10/22/2018. Disclosures. Acknowledgments INSTRUCTIONS. To join this session, please send the text message NYCPTC394 to the number 37607

Transcription

1 The Perfect Storm: STIs and College Students NYSCHA Conference 2018 Disclosures None* Alwyn Cohall, MD FAAP FSAHM Professor, Pediatrics and Public Health Columbia University Medical Center Acknowledgments Dr. Kathy Hsu and Dr. Natalie Neu Gowri Nagendra, MPH and April Pavlish, MPH Carlos Romero INSTRUCTIONS To join this session, please send the text message NYCPTC394 to the number You will be able to text your response to questions on polling slides. 1

2 My background Project STAY Primary affiliations = Columbia University s Mailman School of Public Health and New York Presbyterian Hospital Comprehensive medical and psychosocial services to Youth at risk for, or living with, HIV* Funded by NYS DOH AIDS Institute Integrated into a Designated AIDS Center at New York Presbyterian Hospital The Comprehensive Health Program Project STAY clinic PTC Background Funded by the Centers for Disease Control and Prevention (CDC) The STD/HIV Prevention Training Centers (PTC) are dedicated to increasing the sexual health knowledge and skills of clinical health professionals in the prevention, diagnosis, management and treatment of sexually transmitted diseases 2

3 National Network of Prevention Training Centers (NNPTC)*** Eight regional training centers that comprise the National Network of STD Clinical Prevention Training Centers ( 50% of new STIs: youth $19 billion in annual cost NNPTC FOA Reg Alabama/NC PTC Apex PTC National Techonological In Baltimore (JH) PTC Boston (Ratelle) PTC California PTC Denver PTC Also runs national Quality I Also runs national TI Cente New York PTC Seattle PTC St. Louis PTC Also runs national Curriculu CDC: Incidence, prevalence, and cost of STIs in the US. Feb 2013 Emotional Costs Adolescents and Young Adults and Sexual Activity 3

4 Sexual activity - Overall In the general population, 86% of women and 84% of men, 18-24, report heterosexual vaginal, oral or anal sex 19% of women and 7% of men report same sex contact Sexual Activity - Recent Within the past 30 days: Vaginal sex: 37% of males and 46% of females Anal sex: 6% of males and 5% of females Oral sex: 38% of males and 42% of females Copen CE, Chandra A, Febo-Vazquez I. Sexual Behavior, Sexual Attraction, and Sexual Orientation Among Adults Aged in the United States: Data From the National Survey of Family Growth. Natl Health Stat Report 2016:1 14. ACHA-National College Health Assessment II Undergraduate Student Reference Group Executive Summary Fall 2017 Condom use within the past 30 days Vaginal Sex 55% of males and 46% of females Anal Sex 35% of males and 21% of females Oral Sex 5% of males and 5% of females Alcohol use Last 30 days: 58% males and 60% of females 5 or more drinks at one time within the past two weeks: 36% of males and 26% of females (between 1-6 or more times) Had unprotected sex in the past year while drinking: 21% of males and 21% of females Someone had sex with me without my consent in the past year: 1% of males and 4% of females 4

5 Merriam Webster Dictionary 10/22/2018 Perfect Storm Definition of perfect storm a critical or disastrous situation created by a powerful concurrence of factors Importance of College Health Services Serve a population that Is transitioning from an environment with more oversight and support to one with less is sexually-active, inconsistent with condoms, and may be prone to risk-taking, especially when alcohol and drugs enter the equation Hogben et al. STDs.2017;44, 11 Importance of College Health Services On the frontlines Providing needed evaluation, treatment, education and referrals, which can have immediate and long-term ramifications Your work is key to safeguarding and preserving the health of young people Overview Utilizing a case-based format Epidemiology Risk factors and co-morbidities Expanding the Sexual History Enhancing STI screening Treatment and Management Prevention and Intervention* 5

6 Case #1 Meaghan, 18 yo freshman from Long Island, undecided Has been experiencing frequency, urgency and dysuria for a week No relief with cranberry juice Barriers to care First time on own Overwhelmed Embarrassed Not sure how to access services or know where they are Facilitators Sex hx Advised by her RA,Maria, to get checked at the Student Health Service RA s can be an important resource Garcia et al. Public Health Nurs ; 31(5):

7 Primary care providers and sexual history taking US Preventive Task Force and the National Academy of Sciences recommend providers take a sexual history from their patients at least annually 91% of patients agree with this recommendation Tao et al. Am J Prev Med 2000 But INSTRUCTIONS To join this session, please send the text message NYCPTC394 to the number You will be able to text your response to questions on polling slides. Primary care providers and sexual history taking Studies indicate that only about 10-33% of providers obtain routine sexual histories And, when they do Infrequently ask about key parameters such as sexual practices Wimberly et al Journal National Medical Association

8 Newest vital sign Sexual health should be the newest vital sign Michael Horberg, MD Director, HIV/AIDS for Kaiser Permanente Framework: CDC 5 Ps Partners Who are you attracted to? Male/female/trans? # ltsp?; last 3 months? Practices Types of sex? Prevention of Pregnancy Prescribed and non-prescribed Protection from STDs Condom utilization; barriers and enablers Past history of STDs Lifetime hx; types; treatment; impact on sexual practices? Case #1 Sex hx: Partners: 2 ltsp, sexual debut age 16 Practices: vaginal sex, 2 weeks ago Prevention of Pregnancy: inconsistent with condoms; lmp = 1 week ago Prevention of STIs: inconsistent with condoms Past hx of STIs: none, but no previous screens, pediatrician never asked her about sexual activity, CDC recommends: Initial and annual screening for sexually-active individuals Repeat screening every 3-6 months for those at highest risk* MSMs Multiple sex partners Use of drugs and alcohol Partners who use drugs or alcohol 8

9 STI screening among pediatricians Studies suggest that less than 50% of clinicians report recommending STI screening for sexually-active adolescents Henry-Reid LM et al. Pediatrics 2010 Implications Range of Sexual Health Services Provided by College Health Centers College health services may be the first opportunity for some students to obtain sexual health services 9

10 Sexual Health Services in College Health education 86% Pregnancy testing 74% Diagnosis and treatment of STI 64% HIV testing 62% Contraceptive services 58% CT/GC screening 41% Trich screening 24% LABS Urine preg neg U/a: dip (+) for wbc, rbc and protein Urine culture: neg Urine naats: (+) for CT and (-) for GC Hogben et al. STDs.2017;44, 11 Chlamydia Treatment More Stats Recommended treatment (non-pregnant): Azithromycin 1 g orally in a single dose Doxycycline 100 mg orally twice daily for 7 days Recommended treatment (pregnant): Azithromycin 1 g orally in a single dose 10

11 STIs in NY State Source: CDC Reported Chlamydia Case Rates (per 100,000 population) by age and sex*, 2016, NYC Males Females *excludes persons for whom sex or age were not reported Prevalence of CT in College 2015 ACHA Pap and STI survey report from 128 campuses CT = 6.5% positivity rate GC = 1% positivity rates ,000 1,000 1,000 3,000 5,000 Case Rates/100,000 population Benbrook A, Brown J, Butler S, et al. ACHA 2015 Pap and STI survey for calendar year 2014 data. Available at: st_and_ STI_Survey_fulldatareport.pdf. Accessed December 14,

12 Additional services HIV testing PrEP Additional services: Contraception Pre-exposure prophylaxis Daily dose of Truvada Can reduce the chances of getting infected with HIV 12

13 Health Education Provider- Patient communication Provider-Patient Relationship & Communication Keys to Overall Outcomes Hearing a diagnosis 85% of patients don t fully understand what the doctor tells them OVER 50% of patients leave the office unsure of what they are supposed to do Source: Kaplan SH, et al. Med Care. 27(3 Suppl):S110-S127. Source: Kaplan SH, et al. Med Care. 27(3 Suppl):S110-S127 13

14 Reactions Shock Adolescents/Young Adults feel invincible* College campus are insulated from the outside world a forcefield STIs happen to other people Now I am one of them Reactions Anger How could I have been so reckless, so stupid? How could someone I care about do this to me? Strategies Strategies Non-judgmental approach Avoid piling on How can someone so bright act so irresponsibly? Don t you know chlamydia is a serious infection and can make you sterile! This is a window of opportunity to enhance self-reflection and promote behavior change Bumpy process! Tell me what you know about Provide basic information Many of the students I work with tell me that they have not been taught much about STIs in school, so don t beat yourself up. Here s what you need to know AVOID JARGON!!! Refrain from SCARE tactics CT can cause you to have scarring of your tubes which can lead to infertility In their out of body state, young people hear selectively 14

15 Use Pamphlets and other written materials Advantages: Familiar Non-threatening Reinforces instructions Transfer of information when patient is more receptive Refer to websites GoAskAlice ASHA Planned Parenthood CDC.gov Strategies Tell me how you are feeling right about now Allow for ventilation Gently offer some alternative scenarios Most people have no symptoms with Stis. Your partner may not have know he/she had a problem Let s come up with a plan together about how to deal with this Briefly describe treatment, management, future prevention Explore and address barriers to condom use Outline options for partner notification Arrange for follow-up and referrals, if necessary Additional services Partner management All partners within the last 60 days should be contacted and treated EPT 15

16 Expedited Partner Therapy (EPT) Expedited Partner Therapy (EPT) is a partner management strategy to treat sex partners of patients diagnosed with Chlamydia trachomatis (Ct) EPT can be given without the health care provider first examining the sex partner Clinician provides medication or a prescription for Azithromicin to the patient s partner/s Benefits of EPT Randomized controlled trials have shown: EPT decreases rates of Ct re-infection among the index patients Increases the proportion of sex partner(s) reported to be treated for Ct Particularly important as males less likely to seek health services as compared to females EPT and College Health Survey of 367 college health services EPT was utilized by 36% Hogben et al. Sexually Transmitted Diseases 2017 Additional services: HPV Vaccination 79 million Americans currently infected with HPV 14 million new infections annually Almost half of young people may be infected Certain strains implicated in cervical, vaginal, penile, anal and oropharyngeal cancer 16

17 Additional Services Follow-up HP2020 goal = 80% completion of vaccination series among year olds But more than half (51%) of all adolescents have not completed the HPV vaccination series Traditional barriers such as: lack of insurance coverage, access to health care, and ability to make independent health decisions are less relevant for college students College health services may be able to provide catch up vaccination services No need for TOC, unless symptoms persist* May be a good idea to check in with her in a few days to reinforce messages and strategies for partner notification/management 3 months for repeat screening to ensure patient has not been reinfected Time to Share Health education strategies on your campus/health center? Case #2 Michael, 19 yo sophomore from the Bronx, chem major 17

18 Case #2 Case #2 Presents with rash on hands Wonders if he has a latex allergy from wearing gloves in the lab Sex hx: Partners: 10 ltsp, 2 female, 8 male (for the last year exclusively male partners Expanded Framework: CDC 5 Ps Partners Where do you meet your partners? Mobile apps Providers should be aware of where and how MSM might be meeting their sexual partners 18

19 Meanwhile Where did MSM with P&S syphilis meet sex partners in 2013? Venue n/n (%) Internet only 135/275 (49) Internet + any other 32/275 (12) venue Other single venues 59/275 (21) Other multiple venues 49/275 (18) 61% NOTE: 574 MSM P&S morbidities diagnosed Jan1, 2013 through Dec 31, 2013, preliminary numbers 559/574 (97%) interviewed; 275(49%) reported > 1 venue 77 Implications? Social media makes it easier to meet prospective partners and facilitates casual hook-ups Expanded Framework: CDC 5 Ps Partners Where do you meet your partners? Grindr and clubs 19

20 Framework: CDC 5 Ps Expanded Framework: CDC 5 Ps Practices In addition to asking about oral, vaginal or anal sex, inquire about other practices such as: oral-anal contact Practices: insertive and receptive anal and oral sex ( verse ); as well as oral-anal sex rimming; last sex 2 weeks ago Expanded Framework: CDC 5 Ps Prevention of Pregnancy: n/a at present Prevention of STIs: inconsistent with condoms Past hx of STIs: none LABS RPR: 1:64 FTA: Reactive Previously NR as a freshman Rx: LA Bicillin, 2.4 million units IM 20

21 Cases / 100,000 10/22/2018 Reported P&S Syphilis Case Rates NYC, Male Fem ale STD Screening for MSM* Screen at least annually, q 3-6 mos if high risk* HIV Syphilis Urethral GC and CT Rectal GC and CT (if anal sex) Pharyngeal GC (if oral sex) Also screen for: Hepatitis C (in HIV+ MSM: repeat as indicated by risk) * High risk: multiple and/or anonymous partners, drug use, or high risk partners CDC 2015 STD Tx Guidelines 21

22 Additional services HIV and Syphilis HIV testing 4 out of 10 MSM with syphilis are co-infected with HIV Syphilis will increase the HIV viral load of infected individuals Individuals with syphilis have 2-5 fold increased risk of acquiring HIV if exposed Gail Bolan, CDC.gov Additional services PrEP Additional services Extra-genital screening 22

23 STIs Are a problem for everyone Particularly, MSMs But Only 36% of MSMs report being screened for STIs (at any anatomical site in the past year) When evaluated, urethral screening is more common than pharyngeal or rectal screening Tai E, et al. Self-reported syphilis and GC testing among MSM attending US STD clinics Sex Transm Infect 2008;84: What proportion of CT/GC infections may be missed if extragenital sites in MSM are not screened? 1. 10% 2. 25% 3. 50% 4. Over 50% What s the big deal with extragenital testing? Use STD surveillance Network data from 42 STD clinics Of 21,884 MSM: 84% GC urogenital test 66% GC pharynx 50% GC rectal 81% CT urogenital 32% CT pharynx 46% CT rectal 23

24 Findings Findings 11.1% tested (+) for urogenital GC 7.9% tested (+) for pharyngeal GC 10.2% tested (+) for rectal GC 8.4% tested (+) for urogenital CT 2.9% tested (+) for pharyngeal CT 14.1% tested (+) for rectal CT More than 70% of extragenital GC and 85% of extragenital CT were associated with negative urethral tests and would have been missed!!! Making it Easier Have testing materials available in exam rooms Offer option for self-administered swabs Some patients prefer this approach and there are good results if properly instructed 24

25 Labs HIV (-) Oral CT (-); GC (+) Urethral CT (-); GC (-) Rectal CT (-); GC (+) Treatment: Azithromycin + Ceftriaxone* HIV and rectal STI 7% of MSMs with a rectal STI became HIV (+) within a year as compared to 3% of MSMs without a rectal STI (> 2 fold increase) 70% of those rectal STIs were asymptomatic!!!! Pathela P, Braunstein SL, Blank S, et al. HIV incidence among men with and those without sexually transmitted rectal infections: estimates from matching against an HIV case registry. Clinical Infectious Diseases Oct;57(8): Additional Labs In light of hx of rimming, may also want to inquire about GI symptoms Bloating Flatus Loose stools Blood in stools May be an indication for a GI PCR to look for enteric pathogens Additional services Immunizations Hep A* and Hep B (if susceptible) Gardasil MenACWY (Menactra or Menveo) Booster dose every 5 years if remain at risk CDC. Advisory Committee on Immunization Practices (ACIP). ACIP Votes, June Online at 25

26 Additional layers to the Sex hx General Content Areas: Expanding the Sexual Health History Substance use Mental health issues (depression, anxiety etc.) PHQ2, PHQ9, GAD-7 History of trauma (ACES), abuse, survival sex, sexual victimization, unwanted sex, intimate partner violence Self-administered questionnaires Patients are used to completing general surveys before seeing providers Consider adding questions about sexual behavior Standardizes risk-assessment* May create a new norm Reduces discomfort Saves time* More Communication. Less stigma. Health Risk Screening App Universal. Comprehensive. Designed for Communication. Asking questions about sexual behavior can be challenging. And it s not only about sex. There are other related issues like safety and trauma, anxiety and depression, and alcohol and drugs. Just Health navigates tough questions for a better conversation about health. Features include: Instant Individual Alert Reports Population-Level Aggregate Reports Focus on Intersectionality Clinical Guidance HEEADSSS Counseling Messages Built on ACES EHR Interoperable evidencebased tools GAD-7 PHQ-9 and practices CRAFFT 2.0 CDC Sexual History Guidelines Just Health isn't a substitute for the conversation - it's a bridge to it. 26

27 Contact Information Carlos Romero Additional information obtained Expanded sexual history Substance use Alcohol several times a week Mollies and poppers when clubbing Sexualized Drug Use (SDU) Sexualized Drug Use (SDU) CHEMSEX ; Party and Play; Intensive Sex Partying (ISP) Drug use with the intention of intensifying sexual experiences Used by MSMs for long periods of time, may have multiple partners Drugs = crystal meth; ketamine (Gonzalez-Baeza et al. AIDS Patient Care and STDs 2018) May be associated with ED Use of Viagra, Cialis Another perfect storm = sexual arousal, disinhibition, improved erectile function Viagra + poppers = decreased BP, fainting 27

28 Additional information Additional services Mental health issues (depression, anxiety etc.) PHQ2, PHQ9, GAD-7 PHQ 9 = 12 moderate depression Issues with parents re: sexuality Referral to counseling center to address depressive symptoms and possible self-medication History of survival sex, sexual victimization, unwanted sex, intimate partner violence Denies Case #3 Christina. 20 yo female, Junior from Albany, psych major Presents with sore throat Case #3 Sex hx: Partners: 5 ltsp, 2 female, 3 male; last partner = male Practices: vaginal and oral sex; last sex 2 weeks ago, casual contact, not currently in a relationship Prevention of Pregnancy: nuvaring Prevention of STIs: 90% condoms for vaginal; 0% for oral Past hx of STIs: chlamydia during high school, treated 28

29 Labs Strep neg, mono neg Research Studies Candidate for extra-genital testing? No specific guidelines for extragenital testing among females However, based on sexual practices, may be important to consider 46% of females report lifetime history of anal sex with 23% in past year and 8% in the previous month Herbenick D et al. Sex Med 2010 Research Studies 20-40% of GC infections and 10-25% of CT infections in women would be missed if extragenital testing were not done Often asymptomatic Barry et al Obstet Gynecol 2010 Giannini et al J Ped Adolesc Gynecol

30 STI education Sex myths Sex active but sex illiterate STDs can only be transmitted when there are symptoms Only people with multiple partners have to be concerned about STDS Oral sex is safe sex Health Education 57% of college students say they have gotten some information about STIs from their college/ university But 43% have not Labs Oral naats: CT (-); GC (+) Treated: Azithromycin and Ceftriaxone ACHA-NCHA IIc Undergraduate Reference Group Report, Fall

31 Additional services Partner notification: expresses reluctance, concerned about reactions Options: InSpot Don t Spread IT Options? InSpot.org which will use to alert former partner to the need for testing Will also provide listings of clinics in their communities DontSpreadit.com Dont SpreadIt.com An example of the text message we send: A past sexual partner has sent you a message concerning your health. Visit dontspreadit.com/?s=test to retrieve your message 31

32 Additional services Expanded sexual history Substance use: MJ on weekends Mental health: saw a counselor for anxiety during high school, reports no current issues Unwanted sex: denies Case#4 Jeremy, 20 yo Junior from Syracuse, Economics major Presents to get treatment for athletes feet Exam reveals cracked, peeling skin between toes Rx for econazole given As he is heading out the door Hidden agenda Case #4 Doorknob dx Oh, by the way I got this stuff coming out of my joint Sex hx: Partners: 8 ltsp, all female Practices: vaginal and oral sex; last sex 1 week ago (Went down to Cancun for Spring Break with his Frat Brothers) Prevention of Pregnancy: whatever she is using Prevention of STIs: 50% condoms for vaginal; 0 for oral; during spring break, 2 partners, no condoms, blasted Past hx of STIs: none 32

33 Labs HIV (-); RPR (-) (-) GC; (+) CT Treated: Azithromycin The story continues Returns 2 weeks later, symptoms persist The story continues He reports compliance with treatment and sexual abstinence. 33

34 Treatment Failure? RCT: Chlamydia Treatment Azithromycin vs. Doxycycline Antibiotic group Treatment failures Efficacy Doxycycline 0 100% Azithromycin 5 (3.2%; 95%CI %) 97% Captive audience: juvenile detention facilities Difference in failure rates was 3.2% The non-inferiority of azithromycin was not established Both medications are effective Azithro had some treatment failures, but adherence is likely to be much greater with single-dose azithromycin Geisler et al. NEJM 2015;373: DDx for Persistent Urethritis Trich Testing in Men Consider T. vaginalis More common in heterosexual men Trich does not inhabit oral or anal mucosa No approved point of care tests Wet prep not sensitive Culture available: urethral swab, semen or urine No conclusive studies on sensitivity/specificity Urine and urethral swab NAAT offered through certain labs using analyte-specific reagents (check before sending) May benefit from empiric treatment with metronidazole or tinidazole 34

35 Other organisms? Mycoplasma Mycoplasma genitalium: Epidemiology First identified in the early 1980 s Cause of male urethritis 15-20% of non-gonococcal urethritis (NGU) cases 20-25% of non-chlamydial NGU 30% of persistent or recurrent urethritis More common than N. gonorrhoeae but less common than C. trachomatis Co-infection with C. trachomatis can occu Unknown whether it can cause male infertility or other male anogenital tract disease syndromes Pathogenic role in women also less clear Mycoplasma genitalium: Diagnostics Very slow-growing organism Culture can take up to 6 months Only a few laboratories in the world are able to recover clinical isolates Nucleic acid amplification testing (NAAT) is the preferred method to detect M. genitalium Research settings In-house PCR assays (?) None commercially available (YET) Treatment of MG: Azithromycin but have cases of resistance Takahashi 2011 J Infect Chemother;17:392 Ofloxacin, ciprofloxacin, and levofloxacin not highly active Moxifloxacin No RCTs Reviewed by Manhart 2013 Infect Dis Clin N Am 27:779 Observational studies suggest high efficacy of 400mg PO X 7-14d But recent emergence of fluoroquinoloneresistant mutations with suggestion of clinical Tagg 2013 J Clin Microbiol 51:22; Couldwell 2013 Int J STD AIDS 10:822 and microbiologic treatment failures 35

36 LABS Urine naats (-) for trich Treated presumptively with Moxifloxacin Symptoms resolved Take Home Points Use strict objective criteria to define recurrent or persistent urethritis Likely pathogens depend on sexual behaviors and risk history Management is difficult if neither gonorrhea nor chlamydia are diagnosed on subsequent testing Rule out reinfection Test for T. vaginalis using NAAT Strongly consider M. genitalium in DDx (may be difficult to test for and treat) Additional services Expanded sexual history Substance use: alcohol 5-6 drinks, 1-2x per week, along with MJ Mental health: hx of depression, was in counseling briefly during high school; family hx of depression and alcoholism Unwanted sex: denies Additional services Referral to mental health services 36

37 Case #5 James, 19 yo sophomore, transfer from Michigan, musician Presents with rash on shaft of penis Broke-up with girlfriend 1 month ago Has been masturbating several times a week without use of lubricants Wonders if it might be a friction burn? James s rash Labs Wound culture = negative for staph and strep Viral PCR = (+) for HSV 1 37

38 What About Genital HSV-1? HSV1 now causes MOST of first genital HSV episodes in young adults HSV1 2.3x more common than HSV2 infection Genital HSV1 2.5x more common than oral HSV1 Increasing proportion of anogenital herpetic infections have been attributed to HSV-1 infection in women and MSM Primary genital HSV1 and HSV2 remain indistinguishable clinically, and are treated with the same antiviral regimens HSV2 more likely to recur than HSV1 Bernstein DI et al., CID 2013 Whitley RJ, CID 2013 Ryder N et al., STI 2009 Roberts CM et al., STD 2003 Genital Herpes Manifestations Classic multiple painful vesicular or ulcerative lesions often absent Systemic manifestations (fever, headache, and malaise) can occur Local manifestations (pain, itching, dysuria, vaginal or urethral discharge, and tender local inguinal adenopathy) common, and can be subtle with recurrent genital herpes Complications include aseptic meningitis, autonomic nervous system dysfunction, transverse myelitis, sacral radiculopathy, and fungal superinfection Treatment First Clinical HSV Episode Acyclovir 400 mg PO tid Acyclovir 200 mg PO 5x per day Famciclovir* 250 mg PO tid Valacyclovir** 1 g PO bid for 7-10 days or until clinical resolution *not licensed for <18 yrs **not licensed for pre-pubertal 38

39 Treatment Episodic Recurrent HSV Acyclovir 400 mg PO tid Acyclovir 800 mg PO bid Valacyclovir** 1 g PO qd Famciclovir* 125 mg PO bid all for 5 days, OR Valacyclovir** 500 mg PO bid for 3 days, OR Acyclovir 800 mg PO tid for 2 days, OR Famciclovir* 1 g PO bid for 1 day, OR Famciclovir* 500 mg PO x 1 dose, then 250 mg PO bid for 2 days Start during prodrome or within 1 day of lesion onset Treatment Daily Suppressive HSV Therapy Among patients with frequent recurrences (>6/yr), reduces frequency by 70-80% Safe and efficacious Acyclovir up to 6 yrs documented experience Valacyclovir and famciclovir up to 1 yr Regimens Acyclovir 400 mg PO bid Famciclovir* 250 mg PO bid Valacyclovir** 1 g PO qd Valacyclovir** 500 mg PO qd (may be less effective in those with >10 episodes/yr) Discuss need to continue therapy annually with patient *not licensed for <18 yrs **not licensed for pre-pubertal CDC 2015 STD Treatment Guidelines *not licensed for <18 yrs **not licensed for pre-pubertal Want to know more about STDs? There s an app for that. CDC STD Treatment Guidelines App for Apple and Android Patient reactions I feel like I am radioactive! Available now, FREE! (accept no competitors) Search STD Treatment in App store 39

40 I HAVE WHAT?!? Initial visit suggestions for confirmed cases The 4 T s Transmission (Acquisition) Treatment Telling your partner Therapist Marshall, Contraceptive Tech, Boston 2010 Discuss natural history Potential for recurrence Counseling Asymptomatic shedding Sexual transmission risk First episode Discuss episodic or suppressive therapy Encourage partner notification But they may already be infected and asymptomatic, and should be offered serology to determine if risk for HSV acquisition exists Abstain from sex when lesions or prodrome present Condoms reduce risk of transmission Transmission can occur when asymptomatic More shedding with HSV2 than with HSV1 More shedding in first yr after acquisition of HSV2 Risk of HSV2 transmission reduced with suppressive therapy Risks for neonatal infection Discuss with men and women Counsel pregnant women not known to be infected with either HSV1 or 2, to avoid genital exposure Asx persons dxed with HSV2 by type-specific serology should receive same counseling messages as persons with sx HSV2-infected persons are at greater risk for HIV acquisition following exposure CDC 2015 STD Treatment Guidelines Counseling Study from 2004 showed that patients were satisfied with their care if they had 15 minutes face-to-face with practitioner Much of the initial information was not retained 48 hours after visit Case #6 Ramon 25 yo Law student Just returned from traveling abroad MSM, on Prep Most felt that a follow-up visit would be helpful to answer questions and clarify key points Patrick et al. Sexually Transmitted Infections 2004;80:

41 Ramon in England Informed by partner in England that he may have been exposed to GC Urine naats in England reportedly negative Penicillin allergic* Treated with ciprofloxacin and doxycycline If truly Pen allergic Gemifloxacin 320 mg PO** + Azithromycin 2gm PO Or, Gentamicin 240 mg IM + Azithromycin 2 gm PO Ramon in the US Presents with testicular swelling Presumptive diagnosis made of orchitis Urine naats neg Rx ceftriaxone* and doxy for 10 days The story continues RTC 1 week later Swelling persists 41

42 Epididymo-orchitis treatment regimens Ceftriaxone 250mg IM + Doxy 100mg PO for 10 days If hx of insertive anal sex, consider enteric pathogens Ceftriaxone 250mg IM + Levofloxacin 500mg po daily for 10 days (or Ofloxacin 100mg bid for 10 days) We opted for sono Sono reveals suspicious mass c/w testicular cancer Refer to urology (+) tumor markers CT of abdomen and chest = no mets Orchietomy performed Lessons Learned STIs are common, especially among MSMs, but need to consider other options in the differential diagnosis 42

43 Case History #7 Case Hx Janine, 20 yo, junior, engineering major from Utica Transfemale comes in for refill of T blocker (spironolactone) Has new sex parter Wants to be checked just to be on the safe side No symptoms Sex hx: Partners: 10 ltsp: 4 cis-gender male, 5 cis-gender female, current partner is transmale Practices: vaginal, anal and oral sex; last sexual experience = 2 weeks ago Prevention of Pregnancy: n/a Prevention of STIs: inconsistent with condoms Past hx of STIs: none Labs How Symptomatic are STIs? HIV (-) Rpr (-) Naats (-) for GC: oral, rectal, urine Naats (+) for CT: urine Source: WHO HIV/AIDS/STI Initiative

44 Additional history Expanded sexual history Substance use: occasional cocaine Mental health: hx of anxiety and panic attacks Unwanted sex: denies but hx of intimate partner violence Additional Services Accepted referral for mental health counseling Want to know more about STDs? There s an app for that. CDC STD Treatment Guidelines App for Apple and Android Available now, FREE! (accept no competitors) Search STD Treatment in App store STD Clinical Consultation Network STDCCN NEW!!! Provides STD clinical consultation services within 1-5 business days, depending on urgency, to healthcare providers nationally Your consultation request is linked to your regional PTC s STD expert faculty Just a click away! 44

45 The National STD Curriculum integrates the most recent CDC STD Treatment Guidelines into a free, up-to-date, educational website. The site addresses the epidemiology, pathogenesis, clinical manifestations, diagnosis, management, and prevention of STDs. Seven Self-Study Modules Twelve Question Bank topics with 100+ interactive board-review style questions Modular learning in any order with progress tracker Group registration and tracking for staff, students, and health care organizations FREE CME and CNE credits Conclusion STIs are common, particularly among the college population STIs often co-morbid with each other; and with other risk-taking behaviors Taking an expanded sexual history may identify other issues in need of evaluation A comprehensive, integrated approach is important You can and will and DO make a difference! This curriculum was funded by a grant from the CDC and developed by the National Network of STD Clinical Prevention Training Centers Julissa Contact information Alwyn Cohall, MD Professor of Pediatrics and Public Health Columbia University Medical Center Mailman School of Public Health atc1@cumc.columbia.edu 45