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Common Non-Viral Stis, EPT Common Non-Viral STIs, EPT, and PrEP: Highlights and Updates Angela Kuznia MD, MPH - Clinical Assistant Professor Department of Family Medicine - University of Michigan Medical School 56th Annual Northern Michigan Family Medicine Update June 24, 2021 DISCLOSURES • I have no relevant conflicts of interest to disclose. ACKNOWLEDGEMENT • This presentation was researched and prepared in conjunction with an Adolescent Medicine Fellow from the University of Michigan Department of Pediatrics. • Thank you to Dr. Bernie Stoody! OBJECTIVES • Describe the disproportionate burden of disease among adolescents and sexual and racial minority groups. • Identify signs and symptoms of common non-viral sexually transmitted infections (STIs). • Identify indications for screening and interpret diagnostic test results related to common non-viral STIs. • Formulate management plans, including expedited partner therapy (EPT), for common non-viral STIs. • Identify indications for pre-exposure HIV prophylaxis (PrEP), conduct medication surveillance, and apply strategies to optimize adherence. DEMOGRAPHICS & RISKS Vulnerabilities of adolescents & young adults (AYAs): • Impulsivity, reward-seeking, high risk behaviors • Fear, confidentiality, logistics of accessing clinical care • Cervical ectopy https://www.cdc.gov/std/statistics/prevalence-incidence-cost-2020.htm DEMOGRAPHICS & RISKS Among high-school students: • 38% have undergone sexual debut • 27% sexually active currently (2009:34%) • 21% used substances before last sexual intercourse • 9% have had > 4 sexual partners (2009:14%) • 54% condom at last sexual intercourse (2009: 62%) Qu Y, et al 2015l Newon-Levinson, et al 2016; McKee, et al 2006; National Youth Risk Behavior Surveys 1991-2019; DEMOGRAPHICS & RISKS • Chlamydia (CT) and Gonorrhea (GC) • 2018-2019: increased # cases overall • Highest risk: men who have sex with men (MSM) • GC 42x higher among MSM than men who have sex with women only (MSW) • Trichomoniasis • Disproportionately high disease burden in: • Black females • Older adolescents; especially incarcerated AYAs • Syphilis (25% of cases among 15-24yo) • Disproportionately high disease burden in: • Southeastern states • Black individuals • Males (2019: 56.7% of cases were among MSM) LOCATION, LOCATION, LOCATION Limited access to care = 2019: 30.6% of all cases of Chlamydia, Gonorrhea, and primary and secondary syphilis were among non-Hispanic Black people (i.e. among 12.5% of the US population). Q #1 Q #1 Which of the following is recommended regarding follow-up chlamydia testing for a woman treated for uncomplicated cervical chlamydia who does not have persistent or recurrent symptoms? a) Perform a test-of-cure nucleic acid amplification test (NAAT) 10 days after treatment completion b) Perform a test-of-cure nucleic acid amplification test (NAAT) 2 months After treatment completion c) Send a cervical specimen for culture and sensitivity testing within 2 weeks of the positive nucleic acid amplification test (NAAT) result d) Screen for re-infection 3 months after completion of therapy Q #1 Which of the following is recommended regarding follow-up chlamydia testing for a woman treated for uncomplicated cervical chlamydia who does not have persistent or recurrent symptoms? a) Perform a test-of-cure nucleic acid amplification test (NAAT) 10 days after treatment completion b) Perform a test-of-cure nucleic acid amplification test (NAAT) 2 months After treatment completion c) Send a cervical specimen for culture and sensitivity testing within 2 weeks of the positive nucleic acid amplification test (NAAT) result d) Screen for re-infection 3 months after completion of therapy CHLAMYDIA – SIGNS & SYMPTOMS • Mostly asymptomatic (75% of females and 50% of males) • Females • Cervicitis + discharge • Urethral involvement: dysuria and frequency • Nonspecific: irregular bleeding, pelvic discomfort • Males • Urethritis • Epididymitis • +/- discharge CHLAMYDIA – SIGNS & SYMPTOMS • Untreated infection in females • Pelvic inflammatory disease (PID) with possible perihepatitis • Ectopic pregnancy • Infertility • Both sexes could present with conjunctivitis (autoinoculation), severe pharyngitis, proctitis or proctocolitis, or reactive arthritis Q #2 Q #2 A 19-year-old MSM visits your clinic for HIV testing and STI screening. In the past 6 months, he has had 4 different male partners and practices insertive and receptive anal and oral sex. He intermittently uses condoms. Overall, his health is good and he currently has no genitourinary or pharyngeal symptoms. Which of the following is the most appropriate approach to screen this patient for chlamydia and gonorrhea? a) Screen at anal and oropharyngeal sites at least every 6 months b) Screen at urethral, anal, and oropharyngeal sites at least annually c) Screen at urethral and anal sites at least every 12 months d) Routine screening for chlamydia infection is not recommended Q #2 A 19-year-old MSM visits your clinic for HIV testing and STI screening. In the past 6 months, he has had 4 different male partners and practices insertive and receptive anal and oral sex. He intermittently uses condoms. Overall, his health is good and he currently has no genitourinary or pharyngeal symptoms. Which of the following is the most appropriate approach to screen this patient for chlamydia and gonorrhea? a) Screen at anal and oropharyngeal sites at least every 6 months b) Screen at urethral, anal, and oropharyngeal sites at least annually c) Screen at urethral and anal sites at least every 12 months d) Routine screening for chlamydia infection is not recommended CT & GC – SCREENING • Annual screening of all sexually active women <25 y/o • Should be considered for men if: • Presenting to a clinic with high prevalence of STIs • MSM • New partner or partner with STI • Screen transgender patients according to age, sexual activity, and current anatomy CT & GC – SCREENING PEARLS • Urine NAAT is at least as sensitive as clinician/self-collected vaginal and urethral specimens in clinic settings. • Consider adding screening for trichomonas in high risk individuals (i.e., history of STI, multiple sex partners, adolescents) • In females 15-24yo, consider a UNIVERSAL APPROACH that does not rely on endorsement of sexual activity CT & GC – DIAGNOSTIC TESTING NAAT: gold standard • first catch urine, vaginal, oropharyngeal, or rectal swabs If test positive, offer HIV testing • CT infection increases risk of HIV infection 5-fold CHLAMYDIA – TREATMENT 1st line: Azithromycin 1 g PO once or doxycycline 100 mg PO BID x7d, w/ abstinence for 7d upon completion of rx • Alternative Regimens: - Erythromycin 500 mg PO QID x7d - Levofloxacin 500 mg PO daily x7d - Ofloxacin 300mg PO BID x7d • Test again in 3 mo to assess for repeat infection • If pregnant: avoid doxy, re-test 3-4wk after therapy completed GONORRHEA – SIGNS & SYMPTOMS Men • ~50% are symptomatic • Urethritis: mucopurulent or purulent urethral discharge and dysuria • Proctitis: including anal bleeding, itching, irritation, painful defecation, painless/purulent discharge • Epididymitis • Prostatitis • Perirectal or periurethral abscess GONORRHEA – SIGNS & SYMPTOMS Women • often asymptomatic (80%) • Cervicitis or urethritis • Accessory gland infection (e.g. Skene or Bartholin glands) • PID • Perihepatitis Q #3 Q #3 You diagnose an18-year-old patient with cervical gonorrhea. She has no symptoms, and co-testing for chlamydia is negative. Her weight is 143lb. Based on the 2020 updated recommendations from the Centers for Disease Control (CDC), what regimen should be used to treat this patient’s cervical Neisseria gonorrhoeae infection? a) Ceftriaxone 250 mg IM in a single dose b) Ceftriaxone 500 mg IM in a single dose c) Ciprofloxacin 500 mg PO as a single dose plus doxycycline 100 mg PO BID x7 days c) Cefixime 400 mg PO daily x7 days plus azithromycin 1g PO in a single dose Q #3 You diagnose an18-year-old patient with cervical gonorrhea. She has no symptoms, and co-testing for chlamydia is negative. Her weight is 143lb. Based on the 2020 updated recommendations from the Centers for Disease Control (CDC), what regimen should be used to treat this patient’s cervical Neisseria gonorrhoeae infection? a) Ceftriaxone 250 mg IM in a single dose b) Ceftriaxone 500 mg IM in a single dose c) Ciprofloxacin 500 mg PO as a single dose plus doxycycline 100 mg PO BID x7 days c) Cefixime 400 mg PO daily x7 days plus azithromycin 1g PO in a single dose GONORRHEA – 2020 TREATMENT UPDATE Uncomplicated cervical, urethral, rectal, pharyngeal, or conjunctivitis infections: • Ceftriaxone 500 mg IM once (1G if >300lb) • 2nd line: oral cefixime 800 mg • Pharyngeal or conjunctivitis -- must obtain test of cure 14 days after rx • combination therapy with 2 antimicrobial drugs is recommended only when chlamydia infection has not been excluded • First-line co-infection tx is now doxycycline 100 mg BID x7d • Repeat testing in 3 mo due to high rate of reinfection (not test of cure) EPT – CT & GC • Who is eligible: • Any partners within 60 days preceding symptom onset or diagnosis • most recent partner if >60 days • Should be deferred if: • Female partner experiencing symptoms of PID • MSM, due to high risk of co-infection w/ syphilis or HIV, lack of efficacy data, and increasing resistance to cefixime (GC) in this population • Requires abstinence until 7 days post treatment and resolution of all symptoms EPT PEARLS • Screen for intimate partner violence, human trafficking • Provide resources regarding medication and anticipatory guidance for seeking medical evaluation
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