Sexually Transmitted Infections

Question 1

Chlamydia Trachomatis

Answer 1

• Most common bacterial STI in males and females
• Gram negative bacteria

Presentation:
- Most females and males are asymptomatic
- If symptoms are present:
- Males: Urethritis, dysuria and discharge
- Females: Cervicitis, vaginal discharge, polyuria, dysuria, pain with intercourse and bleeding between menstrual periods.

Diagnosis:
- Nucleic Acid Amplification Testing (NAAT)
- Females: Vaginal swab (Can be “self swab”)
- Males: First catch urine

Treatment:
- Doxycycline first line for non pregnant person without allergy.
- Azithromycin is alternative option
- Refrain from sexual intercourse until antibiotic is finished and all symptoms have resolved.
- Treat sexual partners
- All individuals treated for chlamydia should undergo retesting after three months.

Question 2

Neisseria Gonorrhoeae

Answer 2

• Second most commonly reported STI
• Gram negative bacteria

Presentation:
- Majority of patients are asymptomatic
- If symptoms present, males are more asymptomatic than females.
- Pruritus, purple t discharge and occasionally dysuria.

Diagnosis:
- Test of choice: Nucleic Acid Amplification Testing (NAAT)

Treatment:
- Ceftriaxone
- Treat partners

Question 3

Herpes Simplex Virus

Answer 3

• HSV 1 may cause oral lesions and less commonly genital lesions
• HSV 2 is the predominate cause for genital lesions
• Incubation period for developing lesions after an exposure is 2 to 12 days

Presentation:
- First occurrence may involve systemic illness, with painful genital lesions
- Grouped 2 to 4mm vesicles, with surround erythema that progresses to vesicles or pustules.
- Recurrence of genital HSV are common but are typically less severe than the initial infection

Diagnosis:
- PCR testing from an active lesion
- Serologic testing for patients without active lesion

Treatment:
- First episode:
- Treat with antivirals preferably within 72 hours of lesions first appearance
Example: 1000mg of Valacyclovir BID for 7 to 10 days.
- Episodic therapy:
- Give patient own supply and instruct to start within 24 hours of symptoms
- Suppressive therapy:
- Acyclovir for patients with >6 recurrent episodes per year.

Question 4

Condylomata Acuminata (CA)

Answer 4

• Also known as anogenital warts
• Manifestation of human papillomavirus (HPV) infection
• Low risk types of HPV 6 and GPV 11 are detected in approximately 90%
  
  • HPV types 16 and 18 are the most commonly associated with cervical cancers

Presentation:
- May appear. Flat, dome-shaped, or cauliflower-shaped
- Warts appear in varying colors (white, skin colored or erythematous)
- Usually develops on the vulva, penis, groin or perineum

Treatment:
- Vaccination against HPV can prevent CA from occurring
- Up to 30% spontaneously resolve within 4 months
- Pharmacological options:
- Non-pregnant, immunocompetent patients with 5 or less warts: Imiquimod or Podoophyllotoxin
- Extensive disease or warts that are >20cm in size: surgery or laser ablation.

Question 5

Trichomoniasis

Answer 5

• A genitourinary infection caused by the protozoan Trichomonas Vaginalis

Presentation:
- 11 to 17% of patients with trichomoniasis with experience symptoms.
- Symptoms may include: Purulent, malodorous, thin discharge with associated burning, pruritus and/or dysuria.
- Patient may have a “strawberry cervix”

Diagnosis:
- Nucleic Acid Amplification Test (NAAT)
- Microscopic evaluation (Motile trichomonads are seen)

Treatment:
- Metronidazole, Tinidazole or Secnidazole
- Treat sexual partners
- Sexually active women should be retested within three months of completing treatment, to confirm cure from infection

Question 6

Syphilis

Answer 6

• STI caused by the Spirochete Treponema Pallidum
• Divided into the stages primary infection, secondary infection and tertiary infection

Presentation:
- Primary: Presence of a chancre
- Secondary: Diffuse, symmetric macular or papular eruption involving the entire trunk and extremities and does include the palms and soles
- Tertiary: Aortic insufficiency, general paresis, neurosyphilis

Diagnosis:
- Serologic tests: Nontreponemal tests and treponemal-specific tests
- One test is insufficiency for diagnosis

Treatment:
- Screen for other STI’s, including HIV
- IM Penicillin G Benzathine for early syphilis, syphilis without neurosyphilis
- IV Penicillin G Benzathine for neurosyphilis

Question 7

Human Immunodeficiency Virus (HIV)

Answer 7

• Incurable virus that attacks the body’s immune system by targeting dendritic cells, macrophages and CD4+ T Cells
• Early HIV infection: Viral RNA level is typically very high (eg, >100,000 copies/mL)

Risk factors:
- Men who have sex with men, IV drug users, healthcare works who incur a needle stick injury

Presentation:
- Fever, Lymphadenopathy, sore throat, rash, myalgia/arthralgia, headache, painful mucocutaneous ulceration

Diagnosis:
- Both and HIV virologists test and an antigen/antibody test
- Negative Antigen/antibody test PLUS a negative virologist test.
- Negative Antigen/antibody test PLUS a detectable viral load.
- Positive Antigen/antibody test PLUS a detectable viral load.

Treatment:
- Antiretroviral therapy (ART) as soon as possible

Question 8

Pre-Exposure Prophylaxis (PrEP) with antiretroviral therapy

Answer 8

• If properly adhered to, PrEP can reduce the risk of HIV transmission by more than 99%

Who should received PrEP:
- Person who have a sexual partner with HIV, men who have sex with men, transgender women who engage in anal sex, IV drug users, heterosexual persons who have sex with partners who are at an increased risk of contracting HIV.

Important points:
- Prior to initiating PrEP, it is important to confirm that the individual does not already have HIV.
- Evidence shows association between adherence to the treatment regimen and the efficacy of PrEP.
- Patients who engage in anal sex should be advised to continue using condoms for seven days after beginning their PrEP regimen.
- Patients who engage in vaginal sex should continue to use condoms for 21 days after initiating PrEP.

Question 9

PrEP Regimens

Answer 9

• Oral preparations
  
  • Tenofovir Disoproxil Fumarate-Emtricitabine (TDF-FTC)
    
    • Well tolerated
    • Most studied
    • Avoid in persons with reduced kidney function or osteoporosis
  • Tenofovir Alafenamide-Emtricitabine (TAF-FTC)
    
    • Well tolerated
    • Less bone and renal toxicity (compared to TDF)
    • Should not be used in those whose main risk for HIV is vaginal sex or who inject drugs.
• Long acting injectable:
  
  • Cabotegravir LA (long acting)
    
    • Well tolerated
    • Injectable administered every other month (need to be near a center that administers)
    • Clinical trials suggest greater efficacy than TDF
    • Not yet been studied in persons who inject drugs

Question 10

Post-exposure prophylaxis (PEP) with antiretroviral therapy

Answer 10

• Given post exposure or after a likely exposure

Who should received PEP?
- Patients who present within 72 hours of sexual intercourse or percutaneous exposure to a source with HIV
- Patients who present within 72 hours of sexual or percutaneous exposure to a source with a high risk of having HIV
- Patients who have been sexually assaulted

Important points:
- If you do not know whether you should prescribe PEP, you can call the national clinicians PEP hotline.
- Patients who are already taking PrEP generally do not require additional PEP, unless they report taking their medication sporadically or if they have not taken their PrEP medication within the week before exposure.

Preferred PEP regimen
- Tenofovir Disoproxil Fumarate-Emtricitabine (TDF-FTC) PLUS dolutegravir
- Start ASAP: Do not delay pending HIV testing