Common Sexually Transmitted Diseases (STDs) and HIV-Infected Women

1. Common Sexually Transmitted Diseases (STDs) and HIV-Infected Women October 2007

2. This slide set was developed by members of the Cervical • Cancer Screening Subgroup of the AETC Women's Health • and Wellness Workgroup: • Laura Armas, MD; Texas/Oklahoma AETC • Kathy Hendricks, RN, MSN; François-Xavier Bagnoud Center • Supriya Modey, MBBS, MPH; AETC National Resource Center • Andrea Norberg, MS, RN; AETC National Resource Center • Peter Oates, RN, MSN, ACRN, NP-C; François-Xavier Bagnoud Center • Jamie Steiger, MPH; AETC National Resource Center • Other subgroup members and contributors include: • Abigail Davis, MS, ANP, WHNP; Mountain Plains AETC • Lori DeLorenzo, MSN, RN; Organizational Ideas • Rebecca Fry, MSN, APN; François-Xavier Bagnoud Center • Pamela Rothpletz-Puglia, EdD, RD; François-Xavier Bagnoud Center • Jacki Witt, JD, MSN, WHNP; Clinical Training Center for Family Planning • 2

3. Learning Objectives • Identify the five most common STDs affecting HIV-infected women • Discuss clinical presentations associated with the five common STDs • Recall methods for diagnosing the five common STDs

4. Common STDs in HIV-Infected Women • Herpes Simplex Virus (HSV) • Syphilis • Chlamydia • Gonorrhea • Trichomoniasis

5. Herpes Simplex Virus (HSV)

6. Primary Infection Prodrome phase: Tingling/itching of skin Appearance of painful vesicles in clusters on an erythematous base Vesicles ulcerate then crust over and heal within 7-14 days Viral shedding continues for up to 2-3 weeks Recurrent Disease After primary infection, virus migrates to sacral ganglion and lies dormant Reactivation occurs due to various triggers Reoccurrence is usually milder and shorter in duration HSV: Clinical Presentation

7. Herpes Simplex in Women with AIDS Credit: Jean R. Anderson, MD

8. HSV: Diagnosis • Clinical presentation • Viral culture • Tzanck smear/Giemsa smear • Skin biopsy

9. Antivirals Lesions may be bathed in mild soap and water Sitz baths may provide some relief Sex partners may benefit from evaluation and counseling Transmission is possible when lesions not present due to viral shedding HSV: Treatment Considerations

10. Syphilis

11. Syphilis: Clinical Presentation • Primary / Infectious / Early Syphilis Stage: • Primary Phase • Primary chancre • Begins as papule and erodes into painless ulcer with a hard edge and clean base • Usually in the genital area • Appears 9-90 days after exposure • Can be solitary or multiple (eg. kissing lesions) • Heals with scarring in 3-6 weeks and 75% of patients show no further symptoms

12. Primary Chancre Primary Chancre Credit: Centers for Disease Control and Prevention (CDC)

13. Syphilis: Clinical Presentation (continued) • Primary / Infectious / Early Syphilis Stage: • Secondary Phase • Occurs 6 weeks – 6 months after chancre • Lasts several weeks • Accompanied with fever, malaise, generalized lymphadenopathy, and patchy alopecia • Maculo-papular rash usually on palms and soles • Condyloma lata on perianal or vulval areas • Possible mild hepatosplenomegaly

14. Syphilitic Rash Credit: Dr. Gavin Hart and CDC Credit: Connie Celum and Walter Stamn and Seattle STD/HIV Prevention Training Center

15. Condyloma lata Condyloma lata Credit: CDC

16. Syphilis:Clinical Presentation (continued) • Secondary / Latent Stage: • Positive serology • Rapid Plasma Reagin (RPR) • Venereal Disease Research Lab (VDRL) • Patients are asymptomatic and not infectious after first year, but may relapse • One-third will convert to sero-negative status • One-third will stay sero-positive but asymptomatic • One-third will develop tertiary syphilis

17. Syphilis: Clinical Presentation (continued) • Tertiary Stage: • Cardiovascular: Aortic valve disease, aneurysms • Neurological: Meningitis, encephalitis, tabes dorsalis, dementia • Gumma formation: Deep cutaneous granulomatous pockets • Orthopedic: Charcot’s joints, osteomyelitis • Renal: Membranous Glomerulonephritis

18. Syphilis: Diagnosis • Requires demonstration of: • Organisms on microscopy using dark field • Positive serology on blood or cerebrospinal fluid (CSF) Non-Specific Treponemal Tests: 1. Venereal Disease Research Laboratory (VDRL) 2. Rapid Plasma Reagin (RPR)

19. Syphilis: Diagnosis (continued) • Positive serology on blood or CSF • Specific Treponemal Test: 1. Fluorescent Treponemal Antibody Absorption (FTA-ABS) 2. Microhemagglutination-Treponema pallidum (MHA-TP) • Organism may not be cultured but diagnosis cannot be determined by clinical findings only

20. Syphilis: Treatment Considerations • Primary/ secondary/ latent stage: Benzathine penicillin • Neurosyphilis: Penicillin G • Ask about penicillin allergy before treatment • Jarisch-Herxheimer reaction may occur

21. Chlamydia

22. Chlamydia: Clinical Presentation • Mucopurulent cervicitis/vaginal discharge • Dysuria • Lower abdominal pain • Urethritis, salpingitis, and proctitis • Post coital bleeding – friable cervix • Key Considerations: • 50% of females are asymptomatic • Sterile pyuria with urinary tract symptoms should trigger you to think chlamydia

23. Cervicitis Credit: University of Washington and Seattle STD/HIV Prevention Training Center

24. Chlamydia culture New tests include: Direct immunofluorescence assays (DFA) Enzyme immunoassay (EIA) Chlamydia: Diagnosis

25. Chlamydia: Treatment Considerations • Antibiotics • Azithromycin • Evaluate and treat sexual partners • Avoid sex for seven days after completion of treatment

26. Gonorrhea

27. N. gonorrhoeae-gram negative diplococci Diplococci Credit: Negusse Ocbamichael and Seattle STD/HIV Prevention Training Center

28. Areas of Infection Urethra Endocervix Upper genital tract Pharynx Rectum Signs and Symptoms Frequently asymptomatic Vaginal discharge Abnormal uterine bleeding Dysuria Mucopurulent cervicitis Lower abdominal pain Gonorrhea: Clinical Presentation

29. Gonorrhea: Diagnosis • Clinical exam • Cervical culture • Polymerase chain reaction (PCR) or ligase chain reaction (LCR) • Gram stain–polymorphonucleocytes with gram negative intracellular diplococci

30. Gonococcal Isolate Surveillance Project (GISP) — Percent of Neisseria gonorrhoeae isolates with resistance or intermediate resistance to ciprofloxacin, 1990–2005

31. Gonorrhea: Treatment Considerations • Intramuscular Ceftriaxone • For pregnant women only: • Ceftriaxone single dose but substitute Quinolones with Erythromycin • Do not treat with Quinolones or Tetracyclines • Evaluate and treat all sexual partners

32. Trichomoniasis

33. Trichomoniasis: Clinical Presentation • Signs and symptoms: • Vulvar irritation • Dysuria • Dyspareunia • Pale yellow, malodorous - gray/green frothy discharge • Strawberry cervix, inflamed and friable

34. Strawberry Cervix Credit: Claire E. Stevens and Seattle STD/HIV Prevention Training Center

35. Trichomoniasis: Diagnosis • Flagellated, motile trichomonads on wet mount • Vaginal pH > 4.5 • Diagnosis confirmed by microscopy • Other FDA approved tests: • OSOM Trichomonas Rapid Test • Affirm VP III

36. Trichomoniasis: Treatment Considerations • For HIV-infected women: same treatment as non-HIV infected women • Metronidazole or Tinidazole • Sex partners have to be treated

37. Providing Culturally Competent Care • The following factors can influence a woman’s understanding of STDs and need for screening: • Language and literacy level • Cultural and social background and its impact on her • understanding of health, illness, and the female anatomy • Comfort with discussing sexual health issues • Comfort and previous experience with STD screening or testing • History of sexual abuse and/or domestic violence may cause anxiety and exam refusal

38. Pearls of Wisdom • Get comfortable with obtaining a thorough sexual history • Check oral cavity if genital STD suspected • Minimum of annual screening for STDs is recommended, with more frequent screening if high risk behaviors are reported • Partner notification and risk reduction counseling for both patient and partner is an important part of treatment and follow-up.

39. Conclusion • STD screening and treatment should be a primary intervention and a standard of care in all health care settings. • Women infected with STDs have increased chances of contracting HIV. • Studies show STD and HIV co-infection increases HIV virus shedding in the patients’ genital secretions. • If co-infection is present, proper diagnosis and treatment of STDs will decrease the chances of transmitting HIV.

40. Helpful Resources • AETC National Resource Center (NRC), www.aidsetc.org • Clinical Manual for Management of the HIV-Infected Adult • AIDSMAP,http://www.aidsmap.com • Centers for Disease Control and Prevention, http://www.cdc.gov/std • STD Treatment guidelines 2006 • HIV / AIDS and STDs • Health Resources and Services Administration HIV/AIDS Bureau, http://hab.hrsa.gov/ • A Guide to the Clinical Care of Women with HIV/AIDS • HIVInsite, http://hivinsite.ucsf.edu • Transgender Awareness Training & Advocacy • http://www.tgtrain.org/

41. References • Anderson, J.R, ed. (2005). A Guide to the Clinical Care of Women with HIV. Health Resources and Services Administration HIV/AIDS Bureau. • Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines 2006. MMWR, Aug 4, 2006, 55. • Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines 2006. MMWR, April 13, 2007, 56 • Centers for Disease Control and Prevention. The Role of STD Detection and Treatment in HIV Prevention. Retrieved on September 16, 2007 from http://www.cdc.gov/std/hiv/STDFact-STD&HIV.htm#WhatIs • Health Resources and Services Administation, HIV/AIDS Bureau, AETC National Resource Center. (2006). Guiding Principles for Cultural Competency. Retrieved on September 20, 2007 from http://www.aidsetc.org/doc/workgroups/cc-principles.doc • US Preventive Services Task Force. Screening for gonorrhea: recommendation Statement. Ann Fam Med 2005;3:263-7.