STD Testing NORTHWEST AIDS EDUCATION AND TRAINING CENTER. Shireesha Dhanireddy, MD Assistant Professor University of Washington

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1 NORTHWEST AIDS EDUCATION AND TRAINING CENTER STD Testing Shireesha Dhanireddy, MD Assistant Professor University of Washington Presentation prepared by: Presenter Last Updated:

2 STD s and HIV Overview Patients with HIV frequently acquire other STIs Many STIs increase HIV transmission/acquisition STIs associated with increased detection & concentration of HIV shedding in the genital tract Gonorrhea (GC), Chlamydia (CT), trichomoniasis (TV) increase RR of HIV acquisition fold Treating urethritis & cervicitis, GC, CT, & TV decreases genital HIV RNA Genital ulcers increase HIV acquistion fold Asymptomatic HSV-2 infection increases HIV genital shedding Clinical manifestations and treatment of STIs may differ in HIV-infected persons

3 2010 CDC STD Treatment Guidelines: Screening - Who? Men (most men are symptoma:c) MSM Sexually ac:ve young men in high prevalence sebngs Women ALL sexually ac:ve women 25 yo Women older than 25 if at increased risk Previous gonorrhea or other STI New or mul:ple partners Inconsistent condom use Commercial sex work Drug use Living in high prevalence areas MMWR 2010;59 (RR-12).

4 How & Where to Screen? Urine nucleic acid amplifica:on test (NAAT) for CT and GC Rectal culture for CT* Rectal culture for GC* Pharyngeal culture for GC* Syphilis (non- treponemal vs treponemal) *Pharyngeal & rectal NAATs not FDA approved, but validated by large commercial & many local labs

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6 Syphilis: Clinical Features Primary Stage Genital Ulcer = Chancre OYen painless, non- tender Indurated, heaped up border Clean (non- purulent) base Rubbery appearing RPR+/VDRL+ in ~70% Darkfield microscopy or DFA of lesion exudate diagnos:c

7 Syphilis: Clinical Features Secondary Stage Generalized rash Fever, malaise, lymphadenophathy, alopecia, interstitial keratitis, liver or kidney involvement Mucous patches Condyloma lata Lasts 2-6 wks; 100% RPR/VDRL + 25% have recurrent symptoms

8 Syphilis Early latent - Acquired within prior year Asymptomatic Late Latent or Latent of Unknown Duration Asymptomatic Tertiary Cardiac (aortitis) Ascending aortic aneurysm, valve abnormalities Ocular - associated with neurosyphilis Interstitial keratitis, uveitis, retinitis, optic neuritis, etc. Auditory Cochlear (hearing loss, tinnitus) or vestibular (vertigo, nystagmus) Gummatous lesions Skin, bones, organs

9 HIV and Syphilis All patient with syphilis should be tested for HIV Although can have atypical serologic results, serologic tests usually accurate and reliable More rapid progression of syphilis? Alternatives to penicillin not well studied in HIV- infected persons and should be used with caution HAART might improve clinical outcomes in HIV+ persons with syphilis

10 Diagnosis Neurosyphilis in HIV Invasion of the CSF with lab abnormalities common Symptomatic neurosyphilis develops in only a limited number of persons treated with PCN Serum RPR titers 1:32 or CD4 cell counts 350 cells/ mm 3 more likely to have neurosyphilis In the absence of symptoms, no evidence to support variation from recommended treatment When to LP? Neurologic, ophthalmologic or otologic symptoms Active tertiary syphilis Treatment failure

11 Syphilis Serology Nontreponemal: VDRL & RPR An:body to an:gen not specific to T. pallidum Quan:ta:ve: :ter measured Used to follow treatment response (always use same test) Reac:vity declines with :me Treponemal tests: TP- PA, FTA- ABS, EIAs, chemiluminescense assays Qualita:ve Posi:ve test requires reflex to quan:ta:ve non- treponemal test for clinical management Confirmatory (needs to be done only once) Reac:vity persists over life:me For most HIV+ pa:ents, serologic tests are accurate & reliable

12 2010 CDC STD Treatment Guidelines Treponema pallidum (Primary, Secondary & Early Latent) Benzathine PCN (Bicillin L-A) 2.4 mu IM x 1 HIV+ persons with PCN allergy should be desensitized; alternative regimens not well studied More PCN or antibiotics does NOT enhance treatment efficacy, regardless of HIV status MMWR 2010;59 (RR-12).

13 2010 CDC STD Treatment Guidelines Syphilis - Late Latent or Ter:ary (NO CHANGES) Treponema pallidum (Late Latent or Tertiary) 1 2 Benzathine PCN 2.4 mu IM weekly x 3 Doxycycline* 100 mg bid x 28d If possible desensitize to PCN; alternative regimens not well studied in HIV+ More PCN or antibiotics does NOT enhance treatment efficacy, regardless of HIV status MMWR 2010;59 (RR-12).

14 2010 CDC STD Treatment Guidelines Neurosyphilis Treponema pallidum (Neurosyphilis) Aqueous PCN G mu IV qd x d (3-4 mu q 4h OR continuous) Procaine PCN + probenecid* 2.4 mu IM qd x d Ceftriaxone 2 g IV/IM qd x d *Only if compliance is likely Note: HAART may improve clinical outcomes in HIV+ Picture MMWR 2010;59 (RR-12).

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16 Urethritis Differential Diagnosis Gonococcal urethritis Neisseria gonorrhoeae Non-gonococcal urethritis (NGU) Chlamydia trachomatis (15-40%) Ureaplasma urealyticum Mycoplasma genitalium (15-25%) Trichomonas vaginalis Herpes simplex virus Adenovirus Enteric bacteria

17 Urethritis Diagnosis Characteristic symptoms AND objective evidence of urethral inflammation Mucopurulent or purulent discharge 1 st void urine with positive leukocyte esterase or microscopic examination with 10 WBC/hpf Gram stain of urethral secretions 5 WBC/oil immersion field Intracellular gram negative diplococci diagnostic for GC infection, but absence does not rule out GC/CT culture Nucleic acid amplification test (NAAT) of exudate, urethral swab, or 1 st catch urine

18 Is Gonorrhea the Next Superbug? Source: Bolan et al. N Eng J Med, Feb ;366:

19 2010 CDC STD Treatment Guidelines Neisseria gonorrhoeae Uncomplicated Infection of Cervix, Urethra, or Rectum Ceftriaxone 250 mg IM x 1 Ceftizoxime* 500 mg IM x 1 Cefoxitin (with probenecid)* 2 g IM x 1 Cefotaxime* 500 mg IM x 1 P L U S Azithromycin 1.0 g PO x 1 OR Doxycycline 100 mg PO bid x 7d Cefixime 400 mg PO x 1 Note: If oral sexual exposure treat with regimen effective for pharyngeal infection * These regimens offer no advantage over Ceftriaxone Cefixime only if ceftriaxone NOT an option; use with azithro MMWR 2010;59 (RR-12)

20 Other Treatment Options - Gonorrhea Alternative Regimens Spectinomycin (not available in US) Cefpodoxime 400 mg PO once Cefuroxime axetil 1 g PO once (less favorable) Penicillin Allergy (only if severe) Azithromycin 2.0 g orally once Consult a specialist Test of Cure MMWR 2010;59 (RR-12).

21 Post-Treatment Testing GC/CT Test of cure Not routinely recommended Exceptions: Pregnancy, noncompliance, persistent symptoms, suspect early re- infection, received non- ideal treatment due to cephalosporin allergy Test no earlier than 3 weeks post- treatment if using NAAT If persistent symptoms send GC culture & sensitivities Follow- up testing Repeat testing for GC/CT 3-6 months after treatment If no return in 3 months then at next visit within 12 months MMWR 2010;59 (RR-12).

22 Key Concepts: GC/CT Need to take a detailed sexual history to determine which anatomic sites to screen Due to higher sensitivity, NAATs are the preferred diagnostic test If oral exposure, treat with regimen effective for GC in the pharynx Gonorrhea resistance is an increasing problem; Dual therapy recommended Same in HIV+ as in HIV- men

23 Resources