Sexually transmitted infections
What is the screening for AMAB sex with AFAB (MSW) for syphilis?
Screen asymptomatic with increased risk
What is the screening for women (AFAB) for syphilis?
Screen asymptomatic women at increased risk
** How do you diagnose neurosyphilis?
(An infection site, not a stage)serology positive + VDRL-CSF + elevated protein
** How do you diagnose primary syphilis?
(If chancre/lesion available) - darkfield microscopy + RPR (or VDRL) - no darkfield available: RPR (VDRL) + FTA-ABS
** How do you diagnose secondary, tertiary, or latent syphilis?
(No chancre/lesion) PRP (or VDRL) + FTA-ABS
How do you diagnose human papilloma virus (HPV)?
* VISUAL INSPECTION of genital warts/condyloma on physical exam - Locations: on glans, corona, penile shaft, peri-anal skin, vulva, anus - Majority of warts do not require biopsy, but considered if genital warts cannot be easily identified with a physical exam or with lighted magnifying instrument (ie: colposcopy) * Testing: there is no currently approved routine testing for HPV in men * Anal Pap for those at increased risk of anal cancer: HIV+ or men engaging in anally receptive intercourse
** What are the symptoms of secondary syphilis?
** 3-6 weeks after chancre, but may overlap - may have arthralgia, malaise, lymphadenopathy - characteristic cutaneous manifestations: red papulosquamous/maculopapular rash; palmar/plantar rash; condylomata lata - rash/warts clear spontaneously in 2-6 weeks - course is resolving/relapsing - titers highest in this stage
What is neurosyphilis?
** can happen at any stage: it is an infection site, NOT a stage Early NS: - few months to few years - asymptomatic, meningitis, CN palsies, optic atrophy, deafness, tinnitus, stroke, seizures Late NS: - fews years to decades (rare) - tabes dorsalis: myelopathy, argyll-Robertson pupil, sensory ataxia (worse with eyes closed) - general paresis: dementia, psychosis, flaccid paralysis
What is the time frame for Herpes Simplex Virus (HSV) symptoms?
** generally first episode more symptomatic - recurrence less symptomatic - HSV-1 symptoms last 3-10 days - HSV-2 symptoms last 10-21 days
** what is recurrent/episodic treatment for Herpes Simplex Virus (HSV)?
** must start within 24 hours of onset of symptoms 1. Acyclovir 800 mg PO 3x/day x 3-5 days (cheap) 2. Valacyclovir 1 g PO daily x 5 days (easy) 3. Famciclovir 1 g PO BID x 1 day ($$)
What are symptoms of Herpes Simplex Virus (HSV)?
** oral "cold sores" & Herpes keratitis (ocular) present the same in everyone Genital herpes symptoms: caused by either HSV 1 or 2 - prodrome: low grade fever, HA, malaise, myalgia - cold sores, fever blisters, burning pain - painful vesicular lesions - burning, especially dysuria if lesions are near urethra - vaginal or urethral discharge - may also have pain with intercourse (insertive or receptive) - pain with use or insertion of tampon or objects - tender inguinal adenopathy
** What are the symptoms of primary syphilis?
** painless indurated chancre at 10-21 days after exposure - mouth, genital, anal regions - inital chancre often unnoticed - 30% have multiple chancres - heals spontaneously 1-6 weeks - lymphadenopathy - serology may be negative early on
What is argyll-robertson's pupil?
- "Prostitute's pupil: pupil accommodates, but does not react" - constricts with accommodation testing, but is not reactive to light - pupil may appear unequal - associated with neurosyphilis & tertiary syphilis
What is the screening for HPV, cervical cancer, and anal cancer for women?
- 21-29 years with cytology - 30-65 years with cytology or every 5 years with combo cytology/HPV testing
What is the screening for AMAB sex with AFAB (MSW) for HIV?
- All men 13-64 (can opt out) - all men seeking eval/treat for STI
What is the screening for women (AFAB) for HIV?
- All women 13-64 (can opt out) - all women skeeking eval/treat for STI
What is the screening for transgender & gender diverse folks for gonorrhea & chlamydia?
- Based on anatomy, therefore extended to transgender men & gender diverse people with a cervic - rectal screening based on exposures
** What are reportable STI's?
- Chlamydia - Chancroid - Gonorrhea - Hep A-C - Syphilis - HIV (special laws) 1. Report to county heath department - they try to find source and help pts notify partners 2. Should be reported to sexual contacts
What is the screening for HPV, cervical cancer, and anal cancer for AMAB sex with AMAB (MSM)?
- DRE - date insuffiencet to reccomend routine cancer screening with anal cytology
What is the screening for transgender & gender diverse folks for HIV?
- Disucuss and offer to all - frequency based on level risk
What are the symptoms of human papilloma virus (HPV)?
- Genital warts - dyspareunia for AFAB, pruritis, burning, rectal pain, difficulty passing stool - condyloma, keratotic, papular, flat warts of external genitalia, cervix, perineal region & anus
What is oropharyngeal cancer?
- HPV now causes most oropharyngeal cancers in US - can lead to oropharyngeal squamous cell carcinoma - performing oral sex and having many oral sex partners can increase risk - HPV vaccine can prevent - responds well to therapy
** What is the partner treatment for all STI's except syphilis?
- Notify all partners within the last 60 days - The last partner no matter how long ago if last partner was >60 days in the past - Chlamydia: recommend empiric treatment for partners regardless if seen by provider
** What is the partner treatment for syphilis?
- Notify all partners within the last 90 days - presumptive tx for partners of patients w/ primary/secondary/early latent syphilis - Persons exposed >90 days before diagnosis: presumptive tx if follow up is uncertain
What is the screening for pregnant persons for HIV?
- Screen all at first prenatal visit - retest 3rd trimester if at high risk
What is the screening for pregnant persons for syphilis?
- Screen all first prenatal visit - retest at 28 weeks if at high risk
What are screening guidelines for STI's?
- anyone who exchanges sex for food, money, housing, or shares injection drug equiptment needs to be tested for HIV at least once a year - be aware of all body sites that could be inoculated to test (oropharynx, vagina, anus, etc)
What is the screening for AMAB sex with AMAB (MSM) for HIV?
- at least annually - consider more frequent screening if increased risk
What is the screening for AMAB sex with AMAB (MSM) for syphilis?
- at least annually - every 3-6 months with increased risk - screen asymptomatic adults at increased risk
What is Herpes Simplex Virus (HSV) 1?
- chronic lifelong viral infection - typically acquired in childhood through oral contact - prevalence up to >80% worldwide
What is Herpes Simplex Virus (HSV) 2?
- chronic lifelong viral infection - typically acquired sexually - prevalence: 15-30%
What is the screening for persons living with HIV for gonorrhea & chlamydia?
- for sexually active individuals - screen at first HIV eval & at least annually thereafter - more frequent screening might be appropriate depending on individual risk behaviors & local epidemiology
What is patient education for Herpes Simplex Virus (HSV)?
- herpes is life long illness - asymptomatic intervals (can still shed virus) - reduce transmission: antiviral suppressive therapy (reduces frequency of outbreaks, viral shedding, and risk of infecting sex partner) - condoms reduce transmission by 30%
What are risk factors for human papilloma virus (HPV)?
- increased # of sex partners - being uncircumcised - unvaccinated - smoking - immunosuppression
What are risk factors for Herpes Simplex Virus (HSV)?
- increases with number of sex partners - immunocompromised state - risk for infection is highest with direct contact of blisters or sores during outbreak
What are the physical exam findings of Herpes Simplex Virus (HSV)?
- infection can involve the oral cavity, vulva, penis, urethral meatus, cervix, anal opening, buttocks, and/or thighs - painful clustered vesicular lesions (raindrop on rose petal); can appear crusted - herpes keratitis: vesicular lesions on tip of nose & dendritic lesions on eye
** what is latent syphilis?
- infection suppressed, no lesions, not contagious - infections can still affect other organs, like heart/brain or nervous system & bones - positive serologic tests - not everyone who has syphilis will enter a latent phase
What is tertiary syphilis?
- late signs & symptoms can develop 20-40 years after inital infection (up to 1/3 of untreated cases) - cutaneous lesions: gummatous lesions - a gummy is a solitary granulomatous lesions with central necrosis on mucosa, skin or bone - cardiac manifestations rare: aortic aneurysms & aortic regurgitation, aortitis - neurologic symptoms: iritis, argyll-Robertson pupil, tabes dorsalis
What decreases your risk for STI's?
- less numbers of lifetime sexual partners - Routine STI testing if non-monogamous* - Consistent use of barrier methods - Practice/skill with negotiating boundaries and safer sex - Hep A & B vaccine - HPV vaccine
What increases risk for STI's?
- more number of lifetime sexual partners - Hx of STI in the past - No routine STI testing - Inconsistent use or not using barrier methods - Lack of skill negotiating boundaries & knowledge of safer sex - High risk behaviors (IVDU, sex with sex workers)
** What is the etiology of human papilloma virus (HPV)?
- most common STI in US - high risk types: 16, 18 - low risk types: 6, 11
** how do you stage latent syphilis?
- no current symptoms - positive serology - get titers
What is the Jarisch-Herxheimer reaction?
- onset within 24 hours of antibiotic treatment of spirochetal infection - fever, shaking chills, intensification of skin rashes - resolves in few hours, rarely fatal - adverse effect of antibiotic
What are some treatment notes for syphilis?
- pts with PCN allergy should be desensitized for tx - HIV+ pts must have more frequent and longer course of follow up because of increased likelihood of treatment failure
What is the greatest concern for Zika virus?
- risk for birth defects (highest risk infection during 1st trimester; fetal loss possible) - transmission of ZIKV to women who are pregnant or attempting to become pregnant
What is the screening for HSV among pregnant persons?
- routine HSV-2 serologic screening in asymptomatic women not recommended - type-specific HSV test may be useful to identify high risk or counsel regarding acquiring HSV during pregnancy
What is tabes dorsalis: syphilitic myelopathy?
- slow demyelination of nerves of dorsal late stage neurosyphilis - positive Romberg: sensory ataxia - depressed lower extremity deep tendon reflexes - loss of position sense & vibratory sense below lesions (typically lumbar) - argyll-Robertson pupil - tabetic gait
What infections cause lesions/genital ulcer disease?
- syphilis - granuloma inguinale - lymphogranuloma venereum (LGV) - chancroid
What is the Zika virus like in men who have sex with women (MSW)?
- transmission typically from symptomatic/infected male —> female partners - prevent with mosquito nets to prevent mosquito bites during travel and condoms to prevent transmission during sex - men should abstain for at least 3 month to have unprotected sex - women should abstain for at least 8 weeks to have unprotected sex
** What is chronic suppressive therapy for Herpes Simplex Virus (HSV)?
1. Acyclovir 400 mg PO BID (safe x 6yrs) - cheap 2. Valacyclovir 1 g PO daily (1 yr) - easy 3. Famciclovir 250 mg PO BID x 1 yr ($$)
** what is the initial treatment for Herpes Simplex Virus (HSV)?
1. Acyclovir 400 mg PO TID x 7-10 days (cheap) 2. Acyclovir 200 mg PO 5x/day x 7-10 days (cheap) 3. Valacyclovir 1 g PO BID x 7-10 days (easy)
** how can you prevent Herpes Simplex Virus (HSV)?
1. Condoms - variable based on frequency of sex acts, consistency of use 2. Suppressive therapy - not recommended in pregnancy, unless severe symptom m,management or to treat initial outbreak - recommended at 36 weeks of gestation until onset of labor for any pt who has a symptomatic infection at any time during pregnancy = acyclovir safe in all stages of pregnancy 3. Route of delivery - C-section if active outbreak or prodromal sx at time of delivery 4. Labor management - careful consideration given to use of fetal scalp electrodes, vacuum, or forceps as they may increase risk of transmission
How do you treat human papilloma virus (HPV)?
1. Podofilox 0.5% solution or gel (Condylox™): pt administered for topical warts 2. Imiquimod 5% cream (Aldara™): pt administered for topical warts 3. Provider: cryotherapy, Podophyllin resin, surgical removal, bichloracetic acid (BCA) & trichloroacetic acid (TCA)
** What is syphilis testing?
1. Nontreponemal tests (screening) - rapid plasma reagin (RPR) - venereal disease research laboratory (VDRL) 2. Specific treponemal test (confirmatory & positive for life) - fluorescent treponemal antibody absorption (FTA-ABS) - T. Pallidum particle agglutination assay (TPPA) - T. Pallidum enzyme immunoassay (TP-EIA)
What is the transmission of syphilis: treponema pallidum (spirochete)?
1. Sexual: most contagious during primary & secondary stages 2. Transmitted via skin-skin contact at mucous membranes or non-intact skin site ** increased rates due to increased meth use (risk factor)
How do you transmit human papilloma virus (HPV)?
1. Skin to skin contact/ Genital to genital contact, even non-penetrative/digital - Can be seen in "virgins" 2. Sexual contact: Oral, vaginal, or anal intercourse ** Can be passed by asymptomatic individuals and even with barrier methods - Most infections are asymptomatic & resolve spontaneously (90%) - still present in WSW
How do you diagnose Herpes Simplex Virus (HSV)?
1. Typically diagnosed clinically & confirmed with virology & serology - viral culture (swab of mucocutaneous lesion): pink liquid media - PCR (serum): preferred for CSF and if lesions are healing 2. Additional serology: Western Blot, ELISA - test for HSV antibodies specific for 1 vs 2
What are the possible birth defects with Zika virus?
1. microcephaly 2. congenital Zika syndrome
What is the incubation period for human papilloma virus (HPV)?
2 weeks to 8 months
** what is the incubation period for Herpes Simplex Virus (HSV)?
2-12 days (average 4)
What is the screening for pregnant persons for gonorrhea & chlamydia?
<25; >25 if at increased risk** - retest during 3rd trimester - pregnant women with G/C should be retested 3 months after treatment
What is the screening for women for gonorrhea & chlamydia?
<25; sexually active >25 at increased risk* - retest 3 months after treatment - pharyngeal & rectal screening considered based on exposures & behaviors
What is screening for HEP C among AMAB sex with AFAB (MSW)?
>18 yo should be screened (except in areas Hep C positivity is <0.1%)
What is screening for HEP C among AMAB sex with AMAB (MSM)?
>18 yo should be screened (except in areas Hep C positivity is <0.1%)
What is screening for HEP C among women?
>18 yo should be screened (except in areas Hep C positivity is <0.1%)
What is the screening for AMAB sex with AMAB for gonorrhea & chlamydia?
At least annually for MSM at sites of contact (urethra, rectum, pharynx) regardless of condom use; every 3-6 months if at increased risk
What is the difference between condylomata lata and condyloma acuminata?
Condyloma lata: secondary syphilis Condylomata acuminata: HPV
What is the WHO's recommendation on prevention of Zika Virus?
Couples planning on pregnancy traveling to endemic areas, regardless of symptoms: condoms or abstain for at least 6 months
What are symptoms of Zika?
Fever, rash, HA, arthralgia, myalgia, conjunctivitis
What is the screening for HPV, cervical cancer, and anal cancer for transgender & gender diverse folks?
Indivudals with cervix follow current guidleines for cervical cancer as above
What is the screening for AMAB sex with AFAB for gonorrhea & chlamydia?
No reccomendations
What is screening for HEP C among transgender & gender diverse folks?
No recs
What is the screening for HEP B among transgender & gender diverse folks?
No recs
What is the screening for HPV, cervical cancer, and anal cancer for AMAB sex with AFAB (MSW)?
No recs
What is the screening for HSV among women transgender & gender diverse folks?
No recs
What is the screening for transgender & gender diverse folks for syphilis?
No recs, based on anatomy & behaviors
** how do you treat primary, secondary, and early latent syphilis?
Penicillin G 2.4 million units IM in a single dose
** how do you treat tertiary and late latent syphilis?
Penicillin G 7.2 million units total: 3 doses of 2.4 million units IM each at 1 week intervals
** what is the incubation period for syphilis: treponema pallidum (spirochete)?
Primary chancre appears 10-21 days
What is the screening for HPV, cervical cancer, and anal cancer for pregnant persons?
Same as AFAB
What is screening for HEP C among persons living with HIV?
Serologic testing at initial evaluation; annual HCV testing in MSM with HIV infection
What are the transmission routes for Herpes Simplex Virus (HSV)?
Sexual: direct contacts with infected secretions, lesions Vertical transmission: - occurs during L&D - direct contact w/virus shed from cervix, vagina, vulva, perianal area - women who contact HSV 2 in 3rd semester= 30-50% chance of neonatal infection - can cause miscarriage, congenital anomalies, preterm birth, intrauterine growth restriction
What is the testing like in pregnancy for Zika virus?
Testing in pregnancy recommended: - if symptomatic and there has been travel to a county with a Zika outbreak OR - if risk of exposure to Zika through sex without condom *Testing no longer recommended if asymptomatic & pregnant, but may be considered if travel to area with Zika risk
What questions should you ask as part of the sexual history?
The 5 P's 1. Number of partners (past/present) 2. Practices: sexual behabiors & drugs/IVDU/alcohol 3. Prior history of STI 4. Protection from STI (condoms) 5. Pregnancy plans/prevention
What is the transmission of Zika virus?
Transmitted sexually via semen, saliva, blood, urine, vaginal, & cervical secretions - via bite of mosquito - via body fluids during sex - vertically from mother to child
** how do treat neurosyphilis?
Tx: aqueous penicillin G 18-24 units IV/day Follow up: per stage & CSF monitoring Q6 months until resolution
** How do you prevent human papilloma virus (HPV)?
Vaccine: - Vaccine: prior to onset of sexual activity is best - HPV vaccination: 9-Valent (6, 11, 16, 18, 31, 33, 34, 45, 52, 58) - 2 shot series: dose 1, 6-12 months later (for 9-14 yo) - 3 shot series: dose 1, 2 months, 6 months (13-21 yo males who have not had any or all doses) - FDA approved up to 45 yo
What is the screening for all population for trichomonas?
Women (AFAB): consider screening for those in high risk/prevalence settings and women at high risk* Pregnant Persons: no recs AMAB sex with AFAB (MSW): no recs AMAB sex with AMAB (MSM): no recs Transgender & Gender Diverse: based on anatomy, but no recs Persons living with HIV: for sexually active AFAB at initial screen and then at least annually thereafter, no recs for AMAB
What is the screening for all populations of Zika Virus (ZIKV)?
Women (AFAB): no recs for screening Pregnant Persons: if symptomatic and/or recently traveled to an area with risk of ZIKV/outbreak, Zika-associated abnormalities on ultrasound, or baby delivered with birth defects related to ZIKAV should have molecular testing, otherwise not routine AMAB sex with AFAB (MSW): no recs for screening AMAB sex with AMAB (MSM): no recs for screening Transgender & Gender Diverse: no recs for screening Persons living with HIV: no recs for screening
What is the screening for HEP B among AMAB sex with AMAB (MSM)?
all should be tested HBsAg, anti-HBc, and anti-HBs
What is the screening for HEP B among persons living with HIV?
all should be tested HBsAg, anti-HBc, and anti-HBs
What is the screening for HEP B among women?
at increased risk (>1 sex partner in prior 6 months, past or current IVDU, and an HBsAg-positive sex partner)
What is the screening for HEP B among AMAB sex with AFAB (MSW)?
at increased risk (by sexual or percutaneous exposure)**
What is the screening for persons with HIV for syphilis?
consider at least annually based on reported sexual behaviors & exposures
What is screening for HEP C among pregnant persons?
should be screened during each pregnancy (except in areas Hep C positivity is <0.1%)
What is the screening for HEP B among pregnant persons?
test for HBsAg at first prenatal visit of each pregnancy, retest at delivery if at high risk*
What is the screening for HSV among AMAB sex with AMAB (MSM)?
type-specific HSV serology considered for MSM with previously undiagnosed GU infection/unknown
What is the screening for HSV among AMAB sex with AFAB (MSW)?
type-specific HSV serology considered when presenting for STI evaluation, especially with multiple partners
What is the screening for HSV among persons living with HIV?
type-specific HSV serology considered when presenting for STI evaluation, especially with multiple partners
What is the screening for HSV among women?
type-specific HSV serology considered when presenting for STI evaluation, especially with multiple partners