, L2, L3 (Lymphogranuloma venereum)
Klebsiella granulomatis (Granuloma Inguinale)
Trichomonas vaginalis
Scabies, Pediculosis pubis
HSV, Herpes Simplex Virus
HIV
HBV, HDV
CMV, EBV
Human Papilloma Virus (HPV)
HHV-8, Kaposi’s Sarcoma Herpes Virus (KSHV)

9. ©FMH Graphics

10. Overview Sexually Transmitted Infections Case # 1 Case # 2 Case # 3
Summary

11. Case #1 19 year-old female student presents for routine care
Sexually active with male partner
Feels well, no GU symptoms
Cervical swab
Routine pap smear
Chlamydia/Gonorrhea Nucleic Acid Amplicification Test (NAAT)
Chlamydia NAAT returns positive

12. How should she be treated?
Ceftriaxone 250 mg IM x 1 dose
Azithromycin or doxycycline for patient
Azithromycin or doxycycline for both patient and her partner
Cipro 500 mg PO BID x 7 days
Confirm NAAT with culture prior to treatment

13. Chlamydia Chlamydia trachomatis Most common bacterial STI
Often asymptomatic
Can give urethritis in men
Common cause of infertility
Scarring of fallopian tube (Pelvic Inflammatory Disease)
10-15% of women with untreated Chlamydia develop PID
Women often re-infected if partner not treated
Treat with azithromycin or doxycycline
Sexually active women need yearly Chlamydia/gonorrhea testing

15. Observed Single dose treatment advantage
treatment completed
No sexual intercourse for 7 days after treatment completed
Test of cure not recommended
3 month re-testing recommended to screen for re-infection

16. How should her sexual partner be managed?
Timely treatment of sexual partner important to reduce risk of re-infecting index patient, others
Instruct patient to refer most recent sexual partner, and any other partners within 60 days of Chlamydia diagnosis, for testing and treatment
If sexual partner(s) unlikely to present for treatment, consider Expedited Partner Therapy
Patient must inform partner, provide written material to seek evaluation for symptoms of complications (testicular pain, pelvic pain)
Patient-delivered prescription or antibiotic for partner(s)
Not for Men who have sex with Men (MSM)
Very high HIV risk, partners need testing/treatment

19. Overview Sexually Transmitted Infections Case # 1 Chlamydia Case # 2
Summary

20. Case #2
28 year old man presents with painful, burning urination x 1 week
Yellow urethral discharge x 3 days
“I’ve never had this before!”
Reports 3 female sexual partners in last several months
Intermittent condom use, only when partner is new

21. Public Health Image Library
Urethral swab taken
Gram stain
Gram Negative Diplococci
Public Health Image Library

22. Likely etiology of urethritis?
Chlamydia
Herpes Simplex Virus
Gonorrhea
E. coli UTI/ epididymitis
Syphilis

23. How should this be treated?
Ceftriaxone 250 mg IM x 1
Ceftriaxone 250 mg IM + Azithromycin 1g PO x 1
Doxycycline 100 mg PO BID x 7 days
Ciprofloxacin 500 mg PO BID x 7 days
Cefixime 400 mg PO x 1

24. Gonorrhea Neisseria gonorrhoeae 700,000 cases/year in U.S.
Men: urethral discharge, urethritis
Women: asymptomatic, dysuria, vaginal discharge, PID
Diagnosis:
Gram Stain
Culture: Thayer-Martin media or chocolate agar
NAAT on urine, urethral swab, cervical swab
Will transmit to infant during birth

25. Provide treatment for Chlamydia together with Gonorrhea
Common co-infections
Cipro/Levofloxacin resistent Gonorrhea now common
Resistance to Cephalosporins rare but expected to increase
Routine test of cure not recommended (only if symptoms)
Rescreen at 3 months to detect re-infection

28. Overview Sexually Transmitted Infections Case # 1 Chlamydia
Case # 2 Gonorrhea
Case # 3
Case # 4
Case # 5
Summary

29. Case # 3 32 year old man presents with ulcer on penis
Does not hurt, present for 1 week
Married, wife doesn’t have any symptoms
Travels frequently for business
several sexual encounters per year with other men
2 years ago
Treated for gonorrhea
HIV test negative at that time
Uses condoms “most of the time”

30. Public Health Image Library

31. Most likely etiology of penile ulcer?
Herpes Simplex Virus
Syphilis
Gonorrhea
Chlamydia
Lymphogranuloma Venereum (LGV)

32. Syphilis Treponema pallidum 36,000 cases/year in U.S. 2/3 in MSM
A systemic disease
Primary: painless genital ulcer (chancre)
Secondary: rash
Latent
asymptomatic at first
neurologic, bone, heart disease in years
Pregnancy: transmission to infant
Diagnosis: RPR or VDRL blood test
All patients with Syphilis need HIV testing!
All partners need evaluation, usually presumptive treatment

33. Primary and secondary syphilis
Benzathine PCN G 2.4 Million Units IM x 1 dose
Latent Syphilis
Early: Benzathine PCN G 2.4 Million Units IM x 1 dose
Late, or unknown duration: Benzathine PCN G 2.4 Million Units IM x q week x 3 doses
Tertiary: cardiac, Gumma (need to rule out Neurosyphilis)
Benzathine PCN G 2.4 Million Units IM x q week x 3 doses
Neurosyphilis
Penicillin G 24 million units/day (continuous IV infusion) x days

35. Overview Sexually Transmitted Infections Case # 1 Chlamydia
Case # 2 Gonorrhea
Case # 3 Syphilis
Case # 4
Case # 5
Summary

36. CC: Sore Throat
20 year-old woman presents to University Student Health Service
sore throat
“achy all over” for past 5 days
joints ache, fevers, “I feel rotten”
missed classes for 3 days
“exhausted”

37. PMH:
otherwise well
Meds:
oral contraceptives
Social History
grew up in rural ND
sophomore business major
occasional alcohol use
no tobacco
new boyfriend for 3 months

38. Exam VS: Temp 100.3° F Awake, alert, looks tired and ill
Oropharynx red; tonsils swollen
Small, swollen mobile cervical lymph nodes
Lungs: clear
Cor: RRR with normal s1s2 no murmurs
Abdomen soft, nontender, no HSM
Joints: no effusions or synovitis
Skin: rash on chest, back

41. Labs
WBC N45 L5 M28 B9 E4
Hb 12.8 g/dL
platelets 112,000
Group A Strep PCR: negative
Assessment?
Febrile illness with pharyngitis, leukopenia and rash
Differential diagnosis?

42. Likely Diagnosis? Mononucleosis Epstein-Barr Virus Infection
Streptococcal Pharyngitis
Acute HIV infection
Severe Cold

43. Further testing?
Monospot: negative
CMV Antibody
IgG positive, IgM negative
Testing for HIV infection?
HIV Antibody Screen: negative
HIV Viral Load: 770,000 copies/mL

44. Diagnosis: Acute HIV Infection
Illness associated with initial HIV infection
Fever, body aches, sore throat, swollen lymph nodes common
Rash in 50%
Uncommonly recognized
Important to make diagnosis:
reduce HIV transmission to others
sexual partners, infants
treat HIV before advanced AIDS develops

45. Is there HIV in North Dakota?
ND a low incidence state, but…

47. The data have been adjusted for reporting delays.
In the United States and dependent areas, the prevalence rate of AIDS among adults and adolescents was estimated at per 100,000 at the end of The rate for adults and adolescents living with AIDS ranged from an estimated 2.2 per 100,000 in American Samoa to an estimated per 100,000 in the District of Columbia.
The District of Columbia is a metropolitan area. Use caution when comparing its AIDS rate to state AIDS rates.
Note:
The data have been adjusted for reporting delays. 47

48. The proportional distribution of AIDS cases by transmission category has shifted since the beginning of the epidemic. In 1985, male-to-male sexual contact accounted for 64% of all AIDS cases; in 2006, this transmission category accounted for 43% of all AIDS cases.
The proportion of AIDS cases attributed to injection drug use increased during 1985–1994 and then slightly decreased, accounting for 19% of cases in 2006.
The proportion of AIDS cases attributed to male-to-male sexual contact and injection drug use decreased from 9% in 1985 to 5% in 2006.
The proportion of AIDS cases attributed to high-risk heterosexual contact increased from 3% in 1985 to 32% in 2006.
The remaining AIDS cases were those attributed to hemophilia or the receipt of blood or blood products and those in persons without an identified risk factor.
The data have been adjusted for reporting delays and cases without risk factor information were proportionally redistributed.

49. Of AIDS diagnoses in 2009 among adult and adolescent males, 66% of infections were attributed to male-to-male sexual contact and 15% were attributed to heterosexual contact. Approximately 12% of infections were attributed to injection drug use and 6% were attributed to male-to-male sexual contact and injection drug use.
Most (76%) of the AIDS diagnoses in 2009 among adult and adolescent females had infections attributed to heterosexual contact, and 22% attributed to injection drug use.
All displayed data have been estimated. Estimated numbers resulted from statistical adjustment that accounted for reporting delays and missing risk-factor information, but not for incomplete reporting.
Heterosexual contact is with a person known to have, or to be at high risk for, HIV infection. 49

51. North Dakota Since 1984 ~ 10 new cases/year Total 505 227 live in ND
316 AIDS
189 HIV (non AIDS)
227 live in ND

52. North Dakota

53. Human Immunodeficiency Virus
Infects CD4+ T-lymphocytes
immune system control of infection and cancer
Initial infection often has a febrile, viral syndrome
Retrovirus
integrates into host cell DNA, chronic infection
Usually asymptomatic afterwards
Gradual, progressive failure of T-cell arm of immune system
Death often in 8-12 years if undiagnosed/ untreated

56. CDC 2006 HIV Testing Guidelines
Major departure from prior guidelines
Test all persons years old at least once, regardless of risk factors
Make HIV testing routine, similar to cholesterol or blood pressure screening
“Opt-out” testing:
Inform patient of HIV testing
Verbal assent ok; written consent not required
Patient can “opt out” if desired

57. HIV Testing Healthcare provider orders “HIV 1/2 Antibody” blood test
Lab runs a 2 part test:
Initial screen: HIV Antibody ELISA
very sensitive, not as specific
some false positives occur
if ELISA positive, lab runs
HIV Antibody Western Blot test
very specific

58. Prenatal HIV Testing All pregnant women need an HIV blood test Reason?
Prevent mother-to-child transmission (MTCT) of HIV
Untreated HIV+ mother: 20-30% risk of transmission of HIV to infant
Treated HIV+ mother: <2-5% MTCT

59. Case #4 Lessons Learned
Heterosexual contact most common route of HIV infection in women
HIV Antibody test will not detect HIV infection until 3-5 weeks after infection
Consider Acute Retroviral Syndrome in differential diagnosis of acute febrile illness,
especially if rash, sore throat, leukopenia or thrombocytopenia
Lab testing:
HIV Antibody (takes 3-5 weeks for + Ab)
HIV Viral Load (HIV RNA PCR)

60. Overview Sexually Transmitted Infections Case # 1 Chlamydia
Case # 2 Gonorrhea
Case # 3 Syphilis
Case # 4 HIV
Summary

61. Why does this matter in ND?

64. HIV, STIs have been less common here than in many parts of the country
Potential for missed, delayed diagnoses
North Dakota developing rapidly
More connected than we used to be
Incidence of HIV, STIs likely to rise
Timely recognition of HIV increasingly important

65. Summary Recognize, treat common STIs
Recognize signs of HIV infection and make diagnosis
Screen for HIV infection in order to:
Avoid transmission to others
Prevent advanced AIDS
Prevent transmission to infants

66. Acknowledgements
Anne Grande, Education Coordinator Dakota AIDS Education & Training Center
Christopher Wegner, HIV Prevention Capacity Building Coordinator, American Red Cross
Further resources:
cdc.gov
North Dakota Department of Health,