STD_Clinical-clinicians

Common Sexually Transmitted Diseases: STD 101 for Clinicians: 

1 Common Sexually Transmitted Diseases: STD 101 for Clinicians Something for Everyone! Developed by John F. Toney, M.D. Associate Professor of Medicine Univ. of South Florida College of Medicine Medical Director, Florida STD/HIV Prevention Training Center CDC National Network of STD/HIV Prevention Training Centers

Topics: 

2 Topics Background Information “Sores” “Drips” Role of STDs in HIV Transmission

Background Information: 

3 Background Information

Knowledge About STDs Among Americans: 

4 Knowledge About STDs Among Americans Source : Kaiser Family Foundation, 1996 Background

Where Do People Go for STD Treatment?: 

5 Where Do People Go for STD Treatment? Population-based estimates from National Health and Social Life Survey Private provider 59% Other clinic 15% Emergency room 10% STD clinic 9% Family planning clinic 7% Background Source : Brackbill et al. Where do people go for treatment of sexually transmitted diseases? Family Planning Perspectives. 31(1):10-5, 1999

Percent of Women Who Said Topic Was Discussed During First Visit With New Gynecological or Obstetrical Doctor/Health Care Professional: 

6 Percent of Women Who Said Topic Was Discussed During First Visit With New Gynecological or Obstetrical Doctor/Health Care Professional Percentages may not total to 100% because of rounding or respondents answering “Don’t know” to the question “Who initiated this conversation?” Source : Kaiser Family Foundation/Glamour National Survey on STDs, 1997 Background

Estimated Burden of STD in U.S. - 1996: 

7 Estimated Burden of STD in U.S. - 1996 STD Incidence Prevalence Chlamydia 3 million 2 million Gonorrhea 650,000 --- Syphilis 70,000 --- Trichomoniasis 5 million -- - HSV 1 million 45 million HPV 5.5 million 20 million Hepatitis B 77,000 750,000 HIV 20,000 560,000 Background Source : The Tip of the Iceberg: How Big Is the STD Epidemic in the U.S.? Kaiser Family Foundation 1998

“...the scope and impact of the STD epidemic are under-appreciated and the STD epidemic is largely hidden from public discourse.”: 

8 IOM Report 1997 “...the scope and impact of the STD epidemic are under-appreciated and the STD epidemic is largely hidden from public discourse.” Background

STDs of Concern: 

9 STDs of Concern Actually, all of them “Sores” (ulcers) Syphilis Genital herpes (HSV-2, HSV-1) Others uncommon in the U.S. Lymphogranuloma venereum Chancroid Granuloma inguinale Background

STDs of Concern (continued): 

10 STDs of Concern (continued) “Drips” (discharges) Gonorrhea Chlamydia Nongonococcal urethritis / mucopurulent cervicitis Trichomonas vaginitis / urethritis Candidiasis (vulvovaginal, less problems in men) Other major concerns Genital HPV (especially type 16, 18) and Cervical Cancer Background

Bacterial Vaginosis: 

11 Bacterial Vaginosis Controversy: STD - yes or no Need for treatment 1980: only if patient complains 2002: increased risk of: Preterm birth / premature rupture of membranes Amniotic fluid infection Chorioamnionitis / Postpartum endometritis Pelvic inflammatory disease Postsurgical infection Cervical intraepithelial neoplasia Mucopurulent cervicitis Acquisition of HIV infection Background

“Sores”: 

12 “Sores” Syphilis Genital Herpes (HSV-2, HSV-1)

Genital Ulcer Diseases – Does It Hurt?: 

13 Genital Ulcer Diseases – Does It Hurt? Painful Chancroid Genital herpes simplex Painless Syphilis Lymphogranuloma venereum Granuloma inguinale Sores

Primary Syphilis - Clinical Manifestations : 

14 Primary Syphilis - Clinical Manifestations Incubation: 10-90 days (average 3 weeks) Chancre Early: macule/papule  erodes Late: clean based, painless, indurated ulcer with smooth firm borders Unnoticed in 15-30% of patients Resolves in 1-5 weeks HIGHLY INFECTIOUS Sores

Primary Syphilis Chancre: 

15 Primary Syphilis Chancre Sores Source : Florida STD/HIV Prevention Training Center

Primary Syphilis: 

16 Primary Syphilis Sores Source : Centers for Disease Control and Prevention

Secondary Syphilis - Clinical Manifestations : 

17 Secondary Syphilis - Clinical Manifestations Represents hematogenous dissemination of spirochetes Usually 2-8 weeks after chancre appears Findings: rash - whole body (includes palms/soles) mucous patches condylomata lata - HIGHLY INFECTIOUS constitutional symptoms Sn/Sx resolve in 2-10 weeks Sores

Secondary Syphilis Rash: 

18 Secondary Syphilis Rash Sores Source : Florida STD/HIV Prevention Training Center

Secondary Syphilis: Generalized Body Rash: 

19 Secondary Syphilis: Generalized Body Rash Sores Source : CDC/NCHSTP/Division of STD Prevention, STD Clinical Slides

Secondary Syphilis Rash: 

20 Secondary Syphilis Rash Sores Source : Florida STD/HIV Prevention Training Center

Secondary Syphilis Rash: 

21 Secondary Syphilis Rash Sores Source : Cincinnati STD/HIV Prevention Training Center

Secondary Syphilis: 

22 Secondary Syphilis Sores Source : Diepgen TL, Yihune G et al. Dermatology Online Atlas

Secondary Syphilis – Condylomata Lata: 

23 Secondary Syphilis – Condylomata Lata Sores Source : Florida STD/HIV Prevention Training Center

Genital Herpes Simplex - Clinical Manifestations : 

24 Genital Herpes Simplex - Clinical Manifestations Direct contact – may be with asymptomatic shedding Primary infection commonly asymptomatic; symptomatic cases sometimes severe, prolonged, systemic manifestations Vesicles  painful ulcerations  crusting Recurrence a potential Diagnosis: Culture Serology (Western blot) PCR Sores

Epidemiology of Genital Herpes: 

25 Epidemiology of Genital Herpes One of the 3 most common STDs, increased 30% from late 70s to early 90s 25% of US population by age 35 HSV-2: 80-90%, HSV-1: 10-20% (majority of infections in some regions) Most cases subclinical Transmission primarily from subclinical infection Complications: neonatal transmission, enhanced HIV transmission, psychosocial issues Sores

Underdiagnosis of Genital Herpes: 

26 Underdiagnosis of Genital Herpes 779 women attending STD clinic 372 genital herpes diagnosis: 363 HSV-2 antibody positive 9 HSV-1 culture positive lesions Of the 372 diagnosed with genital herpes 82 (22%) symptomatic 14 (4%) viral shedding without symptoms 60 (14%) history of symptoms 216 (58%) HSV-2 antibody without viral shedding or history of symptoms Sores

Do Patients Want to Know?: 

27 Do Patients Want to Know? 92.4% wanted to know if they were infected 90.8% wanted to know if their partners were infected 65% expected the test as part of STD screening Sores Source : International Herpes Management Forum, 1999

Genital Herpes Simplex: 

28 Genital Herpes Simplex Sores Source : Diepgen TL, Yihune G et al. Dermatology Online Atlas

Genital Herpes Simplex: 

29 Genital Herpes Simplex Sores Source : CDC/NCHSTP/Division of STD, STD Clinical Slides

Genital Herpes Simplex in Females: 

30 Genital Herpes Simplex in Females Sores Source : Centers for Disease Control and Prevention

Genital Herpes Simplex: 

31 Genital Herpes Simplex Sores Source : Florida STD/HIV Prevention Training Center

“Drips”: 

32 “Drips” Gonorrhea Nongonococcal urethritis Chlamydia Mucopurulent cervicitis Trichomonas vaginitis and urethritis Candidiasis

Gonorrhea - Clinical Manifestations : 

33 Gonorrhea - Clinical Manifestations Urethritis - male Incubation: 1-14 d (usually 2-5 d) Sx: Dysuria and urethral discharge (5% asymptomatic) Dx: Gram stain urethral smear (+) > 98% culture Complications Urogenital infection - female Endocervical canal primary site 70-90% also colonize urethra Incubation: unclear; sx usually in l0 d Sx: majority asymptomatic; may have vaginal discharge, dysuria, urination, labial pain/swelling, abd. pain Dx: Gram stain smear (+) 50-70% culture Complications Drips

Gonorrhea: 

34 Gonorrhea Drips Source : Florida STD/HIV Prevention Training Center

Gonorrhea Gram Stain: 

35 Gonorrhea Gram Stain Drips Source : Cincinnati STD/HIV Prevention Training Center

Nongonococcal Urethritis: 

36 Nongonococcal Urethritis Drips Source : Diepgen TL, Yihune G et al. Dermatology Online Atlas

Nongonococcal Urethritis: 

37 Nongonococcal Urethritis Etiology: 20-40% C. trachomatis 20-30% genital mycoplasmas ( Ureaplasma urealyticum, Mycoplasma genitalium ) Occasional Trichomonas vaginalis , HSV Unknown in ~50% cases Sx: Mild dysuria, mucoid discharge Dx: Urethral smear  5 PMNs (usually 15)/OI field Urine microscopic  10 PMNs/HPF Leukocyte esterase (+) Drips

Chlamydia Life Cycle: 

38 Chlamydia Life Cycle Drips Source : California STD/HIV Prevention Training Center

Chlamydia trachomatis : 

39 Chlamydia trachomatis More than three million new cases annually Responsible for causing cervicitis, urethritis, proctitis, lymphogranuloma venereum, and pelvic inflammatory disease Direct and indirect cost of chlamydial infections run into billions of dollars Potential to transmit to newborn during delivery Conjunctivitis, pneumonia Drips

Normal Cervix: 

40 Normal Cervix Drips Source : Claire E. Stevens, Seattle STD/HIV Prevention Training Center

Chlamydia Cervicitis: 

41 Chlamydia Cervicitis Drips Source : St. Louis STD/HIV Prevention Training Center

Mucopurulent Cervicitis: 

42 Mucopurulent Cervicitis Source : Seattle STD/HIV Prevention Training Center Drips

Laboratory Tests for Chlamydia: 

43 Laboratory Tests for Chlamydia Tissue culture has been the standard Specificity approaching 100% Sensitivity ranges from 60% to 90% Non-amplified tests Enzyme Immunoassay (EIA), e.g. Chlamydiazyme sensitivity and specificity of 85% and 97% respectively useful for high volume screening false positives Nucleic Acid Hybridization (NA Probe), e.g. Gen-Probe Pace-2 sensitivities ranging from 75% to 100%; specificities greater than 95% detects chlamydial ribosomal RNA able to detect gonorrhea and chlamydia from one swab need for large amounts of sample DNA Drips

Laboratory Tests for Chlamydia (continued): 

44 Laboratory Tests for Chlamydia (continued) DNA amplification assays polymerase chain reaction (PCR) ligase chain reaction (LCR) Sensitivities with PCR and LCR 95% and 85-98% respectively; specificity approaches 100% LCR ability to detect chlamydia in first void urine Drips

Chlamydia Direct Fluorescent Antibody (DFA): 

45 Chlamydia Direct Fluorescent Antibody (DFA) Drips Source : Centers for Disease Control and Prevention

Pelvic Inflammatory Disease (PID) : 

46 Pelvic Inflammatory Disease (PID) l0%-20% women with GC develop PID In Europe and North America, higher proportion of C . trachomatis than N. gonorrhoeae in women with symptoms of PID CDC minimal criteria uterine adnexal tenderness, cervical motion tenderness Other symptoms include endocervical discharge, fever, lower abd. pain Complications: Infertility: 15%-24% with 1 episode PID secondary to GC or chlamydia 7X risk of ectopic pregnancy with 1 episode PID chronic pelvic pain in 18% Drips

Pelvic Inflammatory Disease: 

47 Pelvic Inflammatory Disease Drips Source : Cincinnati STD/HIV Prevention Training Center

C. trachomatis Infection (PID): 

48 C. trachomatis Infection (PID) Drips Source : Patton, D.L. University of Washington, Seattle, Washington Normal Human Fallopian Tube Tissue PID Infection

HPV and Cervical Cancer: 

49 HPV and Cervical Cancer

HPV and Cervical Cancer: 

50 HPV and Cervical Cancer Infection is generally indicated by the detection of HPV DNA HPV infection is causally associated with cervical cancer and probably other anogenital squamous cell cancers (e.g. anal, penile, vulvar, vaginal) Over 99% of cervical cancers have HPV DNA detected within the tumor Routine Pap smear screening ensures early detection (and treatment) of pre-cancerous lesions HPV and Cervical Cancer

Estimates for HPV-Associated Cancers: 

51 Estimates for HPV-Associated Cancers Cervical cancer: In the U.S., an estimated 14,000 cases and 5,000 deaths Worldwide, an estimated 450,000 cases and 200,000 deaths HPV and Cervical Cancer

Age-Adjusted* Incidence of Cervical Cancer by Year of Diagnosis: U.S. 1973-1999: 

52 Age-Adjusted* Incidence of Cervical Cancer by Year of Diagnosis: U.S. 1973-1999 *Age-adjusted to the 2000 US standard population Source : Ries LAG, Eisner MP, Kosary CL, Hankey BF, Miller BA, Clegg L, Edwards BK (eds). SEER Cancer Statistics Review, 1973-1999 , National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1973_1999/, 2002. HPV and Cervical Cancer

Age-Adjusted* Incidence of Cervical Cancer by Year of Diagnosis and Race: U.S. 1973-1999: 

53 Age-Adjusted* Incidence of Cervical Cancer by Year of Diagnosis and Race: U.S. 1973-1999 *Age-adjusted to the 2000 US standard population Source : Ries LAG, Eisner MP, Kosary CL, Hankey BF, Miller BA, Clegg L, Edwards BK (eds). SEER Cancer Statistics Review, 1973-1999 , National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1973_1999/, 2002. HPV and Cervical Cancer

Perianal Wart: 

54 Perianal Wart Source : Cincinnati STD/HIV Prevention Training Center HPV and Cervical Cancer

HPV Penile Warts: 

55 HPV Penile Warts Source : Cincinnati STD/HIV Prevention Training Center HPV and Cervical Cancer

Intrameatal Wart of the Penis (and Gonorrhea): 

56 Intrameatal Wart of the Penis (and Gonorrhea) HPV and Cervical Cancer Source : Florida STD/HIV Prevention Training Center

HPV Cervical Warts: 

57 HPV Cervical Warts Source : Cincinnati STD/HIV Prevention Training Center HPV and Cervical Cancer

HPV Warts on the Thigh: 

58 HPV Warts on the Thigh Source : Cincinnati STD/HIV Prevention Training Center HPV and Cervical Cancer

Possible HPV on the Tongue: 

59 Possible HPV on the Tongue Source : Cincinnati STD/HIV Prevention Training Center HPV and Cervical Cancer

Role of STDs in HIV Transmission: 

60 Role of STDs in HIV Transmission

Role of STDs in HIV Transmission Summary: 

61 Role of STDs in HIV Transmission Summary At least 2 to 5-fold increased risk of HIV seroconversion confirmed by data from 4 continents Attributable risk of STDs for HIV transmission substantial in some populations HIV susceptibility likely increased through endocervical CD4 recruitment by nonulcerative STDs, as well as through “portal of entry” created by ulcers STDs and HIV

Role of STDs in HIV Transmission Summary: 

62 Role of STDs in HIV Transmission Summary Greater infectiousness because of prevalence & magnitude of HIV shedding increased by STDs; STD treatment reduces shedding to baseline levels 40% reduction in HIV incidence achieved in randomized trial of treatment of symptomatic STDs in Tanzania No reduction of HIV incidence demonstrated with STD mass treatment every 10 months in randomized trial in Uganda STDs and HIV

Percentage of MSM Reporting Selected Sexual Behaviors & Male Rectal Gonorrhea Rates - San Francisco, 1990-1997: 

63 Percentage of MSM Reporting Selected Sexual Behaviors & Male Rectal Gonorrhea Rates - San Francisco, 1990-1997 *Per 100,000 men aged > 15 years +Condoms always used during anal sex during the previous 6 months **Unprotected anal sex with two or more partners during the previous 6 months STDs and HIV Source : MMWR 48:3 1999

STD Treatment for HIV Prevention in the US - Where Do We Start?: 

64 STD Treatment for HIV Prevention in the US - Where Do We Start? Access to & quality of STD clinical services Early & effective STD-related health care behaviors Surveillance systems to monitor STD/HIV trends & interrelationships STDs and HIV

STD Treatment for HIV Prevention Access to Quality Clinical Services: 

65 STD Treatment for HIV Prevention Access to Quality Clinical Services Public & private settings serving HIV-infected or high-risk persons Timely access to quality STD diagnosis & treatment for symptomatic people at high risk (e.g., HIV C/T sites, schools, drug treatment centers, jails) Training for clinicians & program managers STDs and HIV

STD Treatment for HIV Prevention Early, Effective Health Care Behavior: 

66 STD Treatment for HIV Prevention Early, Effective Health Care Behavior Sexual risk reduction counseling PLUS… Messages for at-risk persons & providers Other STDs increase HIV spread Recognize & act on symptoms/sign Most STDs asymptomatic; regular screening critical Specific information on sources of care STDs and HIV

STD Treatment for HIV Prevention Linked STD/HIV Surveillance Systems: 

67 STD Treatment for HIV Prevention Linked STD/HIV Surveillance Systems Capacity & linkages at local level Monitoring of extent of overlap of STD- & HIV-infected populations; relative importance of STD treatment as HIV prevention strategy Monitoring of etiological spectrum of STDs Timely analysis & dissemination to policy makers, program managers, providers STDs and HIV

STD Treatment to Enhance HIV Prevention: 

68 STD Treatment to Enhance HIV Prevention Implementation of Advisory Committee for HIV & STD prevention recommendations [MMWR 1998; 47 (No. RR-12)] Augmentation of HIV Community Planning Groups to focus on STD data issues, detection, & treatment in areas with syphilis or GC rates > HP 2010 targets Local cross-training for STD & HIV staff in project areas with syphilis or GC rates > HP 2010 targets Demonstration projects of on-site STD screening, treatment & related services in setting serving HIV infected & at-risk individuals HIV-STD data systems & surveillance linkages Evaluation & applied research capacity to answer critical operational questions STDs and HIV

“Improved prevention of STDs should be an essential component off a national strategy for preventing sexually transmitted HIV infection.” : 

69 “Improved prevention of STDs should be an essential component off a national strategy for preventing sexually transmitted HIV infection.” The Hidden Epidemic: Confronting STDs Institute of Medicine, 1997 STDs and HIV