S403- Update on STIs for the Generalists

Transcription

1 S403- Update on STIs for the Generalists Mobeen H. Rathore, MD Professor and Director University of Florida Center for HIV/AIDS Research Education and Service (UF CARES) Chief, Pediatric Infectious Diseases and Immunology Jacksonville, Florida

2 Disclosure of Relevant Relationship Dr. Rathore (or spouse/partner) has not had (in the past 12 months) any conflicts of interest to resolve or relevant financial relationship with the manufacturers of products or services that will be discussed in this CME activity or in his presentation. Dr. Rathore will support this presentation and clinical recommendations with the best available evidence from medical literature. Dr. Rathore does not intend to discuss an unapproved/investigative use of a commercial product/device in this presentation.

3 Goals of Talk Today Focus on non-viral STIs Will discuss screening for STIs Will review AAP guidance for STI screening Will compare STI screening by various professional groups Will discuss treatment of STIs

4 ient. What the USPSTF Grades Mean and Suggestions for Practice Grade Definition Suggestions for Practice A B Recommends the service High certainty that the net benefit is substantial. Recommends the service High certainty net benefit moderate or moderate certainty that the net benefit is moderate to substantial. Offer or provide this service Offer or provide this service C Recommends selectively offering/providing service to individual patients based on professional judgment and patient preferences. At least moderate certainty that the net benefit is small Offer or provide this service for selected patients depending on individual circumstances D I Recommends against the service There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. Current evidence insufficient to assess balance of benefits and harms of the service Evidence lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined. Discourage the use of this service Clinical considerations are important If the service is offered, patients should understand the uncertainty about the balance of benefits and harms.

5 USPSTF Recommendation Grades for Screening STI Non-pregnant women Pregnant women Men No Increase risk Increased risk No Increase risk Increased risk No Increase risk Increased risk Chlamydia C A C B I I Gonorrhea D B I B D I Syphilis D A A A D A HIV C A A A C A Hepatitis B D D A A D D Hepatitis C D I - - D I HSV D D D D D D HPV I I

6 STD/HIV Inter-relationships Behavioral Both are sexually transmitted Epidemiological Populations with high rates of STDs show disproportionally high rates of sexually-transmitted HIV Immunological STDs result in changes in immune cells of the mucous membranes ( Pink Parts ), which can facilitate sexual HIV acquisition & transmission

7 Comparison of STI Screening Recommendations for Sexually Active Non-pregnant Women STI USPSTF CDC AAFP ACOG AAP Chlamydia <25 yrs & at increased risk <25 yrs & at increased risk <25 yrs & at increased risk <25 yrs & at increased risk <25 yrs & at increased risk Gonorrhea <25 yrs & at inccreased risk At increased risk <25 yrs & at increased risk Adolescents & at increased risk <25 yrs & at increased risk Syphilis At increased risk Exposed At increased risk At increased risk <25 yrs & at increased risk HIV At increased risk Screen all At increased risk At increased risk Screen All

8 Comparison of STI Screening Recommendations for Pregnant Women STI USPSTF CDC AAFP ACOG AAP Chlamydia <25 yrs & at increased risk Screen all <25 yrs & at increased risk At inc risk <25 yrs & at increased risk Gonorrhea <25 yrs & at increased risk At incr risk At inc risk At inc risk <25 yrs & at increased risk Syphilis Screen all Screen all Screen all Screen all <25 yrs & at increased risk HIV Screen all Screen all Screen all Screen all Screen All

9 Chlamydia Most common reportable communicable disease in the US Most infections asymptomatic Highest rates females year old followed by year old Large racial disparity in prevalence in sexually active Females: Non Hispanic-AA yr old 5-time more than in NH-White Males: Non Hispanic-AA year old 10-time more than in NH-White National Commission on Prevention Priorities: One of the 10 most beneficial and cost effective preventive services for young women, also most underutilized Nucleic Acid Amplification Tests (NAAT) preferred testing Combination Chlamydia and GC tests available require one specimen

10 Adolescent Treatment Guidelines Chlamydia Recommended: Azithromycin 1gm po x 1 Or Doxycycline 100mg po BID x 7d Alternative: Erythromycin base 500mg po QID x 7d Or Erythromycin EES 800mg po QID x 7d Or Levofloxacin 500mg po qd x 7d Or Ofloxacin 300mg po BID x 7d

11 GC 2 nd most common reportable communicable disease in the US Most infections asymptomatic Highest rates females year old followed by year old Large racial disparity in prevalence in sexually active Females: Non Hispanic-AA yr old 15-time more than in NH-White Males: Non Hispanic-AA year old 26-time more than in NH-White Associated with increased HIV transmission Nucleic Acid Amplification Tests (NAAT) preferred testing Combination Chlamydia and GC tests available require one specimen

12 Gonococcal urethritis

13 Gonococcal cervicitis

14 Gonorrhea - gram stain of urethral discharge

15 Bartholin s abscess

16 Disseminated gonorrhea - skin lesion

17 Disseminated gonorrhea - skin lesion

18 Adolescent Treatment Guidelines: Gonorrhea Recommended Ceftriaxone 250 mg IM x 1 OR IF NOT AN OPTION Cefixime 400 mg PO x 1 Or Single-dose injectible cephalosporin regimens PLUS Azithromycin 1gm PO x 1 Or Doxycycline 100mg PO BID x 7d

19 Syphilis Nearly eliminated in early 2000s Re-emerged as a public health issue mainly in MSMs rates in year old males increased 2012 rates in females decreased (vs 2010) Primary and secondary disease rate M:F::10:1 75% cases occur in MSMs Treatable systemic STI Diagnosis: Treponemal (RPR) and non-treponemal tests (TPA, VDRL) Treatment: Penicillin

20 Syphilis - Treponema pallidum

21 Primary syphilis-chancre

22 Primary syphilis - chancre

23 Primary syphilis - chancre of anus

24 Primary syphilis - chancre

25 Secondary syphilis - papulosquamous rash

26 Secondary syphilis - papulo-pustular rash

27 Secondary syphilis

28 Secondary syphilis

29 Secondary syphilis - alopecia

30 Late syphilis - serpiginous gummata of forearm

31 Late syphilis - ulcerating gumma

32 Trichomonas Not nationally reportable communicable disease Believed to be the most common non-viral STI Prevalence % in various studies Common also in older females; and commonly asymptomatic. May increase HIV transmission Usually identified using microscopic examination NAAT and other rapid and POC tests also available Large racial disparity in prevalence in sexually active Females: Non Hispanic-African American 10-time > than in NH-White

33 Comparison of Viral STI Screening Recommendations for Sexually Active Nonpregnant Women STI USPSTF CDC AAFP ACOG Hepatitis B Not general population Pre-vaccination screening for those at increased risk Screen women at increased risk Hepatitis C Not general population; HSV Do not screen Not general population Do not screen general population Not screen general population Do not screen No specific recommendation At increased risk If sexual partner has HSV HPV Insufficient evidence to use as primary screening test for cervical cancer Not for subclinical infection Insufficient evidence to use as primary screening test for cervical cancer Testing with a Pap smear is an option for women older than 30 years

34 Comparison of Viral STI Screening Recommendations for Pregnant Women STI USPSTF CDC AAFP ACOG Hepatitis B Screen all Screen all Screen all Screen all Hepatitis C No specific recommend At increased risk HSV Do not screen No specific recommend HPV No specific recommend No specific recommend No specific recommend Do not screen No specific recommend At increased risk No specific recommend No specific recommend

35 USPSTF Recommendation for Screening Men Does not recommend STI screen for men who not at increased risk Recommend HIV & syphilis screen for men participating in hi-risk sexual behavior Because of significant geographic and community variation consider the risk in the community and populations they serve when making decisions about screening men for syphilis In men, as in women, it is important to take a thorough sexual history to assess if the patient engages in hi-risk sexual behavior In MSM important to focus on hi-risk sexual behavior & not orientation

36 USPSTF Age and Periodicity of Screening Recommendations No evidence-based recommendation about a specific age at which STI screening should begin Age at first sexual encounter varies among populations and communities. Uses epidemiologic data on prevalence of risk behaviors to provide guidance about age to begin screening Persons as young as 12 years may be having sexual intercourse, and the possibility of STIs and high-risk behavior should be considered in all adolescents when making screening decisions. No evidence to support stopping screening at a specific age. Persons continue to be at risk of acquiring STI if exposed, regardless of age; clinical implications of untreated asymptomatic infections (infertility, ectopic pregnancy) are different in women of post-reproductive age

37 USPSTF Age and Periodicity of Screening Recommendations For sexually active women at increased risk only because of demographic reasons (race, ethnicity, geographic location), the optimal age to end screening is not known In the absence of direct evidence, it seems reasonable to consider stopping routine screening at menopause or at 55 years of age. Little evidence available to guide decision making about the periodicity of screening Annual screening for chlamydia in young women adopted as pragmatic approach

38 AAP Guidance for non-viral STI Screening in Adolescent AAP CoA and SAHM Prevalence of STIs higher among adolescents than other age groups MSM & non-white ethnicities carry higher proportions in adolescents To identify and treat individuals with treatable STIs To reduce transmission of STIs to others Avoid or minimize long-term consequences of STIs Identify other STI exposed or potentially infected individuals Decrease the prevalence of STIs Minimize barriers to STI screening including access and stigma Develop routine clinical procedures to incorporate risk assessments, screening, treatment and prevention counseling

39 AAP Guidance for non-viral STI Screening in Adolescent AAP CoA and SAHM Annual screening for chlamydia, GC and syphilis for all sexually active females and MSM <25 years of age Every 3 to 6 month chlamydia, GC and syphilis screening for MSM with INDIVIDUAL high-risk multiple or anonymous partners, sex with drug abuse or partners who participate in these activities Consider annual chlamydia and GC screening for sexually active males in POPULATION high-risk factors jails or juvies, national job training programs, STI clinics, high school clinics (high prevalence settings) Screen youth exposed to chlamydia and GC in previous 60 days Retreat all infected adolescents 3 months after treatment

40 AAP Guidance for non-viral STI Screening in Adolescent AAP CoA and SAHM No routine screening of asymptomatic adolescents females for Trichomonas vaginalis Except if they have high-risk factors new or multiple partners, sex for money or drugs, IVDU Consider rescreening females 3 months after they have been treated for T. vaginalis or whenever they come fo a visit within one year No routine screening for syphilis in non-pregnant, heterosexual adolescents

41 Persons in Correctional Facilities Individuals male an female have higher STI rates, especially Chlamydia and GC Especially females less than 35 years of age Testing for GC and Chlamydia facilitates identification and treatment of persons with undetected infections & reduces prevalence among detainees who are released back into the local community Chlamydia & GC screening recommended for all females <35 years old Syphilis screening recommendations should based on local area and i nstitutional syphilis prevalence

42 PREVENTION Encourage immunizations, including human papillomavirus, and hepa titis A and B virus Provide information regarding HIV infection, testing, transmission, & implications of infection to all adolescents as part of health care Integrate sexuality education into clinical practice USPTFS recommends high intensity behavioral counseling to prevent STIs for all sexually active adolescents Process in offices to address all of these including self reporting questionaires

43 Other STIs Herpes Chancroid Granuloma Inguinale Condyloma auminata (HPV) Lymphgranuloma venereum Lice Scabies Molluscum contagiogum

44 Treatment of STIs CDC website for STI Treatment: CDC App for STI treatment: CDC website for STIs in Pregnancy: