Sexually Transmitted Infections. Dr. Doug McGhee Victoria STI Clinic Dr. Jennifer Ross Island Sexual Health Society

Transcription

1 Sexually Transmitted Infections Dr. Doug McGhee Victoria STI Clinic Dr. Jennifer Ross Island Sexual Health Society

2 ISHS vs STI Clinic Island Sexual Health Society Non-profit society Contraception, IUD, Pap, STI, Outreach Victoria STI Clinic BCCDC satellite / Island Health One-stop STI, communicable Ds and street RNs

3 New BCCDC STI Guidelines 2014

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6 STI Notification

7 HPV Human papillomavirus New vaccine New topical Tx Vaccination to prevent multiple cancers

8 HPV Epidemiology NA cumulative lifetime incidence 80% 1 Canadian F yr prevalence 17% 1 st peak ~5-10 years of sexual debut 2 nd peak > 45 yr Canadian M ~29 yr prevalence 70% 2 1: Syrjanen K, et al: Prev, incidence, and est. life-time risk cervical HPV infect in a nonselected Finnish female pop.sex Transm Dis 1990; 17: : Ogilvie GS, et al Self-coll n gen HPVs specs in heterol men. Sex Trans Infect. 2009, 06;85

9 HPV Natural history Infections clear 2 years in > 90% Seroconversion in 60% Immunity 40% 1 Infections that persist may lead to cancer Stop smoking Condoms 1. Personal communication G Ogilvie

10 HPV Warts Cancers 1 Cervical (100% attributable to HPV) Anal (90% in men and women) Penis (50%) Oropharyngeal (25-35%) 1 Updated on HPV Vaccines Canada Communicable Disease Report. PHAC. 2012; 38.

11 Tx Genital warts LN 2 Imiquimod (37-54% clearance, 16% recur) 1,2 Generic 5% 3x/wk 16/52 12 pktte $150 Vyloma 3.75% od 8/52 28 pktte $333 Sinecatechins (54% clearance, 5% recur) 3,4 Veregen tid 16/52 15 gm tube $75 1. Beutner KR, et al: Treatment of genital warts with imiquimod. J Am Acad Dermatol 1998; Edwards L, et al: Self-administered topical 5% imiquimod. Arch Dermatol 1998; Tatti S, et al: Polyphenon E : a new treatment for EGW. Br J Dermatol 2010; Stockfleth E, et al: Topical Polyphenon E in Tx EGW: Br J Dermatol 2008; 158. Pricing: London Drugs Harris Green 04/15

12 Cervical cancer: Pap Start age 21 or 3 years after 1 st sexual contact Repeat yearly until 3 normals in a row, then q 2 yr Stop age 69 as long as normal x 10 yr 2

13 Anal cancer Incidence in Canada 1.7 per 100K person yr Incidence if HIV /100K person yr ~ rate of colon ca in general male pop n. Anal Pap problematic Medford, RJ, Salit, IE. Anal cancer and intraepithelial neoplasia, CMAJ, 2015, 187(2).

14 HPV prevention Condoms ~ effective 1,2 Vaccination bivalent, quadravalent new 9-valent approved Feb 2015 >99% seroconversion (no waning yet) <70% uptake in girls in BC! SAFE 130 countries, 8 years, 175 million doses 1. Veldhuijzen NJ, et al: Factors affecting trans of mucosal HPV, Lancet Infect Dis 2010; Miksis S, HPV vaccine vs condom, JOGNN, 2008; 37:

15 Gardasil 9 Includes 5 additional oncogenic strains Non-inferior to Gardasil for 6, 11, 16 & 18 high-grade disease from other 5 strains Joura E.A. et al, A 9-Valent HPV Vaccine against Infection and Intraepithelial Neoplasia in Women. NEJM, 2015, 372;8

16 Current Recommendations Females /- AbN pap or Hx warts: HPV4 or HPV2 for cervical cancer Females 26-45: either HPV4 (or HPV2 but no official data) Males 9-26 or all ages MSM: HPV4 for AIN and anal/penile cancer National Advisory Committee on Immunization

17 HPV program in BC Grade 6, two doses, 6 months apart Two doses if 14 yr; same for boys If born in 1994 ( 21 yr) and missed school vaccination, MD can request doses from PH Any HPV vaccine is better than no vaccine

18 Chlamydia Throat / rectal testing PID LGV

19 Chlamydia , Island Health cases BC cases Island Health rate BC rate 14,000 Rae per 100,000 population ,000 10,000 8,000 6,000 4,000 Number of cases , BCCDC

20 Clinical Syndromes Cervicitis 80%+ are asymptomatic PID Under-diagnosed, mostly clinically silent infertility, ectopic preg. and chronic pain Proctitis Mostly in MSM Regular CT or LGV serovars

21 Chlamydia Testing Screen annually: Women < 25, possibly males < 25 IVDU, STW, MSM, street youth Other screening: Pregnant New or multiple sexual partners Previous STI

22 Chlamydia Testing Women: EndoCx, vaginal > urine Rectum if anal sex; tht if STW Men: Urine Tht, rectum if MSM (urine would miss >50%)

23 Gonorrhea Culture vs NAAT Resistance Culture

24 Gonorrhea rates BC Island Health cases BC cases Island Health rates BC rates Rae per 100,000 population Number of cases BCCDC

25 Gonorrhea: Diagnosis Screening same as with Chlamydia Incubation 2-7 days NAAT vs culture

26 Testing for Gonorrhea NAAT Higher sensitivity Can be done immediately after exposure If doing TOC, wait 2-3 weeks after Tx Culture Lower sensitivity Wait 48 hrs after exposure Gives sensitivity profile

27 Gonorrhea Resistance History 1930 s sulfa resistant 1950 s penicillin resistant 1980 s tetracycline resistant 1990 s fluoroquinolone resistant 2001 cefixime resistance in Japan Local resistance in STW, MSM

28 GC Recommendations Cefixime 800mg po x 1 (or ceftriaxone 250gm IM) AND Azithromycin 1gm po (or doxy 100mg po bid x 7/7) Test of cure in 3-7 days with culture if needed.

29 Syphilis New testing algorithm Sampling ulcer

30 Syphilis rates BC Island Health cases BC cases Island Health rates BC rates Rae per 100,000 population Number of cases BCDCD

31 Syphilis: BC & Canada Wong J, Trends in STIs in BC in 2013, Clinical Prevention Service, BCCDC, Oct 2014

32 Diagnosis of Syphilis New testing algorithm 261 / 76,000 tests late latent 1 EIA turns /7, stays positive Test a lesion? If recent exposure or ulcer mention on req. 1. Personal communcation Dr. M Morashed, BCCDC

33 Syphilis Interpreting serology, arranging Tx? BCCDC STI Clinic

34 Hepatitis C ~ <1% in long-term monogamous couples Probably higher if receptive anal sex, HIV+ Test once for Baby Boomers: born Initial test is anti-hcv, most + by /52 Testing for 2 HCV Infection, CDC MMWR, May, 2013 / 62(18); bcguidelines.ca Viral Hepatitis Testing

35 Herpes simplex HSV Less prevalent Pcr swab sensitive How to Tx Suppressive Tx How to counsel

36 HSV epidemiology Adults 17% HSV-2 1,2 decreasing 28% in BC women yr 58% 1 HSV-1 increasing genital 1. Xu f, Trends in Herpes Simplex JAMA 2006; Patrick d, et al, Antenatal seroprevalence HSV2 Canadian women: Sex Transm Dis 2001;28 3 PHAC Canadia STI Guidelines 2013

37 Primary infection Extensive painful lesions Dysuria 80% women Fever, malaise ~60% Lymphadenopathy in 80% Aseptic meningitis in 16-26% Mean 16.5 days (men) and 22.7 days (women) 25% may not be 1 0 infection

38 Recurrent HSV Rx should be started right away Give Rx to have at home No proven efficacy if drug started > 24 hr BCCDC (BUGS and DRUGS 2012) and Canadian STI Guidelines

39 Recurrent HSV Tx Valacyclovir 500mg bid or 1gm od x 3/7? 2 gm bid x 2-4 doses ($18-25 Famciclovir 1gm bid x 2 doses ($17)? 1.5 gm stat ($16) Acyclovir 400mg tid for 5/7 or 800 tid 2/7 Start immediately; have at home BCCDC BUGS and DRUGS 2012

40 Daily suppressive Tx Valtrex 500 mg daily 48% transmission 4 Condoms 50% 4 Additive Decreases HIV blood, genital, rectal and semen levels 1-3 Reassess if symptom free for 12 months Not being used as PrEP 1. Beaten JM et al, J Infect Dis, 2008; 198: Zuckerman R et al, J infect Dis, 2007; 196(10): Zuckerman R et al, AIDS, 2009; 23(4): Corey et al. NEJM 2004

41 HIV HIV results over phone PEP, PrEP

42 HIV rates BC Island Health cases BC cases Island Health rate BC rate Rae per 100,000 population Number of cases BCCDC

43 HIV in BC HIV, Stigma & Society; Gay and Bisexual Men in BC, PHO Annual Report, 2014

44 HIV in BC HIV, Stigma & Society; Gay and Bisexual Men in BC, PHO Annual Report, 2014

45 HIV Transmission HIV, Stigma & Society; Gay and Bisexual Men in BC, PHO Annual Report, 2014

46 IDN IDN

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48 HIV testing guideline Every 5 yr for all patients Yearly for all patients in higher-risk groups Once > 70 if patient s status unknown OR New or worsening health condition Symptoms or risk of HIV Pregnancy They request a test HIV Testing Guidelines for BC, 2014, Provincial Health Officer

49 HIV, Stigma & Society; Gay and Bisexual Men in BC, PHO Annual Report, 2014

50 HIV Testing 3 rd Generation Ab test Window ~22 days; order 6/52, repeat 3/12 Rapid test is 3 rd Generation 4 th Generation Ab test includes p24 Ag Window days; order 3/52, repeat 6-12/52 Alert lab if acute HIV Sx or risk

51 HIV Depot antiretroviral medication 1 npep non-occupational Post-Exposure Prophylaxis 2 PrEP Pre-Exposure Prophylaxis 2 Dr Mark Hull, SPH, Treating acute HIV infection 3 1. Long-acting HIV drugs advanced, Nat. Med. Apr, 2014;20(4); Moore D, PHSA Feb 2015,

52 HIV PrEP PROUD study Feb UK MSM Daily ARV dosing HIV by 86% 1 Partners Dem Project UW / Africa Immediate ARV Tx and PrEP HIV in partners by 96% 2 1. PROUD study, proud.mrc.ac.uk 2. Partners Demonstration Project