Sexually Transmitted Infections:
Epidemiology, Testing and Treatment for
Adolescents
Objectives
Describe the scope and risk factors for sexually
transmitted infections (STIs) in adolescents
Discuss the STIs affecting adolescents.
Assess, treat, and prevent STIs in adolescent
patients.
Adolescents Face Increased Risk for
STIs
Biological
Cognitive
Behavioral
Social/Institutional
Biological Risk Factors: Females
Adolescent cervix
Lack of immunity from prior infections
Smaller introitus
Lack of lubrication can lead to dry, traumatic sex
Cognitive Risk Factors
for STIs in Adolescents
Early adolescence: concrete thinking
Often unable to plan ahead for condoms
Serial monogamy in relationships leading to multiple
partners
Personal fable
Unable to judge risk for STIs
“Other people get STIs”
Behavioral Risk Factors
Age at First
Intercourse
Intimate
Partner
Violence
Substance
Use
Sexual
Activity
with New
Partner
Multiple
Sexual
Partners
Behavioral Risk Factor: Older Partners
Predisposes adolescents to relationship
power imbalance
• Sexual negotiation more difficult
• Increased risk of involuntary intercourse, lack
of protective behavior, and exposure to STIs
Men Who Have Sex With Men (MSM)
In 2013, MSM • 75% of all primary and
accounted for: secondary syphilis cases
An average of 4 in 10 MSM with syphilis
are also infected with HIV.
Women Who Have Sex with Women (WSW)
Adolescent WSW and females with both male and
female partners might be at increased risk for STDs
and HIV
Syphilis transmission, likely to occur during oral sex,
between female sex partners may occur
C. trachomatis among WSW may be more common
HPV transmission can occur from skin-to-skin or skinto-mucosa contact during sex
Risk Factor: Social/Institutional
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
Efficacy of Condoms in Preventing STIs
HIV
Provide up to 85% reduction in
transmission
HPV
May prevent 70% of high- and
low-risk infections in females
GC, CT, and Trich
When used consistently and
correctly, reduce transmission
risk
HSV and Syphilis
Can prevent transmission when
infected areas are covered
www.cdc.gov/condomeffectiveness/references.html
STI Burden
Why it matters
U.S. Preventive Services Task Force:
High Priority Evidence Gaps
Why focus on STI care and treatment for adolescents
and young adults?
USPSTF 4th Annual Report identifies:
Long-term harms of HIV antiretroviral therapy
Interventions to prevent STIs in low-risk adolescents
and
high-risk adolescents
Effectiveness of screening strategies to identify
high-risk adolescents
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
Half of New STIs: Ages 15-24
YRBS 2013 Condom Use
80.00%
% of HS Students Who Used a Condom at Last Intercourse
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
1991
1993
1995
1997
1999
High School Males
2001
2003
2005
2007
High School Females
YRBS 2013
2009
2011
2013
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?
Prevention Counseling
Patient-centered, age-appropriate anticipatory guidance;
Integrate sex ed into clinical practice; can use educational
materials; Prevention guidance, including abstinence, safer
sexual practices, & condoms
AAP
ACOG
Counseling for all sexually active individuals
AAFP
High intensity behavioral counseling (HIBC)
CDC*
HIBC; interactive counseling approaches, i.e., client-centered
STD/HIV prevention counseling; motivational interviewing; videos
and large group presentations to provide information
USPSTF*
Intensive behavioral counseling for all sexually active adolescents
and adults at hi-STI risk
*Draft
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
History of Present Illness
Onset and duration of symptoms
Description of symptoms
Associated symptoms
Nausea
Vomiting
Fever
Chills
Back pain
Sores, lumps, bumps
Erica: History of Present Illness Results
Erica tells you she has burning with urination and a
“yellowish” discharge. She reports itchiness.
She denies abdominal pain and fever and reports no
bumps or lesions.
What is the differential diagnosis?
Differential Diagnosis
Dysuria
Urinary Tract
Infection
Genital Tract
Infection
• Cervicitis
• Vaginitis
Skin-Related
Abnormalities/
mucosal
perineal
• Herpes
• Trauma
Case: Erica
Do you need to perform a pelvic exam?
Erica is symptomatic and sexually active.
A pelvic exam in this case is a diagnostic exam not an
asymptomatic screening.
If Erica had been asymptomatic, would you perform a
speculum exam?
Summary Cervical Cytology Guidelines
When to Begin Pelvic and Screening
Pap smears
Date
Updated
Organization
Initial Screening
Interval for
Under 30
American Congress
of Obstetricians and
Gynecologists
(ACOG)
Age 21, regardless of
sexual initiation
Every three
years
2012
United States
Preventive Services
Task Force (USPTF)
Age 21 or within three
years of sexual initiation,
whichever comes first
At least every
three years
2011
American Cancer
Society (ACS)
Age 21
Every three
years
2012
Differential Diagnosis
You observe discharge in the vault but not in the os
You suspect vaginitis
What are the causes of vaginitis?
Differential Diagnosis
Dysuria
Genital Tract
Infection
Vaginitis
Trichomoniasis
Bacterial
Vaginitis
Candidal
Vaginitis
Erica: Case Continued
Trich, BV, Candidal Vaginitis
Trichomoniasis
Caused by infection with a protozoan
parasite (Trichomonas vaginalis)
Most common curable STI
More women are infected than men
Prevalence
~3.7 million people
Only 30% develop any symptoms
Highest among blacks
Trichomonads
PMN
Yeast
buds
Trichomonas*
Trichomonas*
Squamous
epithelial
cells
PMN
1. Trichomonas: bigger
than PMNs
2. PMNs: dense nucleus;
Trich: many small
vacules
3. Trich: dead once viewed
with microscopy—
flagella rarely seen
Trichomoniasis: Symptoms
Females: ~70%
are
asymptomatic
• Foul-smelling, frothy discharge
• Greenish-yellow discharge
• Vaginal itching, burning, redness
• Dyspareunia
• Dysuria
• Soreness of the genitals
Males: Most are
asymptomatic
and often
missed
• Itching/irritation inside the penis
• Burning after urination or ejaculation
• Discharge from the penis
Routine Trichomoniasis Screening
NOT routinely recommended for asymptomatic
Consider screening ♀ if individual or population-based risk
factors
AAP
ACOG
NOT routinely recommended
Consider screening ♀ based on local prevalence
AAFP
CDC*
NOT routinely recommended: HIV+ ♀
Consider screening persons receiving care in high-prevalence
settings, i.e., STD clinics, correctional facilities or if high risk
(e.g., multiple sex partners, or h/o STD)
USPSTF
*Draft
Trichomoniasis
Sequelae:
Pregnancy Complications
• Preterm delivery; low birth weight
Can increase HIV risk
Vaginitis
Urethritis
Bacterial Vaginosis
Most common vaginal infection in
women of childbearing age
Fewer than normal hydrogen
peroxide-producing lactobacilli
and greater prevalence of other
types of bacteria in the vagina
Vaginal saline prep: normal (below); clue cells (above)
Bacterial Vaginosis
Symptoms
Odorous discharge
Itching, burning, pain
Prevalence
21.2 million (29.2%) among
ages 14–49
Sequelae
Pregnancy complications; Pelvic
Inflammatory Disease (PID)
Susceptibility to other STDs
(HIV, HSV, CT/GC)
Candidal Vaginitis
What is it?
Overgrowth of the yeast
called Candida
Description: yeast seen in 10% KOH wet mount
Candidiasis Symptoms
Females
Males
Experience genital itching or burning,
“cottage cheese-like” discharge
Itchy penile rash
Candidal Vaginitis
Nearly 75% of females experience at least one “yeast
infection” in their lifetime
Males rarely get genital candidiasis
Transmission
Most cases caused by person’s own Candida
organisms
Less commonly passed through sexual intercourse
Erica’s Cervix
During the speculum exam you observe Erica’s
cervix.
You suspect trichomonas.
How do you definitively diagnose the causes
of Erica’s vaginitis?
Evaluating Vaginitis
Source: CA STD Training Center
Trichomonas Diagnosis
Culture
Antigen
Detection
• Sensitivity:
85%-90%
• Specificity:
100%
• Sensitivity:
83%
• Specificity:
97%
Available test:
OSOM Rapid Test
DNA Probe
• Sensitivity:
60%-70%
• Specificity:
100%
Available Test:
Affirm™ VP III
Wet Mount
• Sensitivity:
60%-80%
• Specificity:
>97%
No good test
for males, so
often untested
Candida Diagnosis
DNA Probe
• Sensitivity: 80%
• Specificity: 98%
Wet Mount
• Sensitivity: 35%-45%
• Specificity: 97%-99%
Bacterial Vaginitis Diagnosis
Amsel’s Criteria
Requires the presence of at least three of the
following four criteria:
Whiff test
positive for
fishy or musty
odor when
alkaline KOH
solution added
to smear
Clue cells
(bacteria
attached to the
borders of
epithelial cells,
>20% of
epithelial cells)
Vaginal pH
>4.5
A homogenous
noninflammato
ry discharge
Treatment
Erica’s final diagnosis is
vaginitis related to
trichomoniasis.
How do you treat her?
Trichomoniasis: Treatment
Recommended
Regimen
Alternative
Treatment
Treatment
Failure
• Metronidazole
2 gm PO x 1
• Tinidazole
2 gm PO x 1
• Metronidazole
500 mg PO
BID x 7 days
• Re-treat with
metronidazole
500 mg PO
BID x 7 days
• If repeat
failure, treat w/
tinidazole or
metronidazole
2 gm PO x 5
days
Never use topicals
Trichomoniasis: Partner Management
Sex partners of patients with T. vaginalis should be
treated.
Patients should be instructed to avoid sex until they
and their sex partners are cured.
How Would You Treat if Erica
Was Diagnosed with BV?
Recommended
Regimen
• Metronidazole 500 mg
PO x BID x 7 days
• Metronidazole gel,
0.75%, 1 full applicator
(5 g) PV OD x 5 days
• Clindamycin cream,
2%, 1 full applicator
(5 g) PV QHS x 7 days
Alternative Treatment
• Clindamycin 300 mg
PO BID x 7 days
• Clindamycin ovules
100 mg PV QHS x
3 days
• Tinidazole 2g PO OD x
2 days
• Tinidazole 1g PO OD x
5 days
BV Diagnosis: Partner Management
Clinical trials indicate that a female’s response to
therapy and likelihood of relapse or recurrence are
not affected by treatment of her sex partner(s).
Routine treatment of sex partners is not
recommended.
How Would You Treat if Erica Was
Diagnosed with Candida?
Over-the-Counter
Intravaginal Agents
Prescription
Intravaginal Agents
• Butoconazole 2% cream 5g PV x 3 days
• Butoconazole 2% cream (single
dose bioadhesive product), 5 g PV
x 1 day
• Clotrimazole 1% cream 5g PV x 7–14
days
• Clotrimazole 2% cream 5g PV x 3 days
• Miconazole 2% 5g PV x 7days
• Miconazole 4% cream 5g PV x 3 days
• Miconazole 100mg vaginal suppository,
one suppository for 7 days
• Miconazole 200mg vaginal suppository,
one suppository for 3 days
• Miconazole 1200mg vaginal suppository,
one suppository for 1 days
• Tioconazole 6.5% ointment 5 g PV in a
single application
• Nystatin 100,000-unit vaginal
tablet, one tablet for 14 days
• Terconazole 0.4% 5g PV x 7 days
• Terconazole 0.8% cream 5g PV x
3 days
• Terconazole 80 mg vaginal
suppository, one suppository for
3 days
Treatment for Candida
Oral Agent
Fluconazole 150 mg oral tablet,
one tablet in single dose
Candida: Partner Management
Not usually acquired through sexual intercourse.
Treatment of sex partners not recommended—may be
considered in females who have recurrent infection.
Minority of male sex partners might have balanitis—may
benefit from treatment with topical antifungal agents.
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
Erica: Case Continued
Chlamydia and Gonorrhea
Chlamydia
Curable bacterial STI
Most common reportable communicable disease
Highest reported rates among adolescent and young
adult females (Aged 15-24)
Usually asymptomatic
Chlamydia Symptoms
Females:
Up to ~80-90%
asymptomatic
Males:
Up to 90%
asymptomatic
• Heavy or prolonged menses
• Spotting
• Dysmenorrhea
• Dyspareunia
• Vaginal discharge
• Penile discharge
• Dysuria
68% of All Chlamydia Cases
Among 15- to 24-year-olds
CDC STD Surveillance Report 2013
Chlamydia—Rates by Race/Ethnicity, United
States, 2009-2013
CDC STD Surveillance Report 2013
Sequelae Untreated Chlamydia:
Females
Symptomatic PID occurs in 10-15%
of women with untreated Chlamydia
Increased risk of HIV transmission
Sequelae Untreated Chlamydia:
Males
Epididymitis
Reactive arthritis
HIV transmission
Proctitis
♀ Routine Annual Chlamydia Screening
AAP
all sexually active ≤25 yrs
ACOG
all sexually active adolescents
AAFP
all sexually active <24 yrs
CDC*
all sexually active <25 yrs
USPSTF
all sexually active <24 yrs
*Draft
Chlamydia Screening: Males
Routine Screening NOT
recommended for men
Correctional facilities
STD clinics
Selective screening in
high-prevalence
populations should be
considered
Adolescent-serving clinics
MSM
Multiple partners
AAFP, CDC, USPSTF, AAP Recommendations
Gonorrhea
Curable bacterial STI
Second most commonly reported disease
Found in the cervix, uterus, fallopian tubes, and
the urethra
Can also be found in the mouth, throat, eyes,
and anus
Gonorrhea Symptoms
Females:
~50% are
asymptomatic
• Yellow or bloody vaginal
discharge
• Burning/painful urination
• Bleeding with vaginal
intercourse
Males:
Up to 50%
asymptomatic
• White, yellow/green pus
from the penis with pain
• Burning during urination
• Swollen/painful testicles
Gonorrhea — Rates by Age and Sex,
United States, 2013
CDC STD Surveillance Report 2013
Gonorrhea — Rates by Race/Ethnicity,
United States, 2009–2013
CDC STD Surveillance Report 2013
Clinical Manifestations:
Male Genital Infection
Urethritis—Inflammation
of urethra
purulent discharge
Epididymitis—
Inflammation of the
epididymis
Swollen testicle
Clinical Manifestations:
Female Genital Infection
Most infections asymptomatic
Urethritis—inflammation of the urethra
Cervicitis—inflammation of the cervix
Sequelae of Untreated Gonorrhea
Females:
Cramps and
pain, vomiting,
fever
Males:
Rare
Can
lead to
Left
untreated
• PID
• Infertility
• Ectopic
pregnancy
• HIV
• Prostate
complications
• Epididymis
• HIV
♀ Routine Gonorrhea Screening
AAP
all sexually active ♀ <25 yrs
ACOG
all sexually active ♀ adolescents
AAFP
all sexually active ♀ <24 yrs
CDC
all sexually active ♀ <25 yrs
USPSTF
all sexually active ♀ <24 yrs
♂ Routine Gonorrhea Screening
AAP
Consider screening AYA MSW on basis of individual and population
based risk factors (persons of color, ↑ community prevalence)
AYA MSM for rectal, oral, and urethral GC annually if receptive anal,
oral or insertive intercourse. Screen Q3-6 mo if hi risk w/ multiple or
anonymous partners, sex in with illicit drug use, or risky sex partners;
GC-exposed
AAFP
Insufficient evidence to recommend for or against routine GC screening
for in ♂ at ↑increased risk for infection
CDC*
MSM for rectal, oral, and urethral GC annually if receptive anal, oral, or
insertive intercourse. Screen Q3-6 mo if hi risk w/ multiple partners or
HIV+; GC-exposed
USPSTF
Insufficient evidence to recommend for or against routine GC screening
for in ♂ at ↑increased risk for infection
*Draft
USPSTF GC/CT Risk Factors
Age
♀ ages 15-24 years
♂ ages 20-24 years
New sex partner, >1 sex partner, or sex partner w/
STI infection; inconsistent condom use; H/O or
coexisting STIs; and exchanging sex for money or
drugs
Incarcerated populations, military recruits, and
patients receiving care at public STI clinics
Racial/ethnic differences; blacks and Hispanics
higher GC/CT rates vs. whites
Case: Evaluating Cervicitis
How do you evaluate
Erica for cervicitis?
Chlamydia/Gonorrhea Nucleic Acid
Amplified Tests (NAAT)
Females: Self-collected vaginal swab is preferred
• Urine samples are acceptable.
• Decreased performance compared with genital swabs
Males: Urine is the preferred specimen
• Urethral swab samples are less sensitive than urine
NAAT vs. Culture
Schachter J,et al. Sex Transm Dis. 2008;35:637-42.
Chlamydia Diagnosis
Culture
NAAT
EIA
DFA
Sensitivity:
70%
Specificity:
85–95%
Sensitivity:
85–90%
Specificity:
>98%
Sensitivity:
50–65%
Specificity:
>95%
Sensitivity:
65–70%
Specificity:
95%
Preferred
DNA
Probe
Sensitivity:
65–70%
Specificity:
95%
Gonorrhea Diagnosis
Culture
NAAT
Sensitivity:
90%
Specificity:
99%
Sensitivity:
85–90%
Specificity:
>98%
Preferred
Typical
Gram Stain
Sensitivity:
80%
Specificity:
98%
90% sensitive in
symptomatic male;
only 50% sensitive
in females and in
asymptomatic
males
DNA
Probe
Sensitivity:
35–45%
Specificity:
99%
How to Order Screen
Non-genital GC/CT NAATs can be done by clinical
laboratory with CLIA approval
Gen-Probe
APTIMA
testing
QUEST
diagnostics
test codes
LabCorp
diagnostics
test codes
Pharyngeal
70051X
188698
Rectal
16506X
188672
Urine/Urethral
13363X
183194
Relevant CPT Billing Codes:
CT detection by NAAT:
GC detection by NAAT:
87491
87591
Erica: Case Continued
You collect a specimen and order a
NAAT test for both gonorrhea and
chlamydia.
You administer a pregnancy test,
which is negative.
What else would you do?
Erica: Case Continued
Because your exam was consistent for
trichomoniasis and not cervicitis, you do not
presumptively treat for gonorrhea and chlamydia.
In a week, labs confirm positive gonorrhea and
negative chlamydia tests.
Treatment for Uncomplicated Gonococcal
Infections of the Cervix, Urethra, and Rectum
Recommended
Ceftriaxone
250 mg
IM
Once
Orally
Once
Orally
Twice a day for
7 days
PLUS
Azithromycin
1g
OR
Doxycycline
100 mg
Quinolones are no longer recommended in the United States for the treatment of
gonorrhea and associated conditions, such as PID
www.cdc.gov/mmwr/preview/mmwrhtml/mm6131a3.htm?s_cid=mm6131a3_w
Treatment for Uncomplicated Gonococcal
Infections of the Cervix, Urethra, and Rectum
Alternative 1: If Ceftriaxone is not available
Cefixime
400 mg
Orally
Once
Orally
Once
Orally
Twice a day for
7 days
PLUS
Azithromycin
1g
OR
Doxycycline
100 mg
PLUS
Test of cure in 1 week
www.cdc.gov/mmwr/preview/mmwrhtml/mm6131a3.htm?s_cid=mm6131a3_w
Gonorrhea Treatment Options
for Pharynx
Ceftriaxone
250 mg in a single
intramuscular
dose
PLUS
Azithromycin 1 g orally
in a single dose OR
Doxycycline 100 mg
daily for 7 days
As of 2007, quinolones are no longer recommended in
the US for treatment of gonorrhea and associated
conditions.
Treatment for Uncomplicated Gonococcal
Infections of Cervix, Urethra, Rectum, and Pharynx
Alternative 2: If patient is cephalosporin-allergic
Azithromycin
2g
Orally
Once
PLUS
Test of cure in 1 week
www.cdc.gov/mmwr/preview/mmwrhtml/mm6131a3.htm?s_cid=mm6131a3_w
GC Follow-Up Testing
Test of cure is not recommended if recommended
regimen is administered
Test of cure is recommended if
Alternative regimen is administered
Symptoms persist after treatment and not from
reinfection (prescription failure)
Test of cure by N. gonorrhoeae culture
Test isolated GC for antimicrobial susceptibility
If no cervical access, use NAAT
• Most GC NAATs negative within a week of GC
prescription
Repeat testing in 3 months regardless of prescription
www.cdc.gov/mmwr/preview/mmwrhtml/mm6131a3.htm?s_cid=mm6131a3_w
Positive Gonorrhea:
When to Treat for Chlamydia
If she had tested positive for chlamydia and
gonorrhea
If she had been tested for chlamydia with a test other
than a NAAT, and the chlamydia test was negative
Chlamydia Treatment
Recommended
Regimens
Azithromycin 1 g PO
single dose
Doxycycline 100 mg PO
BID x 7 days
CDC STD Treatment Guidelines. 2010.
STI Partner-Management
Strategies
STI Partner-Management Strategies
Provider
Referral
Patient
Referral
Expedited
Partner
Therapy
(EPT)
Partners contacted by index patient’s
provider or by a disease intervention
specialist
Index patient assumes primary
responsibility to notify and refer
his/her partners at risk
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 35 states and the city of Baltimore, MD
Prohibited in 6 states (FL, KY, MI, OH, OK, WV)
www.cdc.gov/sTd/ept/legal/default.htm
Behaviors Affecting EPT Effectiveness
Patient-delivered
specific
Patient did not give Rx to
any/all partners
Partners noncompliant with Rx
General
noncompliance
Patients did not contact partners
Patients noncompliant with Rx
Resumed sex <7 days after
case and partner treatment
Sex with new partner(s)
EPT Barriers
General theoretical
liability issues
Rx without an exam
Medical records for
treated partner?
Legal issues with minors
Consent to care
Obligation to report sex
in minors with older
partners
Financial: who pays for
partner Rx?
Adverse drug effects
Partner may not seek
complete STI assessment
Potential to miss
partners’ other STIs,
including HIV
Missed counseling
opportunities for partners
Repeat Testing After Treatment
Pregnant females
Repeat testing, preferably by NAAT, 3 weeks after
completion of recommended therapy
Non-pregnant females
Test of cure not recommended unless:
• Compliance is in question, symptoms persist, or reinfection is suspected
Repeat testing recommended 3-4 months after
treatment
• Especially adolescents; high prevalence of repeat
infection
What Is Next for STI Partner
Strategies?
Internet: Facilitating Partner Notification
MSM and in cases where no other identifying
information is available
Many health departments now conduct formal internet
partner notification (IPN)
Expedited Partner Therapy Legal/Policy Toolkit
Assist states interested in adopting EPT supportive
laws
Assist states that have adopted EPT laws with
addressing full implementation barriers
www.cdc.gov/std/ept/legal/LegalToolkit.htm
Erica: Case Continued
HIV Testing
HIV/AIDS
Incidence
Symptoms
1/3 of new infections in 2006
in people ages 13-29
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
HIV and MSM 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
HIV Awareness
Proportion of people unaware of their HIV infection
declined from 20% to 16%
As of 2009, 83 million adults aged 18-64 reported
they had been HIV tested
Routine HIV Screening
Offer routine screening to all by age 16-18 yrs in health care settings when
HIV prevalence > 0.1%
Encourage routine HIV testing for all sexually active teens and those with
other risk factors in low HIV prevalence areas
AAP
ACOG
Routine screen all sexually active adolescent ♀
AAFP
Screen ages 18 to 65 yrs for HIV infection
Screen younger adolescents and older adults at ↑ HIV risk
CDC
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
USPSTF
Screen age 15-65 yrs
Screen younger adolescents and older adults at ↑ HIV risk
Offer “reasonable approach” to screening intervals (1x for low risk; every 35 yrs for increased risk; annually for very high risk)
CDC Backs New HIV Testing
“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
HIV-1 Western Blot no longer recommended
STI Quarterly Contraceptive Technology Update September 2014
HIV 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
Case Study: Justin
Herpes and Syphilis
Case: Justin
Justin is a 17-year-old
male who presents with a
painful sore “down there.”
He noticed it five days
ago.
Sexual History
During the sexual history, Justin discloses that he has
had both male (1 lifetime) and female partners (3
lifetime).
He is currently in a relationship with a female with
whom he has vaginal and oral sex.
He uses condoms “almost all the time.”
He has no known history of STIs.
Physical Exam
You do a genital exam and on the shaft of the penis,
you observe several lesions.
What is your differential diagnosis?
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
Genital Herpes Background
Caused by the herpes simplex viruses type 1
(HSV-1) and type 2 (HSV-2)
Majority of genital and perirectal herpetic
outbreaks caused by HSV-2
Estimated that one million new cases occur in the
U.S. each year
Over 80% new cases undiagnosed
Adolescent Females and MSM
While most recurrent outbreaks are due to HSV-2,
HSV-1 is becoming more prominent as a cause of
first episode of genital herpes
Genital Herpes: Initial Visits to Physicians’
Offices, United States, 1966-2013
CDC STD Surveillance Report 2013
Herpes Simplex 2: Seroprevalence by
Race, Sex, and Age Group
CDC STD Surveillance Report 2013
Genital Herpes: Symptoms
Most cases asymptomatic (up to 90%)
Painful blisters/open sores in genital area
May be preceded by a tingling or burning sensation
in the legs, buttocks, or genital region
Sores usually disappear within 2-3 weeks
Virus remains in the body for life, causing outbreaks to
recur occasionally
Genital Herpes Types of Infection
First clinical episode
Primary
Non-primary
Recurrent symptomatic infection
Asymptomatic infection
Infection Type
Lesions/
Symptoms
Type Antibody at
Presentation
HSV-1
HSV-2
1st Episode
Primary
Type 1 or 2
+/Sever, bilateral
–
–
1st Episode
Non-primary
Type 2
+/Moderate
+
–
1st Episode
Recurrence
Type 2
+/Mild
+/–
+
Symptomatic
Recurrence
Type 2
+/Mild, unilateral
+/–
+
Asymptomatic
Infection
Type 2
–
+/–
+
Asymptomatic Viral Shedding
Most HSV-2 is transmitted during asymptomatic
shedding
Rates of asymptomatic shedding greater in HSV-2
than HSV-1
Rates of asymptomatic shedding are highest in new
infections (<2 years) and gradually decrease over
time
Asymptomatic shedding episodes are of shorter
duration than shedding during clinical recurrences
Genital Herpes Sequelae
Aseptic meningitis
More common in primary infection
Generally no neurological sequelae
Rare complications include:
Stomatitis and pharyngitis
Radicular pain, sacral paresthesias
Transverse myelitis
Autonomic dysfunction
Psychological distress
Painless Ulcer
If Justin’s sore had been
painless and solitary,
what would the
differential diagnosis be?
Syphilis
STI caused by the bacterium
Treponema pallidum
Includes three stages:
• Primary
• Secondary
• Late and Latent
Primary Syphilis: Signs and Symptoms
One or more skin lesions called chancres at the site
where the spirochete penetrated (2 weeks to 3
months after initial infection)
Large numbers of organisms are present in exudates
of lesion and in lymph nodes and infiltration of ulcer
with inflammatory cells
Highly infectious; diagnosis by dark field microscopy
Chancre heals within 2 months
Secondary Syphilis: Signs and
Symptoms
Clinical signs of disseminated disease appear with
prominent skin lesions (rash) dispersed over the
entire body surface (occurs in 50% of cases)
accompanied by flu-like symptoms (sore throat, fever,
headache, etc.) and swollen lymph nodes
Maculopapular skin lesions that are most prominent
on palms of the hands and soles of feet will occur in
80% of patients
Lesions called condylomas may occur on skin in
moist areas (vagina and anus)
Syphilis: Primary
Syphilis: Secondary
Primary and Secondary Syphilis: Rates by
Age and Sex, United States, 2013
CDC STD Surveillance Report 2013
Primary and Secondary Syphilis by
Race/Ethnicity and Sex
CDC STD Surveillance Report 2013
Primary and Secondary Syphilis: By Sex, Sexual
Behavior, and Race/Ethnicity, United States, 2013
CDC STD Surveillance Report 2013
Sequelae
Chancre increases the risk of HIV
• In recent outbreaks, rates of co-infection ranged from 20%–
70%
Evaluating Genital Ulcers
How do you evaluate the
causes of Justin’s genital
lesions?
Genital Herpes: Screening
Current CDC guidelines do not recommend
universal screening with serology
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
Routine Syphilis Screening
NOT routinely recommended
MSM. Screen Q3-6 mo if hi risk;
Consider if behaviors put them at higher risk; consult with LHD
AAP
ACOG
NOT recommended
Screen based on local disease prevalence
AAFP
NOT recommended
Screen persons at increased risk (MSM, CSW, exchange sex for drugs,
correctional facilities)
CDC*
NOT recommended
Screening in correctional facilities based local and institutional prevalence;
MSM. Screen Q3-6 mo if hi risk w/ multiple partners or HIV+
USPSTF
NOT recommended
Screen persons at increased risk (MSM, CSW, exchange sex for drugs,
correctional facilities)
*Draft
HSV Diagnosis
Culture
Sensitivity:
73%
Specificity:
100%
Culture requires a
new lesion and
high viral load
Type Specific
Serology
Sensitivity: 80%98%
Specificity:
>96%
Most HSV-1 is not
sexually transmitted
PCR
Sensitivity: 98%
Specificity:
100%
Sensitivity
decreases as lesion
heals
Syphilis Diagnosis
Classical Testing
1st
Nontreponemal
- RPR
- VDRL
2nd
Treponemal
test
- TPPA
- FTA
Emerging Testing
1st
Treponemal
Test
2nd
Nontreponemal
test
Justin: Case Continued
Results from the RPR negative and culture are
positive for HSV-2
How do you treat?
HSV-2
Treatment for Acute First Episode
Acyclovir 400 Acyclovir 200
mg TID for 7- mg PO 5x/day
10 days
for 7-10 days
Famciclovir
250 mg PO
TID for
7-10 days
Valacyclovir 1
g PO BID 710 days
Simplest regimen preferred with adolescents
Suppressive Therapy
Treatment with:
Acyclovir 400 mg orally twice a day or
Famiciclovir 250 mg orally twice a day or
Valacyclovir 500 mg orally once a day or
Valacyclovir 1.0 g orally once a day
Counseling: Treatment
Suppressive therapy available and effective in
preventing symptomatic recurrences
Episodic therapy sometimes useful in shortening
duration of recurrent episodes
When and how to take antiviral medications
Recognition of prodromal symptoms to know when to
begin episodic therapy
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
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
If Justin Was Positive for Syphilis,
How Would You Treat?
Primary, Secondary, and Early Latent
Benzathine Penicillin G—2.4 million units IM x 1 dose
What Other Tests Should You Order?
HIV
What if Justin discloses to you sexual behavior with
other males?
Chlamydia Testing for MSM Under 25
Screen for urethral/rectal infection in males who in the
past year have had:
Insertive anal intercourse
Receptive anal intercourse (NAAT of a rectal swab
preferred)
Urine based NAAT is preferred
Rescreen for reinfection at 3 months
Screening for pharyngeal infection NOT
RECOMMENDED
Marcell, A.V. and the Male Training Center for
Family Planning and Reproductive Health. 2014.
Gonorrhea Testing for MSM
Screen for urethral/rectal infection in sexually active
MSM at least annually who have had:
Insertive anal intercourse
Receptive anal intercourse (NAAT rectal swab preferred)
Screen for pharyngeal infection in males who in past
year have had:
Receptive oral intercourse (NAAT preferred)
Urine based NAAT is preferred
Rescreen for reinfection at 3 months
More frequent screening for MSM w/multiple or
anonymous partners/illicit drug use
Marcell, A.V. and the Male Training Center for
Family Planning and Reproductive Health. 2014.
Immunizations
Human papillomavirus (HPV4) vaccination
Routine: ages 11-12; Catch-up: ages 13-21; Special
populations: ages 22-26; ages 9-10 can be vaccinated
Hepatitis B vaccination (HBV) among persons aged
<19 years and for all adults who are at risk or who
request vaccination.
Young MSM may require more thorough evaluation
Hepatitis A (HAV) among persons at risk
Marcell, A.V. and the Male Training Center for
Family Planning and Reproductive Health. 2014.
Case Wrap-Up: Justin
Genital lesions can be painful or painless
Painful: Chancroid
Sometimes painful: HSV
Painless: Syphilis, LGV
Patients with genital ulcers should be evaluated with:
• Serologic test for syphilis
• Diagnostic evaluation for HSV
Go-to info sources: CDC!
DSTDP: www.cdc.gov/std
Treatment guidelines
GC/CT lab guidelines
Surveillance stats (slides)
DHAP
Rapid tests
Surveillance stats (slides)
Other STI screening guidelines
CDC: www.cdc.gov/std/treatment
USPSTF:
www.uspreventiveservicestaskforce.org/uspstopics.htm
ACOG: www.acog.org/Resources-And-Publications
Red Book STI Chapters
aapredbook.aappublications.org
Provider Resources:
Sexually Transmitted Infections
National Chlamydia Coalition: ncc.prevent.org
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
Treatment Guidelines:
www.cdc.gov/std/treatment/2010/default.htm
American Social Health Association:
www.ashastd.org/std-sti/hpv.html
U.S. Department of Health and Human Services
womenshealth.gov/faq/stdhpv.htm
Provider Resources and Organizational
Partners
www.advocatesforyouth.org—Advocates for Youth
www.aap.org—American Academy of Pediatricians
www.aclu.org/reproductive-freedom American Civil Liberties
Union Reproductive Freedom Project
www.acog.org—American College of Obstetricians and
Gynecologists
www.arhp.org—Association of Reproductive Health
Professionals
www.cahl.org—Center for Adolescent Health and the Law
www.glma.org Gay and Lesbian Medical Association
Provider Resources and Organizational
Partners
www.guttmacher.org—Guttmacher Institute
janefondacenter.emory.edu Jane Fonda Center at Emory
University
www.msm.edu Morehouse School of Medicine
www.prochoiceny.org/projects-campaigns/torch.shtml NARAL
Pro-Choice New York Teen Outreach Reproductive Challenge
(TORCH)
www.naspag.org North American Society of Pediatric and
Adolescent Gynecology
www.prh.org—Physicians for Reproductive Health
Provider Resources and Organizational
Partners
www.siecus.org—Sexuality Information and Education Council
of the United States
www.adolescenthealth.org—Society for Adolescent Health and
Medicine
www.plannedparenthood.org Planned Parenthood Federation of
America
www.reproductiveaccess.org Reproductive Health Access
Project
www.spence-chapin.org Spence-Chapin Adoption Services
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