X-Treme Primary Care: HPV and STIs. Arti Barnes MD MPH Clinical Director South Central AIDS Education and Training Centers

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2 X-Treme Primary Care: HPV and STIs Arti Barnes MD MPH Clinical Director South Central AIDS Education and Training Centers

3 Learning Objectives Review recommendations for HPV related cancer screening in women Describe strategies for STI management

4 Disclosures There will be no off-label/investigational uses discussed in this presentation.

5 Once upon a time.a 28 year old natal female was tested for HIV routinely at her Primary Care Clinic and was found to be positive. She has been in a monogamous relationship with her boyfriend of 4 years. Her provider refers her for HIV care and as part of her routine care, performs a cervical Pap. She has not been vaccinated for HPV. She denies any history of warts. Pregnancy test is negative.

6 Scenario One Her initial pap is negative. What advice do you give her? A) If her next two Paps are negative too, she can be screened every three years thereafter B) If her pap AND HPV test are negative next year, she can be screened every three years thereafter C) She will need annual screening regardless of pap results D) She will need annual screening till she is 65 y/o

7 Scenario One Her initial pap is negative. What advice do you give her? A) If her next two Paps are negative too, she can be screened every three years thereafter B) If her pap AND HPV test are negative next year, she can be screened every three years thereafter C) She will need annual screening regardless of pap results D) She will need annual screening till she is 65 y/o

8 In January 2016 ACOG/HIVMA recommended q 3 year screening if a) 3 negative paps b) 1 negative pap AND negative HPV test c) HPV co-testing only if 30 years and over IDSA Primary Care guidelines still recommend annual paps There are no age related cut offs for cervical cancer screening for women with HIV ACOG Practice Bulletin Number 167 October 2016 IDSA Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents 2017 Update IDSA HIV Primary Care Guidelines 2013

9 Scenario Two A year later, her pap reveals ASCUS (Atypical Squamous Cells of Undetermined Significance) and reflex HPV is positive for high risk HPV. What do you do next? A) Suggest a repeat Pap in 12 months B) Refer her for a colposcopy C) Recommend an anal pap D) Recommend HPV vaccination

10 Scenario Two A year later, her pap reveals ASCUS (Atypical Squamous Cells of Undetermined Significance) and reflex HPV is positive for high risk HPV. What do you do next? A) Suggest a repeat Pap in 12 months B) Refer her for a colposcopy C) Recommend an anal pap D) Recommend HPV vaccination

11 Management of abnormal results LSIL, ASC-H, HSIL, AGC COLPOSCOPY ASCUS Positive Reflex HPV test Negative No reflex HPV test ASCUS or worse Repeat pap in 6-12 M Normal Pap Return to annual screening ACOG Practice Bulletin Number 167 October 2016

12 Scenario Three She returns 6 months later complaining of a greenish vaginal discharge for 4 days. She tests positive for trichomonas and gonorrhea. She denies any other sexual partners besides her boyfriend. She denies any anoreceptive or oral intercourse. Exam does not reveal any adnexal tenderness or purulent discharge from the cervix. Pregnancy test is negative.

13 Scenario Three What do you recommend next? A) Treatment with Ceftriaxone 250 mg IM + Azithromycin 1g PO X 1 + Metronidazole 2g PO X 1 B) Treatment with Ceftriaxone 250 mg IM + Azithromycin 1g PO X 1 + Metronidazole 500 mg PO BID X 7 days C) Treatment with Ceftriaxone 250 mg IM + Doxycycline 100 mg BID X 7 days + Metronidazole 2g PO X 1

14 Scenario Three What do you recommend next? A) Treatment with Ceftriaxone 250 mg IM + Azithromycin 1g PO X 1 + Metronidazole 2g PO X 1 B) Treatment with Ceftriaxone 250 mg IM + Azithromycin 1g PO X 1 + Metronidazole 500 mg PO BID X 7 days C) Treatment with Ceftriaxone 250 mg IM + Doxycycline 100 mg BID X 7 days + Metronidazole 2g PO X 1

15 Gonorrhea Uncomplicated urethral/cervical/rectal gonorrhea Ceftriaxone 250 mg in a single intramuscular dose PLUS Azithromycin 1 g orally in a single dose OR Doxycycline 100 mg orally twice a day for 7 days If no ceftriaxone then can use PO cefexime 400 mg instead but test of cure in 1 week CDC 2015 STD treatment guidelines

16 Trichomonas No oral and low rectal prevalence Treatment: HIV uninfected- Metronidazole 2g X 1 Metronidazole 500 mg BID X 7d Tinidazole 2 g X 1 HIV infected : Metronidazole 500 mg BID X 7d Rescreen at 3 months CDC 2015 STD treatment guidelines

17 Keeping things simple Less than 30 years Perform Paps annually IF three consecutive negative paps can THEN screen every three years NO HPV Co-testing!! 30 years and older Perform Pap and HPV cotesting if possible at baseline If pap and HPV co-test are BOTH negative THEN can screen every three years If NO HPV co-test available AND three consecutive paps are negative THEN can screen every 3 years

18 Thank you! Questions for later

Cervical Cancer Screening Update. Melissa Hartman, DO Women s Health

Cervical Cancer Screening Update Melissa Hartman, DO Women s Health Previous Cervical Cancer Screening Organization Recommendation ACS (2011) ACP (2008) NCI (2003) Age 21 or 3 years after first intercourse