Diseases without Borders:
Best Practices for Sexually Transmitted
Diseases Care and Prevention
Linda Creegan, MS, FNP
California STD/HIV Prevention Training Center
linda.creegan@ucsf.edu
Border Conference
El Centro, CA June 2014
I do not have any financial
arrangements or affiliations with
commercial sponsors which have
direct interest in the subject
matter:
SEXUALLY TRANSMITTED DISEASES
• Chlamydia
• Chancroid
• Gonorrhea
• Trichomonas • Genital herpes
• Syphilis
• Granuloma
• HIV / AIDS
inguinale
• HPV
• Lice
• Scabies
• Hepatitis B
• LGV
• Hepatitis C
• M. genitalium • Others…..
• BV?
Complications of STDs
Infertility
PID
Infection
Chlamydia
Gonorrhea
HPV
Hepatitis B
Trichomona
s
o HSV
o Syphilis
o
o
o
o
o
Cancer
HIV
Perinatal
Brain/organ
damage
Ectopic
pregnancy
Chronic
pain
Congenital
infection
Low birth
weight
Stillbirth
CA STD Data and Statistics
Priority Populations
• Teens & young people
• Pregnant women
• Gay/Bi men (MSM)
• People of color
Testing in STD Care
Testing applications
• Case finding
– Asymptomatic (screening)
– Symptomatic (diagnostic)
• Follow-up
• Guide treatment (HIV
resistance testing)
• Surveillance
Types of tests
• Culture (susceptibility testing)
• Serologic tests (antibodies
in the blood)
• Molecular-based tests
(NAAT)
• Combo tests
– CT/GC
– HIV/syphilis
– Non-treponemal and
treponemal
Testing Approaches
• In clinic
– Clinician-collected
– Self-collected
• Outside the clinic
– Collected at lab
– Field-based program
– Home testing
Provide Those Free Sexual Health Services!
• Essential Health Benefits related to
STD/HIV prevention and care
• Must be included in all health plans at no
cost-sharing to patient
–
–
–
–
–
–
Annual Wellness visit
STD and HIV screening
STD and HIV care
HPV and Hep B Immunizations
Risk Reduction counseling
Pap smears
1. Ask three essential sexual
history questions
 WHO are your partners?
 WHAT are your sexual and drug use practices?
 HOW do you try to prevent STDs/HIV?
Risk assessment important since many STDs are asymptomatic
2. Screen for Chlamydia and
Gonorrhea
ALL sexually active adolescent and
young women ≤ 25 years
Pregnant women
Men who have sex with men (MSM)
Persons living with HIV
Others according to risk
CDC 2010 STD Tx Guidelines. www.cdc.gov/std/treatment
Why screen?
•
•
•
•
•
Highly prevalent
Frequently asymptomatic
Reduces transmission
Prevents complications
HEDIS measure: chlamydia screening in
females under 25 years old
• Standard of care
Sexually Active adolescents & up to age 25
Routine chlamydia and gonorrhea screening
Others STDs and HIV based on risk
Women over 25 years of age
STD/HIV testing based on risk
Pregnant women
Chlamydia
Gonorrhea (<25 years of age or risk)
HIV
Syphilis serology
HepB sAg
Hep C (if high risk)
CDC 2010 STD Tx Guidelines www.cdc.gov/std/treatment
Estimated Chlamydia Screening Coverage (HEDIS),
Females Age 15–24, USA and California, 1999–2010
100
1999
2004
2010
90
Percent Screened
80
70
60
50
40
30
20
10
0
Natl MCO
Natl Medicaid
National
MediCal MC
Cal HMO
FPACT
California
Source: National Committee on Quality Assurance; California DHCS Division of Medi-Cal Managed Care;
Kaiser Permanente Northern CA; California DPH Office of Family Planning
Rev. 4/2012
Who is falling through the cracks?
 Visits that do not require an exam
 Pregnancy test only
 Emergency contraception
 Contraception method follow-up
• Refills
• Depo-provera injection
A pelvic exams is not necessary
to obtain a chlamydia test

Nucleic acid amplification tests (NAATs)
u
Highest sensitivity
• Noninvasive samples
– Urine
– Self-collected vaginal swabs
Major conclusions
NAATs recommended for detection of genital tract infections in men and
women – with and without symptoms
Optimal specimen types are:
First catch urine for men
Self collected vaginal swabs from women
NAATs recommended for: detection of rectal and oropharyngeal infections
What about Women over age 25?
CT Test Volume & Prevalence among Females by Age
Test Volume
% CT Pos
7
50% Test Volume
45000
6
40000
35000
5
30000
4
25000
20000
3
15000
2
10000
1
5000
0
0
10-14
15-19
20-24
25-29
30-39
40+
AGE (YEARS)
CA FPACT Data, 2006
*Quest Diagnostics/Unilab: West Hills/Tarzana, Sacramento, San Jose
CHLAMYDIA PREVALENCE
CHLAMYDIA TEST VOLUME
50000
Which women over age 25
should be screened?
Based on risk:
–
–
–
–
Infection with CT or GC in past 2 years
> 1 sex partner in past 12 months
New partner in past 3 months
Belief that a partner in the past 12 months may have
had other sex partners at the same time
Other indications:
– Pregnancy
– Contact to STD
– New STD diagnosis
CA CT Screening Guidelines Draft;
Howard et al. Over 20. In prep.
STI Screening Recommendations:
HIV-positive Men & Women
STI
Chlamydia
Gonorrhea
Anatomic Site
Genital, rectal if exposed
Genital, rectal & oral if exposed
Syphilis
Trichomoniasis
HSV-2
Serology
Women only
Serology
Hep B sAg
Hep C
Serology
Serology
* Screen at least annually; repeat screening every 3-6 months as
indicated by risk.
MSM- Consider anal Pap screening
Women-Cervical Pap screening; Consider anal Pap if hx of dysplasia.
Primary Care Guidelines for the Management of Persons Infected with HIV:
2009 Update by the HIVMA of the IDSA. Clin Infect Dis 2009;49, 651-681.
*
STD Screening for MSM
•
•
•
•
•
•
•
•
HIV
Syphilis
Urethral GC and CT
Rectal GC and CT (if RAI)
Pharyngeal GC (if oral sex)
HSV-2 serology (consider)
Hepatitis B (HBsAg)
Anal Pap (consider for HIV+)
*
* At least annually, more frequent (3-6 months) if at high risk
(multiple/anonymous partners, drug use, high risk partners)
CDC 2010 STD Tx Guidelines www.cdc.gov/std/treatment
Majority of Rectal Infections in MSM are
Asymptomatic
Rectal Infections
86%
84%
Chlamydia
Gonorrhea
n=316
n=264
Asymptomatic
Symptomatic
10%
Urethral Infections
42%
Chlamydia
n=315
Gonorrhea
n=364
Kent, CK et al, Clin Infect Dis July 2005
Proportion of CT and GC infections MISSED among
3398 asymptomatic MSM if screening only
urine/urethral sites, San Francisco, 2008-2009
Chlamydia
Gonorrhea
Marcus et al, STD Oct 2011; 38: 922-4
Chlamydia and Gonorrhea
NAA Testing
• …not FDA-cleared for rectal or pharyngeal
specimens but now the preferred testing
method over culture
• Validation procedures can be done by labs to allow
use of a non-FDA-cleared test or application
• Quest & LabCorp currently provide GC/CT NAAT for
rectal/pharyngeal specimens
NAAT Laboratory Ordering and Billing Codes
Company-Specific Ordering Codes for
Combined GC/CT Nucleic Acid Amplified
Tests (NAATs)
Company-Specific
Ordering Codes for CT
test only
LabCorp*
Quest*
LabCorp
Rectal
188672
16506
188706
Pharyngeal
188698
70051
188714
NAATs are offered at (or from) any location in the country with these two codes.
For information on specimen collection and transportation, clinicians should
contact the local reference laboratory representative.
CPT Billing Codes
CT detection by NAAT 87491
GC detection by NAAT 87591
*CDC does not endorse these laboratories, however, they represent the largest laboratories nationally.
There may be other private laboratories that have verified rectal and pharyngeal testing with NAATs.
Many PHLs have also verified rectal and pharyngeal testing.
Bolan, CDC webinar March 2011
Case Scenario
•
•
•
•
22 year old female
Asymptomatic, no prior STDs
STD Screening done on intake
No known drug allergies
• GC positive
• CT negative
What regimen would you use to
treat Gonorrhea?
A. Ceftriaxone 250 mg IM
B. Azithromycin 2 gm PO
C. Ceftriaxone 250 mg IM
plus azithromycin 1 gm
PO
D. Ceftriaxone 125 mg IM
plus azithromycin 1gm
PO
59%
18%
18%
p.
..
M
gI
xo
ne
12
5
m
Ce
ftr
ia
xo
ne
25
0
yc
in
Ce
ftr
ia
m
gI
M
gm
2
m
25
0
Az
ith
ro
m
on
e
ax
Ce
ftr
i
p.
..
PO
gI
M
5%
Development of GC Resistance
1945: Penicillin
first used
widely for TX
1976: Pen-R
NG first
identified in
US (in CA)
1930s-1970s
1936:
Sulfanilamides
introduced as TX
2001: First
cephalosporin
TX failures in
Japan
1980s
1986: GISP
started by
CDC
1990s
2002:
Fluoroquinolones no
longer recommended
for TX by CA
2000s
1991: QRNG
first identified
in US (in HI)
1989: Penicillin
no longer
recommended for
TX by CDC
2010s
2010: Dual TX
recommended
for TX by CDC
2007:
Fluoroquinolones no
longer recommended
for TX by CDC
Who is most likely to be affected
by cephalosporin-resistant GC?
Men who have
sex with men
California
30
3. Use Current Treatment for
Gonorrhea
Gonorrhea Treatment: Uncomplicated
Genital/Rectal/Pharyngeal Infections
Ceftriaxone 250 mg IM
in a single dose
PLUS*
Azithromycin
1 g orally **
or
Doxycycline
100 mg BID x
7 days
* Regardless of CT test result
MMWR Weekly August 10, 2012
MMWR updates CDC 2010 Guidelines
**Azithromycin preferred
as 2nd antimicrobial
Do you have ceftriaxone and
azithromycin available onsite?
78%
No
22%
Ye
s
1. Yes
2. No
Gonorrhea Treatment Alternatives
Anogenital Infections
ALTERNATIVE CEPHALOSPORINS:
 Cefixime 400 mg orally once
PLUS
 Dual treatment with azithromycin 1 g (preferred) or
doxycycline 100 mg BID x 7 days, regardless of CT
test result
IN CASE OF SEVERE ALLERGY:
 Azithromycin 2 g orally once
(Caution: GI intolerance, emerging resistance)
Proposed in case of allergy: gentamicin 240 mg IM + azithromycin 2g orally
or gemifloxacin 320 mg orally + azithromycin 2g orally
MMWR 2012 / 61(31);590-594
Test of Cure
• Current TOC recommendation: Test of
cure in 1 week for anyone treated w/
alternative regimens
– Routine TOC poses implementation challenges
– No data on TOC positivity rates in absence of
symptoms
• Proposed: Limit TOC only to pharyngeal
GC treated with alternative regimen, may
extend interval to 14 days
How to slow the spread of A-R
Gonorrhea
• New antibiotics
• Multiple antibiotics
• Surveillance
– Rapid response plans
– Resistance testing of isolates
Suspected GC Treatment Failure
What should I do?
CDPH Recommendations
CULTURE: if GC culture not available on-site, call CA STD Control
Branch for resources 510 620 3400
REPEAT TREATMENT: Ceftriaxone 500 mg IM PLUS
Azithromycin 2 g orally in a single dose*
REPORT: To your local health department within 24 hours; call
STD Control Branch if consult desired
TREAT PARTNERS: All partners in last 60 days should be
treated with CTX 500 mg + AZ 2g
TEST OF CURE (TOC): Patient returns in 1 week for TOC with
culture (if culture not avail, with NAAT)
* If reinfection suspected instead of treatment failure, OK to repeat
treatment with CTX 250 + AZ 1g
4. Ensure Partner Management
Patient referral
• Ask patient to notify partner and ensure treatment
• Suggest patient bring partner to clinic for concurrent
treatment (“BYOP”)
• Internet-based anonymous notification
Expedited partner treatment (EPT)
• Patient-delivered partner treatment (PDPT)
• Health department field-delivered treatment
• Pharmacy-based
Provider or clinic-based referral
Health department referral
Legal Status of EPT in the U.S.
PERMISSIBLE
32 states
UNCERTAIN
11 states
PROHIBITED
7 states
CDC EPT Legal Status Updated August 2012
www.cdc.gov/std/ept
Online Partner Referral
Patients use website
to notify partners
- anonymous
- free
- referrals for testing
inspot.org
sotheycanknow.org
Nadine
28 y/o non-pregnant female treated for CT.
When should you schedule her follow-up?
46%
19%
15%
15%
e
su
r
No
t
he
r..
.
ye
ar
1
th
s
on
m
3
fo
r
fo
ra
...
...
a
fo
r
ee
ks
w
3
w
ee
k
fo
ra
T.
..
4%
1
A. 1 week for a TOC
B. 3 weeks for a TOC
C. 3 months for a test
for reinfection
D. 1 year for her annual
exam
E. Not sure
5. Retest for CT and GC at three
months following treatment
Retesting Recommendations:
 Retest all women and men with CT or GC
3 months after treatment*
“Opportunistic” testing
 Retest whenever possible, 1-12 mo
*CDC 2010 STD Tx Guidelines, www.cdc.gov/std/treatment
Repeat Chlamydial Infection is
Common
Reinfection (%)
40
Retesting
Prevalence
30
20
Typical
Screening
Prevalence
10
0
0
2
4
6
8
10
12
Months Follow-up
Hosenfeld C, et al. Sex Transm Dis. 2009 Aug;36(8):478-89
Repeat Infection is Dangerous
• Repeat CT infection
6
leads to higher risk
5
of complications:
pregnancy, infertility
• Most infections are
Ectopic
Pregnancy
4
Relative Risk
PID, ectopic
Pelvic
Inflammatory
Disease
3
2
1
asymptomatic
0
1st
2nd
3rd
Infection Infection Infection
Hillis SD, et al. (1997). Am J Obstet Gynecol 176(1 Pt 1): 103-7.
Chlamydia Care Continuum:
Family PACT females age ≤25 years
(N=686,327)
Total Est Cases
Cases detected
78%
Cases treated
92%
Pt returns 1-6 mo.
retested
60%
59%
Pos at Restest
Source: Family PACT Annual Report FY 11-12
http://www.familypact.org/Research/reports/FamPactAnnualReport2011-12_ADA.pdf
Getting clients back in for
retesting:
• Counseling at treatment visit
• Written materials
• Advance appointments
• Traditional reminder systems
(telephone and postcards)
• Text message and/or email
reminders
Downer SR et al Aust Health Rev 2006;30:389;
Leong KC et al. Fam Pract 2006; 23:699.
Appointment and STI Retest Reminders
For more information:
providers@bedsider.org
6. Recommend the HPV Vaccine
Population
ACIP Recommendation
Gender
Age
Females
11-12
(as young as 9)
Males
Routine vaccination with either
HPV4 or HPV2
13-26
Routine catch-up vaccination either
HPV4 or HPV2*
11-12
Routine vaccination w HPV4
(as young as 9)
MSM & HIV+
Males
13-21
Routine catch-up vaccination HPV4
22-26
Permissive recommendation HPV 4
22-26
Routine catch-up vaccination HPV 4
* Irrespective of history of abnormal Pap, HPV, genital warts
MMWR, May 28 2010; 59(20):626-629 , 630-632
MMWR , December 23 2011; 60(50);1705-1708
The HPV Family
Dermal HPVs
Common skin warts
(~60 types)
“Low-risk”
Wart types
Mucosal HPVs
(~40 types)
“High-risk”
Cancer types
Incidence of Cervical HPV Detection in
Women from the Time of Sexual Debut
70%
60%
Cervical HPV Detection
50%
40%
30%
20%
10%
0%
0
6
12
18
24
30
36
42
48
Time since first intercourse (months)
Collins et al. Br J Obstet Gynecol 2002;109:96
Clearance of HPV Infections
Over 2 Years
Percent HPV Infected
100
80
60
40
20
0
0
3
6
9
12
15
18
21
24
Time from HPV infection (months)
Adapted from Brown et al. JID 2005:191;182
Low Risk Mucosal HPVs
TYPES
• Most common: 6, 11
• Others: 40, 42, 43, 44, 54, etc
DISEASES • Genital and oral warts
• Respiratory papillomatosis
• Low grade cervical Pap
abnormalities
Anogenital Warts
Source: DOIA Website, 2000
HPV Vaccine Efficacy in Preventing
Precancer and Warts
FEMALES
MALES
HPV Disease
CIN 2+
Genital Warts
VIN/VaIN 2+
HPV 4
98%
100%
100%
HPV 2
98%
-----
Genital warts
AIN
90%
78%
-----
CIN = Cervical Intraepithelial Neoplasia
VIN = Vulvar Intraepithelial Neoplasia
AIN = Anal Intraepithelial Neoplasia
VaIN = Vaginal Intraepithelial Neoplasia
Future II Study Group. N Engl J Med 2007;356(19):1915-27
Garland SM et al. NEJM 2007;356(19):1928-43
Paavonen et al. Lancet. 2009;374(9686):301-14
Giuliano et al. NEJM 2011; 364:401-11
Palefsky et al. NEJM 2011; 365:1576-85.
ACIP Recommendations:
Administration, Precautions and
Contraindications
• Synchronized dosing: 3-dose schedule, second dose at 1-2
months after first dose, third dose 6 months after first dose
• Minimum intervals:
– Minimum time b/w 1st & 2nd = 4 wks
– Minimum time b/w 2nd & 3rd = 12 wks
– Minimum time b/w 1st & 3rd = 24 wks
• If schedule is interrupted, the series does not need to be
restarted
• HPV vaccines can be given simultaneously/before/after other
vaccines
• If possible, the same product should be used for all doses in the
series
• No change in cervical cancer screening recommendations
MMWR, May 28, 2010; 59(20):626-629, 630-632
ACIP Recommendations:
Administration, Precautions and
Contraindications
• Pregnancy: HPV vaccines are not recommended for use in
pregnant women; however pregnancy testing is not needed
before vaccination. Any exposure to vaccine during pregnancy
should be reported to the appropriate vaccine pregnancy
registry: Pregnancy Registry: 800-986-8999 (Merck) or 888452-9622 (GSK vaccine)
• Contraindications: allergy to vaccine component, severe illness
• Quadrivalent HPV vaccine contains yeast antigens
• Bivalent HPV vaccine in prefilled syringes contraindicated
for persons with anaphylactic latex allergy
 Adverse reactions should be reported to VAERS:
www.vaers.hhs.gov or 800-822-7967
MMWR, May 28, 2010; 59(20):626-629, 630-632
Vaccine Funding Programs
Vaccines for Children Program
• Up to age 18, Medicaid eligible, uninsured or underinsured
• Receiving immunizations through a Federally Qualified Health
Center or Rural Health Clinic, or
• Native American or Alaska Native
Merck Vaccine Assistance Program
• Age ≥ 19, low income, and no health insurance coverage
• Phone number 1-800-293-3881 (8a-8p EST)
• http://www.merck.com/merckhelps/vaccines/home.html
Merck Dose Replacement Program
• Vaccine doses provided but not reimbursed
• https://www.drp4gardasil.com/Site/Home.aspx
GSK Vaccines Access Program
• Age 19-25, income eligible, and no heath insurance
• www.gskforyou.com
HPV Vaccine Uptake, Girls Ages 13-17
National Immunization Survey, 2007-2010
49%
44%
37%
25%
MMWR 2008 / 57(40):1100-3; MMWR 2009 / 58(36):997-1001;
MMWR 2010 / 59(32):1018-23; MMWR 2011 / 60(33):1117-1123
7. Offer Management for
Recurrent/Persistent Vaginitis
Challenges in Managing Vaginitis
• Patient factors
– Self-treatment may preclude diagnosis
– Clients seek help from multiple providers
• Provider factors
– Under-utilization of available tests
– Insensitive clinic-based tests
– Dependent on provider skills
Bacterial Vaginosis
Decrease in lactobacilli
Polymicrobial overgrowth
Enzymes degrade the protective effects of cervical mucus and immune factors
Photo: Seattle PTC
Bev….. “I have BV again!”
Recurrence rates as
high as 30% at 3 months
and 80% at 9 months
Etiology unclear
 Resistance?
 Re-infection?
 Unrecognized trigger?
 Failure of lactobacilli to
recolonize?
Management
Confirm diagnosis
Condoms
No douching
Intermittent
metronidazole gel
(twice a week
intravaginally)
Recurrent BV: Success with
Suppressive Treatment
Recurrence
Prophylactic phase (4 mo)
MTNZ
13/51 (26%)
Clinical
Gram Stain 8/45 (18%)
Placebo
P value
26/44 (59%)
<.001
14/35 (40%)
.03
Observation phase (3 mo)
Clinical
26/51 (51%)
33/44 (75%)
.02
Gram Stain
17/45 (38%)
17/35 (49%)
.33
Sobel JD et al, Am J ObGyn. May 2006
Candice…….
 Majority of women have
no predisposing or
underlying conditions
 Non-albicans more
common
 Pathogenesis is unclear
 Deficient host response?
 Overactive host response?
 Relapse/reinfection?
Photos; Mosby STD Atlas 1997 and Seattle
STD/HIV PTC
 Initial Treatment
 Longer regimen of topical
therapy (7-10 d)
 Fluconazole (100 mg, 150
mg, or 200 mg) p.o. every
3rd d x 3
 Maintenance Regimens
 Fluconazole (100 mg, 150
mg, 200 mg) qw x 6 m
OR if not feasible
 Topical antifungals used
intermittently
Trixie…..
First treatment failure, re-treat with:
 Metronidazole 500 mg PO BID x 7 days
If repeat failure, treat with:
 Metronidazole 2 g PO x 5 days
 Tinidazole 2 g PO x 5 days
Susceptibility testing: send isolate to CDC
CDC Consult & T. vaginalis susceptibility
(404-718-4141)
Diagnostic tests for
Trichomonas
Sekisui Diagnostics
BioMed Diagnostics
– CLIA-waived
– Needs incubator
– Results in 10 minutes
Gen-Probe APTIMA
– Read at 3 and 5 days
– 83% sensitive compared
Trichomonas vaginalis Assay
to culture
• Same specimen types as for
• other APTIMA tests
• Close to 100% sensitive;
• Slightly less sensitive using urine
• Over 99% specific
Trich in HIV + Women
• Screen on entry to care
• Retest at 3 months after treatment
• Consider metronidazole 500 mg p.o.
bid x 7d instead of stat dose
OH, NO!! She’s allergic to
metronidazole!
Treatment Options with
“Azole” Allergy
• Consult with specialist
– Metronidazole desensitization
• Helms et al, Am J Obstet Gynecol 2008
• Perlman et al, Am J Obstet Gynecol, 1996
• Kurohara et al, j Allergy Clin Immunol, 1991
• Paramomycin vaginal inserts
– not as effective
8. Encourage Good Old Condoms!
Openers for a Conversation
about Condoms
• Tell me about your experience with
condoms.
• Some men take condoms almost for
granted, and other men really dislike them.
What about you?
• How willing have you found guys to be
about using condoms?
Making the Change
Goal: to improve patient care by improving
medical practice
What can you do on your own?
What can you realistically influence?
What can you advocate for?
THANK YOU!!!!
Questions?
A bit more info…..
Online STD Resources
CDC Treatment Guidelines
www.cdc.gov/std/treatment
California STD/HIV Prevention Training
Center
www.stdhivtraining.org
California Department of Public Health
STD Control Branch
www.std.ca.gov
California Laws and
Regulations
STD Reporting to Public Health
• Which diseases?
–
–
–
–
–
–
Syphilis  within 1 day
HIV/AIDS
Chlamydia, including LGV
Gonorrhea
Chancroid
Pelvic Inflammatory Disease (PID)
Within
7 days
• By whom?
– Provider and Laboratory
• To whom? The jurisdiction where patient resides
• How? CMR to be completed by the provider
Partner Management
Provider Responsibility
• The clinician should:
– Attempt to determine the source of infection
– Determine the intimate and sexual contacts of the
infected patient
– Make an effort with patient to bring in those contacts
for exam and treatment
• Persons determined as source of infection but not
under treatment within 10 days of infection should
be reported to the health officer
• EPT is allowable for CT, GC, and trichomoniasis
CCR Title 17 §2636
Minor’s Rights to STD Care in
California
• Minors age 12 and above are able to consent to
STD and reproductive health care without parental
permission
• As of January 1, 2012, minors may also consent to
medical care related to prevention of STD (e.g.,
HPV vaccine)
• Minors have a right to confidentiality
• Parents are not liable for costs of STD care
• Reporting requirements for non-consensual (and
“unlawful”) sexual activity
CA Family Code §6926
Transmission of HSV-2 to Susceptible Partners is
Reduced with Once-Daily Suppression
• Monthly serum samples
collected from susceptible
partners
• Valacyclovir group showed
• decreased transmission
• lower frequency of shedding
• fewer copies of HSV-2 DNA
when shedding occurred
4
Percent Transmission
• 1484 heterosexual couples
randomized to 500 mg of
valacyclovir vs placebo once
daily for 8 months
3.6%
3.5
3
2.5
2
1.9%
1.5
1
0.5
0
Valacyclovir
Group
Control
Group
(N=743)
(N=741)
Corey et al, NEJM 2004; 350(1):11-20.
Gardasil or Cervarix: Which is better?
• BOTH HPV Vaccines:
• Effective in preventing 16/18-related cervical dysplasia
• Good safety profile
• High cost
– Gardasil advantages:
• Protects against 6/11-related genital warts
• Licensed for males
• Indications vulvar/vaginal dysplasia
– Cervarix advantages:
• Higher titer levels
• May give greater cross-protection against other oncogenic
HPV types
• Effectiveness data for preventing persistent re-infection