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Disclosure of Financial Relationships This speaker has the no significant financial relationships with commercial entities to disclose.. . This slide set has been peer-reviewed to ensure that there are no conflicts of interest represented in the presentation.. STD Prevention. Accurate identificatio
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1. 2006 STD Treatment Guidelines Forum: Implications for HIV Care Providers Jeffrey Beal, M.D.
Clinical Director
Florida/Caribbean AIDS Education and Training Center Please include the title of your presentation, your full name and affiliations (including your role within the AETC, if applicable).Please include the title of your presentation, your full name and affiliations (including your role within the AETC, if applicable).
2. Disclosure of Financial RelationshipsThis speaker has the no significant financial relationships with commercial entities to disclose. Use this slide if you have any significant financial relationships with any commercial entities.
If you use this slide, please delete slide 2.
Use this slide if you have any significant financial relationships with any commercial entities.
If you use this slide, please delete slide 2.
3. STD Prevention Accurate identification of STDs and effective clinical management are important strategies to improve HIV prevention efforts
CDC has published guidance for STD prevention and management for 20 yrs
Guidelines development- evidence based systematic review- public/private sectors; professional organizations
4. CDC STD Treatment Guidelines Authoritative source of STD treatment and management
Screening, prevention and vaccination strategies, treatment regimens
Order hard copies http://www.cdc.gov/ std/treatment
Pocket guides, wall charts
5. Clinical Prevention Guidance Education/counseling to reduce risk of STD acquisition
Detection of asymptomatic infection and/or symptomatic persons unlikely to seek services
Effective diagnosis and treatment
Evaluation, treatment, counseling of sexual partners
Pre-exposure vaccination of persons at risk - hepatitis A, B The guidelines focus on 5 issues to reduce the occurrence of STDs and thus also decrease the incidence of HIV
The guidelines focus on 5 issues to reduce the occurrence of STDs and thus also decrease the incidence of HIV
6. STD/HIV Prevention Counseling Routine discussion of sex behaviors- client centered counseling
# partners, serostatus, type of activity, condom use (barriers), pregnancy prevention
Specific actions necessary to avoid acquisition or transmission of STDs
Abstinence, condom use, limiting sex partners, modifying sex behaviors, vaccines Culturally appropriate client-centered counseling: Abstinence, ? sexual partners, mutually monogamous relationship with both STD screened prior to sex, male/female condom education, specific counseling regarding sex act and risk
Culturally appropriate client-centered counseling: Abstinence, ? sexual partners, mutually monogamous relationship with both STD screened prior to sex, male/female condom education, specific counseling regarding sex act and risk
7. Prevention Methods - Male Condoms Correct and consistent male latex condom use is highly effective in preventing the sexual transmission of HIV; can reduce risk of CT, GC, trichomoniasis
May reduce the risk of transmission of HSV-2
May reduce risk of HPV-associated genital warts, cervical cancer
Higher rates of regression of CIN, HPV clearance (women), penile lesions in men
Protective effect on HPV acquisition among newly sexually active women (70%?) Condom use might
reduce the risk for HPV-associated diseases (e.g., genital warts
and cervical cancer [17]) and mitigate the adverse consequences
of infection with HPV, as their use has been associated
with higher rates of regression of cervical intraepithelial
neoplasia (CIN) and clearance of HPV infection in women
(18), and with regression of HPV-associated penile lesions in
men (19).
one recent prospective study among newly sexually
active college women demonstrated that consistent condom
use was associated with a 70% reduction in risk for HPV
transmission (20).
When used consistently and correctly, male latex condoms
are highly effective in preventing the sexual transmission of
HIV infection (i.e., HIV-negative partners in heterosexual
serodiscordant relationships in which condoms were consistently
used were 80% less likely to become HIV-infected compared
with persons in similar relationships in which condoms
were not used)
2006 CDC GuidelinesCondom use might
reduce the risk for HPV-associated diseases (e.g., genital warts
and cervical cancer [17]) and mitigate the adverse consequences
of infection with HPV, as their use has been associated
with higher rates of regression of cervical intraepithelial
neoplasia (CIN) and clearance of HPV infection in women
(18), and with regression of HPV-associated penile lesions in
men (19).
one recent prospective study among newly sexually
active college women demonstrated that consistent condom
use was associated with a 70% reduction in risk for HPV
transmission (20).
When used consistently and correctly, male latex condoms
are highly effective in preventing the sexual transmission of
HIV infection (i.e., HIV-negative partners in heterosexual
serodiscordant relationships in which condoms were consistently
used were 80% less likely to become HIV-infected compared
with persons in similar relationships in which condoms
were not used)
2006 CDC Guidelines
8. Prevention Methods - Spermicides Spermicides (N-9 )
not effective in preventing cervical GC, CT, HIV
frequent use -disruption of vaginal, anal epithelium
may increase risk of HIV transmission with vaginal intercourse (IC)
Condoms lubricated with N-9
no more effective than other lubricated condoms in protection against HIV, STDs
9. STD Screening Strategies STD screening for MSM or HIV+ at initial visit
Syphilis serology
Trichomonas, pap smear (women)
GC/CT (Urethral culture or NAAT)
Pharyngeal culture, GC (oro-genital)
Rectal culture, GC/CT (receptive anal IC)
Type specific HSV2 serology (some specialists)
Hepatitis A, B serology; C (HIV + or risk factors)
Periodic screening- as indicated q3-6 mo What is the argument for HSV-2 screening?
Note older assays that do not accurately
distinguish HSV-1 from HSV-2 antibody (despite claims
to the contrary) remain on the market. Therefore, the serologic
type-specific glycoprotein G (gG)-based assays should
be specifically requested when serology is performed
What is the argument for HSV-2 screening?
Note older assays that do not accurately
distinguish HSV-1 from HSV-2 antibody (despite claims
to the contrary) remain on the market. Therefore, the serologic
type-specific glycoprotein G (gG)-based assays should
be specifically requested when serology is performed
10. Emerging Issues STD/HIV in MSM Syphilis
Increases in US and Western Europe
40-60% HIV co-infected
Methamphetamine use, internet partnering
Gonorrhea
Increase in Flouroquinolone-resistant Neisseria gonorrhea (QRNG)
Chlamydia- LGV proctitis
Acute hepatitis C- high risk sexual behavior (fisting)
HIV - drug resistance, superinfection
11. MSM Prevalence Monitoring Project – Median Test Positivity for GC, CT, HIV,and Syphilis Seroreactivity among MSM by Race/Ethnicity, STD Clinics, 2005 2005 increased incidence of GC and Syphilis in Black Hispanic2005 increased incidence of GC and Syphilis in Black Hispanic
12. Median Test Positivity for GC, CT, Syphilis among MSM, by HIV Status, STD Clinics, 2005 MSM Prevalence Monitoring Project And more common in the HIV infected – prevention efforts not working. And more common in the HIV infected – prevention efforts not working.
13. Both syphilis chancers Primary syphilis
Consider using to introduce historical factors of ulcers:
Note number of lesions, depth of lesion, presence of vesicles, induration, necrotic material on the ulcer bed, presence or absence of pain, associated lymphadenopathy, change over time, history of trauma, does the ulcer invade under the superficial edges or is it well demarcated.
An incorrect diagnosis frequently results from a purely clinical approach to genital ulcers.
Both syphilis chancers Primary syphilis
Consider using to introduce historical factors of ulcers:
Note number of lesions, depth of lesion, presence of vesicles, induration, necrotic material on the ulcer bed, presence or absence of pain, associated lymphadenopathy, change over time, history of trauma, does the ulcer invade under the superficial edges or is it well demarcated.
An incorrect diagnosis frequently results from a purely clinical approach to genital ulcers.
14. Genital UlcerEvaluation History and physical examination often inaccurate
Serologic test for syphilis
Diagnostic evaluation for HSV
Haemophilus ducreyi culture (chancroid prevalent)
Biopsy may be useful
Treat for diagnosis most likely - clinical/epidemiology
25% have no lab confirmed dx
Treat for most likely which in US would be HSV, syphilis or chancroid Treat for most likely: genital HSV, syphilis, chancroid most common in the USTreat for most likely: genital HSV, syphilis, chancroid most common in the US
15. Genital herpes — Initial visits to physicians’ offices: US, 1966–2004
16. HSV-2 / HIV Infection Lesions may be severe, prolonged, and atypical
HSV shedding increased despite ARV
Antiviral suppressive or episodic therapy effective in decreasing clinical manifestations; may need higher doses or more frequent dosing
Extent to which suppressive therapy decreases HIV transmission is unknown
Suppressive therapy can ? recurrence by 70-80%
Persistent lesions on antivirals - foscarnet 40 mg/kg q8 or topical cidofovir gel 1% Suppressive therapy does reduce the frequency of genital HSV recurrences by 70-80% in patients with frequent recurrences (= 6/yr).Suppressive therapy does reduce the frequency of genital HSV recurrences by 70-80% in patients with frequent recurrences (= 6/yr).
17. The classical painful multiple vesicular or ulcerative lesions are absent in many infected persons. The classical painful multiple vesicular or ulcerative lesions are absent in many infected persons.
19. Primary and secondary syphilis — Rates: Total and by sex: United States, 1986–2005 and the Healthy People 2010 target The 2000 re-emergence of syphilis – MSM related?The 2000 re-emergence of syphilis – MSM related?
20. Painless ulcer on genitalia, perianal area, pharynx, tongue, lips – appears 10-90 days after infection, spontaneously heals in 5-6 wk. May have associated nontender, rather firm, unilateral regional lymphadenitis.Painless ulcer on genitalia, perianal area, pharynx, tongue, lips – appears 10-90 days after infection, spontaneously heals in 5-6 wk. May have associated nontender, rather firm, unilateral regional lymphadenitis.
21. Secondary syphilitic rash – wide variety of skin lesion – macular, papular, maculopapular, pustular, ulcerative, follicular or nodular, mucous patches (highly infectious lesions of the mucous membrane with ‘snail-track ulcers”, condylomata lata.
90% have generalized lymphadenopathy.
99% will have + VDRL and FTA-ABS or TPHASecondary syphilitic rash – wide variety of skin lesion – macular, papular, maculopapular, pustular, ulcerative, follicular or nodular, mucous patches (highly infectious lesions of the mucous membrane with ‘snail-track ulcers”, condylomata lata.
90% have generalized lymphadenopathy.
99% will have + VDRL and FTA-ABS or TPHA
22. Syphilis Laboratory Testing Darkfield or Direct Flourescent Antibody (DFA) test of lesion exudate or tissue – definitive for early syphilis
Presumptive diagnosis:
Nontreponemal (VDRL or RPR) – false + occur in other medical conditions
Treponemal tests (FTA-ABS or TP-PA) - confirmatory
Quantitative non-treponemal (RPR, VDRL) testing to guide treatment (= 4-fold change is significant)
False + RPR: HIV/Lyme Ds./certain types of pneumonia/ Malaria/ SLE
4 fold change; 1:16 – 1:4 or 1:8 – 1:32
VDRL/RPR usually revert to negative over time, may remain low titre ‘serofast’
FTA-ABS/TP-PA – usually remain + for life (15-25% treated will become nonreactive after 2-3 yrs)
Sonicated treponemes – recombinant proteins of Treponema pallidum used as antigen.
FTA-ABS (flourescent treponemal antibody-absorption test) as second treponemal test; TP-PA Treponemal Pallidum particle agglutination
EIA’s more expensive. Ready for use today?False + RPR: HIV/Lyme Ds./certain types of pneumonia/ Malaria/ SLE
4 fold change; 1:16 – 1:4 or 1:8 – 1:32
VDRL/RPR usually revert to negative over time, may remain low titre ‘serofast’
FTA-ABS/TP-PA – usually remain + for life (15-25% treated will become nonreactive after 2-3 yrs)
Sonicated treponemes – recombinant proteins of Treponema pallidum used as antigen.
FTA-ABS (flourescent treponemal antibody-absorption test) as second treponemal test; TP-PA Treponemal Pallidum particle agglutination
EIA’s more expensive. Ready for use today?
23. Syphilis Drug of choice remains penicillin
PCN allergy-
doxycycline (100 mg BID x 14 d if primary or secondary),
ceftriaxone - optimal dose not defined (1 gm IV/IM x 8-10 d for early disease)
Azithromycin 2 gm may be effective; resistance and treatment failure reported
PCN alternatives - not well studied in HIV+ Cef try ax oneCef try ax one
24. Primary/Secondary SyphilisResponse to Therapy/HIV Infection Most respond to benzathine penicillin G 2.4 million units IM single dose
No regimens more effective in preventing neurosyphilis – majority respond to above
Some increased risk of treatment failure/neurologic complications not precisely defined
Benzathine pen x 3 wkly (some specialists)
CSF exam - neurologic signs/sx; CSF exam if RPR >1:32 or CD4 <350 (some specialists)
Clinical/serologic evaluation at 3, 6, 9, 12, 24 mo
Tx/serologic failure (6-12 mo after tx) - CSF exam, retreat with benzathine penicillin wkly x 3 Bullet 3?Bullet 3?
25. Latent Syphilis - HIV Infection CSF exam before treatment
WBC > 5cells/mm3, ?Pro., + VDRL-CSF, if FTA-ABS negative may exclude neurosyphilis
CSF exam for RPR >1:32 or HIV+ CD4 <350 regardless of stage (some specialists)
Benzathine PCN 2.4 MU IM weekly x 3
Doxycycline 100 mg BID x 28d, or
TCN 500 mg QID x 28d
Evaluation at 6,12,18, 24 mo after tx
CSF exam - no 4x decline by 12-24 mo CSF FTA-ABS highly sensitive but less specific.
And if PCN allergic? Doxycycline 100 mg orally BID or TCN 500 mg QID X 28 days.
Last bullet 4 fold decline in titre based on CSF, or on Serum RPRCSF FTA-ABS highly sensitive but less specific.
And if PCN allergic? Doxycycline 100 mg orally BID or TCN 500 mg QID X 28 days.
Last bullet 4 fold decline in titre based on CSF, or on Serum RPR
26. Neurosyphilis Treatment LP recommended to rule out neurosyphilis in all HIV-infected patients with syphilis
Recommended regimen
Aqueous crystalline penicillin G, 18-24 million units administered 3-4 mu IV q4h for 10-14 days (may be given via continuous infusion)
Alternative regimen
Procaine penicillin 2.4 million units IM daily plus probenecid 500 mg orally qid for 10-14 days
Some experts give benzathine penicillin G 2.4 million units IM wkly x 3 after completion of these regimens to provide comparable duration of treatment for late latent syphilis
CDC MMWR 2006; Vol 55 (RR11)
27. Chlamydia — Rates: Total and by sex: US, 1986–2005
28. Chlamydia trachomatis Most frequently reported infectious disease in US
3-4 million cases per year
Properties of both viruses and bacteria
Requires material from host cells for replication
Coinfection with chlamydia occurs in 60% of cases of gonorrhea
29. Lymphogranuloma venereum Proctitis presentation among HIV(+) MSM
Diagnosis
Genital or lymph node aspirates-culture, DFA
Caused by Chlamydia trachomatis serovars L1, L2, L3
Serology can support (CF > 1:64), not validated for proctitis
Empiric Rx warranted for appropriate clinical syndrome
Doxycycline 100 mg PO bid x 21 d
?? Azithromycin 1 g PO q wk x 3 wks LGV caused by serovars L1, L2, or L3
DFA Direct Flourescent Antibody
Compliment fixation titre >1:64 can support the diagnosis in the appropriate clinical context.
LGV caused by serovars L1, L2, or L3
DFA Direct Flourescent Antibody
Compliment fixation titre >1:64 can support the diagnosis in the appropriate clinical context.
30. A self limiting genital ulcer or papule occurs at the site of infection. Tender inguinal and or femoral lymphadenopathy, typically unilateral may A self limiting genital ulcer or papule occurs at the site of infection. Tender inguinal and or femoral lymphadenopathy, typically unilateral may
31. LGV Proctocolitis Rectal ulcers or lesions
Mucoid anal discharge
Rectal bleeding
Tenesmus or constipation
Rectal scarring and fistulas
32. Detection of CT/GC using NAATRectal Specimens NAAT (nucleic acid amplification test) not FDA cleared- rectal/pharyngeal
NAAT urine for GC/Chlamydia
CDC/FDA/manufacturers - NAAT rectal indication
PCR assays for LGV serovars
Culture specimens for GC/Chlamydia
DNA probes for GC/Chlamydia Bullet 2? 3/
Why is bullet 4 on this slideBullet 2? 3/
Why is bullet 4 on this slide
33. Chlamydia Treatment Same treatment regimens for HIV+
Equivalent efficacy and tolerance of
azithromycin 1g po single dose or
doxycycline 100 mg BID x 7d
Retest 3-4 mo after therapy - high prevalence of repeat infection (women)
Azithromycin recommended in pregnancy
34. Other Diseases CausingGenital Ulcers/HIV Chancroid (H. Ducreyi)
Painful genital ulcers heal slowly, lymphnodes may need drained
some specialists prefer erythromycin 500 mg tid x 7 d
ceftriaxone 250 mg IM, or azithromycin 1 g po single dose therapies, or cipro 500 BID X 3d
Granuloma inguinale (Donovanosis) (Klebsiella granulomatis)
Rare in us, painless progressive ulcerative lesions, no ? nodes
Doxycycline for 3 wks or until all lesions healed No cipro if PG or lactating
H Ducreyi – Chancroid - painful genital ulcer and tender supperative inguinal adenopathy. 10% in US coinfected with HIV or syphilis.
Probable diagnosis made if all the following criteria met:
1)one or more painful genital lesions
2) No evidence of T. pallidum by darkfield or negative serologic test for syphilis at least 7 days after onset of lesion
3) Appearance of lesion oand regional lymphadenopathy are typical for chancroid
4) HSV testing on the ulcer exudate is negative
Klebsiella granulomatis – Granuoma inguinale (Donovanosis) – rare in US; painless, progressive ulcerative lesions without regional lymphadenopathy, highly vascular, beefy red appearance and bleed easily on contact.No cipro if PG or lactating
H Ducreyi – Chancroid - painful genital ulcer and tender supperative inguinal adenopathy. 10% in US coinfected with HIV or syphilis.
Probable diagnosis made if all the following criteria met:
1)one or more painful genital lesions
2) No evidence of T. pallidum by darkfield or negative serologic test for syphilis at least 7 days after onset of lesion
3) Appearance of lesion oand regional lymphadenopathy are typical for chancroid
4) HSV testing on the ulcer exudate is negative
Klebsiella granulomatis – Granuoma inguinale (Donovanosis) – rare in US; painless, progressive ulcerative lesions without regional lymphadenopathy, highly vascular, beefy red appearance and bleed easily on contact.
35. Gonorrhea — Rates: Total and by Sex: US, 1986–2005
36. Treatment of Gonorrhea Recommended regimens
Ceftriaxone 125 mg IM x 1
Cefixime 400 mg PO x 1
Quinolone (ciprofloxacin 500 mg, or ofloxacin 400 mg, or levofloxacin 250 mg po x 1)
Quinolones should not be used in MSM
If cefixime unavailable
cefpodoxime 400 mg
cefuroxime axetil 1 g (marginal)
azithromycin 2 g (possible emergence of resistance)
Quinolones should not be used in MSM in areas of HIGH prevalence QRNG or if infected while traveling abroad
Quinolones should not be used in MSM in areas of HIGH prevalence QRNG or if infected while traveling abroad
37. GC Treatment - Spectinomycin Discontinuation of distribution in US 11/05- inventory expired 5/06
Preferred - PCN/cephalo allergy in pregnancy, high prevalence of QRNG, or MSM
Options- desensitize; azithromycin 2 gm effective
GI side effects
Potential emergence of resistance
TREAT ALL FOR CHLAMYDIA AS WELL
38. Cervicitis CT, GC, TV, HSV; M genitalium, BV
Evaluation - CT/GC NAAT, trichomonas culture if smear neg., BV; vaginal WBC >10 may indicate endocervical CT or GC
Cervicitis increases HIV shedding
Same treatment regimen for HIV+
Presumptive tx: Azithromycin 1 g po x 1 or Doxy 100 mg BID x 7d
39. Tinidazole Second generation 5-nitromidazole
Long duration of action ( t1/2 12-14 hr)
One of the recommended regimens for trichomoniasis (2g po single dose)
Effective in metronidazole resistant trichomonas
Lower tinidazole MLC in MTZ-resistant isolates MTZ 2 g po single dose
WHAT IS MLethalC?
Tye ni da zoleMTZ 2 g po single dose
WHAT IS MLethalC?
Tye ni da zole
40. Genital warts — Initial visits to physicians’ offices: US, 1966–2004
41. Genital Warts-Male
42. Genital Warts-Female
43. HPV/HIV Infection May have larger or numerous warts, might not respond as well to tx, more frequent recurrences
Same treatment regimens recommended
Anal cancer screening (some specialists)
natural history of anal intraepithelial neoplasia
reliability of screening methods
response to treatments
programmatic considerations
44. Sexually Transmitted GI Syndromes History of receptive anal intercourse or analingus
Proctitis
Anorectal pain, tenesmus, or rectal disch.
N. gonorrhea, C. Trachomatis, T. pallidum, HSV
Proctocolitis
Sxs. of proctitis + diarrhea, abd. Cramps
Campylobacter, shigella, entamoeba histolytica, & rarely LGV Most common infectious causesMost common infectious causes
45. Sexually Transmitted GI Syndromes Enteritis
Diarrhea and abd. cramping without signs of proctitis or proctocolitis
Associated with analingus
Giardia lamblia most frequently implicated
Emperic therapy while workup in progress:
Cefriaxone 125 mg IM + Doxycycline 100 mg BID x 7d
46. Summary STD Treatment Guidelines MMWR 2006; Vol. 55 (No. RR-11)
Critical importance of open dialogue
Routine screening
Diagnostic studies better than clinical diagnosis
Match treatment to the patient
Partner assessment and treatment
Advancing HIV prevention
47. Acknowledgement Kimberly A Workowski, MD, FACP
Associate Professor of Medicine,
Emory University, Division of Infectious Diseases
Epidemiology and Surveillance Branch,
Division of STD Prevention, CDC
John F. Toney, M.D. and Joanne Orrick, PharmD,
with the Florida/Caribbean AETC