STD Prevention Among Youth Jody Pierce Glover New Beginnings Emer S. Smith, MPH Maine Center for Disease Control & Prevention
In Today s Talk... Maine Learning Results: Education Content Areas Health Behaviors and Personal Health (A1) Diseases and Other Health Problems (A3) Health Practices and Behaviors (C1) Locating Health Resources (B2)
In Today s Talk... Demo: Routes of Transmission Review of STDs Epidemiology, Clinical Manifestations, Screening and Treatment Recommendations What is it, how bad is it, what can we do about it Resources Lesson plans Online Tools
Scope of the Problem STDs are common 19 million new cases annually in the U.S. 1 in 2 sexually active young people will get an STD by the age of 25 Young people account for half (50 percent) of all new STIs, although they represent just 25 percent of the sexually experienced population Many STDs are asymptomatic Many STDs are undiagnosed, untreated, or incurable Complications include infertility, chronic pain, prenatal complications and illness in newborns, severe illness, cancer, and death Centers for Disease Control. (2016). http://cdc.gov/std
DEMO: ROUTES OF TRANSMISSION
HPV, HSV NON-REPORTABLE STDS
Herpes (HSV-1/HSV-2) Estimated 776,000 new cases annually (CDC) HSV-2 Prevalence: 1 in 6 persons 14-49 years old (15.5%) HSV-1 Prevalence = estimated about 58% HSV-2 infection is more common among women than among men (20.3% versus 10.6% in 14 to 49 year olds) Centers for Disease Control. (2016). http://cdc.gov/std
Herpes (HSV-1/HSV-2) Symptoms (if present): genital or anal lesions that resemble small pimples Typically no or very mild symptoms which are mistaken for something else (yeast infection, jock itch, insect bites, abrasions) 87.4% of those infected with herpes are unaware they are infected because they have no or very mild symptoms Transmission most commonly occurs from an infected partner who does not have visible sores and who may not know that he or she is infected Centers for Disease Control. (2016). http://cdc.gov/std
The thing with herpes is...
Herpes Testing & Treatment Testing Not recommended for routine screening All patients with genital ulcers should be evaluated for syphilis and a diagnostic evaluation for genital herpes Viral detection by culture and PCR are the preferred tests for active symptoms Type-specific herpes serology (antibody) testing for asymptomatic (IgG, not IgM) Treatment No cure, no vaccine All patients with initial genital herpes should receive treatment Antiviral meds can shorten and/or prevent recurrent outbreaks Daily suppressive therapy can reduce risk of transmission to others Centers for Disease Control. (2016). http://cdc.gov/std
Human Papilloma Virus Estimated 79 million currently infected, 14 million new infections So common that sexually active people will become infected with at least one type over their lifetime Most genital HPV infections are transient, asymptomatic, and have no clinical consequences Genital warts: 360,000 cases annually Cervical cancer: 11,000 cases annually More than 40 HPV types can infect the genital tract Low-risk types (non-oncogenic) associated with genital warts and mild Pap test abnormalities (Type 6 & 11) High-risk types (oncogenic) associated with moderate to severe Pap test abnormalities, cervical dysplasia and cervical cancer, and other cancers (Type 16 & 18) Centers for Disease Control. (2016). http://cdc.gov/std
HPV Prevalence of High-risk and Low-risk Types Among Females Aged 14 59 Years; NHANES, 2003 2006 and 2007 2010 From: http://www.cdc.gov/std/stats14/figures/49.htm
HPV-associated Cancers in the US, 2006-2010
Estimated HPV Vaccination Coverage in Adolescents 13-17 years, 2013-2014 Region Year HPV Vaccine Series Females Males US 2013 At least 1 Dose 57.3% 34.6% Completed 3 Dose Series 37.6% 13.9% 2014 At least 1 Dose 60% 41.7% Completed 3 Dose Series 39.7% 21.6% Maine 2013 At least 1 Dose 60.2% 42.2% Completed 3 Dose Series 45.8% 17.6% 2014 At least 1 Dose 66.8% 53.1% Completed 3 Dose Series 43% 27.5% From: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6429a3.htm
ACIP HPV Vaccine Recommendations Population Gender Age Females 11-12 (as young as 9) 13-26 Males 11-12 (as young as 9) MSM & HIV+ males Recommendation Routine vaccination with either 9vHPV, 4vHPV, or 2vHPV Routine catch-up vaccination either 9vHPV, 4vHPV, or 2vHPV* Routine vaccination with 9vHPV or 4vHPV 13-21 Routine catch-up vaccination 9vHPV or 4vHPV 22-26 Permissive recommendation 9vHPV or 4vHPV 22-26 Routine catch-up vaccination 9vHPV or 4vHPV * Irrespective of history of abnormal Pap, HPV, genital warts For more information, visit http://www.cdc.gov/vaccines/ MMWR. (2015); 64(11):300-304
HPV Screening & Treatment Screening Screen for cancer, not HPV When is an HPV Test appropriate? Triage of abnormal Pap result (if age >21) Co-test with Pap in women age 30+ Very selective follow up situations When is it NOT appropriate? STD screening Before vaccination Diagnosis of genital warts Screening in women under 30 Any use in women under 21 Testing in males ASC-H, LSIL or higher grade lesions Treatment No best or curative therapy All therapies have potential side effects and high recurrence rates Consider: Provider s experience Patient s preference and abilities Size, number, and location of warts Potential side effects Availability and expense of therapy Centers for Disease Control. (2016). http://cdc.gov/std
Chlamydia, Gonorrhea, Syphilis, HIV REPORTABLE STDS
CHLAMYDIA & GONORRHEA (CT & GC)
Chlamydia Rates by Age and Sex, United States, 2014 From: http://www.cdc.gov/std/stats14/figures/5.htm
Trends in Reported Chlamydia Cases in Maine, 2009-2014 Maine Centers for Disease Control. (2016). http://mainepublichealth.gov/std
Chlamydia Symptoms *Most people have no symptoms* In Males: Urethritis Urethral discharge (clear or cloudy), dysuria (painful urination) Incubation period unknown (probably 5-10 days in symptomatic infection) In Females: Cervicitis Cervical discharge Edematous cervical ectopy with erythema and easily induced bleeding ( angry protruding cervix ) Urethritis Dysuria (painful urination), pyuria (cloudy urine) Centers for Disease Control. (2016). http://cdc.gov/std
Gonorrhea Rates by Year, United States, 1941 2014 From: http://www.cdc.gov/std/stats14/figures/12.htm
Gonorrhea Rates by Age and Sex, United States, 2014 From: http://www.cdc.gov/std/stats14/figures/17.htm
Gonorrhea Case Reports in Maine, 2007-2014 Maine Centers for Disease Control. (2016). http://mainepublichealth.gov/std
Gonorrhea Symptoms *Most people have no symptoms* In Males Urethritis Typically urethral discharge, may be clear or cloudy Often accompanied by dysuria Epididymitis In Females Cervicitis Cervical discharge, easily induced cervical bleeding Urethritis Other symptoms: Abnormal vaginal discharge, intermenstrual bleeding, dysuria, lower abdominal pain, pain during sex Centers for Disease Control. (2016). http://cdc.gov/std
Chlamydia/Gonorrhea Complications If left untreated... Pelvic Inflammatory Disease (PID) May be asymptomatic May present with lower abdominal pain, discharge, pain during sex, irregular menstrual bleeding and fever Epididymitis Accessory gland infection Bartholin s glands Skene s glands Fitz-Hugh-Curtis Syndrome Perihepatitis Centers for Disease Control. (2016). http://cdc.gov/std 26
Chlamydia trachomatis & Neisseria gonorrhoeae SCREENING FOR CHLAMYDIA & GONORRHEA
CT/GC Screening Recommendations: Females Sexually active women age <25 years: annually >25 years old: if risk factors are present Repeat re-testing of all women 3-4 months after treatment for infection, or when they next present for care within 12 months (especially for adolescents). Pregnant: Screen all at first prenatal visit. At third trimester if <25 years or at increased risk Centers for Disease Control. (2016). http://cdc.gov/std 28
CT/GC Screening Recommendations: Males Insufficient evidence to recommend routine screening in most men Should be considered in clinical settings with high prevalence of CT/GC (i.e. teen clinics, correctional facilities, STD clinics) MSM (men who have sex with men) Urethral testing for insertive MSM intercourse in preceding year, rectal, oropharyngeal testing for men who indicate receptive MSM sex in preceding year ( Triple Dip ) Test every 3-6 months if at risk Centers for Disease Control. (2016). http://cdc.gov/std
Proportion of CT and GC infections MISSED among 3398 asymptomatic MSM if screening only urine/urethral sites, San Francisco, 2008-2009: Marcus et. al (2011), Sexually Transmitted Diseases, 38: 922-4.
Anatomical Site of Infection Portland STD Clinic, 2014 & 2015 (thru 11/20/15) # Pos. Tests/ GC Tests 2014 GC Pos. Rate 2015 (thru 11/20/15) # Pos. Tests/ GC Tests GC Pos. Rate Urogenital 27/1035 1.55% 23/923 2.49% Pharyngeal 11/353 3.12% 28/348 8.05% Anal 18/334 5.39% 26/320 8.13%
Chlamydia trachomatis & Neisseria gonorrhoeae TREATMENT & FOLLOW-UP
Recommended Treatment Chlamydia Azithromycin, 1 gram orally in a single dose Gonorrhea Recommended Regimen Ceftriaxone 250 mg IM in a single dose (injection) PLUS Azithromycin 1g orally in a single dose *Alternative Regimen* Cefixime 400 mg orally in a single dose PLUS Azithromycin 1 g orally in a single dose *Not recommended for treating pharyngeal infection* Centers for Disease Control. (2016). http://cdc.gov/std
History of discovered and recommended antimicrobials and evolution of resistance in Neisseria gonorrhoeae, including the emergence of genetic resistance determinants, internationally. Magnus Unemo, and Shafer. Clin. Microbiol. Rev. 2014;27:587-613
Partner Management Sex partners should be evaluated, tested, and treated if they had sexual contact with the patient during the 60 days preceding the onset of symptoms or diagnosis of chlamydia. Most recent sex partner should be evaluated and treated even if the time of the last sexual contact was >60 days before symptom onset or diagnosis. Abstain from sexual intercourse until partners are treated and for 7 days after treatment is initiated or until completion of a treatment regimen. Centers for Disease Control. (2016). http://cdc.gov/std 35
Treponema pallidum SYPHILIS
Syphilis Reported Cases by Stage of Infection: United States, 1941 2014 Centers for Disease Control. (2015). http://www.cdc.gov/std/stats14/figures/31.htm 37
Primary and Secondary Syphilis Rates by Age and Sex, United States, 2014 From: http://www.cdc.gov/std/stats14/figures/37.htm
Syphilis Outbreak in Southern Maine MSM transmission (70%) HIV Co-infection (25%) Mirrors national trends Worrying increase in congenital syphilis nationally Maine Centers for Disease Control (2016). http://mainepublichealth.gov/std
Screening & Treating for Syphilis Screening Guidelines MSM (at least annually, more frequently if at risk) All pregnant women 1 st prenatal visit, 3 rd trimester if at increased risk People living with HIV Other persons at increased risk (commercial sex work, those in correctional facilities) Treatment For Primary, Secondary, or Early Latent: Benzathine penicillin G 2.4 million units IM once Alternate: Doxycycline 100mg 2x daily for 14 days OR Tetracycline 500mg orally 4 times daily for 14 days For Late Latent or Unknown Duration: Benzathine penicillin G 2.4 mu IM for 3 doses at 1 week intervals (7.2 million units total) Alternate: Doxycycline 100mg 2x daily for 28 days OR Tetracycline 500mg orally 4 times daily for 38 days Centers for Disease Control. (2016). http://cdc.gov/std
HAV, HBV, & HCV VIRAL HEPATITIS
Viral Hepatitis Multiple viral types that damage the liver Untreated chronic infection leads to liver damage, liver cancer, liver failure, and death Vaccine-preventable HAV Fecal-oral HEV is similar to HAV, but found mostly in Asia HBV Bloodborne, Perinatal HDV is a co-infection of HBV Not vaccine preventable HCV Bloodborne Treatable
Viral Hepatitis Risk Populations People who inject drugs (B & C) People who share needles and drug equipment, i.e. works (A, B, C) Cottons, cookers, water, syringes, ties, blood on surfaces/fingers MSM and HIV+ MSM (A, B, C) Sexually active people at high risk (A & B) Foreign-born people born in Asia (esp. China), Africa, or other high risk countries, and their children (B, D, E) Health care worker occupational exposure (A, B, C) Travelers (A, B, E) http://cdc.gov/hepatitis
Injection Drug Use & Hepatitis C Highly efficient Contamination of drug paraphernalia, not just needles and syringes Rapidly acquired after initiation of injecting 30% prevalence after 3 years of injecting >50% (up to 90%) after 5 years injecting One-third of young IDUs (18-30 yrs) are infected with HCV Older and former IDUs have a higher prevalence (70-90%) High HCV prevalence among former IDUs is largely due to works sharing in 1970s and 1980s 44
FYI: Harm Reduction Practices Try to use less risky methods to take drugs Never share: this goes for all works, especially cotton and water Clean surfaces with 10% bleach before and after Wash hands, use hand sanitizer to clean off fingers Utilize Needle Exchanges 45
Human Immunodeficiency Virus HIV
HIV Epidemiology 1.2 million people living with HIV in U.S. ~50,000 new infections each year 12.8% unaware they have it 14,00 deaths annually 36.9 million people living with HIV globally (70% in Sub-Saharan Africa) 2 million new cases annually 1.2 million deaths annually Disproportionate Impact Race/Ethnicity, Transmission Category, Geography Centers for Disease Control. (2016). http://cdc.gov/hiv
Maine Centers for Disease Control. (2014). http://mainepublichealth.gov/hiv
Lifetime Risk of Being Diagnosed with HIV, 2009-2013 Overall, an estimated 1 in 99 people in the US will be diagnosed with HIV 1 in 6 MSM will be diagnosed with HIV Nearly 80x more likely than for heterosexual men. 1 in 2 black MSM, and 1 in 4 Latino MSM will be diagnosed with HIV in their lifetime, compared to 1 in 11 white MSM. African Americans 1 in 20 men, and 1 in 48 women at risk People who inject drugs 1 in 23 for women, and 1 in 36 for men Hess et. al. Estimating the Lifetime Risk of a Diagnosis of HIV Infection in the United States. Presented at Conference on Retroviruses and Opportunistic Infections, 2016. http://www.cdc.gov/nchhstp/newsroom/2016/croi-press-release-risk.html
HIV Screening Guidelines All patients ages 13 64 in all health care settings (at least once in lifetime) All adolescents and adults at increased risk for infection should have more frequent screening (annually) MSM People who inject drugs Commercial sex workers Unprotected sex and multiple partners Pregnant women (First prenatal visit, re-test during 3 rd trimester if at increased risk) Centers for Disease Control. (2016). http://cdc.gov/hiv
RESOURCES
Resources STD Treatment Guidelines, 2015 Prevention, screening, counseling, management AND treatment guidelines Guide to taking a sexual history Apple/Android App ebook for ipad, iphone, and ipod Touch http://www.cdc.gov/std/treatment/
Professional Resources CDC STD Training Tools http://www.cdc.gov/std/training/ CDC National Prevention Information Network http://npin.cdc.gov/stdawareness/ American STD Association http://www.astda.org/ Sylvie Ratelle STD/HIV Prevention Training Center of New England http://www.ratelleptc.org
Lesson Plans & Curricula Advocates for Youth http://www.advocatesforyouth.org/for-professionals/lessonplans-professionals Answer http://answer.rutgers.edu/page/lesson_plans/ American Sexual Health Association http://www.ashastd.org/ Sex Ed Library http://www.sexedlibrary.org/
Questions? Emer S. Smith, MPH HIV/STD Public Health Educator Emer.Smith@maine.gov (207) 287-5193 http://mainepublichealth.gov/std http://cdc.gov/std http://cdc.gov/hiv Jody Pierce Glover Prevention Educator jody@newbeginmaine.org (207) 795-6048 http://newbeginmaine.org