Prevention and Treatment of HPV and Other Common STDs

General Session Prevention and Treatment of HPV and Other Common STDs Clare Hawkins, MD Clinician, Legacy Community Health Services FQHC Faculty Member, Houston Methodist Family Medicine Residency Lead Physician Texas, Aspire Health Care: Palliative Care Baytown, Texas Educational Objectives By completing this educational activity, the participant should be better able to: 1. Discuss the most common sexually transmitted diseases seen in the primary care setting. 2. Discuss prevention of HPV and other common STDs. 3. Implement a management strategy of a patient with an STD. 4. Become familiar with the various pharmacological treatments available. Speaker Disclosure Dr. Hawkins has disclosed that he has no actual or potential conflict of interest in relation to this topic. 8

Speaker Disclosure Sexually Transmitted Diseases Dr. Hawkins has disclosed that he has no actual or potential conflict of interest in relation to this topic. Clare Hawkins MD MSc FAAFP CFW April 2016 First Case Your 17 yo F patient is going to college and asks about birth control You think to explain about barrier contraception What is the chance she will get a STI while on campus? What is the chance she will already have one? Why do we even let our children out of the house? Educational Objectives By completing this educational activity, the participant should be better able to: 1. Discuss the most common sexually transmitted diseases seen in the primary care setting 2. Discuss prevention of HPV and other common STDs 3. Implement a management strategy of a patient with an STD 4. Become familiar with the various pharmacological treatments available Polling Slide 1 What is the most prevalent STD? 1. HIV 2. HSV 3. HPV 4. HIN (Heck if I know) Most Common STD: HPV HPV 100 subtypes 40 are genital 16 & 18 oncogenic, 6 & 11 genital warts 34,788 new HPV-associated cancers (09) 355,000 new cases of anogenital warts were associated with HPV infection (09) Common: most people get it some time in their life asymptomatic 1

HPV Facts Most spontaneous clear, but remote neoplasms may develop No way to ascertain latency status Anogenital area (bathing suit area) but also oropharynx Transmission anogenital, genital-genital, oral Condoms, limiting sex partners helpful HPV Causal for Cancer Persistent infection with oncogenic types of HPV has a causal role in; Nearly all cervical cancers In many vulvar Vaginal cancer Penile cancer Anal cancer Propharyngeal cancers Forman D, de Martel C, Lacey CJ, et al. Global burden of human papillomavirus and related diseases. Vaccine 2012;30(Suppl 5):F12 23. Polling Slide 2 Your 25 yo patient is concerned about HPV vaccination, he has sex with other men, insertive and receptive 1. It is too late to administer HPV vaccine 2. You can begin a 3 vaccine series regardless of if he has had warts 3. You should begin vaccination only if he hasn t had warts 4. He is too old HPV (Cancer) Vaccination F (9) 12-26 M (9) 12-21 (MSM 26) 3 doses within 6 months Vaccinate even if already abn PAP or genital wart Promote as cancer prevention Have office-systems to track vaccination Not licensed for pregnant women Cervical Cancer Screening Only Screening approved by systematic evidence Starting age 21, every 3 years >=30 pap every 3, or co-testing for HPV every 5 Continue to test those who have had HPV vaccine Anal Cancer Screening Insufficient evidence for Anal Pap Some clinical centers perform anal cytology to screen for anal cancer among high-risk populations Then high-resolution anoscopy (HRA) for those with abnormal cytologic results Persons with HIV infection MSM History of receptive anal intercourse Oncogenic HPV tests are not clinically useful for anal cancer screening among MSM because of a high prevalence of anal HPV infection 2

Treatments Imiquimod self-administered 3.75, 5% cream Podofilox self-administered,.5% soln or gel Podophyllin resin 10% 25% - no longer recommended Sinecatechins Trichloroacetic Acid TCA or BCA External, vaginal, cervical Cryotherapy exp urethral, vaginal, cervical Key Messages for Persons with Anogenital Warts 1. If untreated, may resolve, or proliferate 2. No need for extra Pap 3. Timing of HPV acquisition cannot be determined. Sex partners can share HPV though warts only for one 4. Common/benign but significant psychosocial 5. Treatment does not cure, therefore they may return within 3m 6. Test for other STD, and be aware of transmission risk 7. Condoms may lower transmission risk 8. HPV Vaccine can prevent most genital warts, but if given after they are present, will not reduce wart burden 3. Implement a Management Strategy of a Patient with an STD Diagnosis Treatment Health Education/Coaching Contact Tracing Reporting 4. Become Familiar with the various pharmacological treatments available Guidelines from CDC Accessible, current and timely Urethritis and Cervicitis Chlamydia Urethritis Nongonococcal Urethritis Cervicitis 3

Polling Slide 3 Chlamydia screening is indicated for women under age 25 1. Regardless of whether they are having sexual intercourse 2. Using urine chlamydia NAAT test 3. Using vaginal or cervical NAAT test 4. Using only cervical NAAT test Chlamydia Testing TEST: High index of suspicion for those with symptoms Spotting, Dysuria, Urethral or Vaginal Discharge If abdominal pain (F), consider PID If saddle pain or testicle pain consider epididymitis or prostatitis NAAT (DNA) First Morning Urine (M) Self Collected Vaginal Swab (F) Physician Collected Vaginal or Cervical Specimens Oropharyngeal Swabs or Rectal (not FDA approved) Anal Cytological Specimens not as sensitive but approved Pregnancy & Neonatal Pregnancy Test of cure 3-4 weeks later Test of persistent cure 3 months later Third trimester re-testing, advised for pregnant women < 25 years Neonatal (trans-cervical spread to eye, rectum and oropharynx for up to 3 yrs) Conjunctivitis, (7-28 days) (erythro prophylaxis?) Pneumonia (1-3 months) afebrile pneumonia, staccato cough and hyperinflation Non-Culture testing from everted lid DFA Chlamydia Screening USPSTF Asymptomatic Women < 25 who are sexually active Other High Risk New Sexual Partner in last 6 months? Treatment Directly observed single dose treatment Azithromycin 1 gm po Expedited Partner Therapy: (EPT) Give a written prescription to your patient to treat their partner Partners accompanying patient to follow-up appt MSM advised to have in person visit for testing Polling Slide 4 Expedited Partner Therapy EPT 1. Is legal in Texas 2. Should be issued together with patient education regarding drug and risks 3. Is appropriate if patient s partner unlikely to come in for evaluation 4. Can be used for contacts < 6 months in past or beyond if no other source of infection 5. All of the above 4

Chlamydia Treatment Azithromycin 1 g po single dose or Doxycycline 100 mg bid 7 d Alternate Regimens Erythromycin base 500 mg qid 7 d Erythromycin ethylsuccinate 800 mg orally qid 7 d Levofloxacin 500 mg daily 7 d Ofloxacin 300 mg bid 7 d Gonococcal Infections Gonorrhea is the second most commonly reported communicable disease 820,000 new N. gonorrhoeae infections occur each year Very symptomatic in M, less so in F, therefore leads to PID Emerging resistance Gonorrhoeae Testing TEST: High index of suspicion for those with symptoms Urethral or Vaginal Discharge If abdominal pain (F), consider PID If saddle pain or testicle pain, consider epididymitis or prostatitis Fitz Hugh Curtis, perihepatitis Petechial or pustular acral skin lesions, Asymmetric polyarthralgia, tenosynovitis, or oligoarticular septic arthritis NAAT (DNA) First Morning Urine (M) Self-Collected Vaginal Swab (F) Physician Collected Vaginal or Cervical Specimens Oropharyngeal Swabs or Rectal (not FDA approved) Anal Cytological Specimens not as sensitive but approved Gonorrhoeae Screening Annually Women < 25 High Risk Those who have a new sex partner More than one sex partner A sex partner with concurrent partners A sex partner who has an STI Exchanging sex for money or drugs Inconsistent condom use in those not mutually monogamous How would you ask about this? Gonorrhoeae Risk Groups Concentrated in specific geographic locations and communities. Subgroups of MSM are at high risk Ask public health authorities in community for guidance about local high-risk groups A recent travel history with sexual contacts outside of US GC Testing NAAT (More Sensitive) Urethral, Cervical, Vaginal Oropharyngeal, Rectal, Conjunctival (not FDA approved) read product insert, caution with other pharyngeal neisseria sp. Culture (Fastidious) Urethral, Cervical Less Sensitive, More Specific and allows Sensitivity testing Gram Stain Sens/Spec for symptomatic discharge, but not to r/o for screening 5

GC Treatment cx, Urethra, Pharynx Ceftriaxone 250 mg IM in a single dose and Azithromycin 1g orally in a single dose If ceftriaxone is not available: Cefixime 400 mg orally in a single dose and Azithromycin 1 g orally in a single dose Treatment: GC Resistance Co-treatment for (relatively asymptomatic) Chlamydia, even if chlamydia test negative because decreased antimicrobial resistance Ceftriaxone 250 IM plus Azithromycin 1 g (or Doxycycline) Cefixime 400 po no longer recommended as firstline due to resistance Gemifloxacin 320 mg plus oral Azithromycin 2 g was associated with cure rates of 99.5%, (8% vomiting) Direct observed treatment, and remain abstinent 7 days Treatment of Contacts Treat sexual contact within the 60 days preceding onset of sx or dx EPT, public health, bring partner in Inspot.org Vaginal Discharge History: Sexual behaviors and practices Gender of sex partners Menses Vaginal hygiene practices (e.g., douching) Self-treatment with medications should be elicited Since most yeast vaginitis is self treated Vaginal Discharge: Testing Vaginal Discharge: BV Not transmitted sexually but is in DDx for discharge ph (> 4.5 in BV or Trich) KOH test for hyphae Microscopic examination of fresh samples of the discharge: Clue cells or trichomonads High Specificity, 50% Sensitivity NAAT (trich) higher sensitivity but expensive DNA probe for G. vaginalis available but uncertain performance Replacement of N flora with; Prevotella sp. Mobiluncus sp. G. vaginalis Ureaplasma Mycoplasma, Numerous fastidious or uncultivated anaerobes Associated With; Multiple male or female partners Anew sex partner Douching Lack of condom use Lack of vaginal lactobacilli (Women who have never been sexually active are rarely affected) 6

BV Complications & Treatment HIV Acquisition HIV Transmission to M (But partner treatment not recommended) Acquisition of GC, Chlamydia, HSV-2 Preterm Labor Gyn Surgery complications Recurrent BV Metronidazole 500 mg bid 7d Metronidazole gel 0.75% one full applicator (5 g) daily x 5 days (Disulfiram reaction 72 h) Clindamycin 2% one app (5g) daily x 7 d No studies support the addition lactobacillus intravaginally or probiotic as an adjunctive or replacement therapy in women with BV Recurrent BV 1. Metronidazole or tinidazole 500 mg twice daily for 7 days) followed by intravaginal boric acid 600 mg daily for 21 days and then suppressive 0.75% metronidazole gel twice weekly for 4 6 months 2. Monthly oral metronidazole 2 g administered with fluconazole 150 mg has also been evaluated as suppressive therapy; this regimen reduced the incidence of BV and promoted colonization with normal vaginal flora 1. Reichman O, Akins R, Sobel JD. Boric acid addition to suppressive antimicrobial therapy for recurrent bacterial vaginosis. Sex Transm Dis 2009;36:732 4. 2. McClelland RS, Richardson BA, Hassan WM, et al. Improvement of vaginal health for Kenyan women at risk for acquisition of human immunodeficiency virus type 1: results of a randomized trial. J Infect Dis 2008;197:1361 8 Vaginal Discharge: Trich Most common non-viral STD 3.7 million 13% BF 1.8% of non-hispanic white women >11% of women aged 40 years High prevalence in STD clinic patients 26% of symptomatic F 6.5% asymptomatic F 9% 32% of incarcerated women 2% 9% of incarcerated men) Prevalence in MSM is low 53% of HIV infected women and associated with PID Testing Wet Prep: Inexpensive, rapid 55% sensitive NAAT 95% sensitive and specific but $ 17% reinfection rate Therefore retest 2-12 weeks Trich Infected men have symptoms of Urethritis, epididymitis, or prostatitis Infected women have Vaginal discharge that might be diffuse, malodorous, or yellow-green With or without vulvar irritation. Metronidazole or tindazole 2 g single dose Metronidazole 500 bid 7 d Treat sex partners Vaginal Discharge: Yeast Not a Sexually Transmitted Disease 75% of women develop Vaginal yeast infections 90% Candida Albicans Candida glabrata, Candida parapsilosis and Saccharomyces cerevisiae are responsible for up to 33 percent of recurrent infections 73% of women self-treat OTC 1,3,7 day topical imidazole or single dose rx fluconazole (Inverse relationship to vaginal burning risk) Recurrent: (ddx contact derm, HSV, Vaginismus) Fluconazole 100-200 mg weekly Consider Diabetes testing (and HIV?) 15 percent of women in a study who had irritant dermatitis, their selftreatment played a role in the perpetuation of their symptoms Am Fam Physician. 2001 Feb 15;63(4):697-703. 7

PID Spectrum: endometritis, salpingitis, tuboovarian abscess, and pelvic peritonitis GC, Chlamydia 50% Normal Vaginal Flora BV association, but not reduced by treating Cytomegalovirus (CMV), M. hominis, U. urealyticum, and M. genitalium PID Clinical diagnosis of symptomatic PID has a PPV for salpingitis of 65% 90% compared with laparoscopy Low threshold for diagnosis (any of cervical motion tenderness, uterine or adnexal tenderness) Asymptomatic, or abnormal bleeding, dyspareunia, and vaginal discharge) Even women with mild or asymptomatic PID might be at risk for infertility PID Treatment IV Cefotetan 2 g IV every 12 hours PLUS Doxycycline 100 mg orally or IV every 12 hours OR Cefoxitin 2 g IV every 6 hours PLUS Doxycycline 100 mg orally or IV every 12 hours OR Clindamycin 900 mg IV every 8 hours PLUS Gentamicin loading dose IV or IM (2 mg/kg), followed by a maintenance dose (1.5 mg/kg) every 8 hours. Single daily dosing (3 5 mg/kg) can be substituted. PID Treatment PO Ceftriaxone 250 mg IM in a single dose PLUS Doxycycline 100 mg orally twice a day for 14 days WITH* or WITHOUT Metronidazole 500 mg orally twice a day for 14 days Cefoxitin 2 g IM in a single dose and Probenecid, 1 g orally administered concurrently in a single dose PLUS Doxycycline 100 mg orally twice a day for 14 days WITH or WITHOUT Metronidazole 500 mg orally twice a day for 14 days Other parenteral third-generation cephalosporin (e.g., ceftizoxime or cefotaxime) PLUS Doxycycline 100 mg orally twice a day for 14 days WITH* or WITHOUT Metronidazole 500 mg orally twice a day for 14 days Sex Partners should be evaluated, tested, and presumptively treated for chlamydia and gonorrhea, regardless of the etiology of PID Epididymitis Testicular/ scrotal pain r/o torsion <35 yo Chlamydia/ GC Coexists with urethritis Insertive MSM partner highest risk >35 yo Enteric Organisms more likely (bladder outlet obstruction Chronic > 6 wks sx granulomatous disease i.e., TB HIV Prevalence 1,218,400 persons aged 13 years and older are living with HIV infection 156,300 (12.8%) who are unaware of their infection Number living with HIV increased but new HIV infections stable. 8

HIV Epidemiology 44,073 people were diagnosed with HIV 2014 New Dx declined by 19% from 2005 to 2014 1.2 million persons living HIV in US 2011 14% were living with undiagnosed infection 62% of new HIV infection in US in 2011 were men who have sex with men 32% develop AIDs within 12 months of dx HIV Screening CDC recommends HIV screening for patients aged 13 64 years in all health-care settings Opt-out testing preferred Consent is part of consent for general medical care and separate consent not recommended Provide preventive counseling but don t require it HIV 1 & 2 antibody, antigen or RNA then confirmatory (HIV-2 antibody differentiation assay, Western blot or IFA) POC testing 30 minutes, less able to detect early infection HIV Epidemiology Incarcerated Since epidemic began 92,613 persons with AIDS that were infected through heterosexual sex, have died, including an estimated 4,550 in 2012 New HIV infections among women are primarily attributed to heterosexual contact (84% in 2010) or injection drug use (16% in 2010 Source: CDC. Estimated HIV incidence among adults and adolescents in the United States, 2007 2010. HIV Incarcerated Men 5 x the general population to have HIV AA-Males 5 times as likely as white men, 2x Hispanic/Latino men AA-Females 2 x as likely to be pos HIV as white or Hispanic/Latino women 9/10j inmates are released in under 72 hours, making HIV testing/ treatment difficult Inmates reluctant to disclose risk behaviors HIV Epidemiology Reservoir 18.1% of US adults and adolescents living with HIV infection in 2009 were unaware of their HIV infection Spread by anal or vaginal sex or by sharing drug-use equipment with an infected person New infections are increasing among young men who have sex with men, especially young, black men men who have sex with men HIV Epidemiology: Age >55 are ¼ one-quarter of Americans living with HIV in 2012. More likely to be diagnosed late in disease course 20 to 24 99% survived more than 12 months 50 to 54, 89% 55 to 59 86% 60 to 64, 82% > 65 73% Less likely to discuss sex with their physicians ED meds facilitate sex for older men otherwise incapable of SI. 9

HIV Epidemiology Gender Women were 23% of those living with HIV infection in 2011 2010, the estimated number of new HIV infections among MSM was 29,800, a significant 12% increase from 2008 MSM are 4% of the M pop in US MSM were 78% of new HIV among M & 63% of all new infections MSM accounted for 54% of all people living with HIV infection in 2011 The greatest number of new HIV infections (4,800) among MSM occurred in young black/african American MSM aged 13 24 Young black MSM accounted for 45% of new HIV infections among black MSM and 55% of new HIV infections among young MSM overall Texas 18,000/104,300 unaware of their infection Texas Males MSM > 13 yo unaware 12,110/62,400 (19.4% ) HIV Epidemiology Sex-Work Use of sexual activity for income or employment or for nonmonetary items, such as food, drugs, or shelter ( survival sex) Crosses many socioeconomic groups High-end escorts People who work in massage parlors Adult film industry Exotic dancers State-regulated prostitutes (in Nevada) Street-based men, women, and transgender people who participate in survival sex Drug and alcohol abuse co-exist HIV 11 yrs between HIV and AIDS if not treated As of 2011, approximately 16% of the estimated 1.2 million persons with HIV infection in the United States are unaware of their infection Acute HIV asymptomatic 50-90% of the time Important to dx early http://www.cdc.gov/hiv/ Acute HIV 50-90% are asymptomatic during acute infection Tests are often negative during this phase Repeat test 30-60 days Genital, Anal or Perianal Ulcers Genital HSV, most common Syphilis, if unsure, treat as presumptive dx Chancroid Haemophilus ducreyi (sporadic outbreaks Africa/Caribbean) Azithromycin 1 g orally in a single dose Ceftriaxone 250 mg IM in a single dose Ciprofloxacin 500 mg bid 3 d Erythromycin base 500 mg tid 7 d Granuloma Inguinale (Donovanosis) Lymphogranuloma Venereum 10

Herpes Simplex Virus, (HSV) HSV 1 & II (50 million HSV II in the US) Most HSV-2 are undiagnosed Many have mild or unrecognized infections BUT will shed virus intermittently in the anogenital area Most genital herpes infections are transmitted by persons Management of genital HSV should address the chronic nature of the disease rather than focusing solely on acute episodes Management of discordant partners Suppressive therapy in HSV positive individual to reduce transmission Barrier HSV Testing Culture of vesicles specific but not sensitive NAAT becoming more available PCR is the test of choice for diagnosing HSV infections affecting the central nervous system and systemic infections Cytologic detection of cellular changes associated with HSV infection is an insensitive and nonspecific method of diagnosing genital lesions (i.e., Tzanck preparation) and therefore should not be relied on Screening not indicated HSV Counseling Natural hx Recurrences and Asymptomatic viral shedding Suppressive rx Episodic rx Informing current partners Informing future partners Risk of neonatal infection Increased HIV transmission risk HSV-2 viral shedding more than HSV-1 and most in first year after acquisition Avoid contact if prodromal Daily suppression partly effective to reduce transmission unless coinfection Type-specific couple testing HSV Treatment Acute Acyclovir 400 mg tid 7-10 d Acyclovir 200 mg 5 x / d 7-10 d Valacyclovir 1 g bid 7 10 d Famciclovir 250 mg tid 7 10 d May extend treatment if resolution not apparent HSV Treatment Episodic Recipes Episodic HSV with HIV Co-infection Acyclovir 400 mg tid or 800 bid or 800 tid for 5 d Acyclovir 800 mg tid 2 d Valacyclovir 500 mg bid 3 days Valacyclovir 1 g daily 5 days Famciclovir 125 mg bid 5 d Famciclovir 1 gram orally twice daily for 1 day Famciclovir 500 mg once, followed by 250 mg bid 2 d Acyclovir 400 mg tid 5-10 d Valacyclovir 1 g bid 5-10 d Famciclovir 500 mg bid 5 10 days 11

HSV Suppressive Non-HIV Acyclovir 400 800 bid-tid Valacyclovir 500 mg bid Famciclovir 500 mg bid Syphilis Treponema pallidum Multiple manifestations Most frequently detected in primary care with screening/ serology Increased incidence related to HIV Epidemic in some populations Sexual transmission only when mucocutaneous syphilitic lesions present Uncommon after the first year of infection Syphilis Primary (i.e., ulcers or chancre at the infection site) Secondary (i.e., manifestations that include, but are not limited to, skin rash, mucocutaneous lesions, and lymphadenopathy) Tertiary (i.e., cardiac, gummatous lesions, tabes dorsalis, and general paresis) Latent lacking clinical manifestations, detected by serologic testing Early (one year), or late latent Syphilis Testing: 2 Tests Required Nontreponemal test: VDRL or RPR False Positives common: HIV, autoimmune conditions, immunizations, pregnancy, injection-drug use, and older age Treponemal test: FTA-ABS, TP-PA, or EIA Fluorescent treponemal antibody absorbed T. pallidum passive particle agglutination assay, Immunoblots, or rapid treponemal assays also available DFA Positive RPR 4x change, from 1:16 to 1:4 or from 1:8 to 1:32, shows a significant difference between two nontreponemal test results (same test, same lab) 15% 25% of patients treated during the primary stage revert to being serologically nonreactive after 2 3 years Neurosyphilis: depends on a combination of CSF tests (CSF cell count or protein & reactive CSF-VDRL) in the presence of reactive serologic test results and neurologic signs and symptoms (csf VDRL not sensitive) Syphilis Treatment Adult Treatment Benzathine penicillin G 2.4 million units IM in a single dose Child Treatment Benzathine penicillin G 50,000 units/kg IM, up to the adult dose of 2.4 million units in a single dose Early Latent Syphilis Benzathine penicillin G 2.4 million units IM in a single dose Late Latent Syphilis or Latent Syphilis of Unknown Duration Benzathine penicillin G 7.2 million units total, administered as 3 doses of 2.4 million units IM each at 1-week intervals 12

More Penicillin!! Tertiary Syphilis with Normal CSF Examination Benzathine penicillin G 7.2 million units total, administered as 3 doses of 2.4 million units IM each at 1-week intervals Neurosyphilis and Ocular Syphilis Aqueous crystalline penicillin G 18 24 million units per day, administered as 3 4 million units IV every 4 hours or continuous infusion, for 10 14 days Procaine penicillin G 2.4 million units IM once daily & Probenecid 500 mg orally four times a day, both for 10 14 days Hepatitis A: Fecal Oral, vaccinate B: Very infectious, percutaneous or infectious 1000x HIV, 1% hepatic failure Reservoir is those who are persistent HBSag pos 90% of infants become chronic carriers, 30% children Identify through testing high risk groups, including pregnant Immunize at birth preventing vertical transmission Vaccination IDU, MSM, and adults with multiple sex partners), and all adults seeking protection from HBV infection PEP: HBIG and HB vaccine C: Not usually sexually acquired Proctocolitis Inflammation of rectum with tenesmus or rectal discharge GC, Chlamydia, LGV serovars, T pallidum, HSV Recent onset among persons who have recently practiced receptive anal intercourse is usually sexually acquired Presumptive therapy should be initiated while awaiting results of laboratory tests Ceftriaxone 250 im and Doxycycline 100 bid 7d Sexually Transmitted Diseases Treatment Guidelines 2015, CDC, Pg. 96. MMWR, June 5, 2015, Vol. 64, No. 3 Prevention Abstinence Male Condoms Pre-Exposure Vaccination Pre-exposure vaccination is one of the most effective methods for preventing transmission of human papillomavirus (HPV),up to age 26 HAV, and HBV Pre-Exposure Prophylaxis Other Prevention Strategies Male Circumcision Emergency Contraception Post-exposure Prophylaxis for HIV and STD Antiretroviral Treatment of Persons with HIV Infection to Prevent HIV Infection in Partners HSV Treatment of Persons with HIV and HSV Infections to Prevent HIV Infection in Uninfected Partners Retesting after 3 months Partner Services: Expedited Partner Therapy 13

Pregnancy Screening HIV, Hep B, GC, Syphilis, Chlamydia, <25 years (twice) HCV if high risk (Injection Drug User IDU) No evidence for HSV, Trich, BV Prevention: 5 Strategies 1. Accurate risk assessment and education and counseling of persons at risk on ways to avoid STDs through changes in sexual behaviors and use of recommended prevention services; 2. Pre-exposure vaccination 3. Identification of asymptomatically infected persons and persons with symptoms associated with STDs; 4. Effective diagnosis, treatment, counseling, and follow up of infected persons 5. Evaluation, treatment, and counseling of sex partners of persons who are infected with an STD. Sexual History Taking: Rapport Open-ended questions Tell me about any new sex partners you ve had since your last visit, What has your experience with using condoms been like? ); Understandable, nonjudgmental language Are your sex partners men, women, or both? Have you ever had a sore or scab on your penis? Normalizing language Some of my patients have difficulty using a condom with every sex act. How is it for you? 1. Partners Do you have sex with men, women, or both? In the past 2 months, how many partners have you had sex with? In the past 12 months, how many partners have you had sex with? Is it possible that any of your sex partners in the past 12 months had sex with someone else while they were still in a sexual relationship with you? 2. Practices To understand your risks for STDs, I need to understand the kind of sex you have had recently. Have you had vaginal sex, meaning penis in vagina sex? If yes, Do you use condoms: never, sometimes, or always? Have you had anal sex, meaning penis in rectum/ anus sex? If yes, Do you use condoms: never, sometimes, or always? Have you had oral sex, meaning mouth on penis/ vagina? For condom answers: If never : Why don t you use condoms? If sometimes : In what situations (or with whom) do you use condoms? 3. Prevention of pregnancy 4. Protection from STDs What are you doing to prevent pregnancy? What do you do to protect yourself from STDs and HIV? 14

5. Past History of STDs Have you ever had an STD? Have any of your partners had an STD? Additional questions to identify HIV and viral hepatitis risk include: Have you or any of your partners ever injected drugs? Have your or any of your partners exchanged money or drugs for sex? Is there anything else about your sexual practices that I need to know about? 15

Medication Index Prevention and Treatment of HPV and Other Common STDs The following medications were discussed in this presentation. The table below lists the generic and trade name(s) of these medications. Generic Name Acyclovir Azithromycin Benzathine Penicillin Bivalent HPV Vaccine Cefixime Cefotetan Cefoxitin Ceftriaxone Clindamycin Disulfiram Doxycycline Erthromycin Erthromycin Ethylsuccinate Famciclovir Fluconazole Gemifloxacin Gentamicin Imiquimod Levofloxacin Metronidazole Ofloxacin Podofilox Podophyllin Probenecid Quadrivalent HPV Vaccine Sinecatechins Tinidazole Valacyclovir Trade Name Zovirax Zithromax, Zmax Bicilin, Permapen Cervarix Suprax Cefotan Mefoxin Rocephin Cleocin, Clindesse, Clindets, Evoclin Antabuse Acticlate, Doryx, Doxteric, Doxy, Monodox, Oracea, Vibramycin Ery Tab, Eryc, Erythrocin, PCE E.E.S., Eryped Famvir Diflucan Factive None Aldara, Zyclara Levaquin Flagyl, Metrogerl Vaginal, Nevessa, Vandazole None Condylox Podocon 25 Probalan Gardasil Veregen Tindamax Valtrex

Notes