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Home , Pediculosis pubis, Trichomoniasis

8/12/19

Disclosures

• Lupin: Advisory committee for Solosec

• Merck: Nexplanon trainer

• Pfizer pharmaceutical: Advisory Committee for Menopause Questionnaire/teaching tool

• TherapeuticsMD: Advisory Committee for vaginal hormone insert

Shelagh Larson DNP, APRN, WHNP, NCMP

Distinguish the differential diagnosis of STI. Objectives

• 1. The attendees will recognize the non-genital presentations of sexually transmitted in women and men. • •Herpes • 2. The attendees will understand the prescription therapy for STIs in alternative sites. • •HPV • 3. The attendees will know the differential diagnosis of STI and other tradition . • •HIV *

STI Presentations

Discharge Syndrome Genital Ulcer Syndromes Dermatologic Syndromes • Chlamydia • HPV • Gonorrhea Secondary Syphilis • Primary Syphilis Disseminated Gonococcal • Trichomoniasis • Infection • Pubis • Candidiasis

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Facts

• most frequently reported bacterial sexually transmitted infection in the US • The silent disease 75% of infected females and 50% males do not realize they have it • Transmitted: vaginally, anal, oral • Once an infected person has completed treatment, they should be re-tested after approximately three months to make sure the condition is cured. • Almost 2/3 of new chlamydia infections occur among youth aged 15-24 years. most frequently reported bacterial STI in the United States • known as a ‘silent’ infection because most infected people are asymptomatic and It is estimated that 1 in 20 sexually active young women aged 14-24 years lack abnormal physical examination findings. has chlamydia Easily treated with Azithromycin

Symptoms (if any) occur 1-3 weeks after exposure

• Women • Men • –Abnormal (Odor or Odorless) • Cloudy or Clear Discharge From the Tip of the Penis • –Spotting/Bleeding Between Periods • –Painful and Swollen Testicles • –Painful Periods • –Itching and/or Burning Around • –Pain During the Opening of the Penis • –Painful • –Painful Urination • –Abdominal Pain With Fever • –Burning and/or Itching in or Around the

unilateral eye discomfort with hyperemia. The secretions may be mucopurulent, but are more typically clear to cloudy

Chlamydial tonsillopharyngitis is marked by generalized pharyngeal and tonsillar hyperemia with possible addition of swollen anterior pillars and uvula, as well as diffuse purulent exudate on the tonsils Oztürk O, Seven H. tonsillopharyngitis. Case Rep CDC/ Susan Lindsley Otolaryngol. 2012;2012:736107

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Reactive arthritis (formerly Reiter’s syndrome) “Fitz-Hugh-Curtis Syndrome” • a post-inflammatory autoimmune disease that can result from urogenital chlamydia infection. • Characteristics of the syndrome include Some patients with chlamydial PID develop , , oligoarthritis, and skin lesions (keratoderma perihepatitis, an of the liver blennorrhagica) and circinate balanitis • the onset is typically 3 to 6 weeks after capsule and surrounding peritoneum, which urogenital chlamydia infection and it can occur even in persons who receive effective treatment for chlamydia is associated with right upper quadrant pain. infection.

• affects predominantly males, particularly those positive for HLA-B27, and it usually Source: photograph from Public Health—Seattle & King County STD Clinic. resolves within 3 to 6 months Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. Chlamydial infections. MMWR Recomm Rep. 2015;64(No. RR-3):1-137

Treatment : CZ, and you would be mad! Screening recommendations: Azithromycin 1 g po a single dose Women Men (Doxycycline 100 mg po BID x 7 days) • Sexually active women under 25 years of age, • *Consider screening young men in high prevalence clinical settings or in • Sexually active women aged 25 years and older if at • an oropharyngeal infection should be treated increased risk populations with high burden of infection (e.g. MSM) with azithromycin or doxycycline. • Test for reinfection approximately 3 months after treatment Men Who have Sex With Men (MSM) For rectal chlamydial infections, some experts prefer Pregnant Women • At least annually for sexually active MSM using doxycycline rather than azithromycin • Retest during the 3rd trimester for women under 25 at sites of contact (urethra, rectum) years of age or at risk regardless of use with Azithromycin allergy: • Should have a TOC 3-4 weeks after treatment and be • Every 3 to 6 months if at increased risk Amoxicillin 500 mg po TID x 7 days retested during the third trimester. Persons with HIV • Routine oropharyngeal screening for CT is not Alternative Regimens recommended, although evidence suggests it can be • sexually transmitted to genital sites For sexually active individuals, screen at first HIV evaluation, and at least annually Erythromycin base 500 mg po QID x 7 days • diagnostic accuracy indicate that screening for thereafter Erythromycin ethyl succinate 800 mg po QID x 7 days chlamydia and gonorrhea with NAATs is highly accurate for specimens from various anatomical sites Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted Levofloxacin 500 mg po qD x7 days for women and men CDC, 2017. Chlamydia Fact sheet. detailed diseases treatment guidelines, 2015. Chlamydial infections. MMWR Recomm Rep. 2015;64(No. https://www.cdc.gov/std/chlamydia/stdfact-chlamydia-detailed.htm RR-3):1-137 Ofloxacin 300 mg PO BID x7 days

Gonorrhea

• caused by the • When symptoms are present they can include thick white or yellow/greenish discharge, painful urination, increased urination, sore throat and severe pain in lower abdomen.

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Who gets it? Symptoms • Any sexually active person can be infected with gonorrhea. • Unpleasant smelling and • Discomfort while having • In the United States, the highest reported rates of infection are among frothy vaginal discharge intercourse sexually active teenagers, young adults, and African Americans • Itching in and around the • Green, white, yellow or gray • transmitted through sexual contact with the penis, vagina, mouth, or vaginal area vaginal discharge anus of an infected partner. • • • Ejaculation does not have to occur for gonorrhea to be transmitted or Blood spotting in discharge Genital swelling or redness acquired. • Frequent urination • Low abdominal pain in rare • Gonorrhea can also be spread perinatally from mother to baby during accompanied by burning cases childbirth. sensation and pain • Groin swelling

Screening recommendations: Gonorrhea Women Men Who have Sex With Men (MSM) • Sexually active women under 25 • At least annually for sexually active MSM at sites of years of age contact (urethra, rectum, pharynx) regardless of condom use • Sexually active women age 25 years • Every 3 to 6 months if at increased risk Pharyngeal infection may cause a and older if at increased risk • testing of specimens was slightly more sore throat, but usually is sensitive than urethral specimens Courtesy of the CDC asymptomatic • Retest 3 months after treatment Consider one-time lavage of the Pregnant Women infected eye with saline solution Persons with HIV • All under 25 years of age and older • For sexually active individuals, screen at first HIV Culture is available for detection of rectal, women if at increased risk evaluation, and at least annually thereafter oropharyngeal, and conjunctival gonococcal • More frequent screening for might be appropriate infection, but NAAT is not FDA-cleared for • Retest 3 months after treatment depending on individual risk behaviors and the local use with these specimens. Yet some have epidemiology met CLIA regulatory requirements and • Retest in 3rd Trimester if continual risk Courtesy of the CDC/Joe Miller Courtesy of the CDC established performance specifications for Culture is available for detection of rectal, oropharyngeal, and conjunctival gonococcal infection, WorkowskiKA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. using NAAT with rectal and oropharyngeal Gonococcal infections. MMWR Recomm Rep. 2015;64(No. RR-3):1-137. but NAAT is not FDA-cleared for use with these specimens. . swab specimens . https://www.std.uw.edu/custom/self-study/gonorrhea

Gonorrhea: • Ceftriaxone 250 mg IM/single dose “Happy Hour” PLUS If ceftriaxone is not available or • Azithromycin 1g po/single dose Expedited Partner Therapy: on the same day, same time

• safe and effective for tx of uncomplicated gonorrhea at all anatomic sites, curing 99.2% of •Cefixime 400 mg orally in a single dose urogenital and anorectal infections and 98.9% of pharyngeal infections in clinical trial. PLUS Conjunctivitis: Ceftriaxone 1 g IM/single dose +Azithromycin 1 g po/single dose • Azithromycin 1 g orally in a single dose • Laws and regulations in all states require clinicians, laboratories, or both to report persons Laws and regulations in all states require clinicians, laboratories, or both to report persons with gonorrhea to public with gonorrhea to public health authorities. health authorities. Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. Gonococcal infections. MMWR Recomm Rep. Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. 2015;64(No. RR-3):1-137 Gonococcal infections. MMWR Recomm Rep. 2015;64(No. RR-3):1-137

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GONOCOCCAL TREATMENT FAILURE Disseminated Gonococcal Infection • suspected in patients who have recurrence of symptoms or a positive culture after a documented, appropriate treatment DGI • majority of suspected treatment failure are reinfection rather than true treatment failure •vary greatly from patient to patient • true treatment failure should be considered in a person: • whose symptoms do not resolve within 3 to 5 days after appropriate treatment and they report no sexual contact during the post-treatment follow-up period and •no longer have any localized symptoms • with a failed test-of-cure (i.e. positive culture at least 72 hours or positive NAAT at least 7 days after receiving recommended treatment) when no sexual contact is reported during the post- treatment follow-up period. •The classic presentation: an arthritis syndrome Risk factors for treatment failure due to resistant organisms include •Joint or tendon pain is the most common 1) multiple prior treatment courses for gonorrhea, 2) international travel, or 3) pharyngeal disease.

Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. Gonococcal infections. MMWR Recomm Rep. 2015;64(No. RR-3):1-137.

Disseminated DGI: The early Gonorrhea stage • Skin rash in approximately 25% of patients • classic manifestations are fever • found below the neck and (for 5 to 7 days); may also involve the palms and soles • migratory polyarthralgia, especially of the knees, elbows, and more • Lesions varying from distal joints. maculopapular to pustular, often with a hemorrhagic • May also have tenosynovitis ; most component. Lesions usually commonly affects the flexor tendon sheaths of the wrist or the Achilles number 5-40, are peripherally Stendon ("lovers' heels"). located, and may be painful before they are visible. Fever is common but rarely exceeds

39°C. CDC courtesy of Dr. S. E. Thompson and J. Pledger

Arthritis-Dermatitis Syndrome:

• Symptoms usually for 3-5 days before diagnosis •If you find • Classic triad of migratory polyarthritis, tenosynovitis and dermatitis young kids • Migratory arthralgias most common presenting symptom • Typically asymmetrical, polyarticular and involve upper extremities more than developing STD lower extremities • Wrists, elbows, ankles and knees most commonly affected

infection it can • Tenosynovitis can occur, usually over dorsum of wrist and hand

be due to sexual • Painless, non-pruritic rash, typically on extremities – small papules, pustules or abuse. vesicles • Non-specific constitutional symptoms (fever, myalgia, malaise)

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Treatment: Hospitalization

• Ceftriaxone 1 g IM or IV every 24 hours • PLUS Azithromycin 1 g orally in a single dose

Alternative Regimens

• Cefotaxime 1 g IV every 8 hours OR Ceftizoxime 1 g IV every 8 hours

• PLUS Azithromycin 1 g orally in a single dose • The provider can switch to an oral agent guided by antimicrobial susceptibility testing 24–48 hours after substantial clinical improvement, for a total treatment course of at least 7 days. The duration of treatment of DGI has not been systematically studied and should be determined in consultation with an infectious-disease specialist is one of the most common curable sexually transmitted infections worldwide. An estimated 3.7 million people have Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. Gonococcal infections. MMWR Recomm Rep. 2015;64(No. RR-3):1-137. trichomoniasis in the US, with approximately 1.1 million new cases occurring each year

Trichomoniasis Difference with BV and Trich In women, the most commonly infected part of the body is the lower genital tract (, vagina, cervix, or urethra) Bacterial Vaginosis Trichomoniasis

70% of infected people do not have any signs or • Fishy odor • Musty odor symptoms • Thin, off-white homogeneous discharge • Pale green watery discharge Symptoms are within 5 to 28 days • Usually no , , pruritis • Can cause tenderness, dysuria or inflammation dyspareunia, pruritis 1 in 5 people get infected again within 3 months after receiving treatment • Mild vulvar irritation • Vulvar erythema, cervical PETECHIA • NAAT is highly sensitive, often detecting three to five • Wet Prep: bacterial coated (dipped and Wet Prep: motile , pear-shaped , flagellated times more T. vaginalis infections than wet-mount fried) epithelial cells • No partner treatment • Treat Partners In men, multiple specimens used to inoculate a single culture.

CDC. 2017.Trichomoniasis - CDC Fact Sheet https://www.cdc.gov/std/trichomonas/stdfact-trichomoniasis.htm

Tric or Treat! • 2 g po in a single dose • OR 2 g po in a single dose

• Alternative: Metronidazole 500 mg orally twice a day for 7 days*

• male partners should be evaluated with 3 swabs • Persistent or Recurrent Trichomoniasis: • with metronidazole 2 g single dose (reinfection is excluded), the patient / their partner[s]) can be treated with metronidazole 500 mg orally twice daily for 7 days. • If this regimen fails, clinicians should consider metronidazole or tinidazole at 2 g orally for 7 days. • Metronidazole gel is considerably less efficacious for the treatment of Trichomoniasis • rescreening forT. vaginalis at 3 months following initial infection • About 1 in 5 people get infected again within 3 months after treatment.

CDC, 2017. Trichomoniasis. https://www.cdc.gov/std/trichomonas/stdfact-trichomoniasis.htm

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Syphilis • is a disease with a highly variable clinical course. • called “ the great imitator, ” because the various clinical manifestations match many other diseases. • rates increased by nearly 18 % overall from 2015 to 2016 • 36 % increase in rates among women • 28 % increase among newborns

Primary Stage

appearance of a single chancre marks the primary chancre appears at the usually (but not always) (first) stage of syphilis location where syphilis firm, round, and symptoms, but there may entered the body painless. be multiple sores.

average time between chancre lasts 3 to 6 weeks and acquisition and the start of the heals regardless of whether a first symptom is 21 days, but can person is treated or not be from 10 to 90 days

CDC/ Joyce Ayers Secondary Stage : The Rash as the original sore will be is healing or several weeks after the chancre has healed, the person will develop sudden rash on his/her entire body. will NOT cause itching and may looks like warts. may appear as rough, red, or reddish brown spots both on the palms of the hands and the bottoms of the feet. so faint that they are not noticed. different appearance may occur on other parts of the body, sometimes resembling rashes caused by other diseases may include fever, swollen lymph glands, sore throat, patchy hair loss, headaches, weight loss, muscle aches, and fatigue Large, raised, gray or white lesions, known as condyloma lata, may develop in warm, moist areas such as the CDC. 2017. Syphilis - CDC Fact Sheet (Detailed) mouth, underarm or groin region https://www.cdc.gov/std/syphilis/stdfact-syphilis-detailed.htm

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Latent Syphilis • Characterized by seroreactivity without other evidence of primary, secondary, or tertiary disease.

• Persons who have latent syphilis and who acquired syphilis during the preceding year are classified as having early latent syphilis, a subset of latent syphilis.

• Persons can receive a diagnosis of early latent syphilis if, during the year preceding the diagnosis, they had • 1) a documented seroconversion or a sustained (>2 week) fourfold or greater increase in nontreponemal test titers; • 2) unequivocal symptoms of primary or secondary syphilis; or • 3) a sex partner documented to have primary, secondary, or early latent syphilis

• Persons with reactive nontreponemal and treponemal tests whose only possible exposure occurred during the previous 12 months, early latent syphilis can be assumed • latent syphilis is not transmitted sexually

Testing Treatment •Primary and Secondary Syphilis and Early Latent Syphilis: • Two types of blood tests available for syphilis: Both types of tests are needed to confirm a diagnosis of syphilis • Benzathine penicillin G 2.4 million units IM in a single dose • 1) Nontreponemal tests (VDRL and RPR) • used for screening, they are not specific for syphilis, can produce false-positive results, and, by themselves, • Available data reveal additional doses of benzathine penicillin G, amoxicillin, or other in are insufficient for diagnosis early latent syphilis do not enhance efficacy, regardless of HIV infection • should each have their antibody titer results reported quantitatively • a reactive nontreponemal test should always receive a treponemal test to confirm a syphilis diagnosis. •Late Latent Syphilis or Latent Syphilis of Unknown Duration: This sequence of testing (nontreponemal, then treponemal test) is considered the “classical” testing algorithm. • Benzathine penicillin G 7.2 million units total, divided in 3 doses of 2.4 million units IM • 2) Treponemal tests ( FTA-ABS, TP-PA, various EIAs,). each at 1-week intervals • detect antibodies that are specific for syphilis. • Treponemal antibodies appear earlier than nontreponemal antibodies and usually remain detectable for life, even after successful treatment • that an interval of 7–9 days between doses is optimal. However, 10–14 days between • If a treponemal test is used for screening and the results are positive, a nontreponemal test with titer should be performed to confirm diagnosis and guide patient management. Called a Reverse Sequence Testing doses might be acceptable before restarting the sequence • Combinations of some penicillin preparations (e.g., Bicillin C-R, a combination of benzathine penicillin and procaine penicillin) are not appropriate replacements for benzathine penicillin

Pregnancy and Syphilis Recommended Regimens for Infants and Children • *Benzathine penicillin G 2.4 million units IM in a single dose with

a second dose of 2.4 million units 1 week after the initial dose • Early Latent Syphilis: Benzathine PCN G 50,000 units/kg IM, up to the adult dose of 2.4 million units in a single dose for primary, secondary, or early latent syphilis • Late Latent Syphilis: Benzathine PCN G 50,000 units/kg IM, up to the adult dose of 2.4 million units, given in 3 doses at 1-week intervals (total 150,000 units/kg up to the adult • Dx’d during the second half of pregnancy, management should include a sonographic fetal total dose of 7.2 million units evaluation for congenital syphilis.

• At a minimum, serologic titers should be repeated at 28–32 weeks’ gestation and at delivery. • All infants born to mothers who have reactive nontreponemal and treponemal test • Serologic titers checked monthly in women at high risk for reinfection or in geographic areas in results should be evaluated for congenital syphilis which the prevalence of syphilis is high. • A quantitative nontreponemal test should be performed on infant serum and, if • Any woman who has a fetal death after 20 weeks’ gestation should be tested for syphilis reactive, the infant should be examined thoroughly for evidence of congenital syphilis. • Inadequate maternal treatment is likely if delivery occurs within 30 days of therapy, clinical • Suspicious lesions, body fluids, or tissues (e.g., umbilical cord, placenta) should be signs of infection are present at delivery, or the maternal antibody titer at delivery is fourfold higher than the pretreatment titer. examined by darkfield microscopy, PCR testing, and/or special stains. CDC. 2016, Syphilis. https://www.cdc.gov/std/tg2015/syphilis.htm CDC. 2016. Syphilis. https://www.cdc.gov/std/tg2015/syphilis.htm

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Chancroid: Treatment

•Azithromycin 1 g orally in a single dose

• Ceftriaxone 250 mg IM in a single dose • Ciprofloxacin 500 mg orally twice a day for 3 day • Erythromycin base 500 mg orally three times a day for 7 days

CDC. 2015. Chancroid. https://www.cdc.gov/std/tg2015/chancroid.htm

Herpes Genital HSV-2 Oral HSV-1 Screening Recommendation: HSV • is typically acquired in childhood; because • is more common among women than among men • CDC does not recommend screening for HSV-1 or HSV-2 in the general population the prevalence of oral HSV-1 infection has • more common among non-Hispanic blacks (34.6%) declined in recent decades, than among non-Hispanic whit • Routine serologic HSV screening of pregnant women is not recommended

• receiving from a person with an • Estimated 87.4% of 14 to 49 year olds infected with HSV-2 have never received a clinical diagnosis. oral HSV-1 infection can result in getting a Several scenarios where type-specific serologic HSV tests may be useful include: genital HSV-1 infection • Generally, a person can only get HSV-2 infection during genital contact with someone who has a • Patients with • Recurrences and subclinical shedding are genital HSV-2 infection. • recurrent genital symptoms or atypical symptoms and negative HSV PCR or culture; much less frequent for genital HSV-1 • clinical diagnosis of but no laboratory confirmation; infection than for genital HSV-2 infection. • In persons with asymptomatic HSV-2 infections, genital HSV shedding occurs on 10.2% of days, • report having a partner with genital herpes; compared to 20.1% of days among those with • presenting for an STD evaluation (especially those with multiple sex partners); symptomatic infections • with HIV infection; and • an estimated 2- to 4-fold increased risk of acquiring • MSM at increased risk for HIV acquisition WorkowskiKA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment HIV, if individuals with genital herpes infection are guidelines, 2015. Diseases Characterized by genital, anal, or perianal ulcers: Genital HSV infections. MMWR Recomm Rep. 2015;64(No. RR-3):1-137. genitally exposed to HIV.

Treatment for HSV Types of lesion Syphilis First Clinical Episode Episodic Therapy for Recurrent Suppressive Therapy Cold Sore (HSV) • Valacyclovir 1 g po • Acyclovir 400 mg po TID x 5 days • Acyclovir 400 mg po BID Fever blisters • Hard chancre BID x7–10 days • Acyclovir 800 mg po BID x 5 days • Valacyclovir 500 mg po daily* • break open, crust over, and heal • Firmly indurated with mild erythema • over the period of a week to 10 days Acyclovir 800 mg po TID x 2 days • Valacyclovir 1 g po daily • Usually painless, unless a secondary • Acyclovir 400 mg po • Painful infection • Famiciclovir 250 mg po BID TID x 7–10 days • Valacyclovir 500 mg po BID x 3 days • Serum or culture Dx direct : Dark field • Valacyclovir 1 g po qD x 5 days *might be less effective than other • Acyclovir 200 mg po valacyclovir or acyclovir dosing regimens in persons who have very frequent 5x/D x 7–10 days • Famciclovir 125 mg po BID x5 days recurrences (i.e., ≥10 episodes/year • Famciclovir 250 mg • Famciclovir 1 gram PO BID for 1 day Pregnancy • Famciclovir 500 mg pox1, followed po TID x 7–10 days • Acyclovir 400 mg poTID -or- by 250 mg BID x 2 days • Valacyclovir 500 mg po BID * recommended starting at 36 weeks of gestation Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. Diseases Characterized by genital, anal, or perianal ulcers: Genital HSV infections. MMWR Recomm Rep. 2015;64(No. RR-3):1-137. CDC. 2015. Genital HSV Infections https://www.cdc.gov/std/tg2015/herpes.htm

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• Most clear the infection spontaneously and have no HPV: Warts associated health problems. • flesh-colored growths found in the genital area and anal region in both men and women. • They are also known as venereal warts.

the most common sexually transmitted infection in the United States

Treatment • Treatments are available for the conditions caused by HPV, but not for the virus itself. Vaccination • Subclinical genital HPV infection typically clears spontaneously; therefore, specific antiviral therapy is not recommended to eradicate HPV infection.

• Vaccine: 2-dose schedule for HPV vaccination of girls and boys if series is initiated • Precancerous lesions are detected through screening, HPV-related before the 15th birthday. The second dose should be administered 6–12 months precancer should be managed based on existing guidance. after the first dose (0, 6–12 month schedule)

• Three doses remain recommended for persons who initiate the vaccination series at ages 15 through 26 years and for immunocompromised persons. • Surgical and other procedures • Cryosurgery: Freezing the warts off with liquid nitrogen. • Vaccination for females and males through age 26 years who were not adequately • Loop electrosurgical excision procedure (LEEP): Using a special wire loop to remove the vaccinated previously. abnormal cells.

• 64% decrease in vaccine-targeted HPV prevalence among females aged 14 to 19 • Electrocautery: Burning the warts off with an electrical current. years and a 34% decrease among those aged 20 to 24 years; • Laser therapy: Using an intense light to destroy the warts and any abnormal cells.

Meites E, Kempe A, Markowitz LE. 2016.Use of a 2-Dose Schedule for Papillomavirus Vaccination - Updated Recommendations of the Advisory Committee on Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. Anogenital warts. MMWR Recomm Rep. Immunization Practices. MMWR Morb Mortal Wkly Rep.65:1405-140 2015;64(No. RR-3):1-137

Medications

• to eliminate warts are typically applied directly to the lesion and usually take many applications before they're successful. Examples include:

• Salicylic acid. OTC treatments that contain salicylic acid work by removing layers of a wart a little at a time. For use on common warts, salicylic acid can cause skin irritation and isn't for use on your face.

• Imiquimod (Aldara, Zyclara). • Zyclara 3.75%: Apply as thin film to entire area and rub in until cream is no longer visible; use 1 packet or 1 full actuation of pump • Aldara 5%: Apply at bedtime for 3 days, then rest 4 days; alternatively, may apply every other day for 3 applications; may repeat weekly cycles up to 16 weeks.

• Podofilox (Condylox). Apply BID (every 12 hours), for 3 consecutive days, then withhold use for 4 consecutive days. May be repeated up to four times until there is no visible . • Trichloroacetic acid. Apply a small amount to visible warts and allow to dry; may be repeated weekly, if necessary.

1)Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. Anogenital warts. MMWR Recomm Rep. 2015;64(No. RR-3):1-137. 2)CDC. 2015. Anogenital Warts. https://www.cdc.gov/std/tg2015/warts.htm

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How is HIV Transmitted

To transmit HIV one has to come in contact with one of the following body fluids • Blood • Semen • Vaginal fluid • Breast milk The risk of contacting HIV follows : • Unprotected Sex • Multiple sex partners • Prostitution • IV drug use

HIV HIV Screening Recommendations

• Acute retroviral syndrome is Women Men characterized by nonspecific • All men aged 13-64 (opt-out)* • All women aged 13-64 years (opt-out)* symptoms, including fever, • All men who seek evaluation and malaise, , • All women who seek evaluation and treatment for STDs and skin rash treatment for STDs Men Who have Sex With Men (MSM) Pregnant Women • At least annually for sexually active MSM • All pregnant women should be screened if HIV status is unknown or negative and at first prenatal visit (opt-out) the patient himself or his sex partner(s) • Retest in the third trimester if at high risk have had more than one sex partner since most recent HIV test

* USPSTF recommends screening in adults and adolescents ages 15-65

CDC. 2017. HIV Infection: Detection, Counseling, and Referral. https://www.cdc.gov/std/tg2015/hiv.htm, 2) USPSTF. 2016Final Recommendation Statement: Human Immunodeficiency Virus (HIV) Infection: Screening. U.S. Preventive Services Task Force. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/human-immunodeficiency-virus--infection-screening

References

• Barber, L. G., & Gudgel, D. T. (2018). How sexual activity can affect your vision. American Academy of Ophthalmology. Retrieved from https://www.aao.org/eye-health/tips-prevention/sex-stds-and-eye-health

• Centers for Disease Control and Prevention (CDC). (2018). Gonococcal Infections in Adolescents and Adults. Retrieved from https://www.cdc.gov/std/tg2015/gonorrhea.htm

• CDC. 2015. Anogenital Warts. https://www.cdc.gov/std/tg2015/warts.htm

• CDC. 2015. Chancroid. https://www.cdc.gov/std/tg2015/chancroid.htm

• CDC. 2015. Genital HSV Infections https://www.cdc.gov/std/tg2015/herpes.htm

• Centers for Disease Control and Prevention. (September 2017). STDs at record high, indicating urgent need for prevention. Retrieved from https://www.cdc.gov/media/releases/2017/p0926-std-prevention.html

• Hoffman, J. (April 7, 2016). Misconception: You can’t get an S.T.D. from oral sex. New York Times. Retrieved from https://www.nytimes.com/2016/04/07/health/misconceptions-oral-sex-

stds.html?action=click&module=RelatedCoverage&pgcype=Article®ion=Footer

• Meites E, Kempe A, Markowitz LE. 2016. Use of a 2-Dose Schedule for Human Papillomavirus Vaccination - Updated Recommendations of the Advisory Committee on Immunization Practices. MMWR Morb

Mortal Wkly Rep. 65:1405-140 • Oztürk O, Seven H. Chlamydia trachomatis tonsillopharyngitis. Case Rep Otolaryngology. 2012;2012:736107 • USPSTF. 2016. Final Recommendation Statement: Human Immunodeficiency Virus (HIV) Infection: Screening. U.S. Preventive Services Task Force. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/human-immunodeficiency-virus-hiv-infection-screening

• Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015;64(No. RR-3):1-137

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