British Columbia Treatment Guidelines

Transcription

1 655 West 12th Avenue Vancouver, BC V5Z 4R4 General Inquiries: Provincial STI/HIV Clinic Phone: Provincial STI/HIV Clinic Fax: British Columbia Treatment Guidelines Sexually Transmitted Infections in Adolescents and Adults 2014 Richard Lester, MD, FRCP(C), Medical Head, Provincial STI/HIV Clinic, Clinical Prevention Services (CPS) Carolyn Montgomery, MB, BCh, Provincial STI/HIV Clinic Physician, CPS Barbra Arnold, MD, CCFP, DTMH, Provincial STI/HIV Clinic Physician, CPS Sylvia Makaroff, MD, CCFP, Provincial STI/HIV Clinic Physician, CPS Avril Spencer, BScN, Provincial STI/HIV Clinic Educator, CPS Gina Ogilvie, MD FCFP DrPH, Medical Director, CPS

2 These guidelines are based on the Canadian Guidelines on Sexually Transmitted Infections (STI) 2010 Edition and online updates to 2014 This document contains treatment guidelines for clinicians and public health professionals regarding care and treatment of STIs in British Columbia and are based on the DID best YOU available KNOW scientific CAPTIONS: knowledge and medical practices. These guidelines are for information purposes only and are not intended in any manner to replace clinical judgment or to establish the only approach to all patients. Clinicians and public health professionals must use their independent medical judgment in the context of the individual clinical circumstances to determine patient care or treatment. Clinicians and public health professionals are encouraged to consult other sources in order to confirm adipiscing the information elit, sed diam contained nonummy in these nibh guidelines, including, but not limited to, individual product monograph(s), and standards or instructions provided by licensed manufacturers. euismod tincidunt ut laoreet dolore magna aliquam erat These guidelines may be updated as evidence and current practice regarding the management of STIs evolves. Clinicians and public health professionals must ensure the guidelines they have are current. Although all efforts are taken by BCCDC to ensure the completeness of the guidelines, BCCDC does not guarantee the completeness or accuracy of the information nor is the BCCDC responsible for damages resulting from the misuse of the information. Look PULL QUOTES: for this mark throughout the document to identify Lorem infections ipsum dolor notifiable sit to the medical health officer amet, consectetuer REPTABLE Include routine HIV screening with any other tincidunt STI testing. ut With laoreet certain dolore sexually testing, before results are available. transmitted infections, it is important to treat partners and contacts at the time of Recommendations regarding treatment of paediatric infections are excluded from these guidelines. In general, children diagnosed with a STI should be managed in conjunction with a specialist and investigation of possible sexual abuse needs to be considered. Contact the Provincial STI/HIV Clinic Physician for further management or the Child Protection Service Unit (a multidisciplinary team located at BC Children s Hospital) or (toll free in BC only). Routine STI updates are communicated via admin circulars on the BCCDC website. To receive ongoing STI Updates, go to the BCCDC website: - CDC Manual- Admin Circulars, enter your address and SUBMIT To keep the guidelines concise, references are not published with the guidelines. References are available on the BCCDC website, Chapter 5 - CDC Manual CDManualChap5.htm or the Public Health Agency of Canada website: gc.ca/hc-ps/dc-ma/sti-its-eng.php Body Copy: Ut wisi enim ad minim veniam, quis nostrud etre exerci tation ullamcorper suscipit lobortis nisl ut aliquip ex ea commodo consequat. Duis autem vel eum iriure dolor in hendrerit in vulputate velit esse molestie consequat, vel feugiat nulla facilisis at vero eros et accumsan et iusto odio blandit praesent luptatum zzril delenit augue duis dolore te feugait nulla facilisi. Lorem ipsum dolor sit The level of evidence and strength of recommendations are graded and summarized below. amet, consectetuer tincidunt ut laoreet dolore Table 1. Levels of Recommendation Ut wisi Recommendation: enim ad minim A veniam, quis nostrud exerci tation ullamcorper suscipit lobortis nisl ut aliquip ex ea commodo eu feugiat nulla facilisis at vero eros et accumsan et iusto outweigh odio harms. blandit praesent luptatum augue duis dolore te feugait nulla facilisi. Recommendation: B Strongly recommends that clinicians routinely provide the treatment to eligible individuals. Good evidence that the treatment improves important health outcomes and concludes that benefits substantially Recommends that clinicians routinely provide the treatment to eligible individuals. At least fair evidence that the treatment improves important health outcomes and concludes that benefits outweigh harms. eleifend option congue nihil imperdiet Recommendation: C doming id quod mazim placerat facer possim assum. No recommendation for or against routine provision of the treatment. At least fair evidence that the treatment can improve health outcomes but concludes that the balance of the benefits and harms is too close to justify a general recommendation. nonummy Recommendation: nibh euismod D tincidunt Recommends ut laoreet against routinely dolore providing magna the aliquam treatment to erat Duis autem vel eum iriure dolor in hendrerit in vulputate velit ineffective or that harms outweigh benefits. esse molestie consequat, vel feugiat nulla facilisis at vero eros Recommendation: et accumsan Iet iusto odio Evidence dignissim is insufficient qui to blandit recommend praesent for or against luptatum routinely augue duis dolore te nulla facilisi. asymptomatic individuals. At least fair evidence that the treatment is providing the treatment. Evidence that the treatment is effective is lacking, of poor quality or conflicting, and the balance of benefits and harms cannot be determined. tincidunt ut laoreet dolore Table 2. Quality of Evidence Ι Evidence from at least one properly randomized, controlled trial. П Duis autem case-control vel eum analytic iriure studies dolor (preferably in hendrerit from more in vulputate than one centre), velit from esse multiple timeseries studies or from dramatic results in uncontrolled experiments. molestie consequat, vel feugiat Ш nulla facilisis at vero eros et Evidence from opinions of respected authorities based on clinical experience, descriptive accumsan studies et iusto or reports odio of expert committees. Name here blandit praesent luptatum augue For reportability duis dolore of sexually te transmitted Date here infections refer to the Public feugait Health etre Act of British Columbia (PHA): Health Act Communicable Disease Regulation nulla facilisi. See: Evidence from at least one well-designed clinical trial without randomization, from cohort or Nam To consult liber tempor with the cum Provincial STI/HIV Clinic Physician call tincidunt ut laoreet 1 dolore

3 Chlamydia - Chlamydia trachomatis If Lymphogranuloma Venereum (LGV) is suspected please contact the Provinicial STI/HIV Clinic Physician and refer to LGV Section. DID Doxycycline YOU KNOW 100 CAPTIONS: mg PO bid for 7 days (A-Ι) Azithromycin 1 g PO in a single dose (A-Ι) nonummy nibh (If vomiting occurs more than one hour posteuismod administration, tincidunt a repeat ut laoreet dose is dolore not required.) magna aliquam erat Alternate Treatment Erythromycin 500 mg PO qid for 7 days (B-Ι) Erythromycin 250 mg PO qid for 14 days (B-Ι) PULL QUOTES: Lorem ipsum dolor sit amet, (See PID consectetuer or Epididymitis Section) therefore a negative gonorrhea test usually rules out a gonorrhea coinfection. tincidunt ut laoreet dolore magna Pregnancy/Lactation aliquam erat Assess for pelvic inflammatory disease (PID) or epididymitis and treat accordingly Gonorrhea is less common and has a shorter window period than chlamydia, Amoxicillin 500 mg PO tid for 7 days (A-Ι) Azithromycin 1g PO in a single dose (B-Ι) (If vomiting occurs more than one hour postadministration, a repeat dose is not required.) Lymphogranuloma Venereum (LGV) C. trachomatis - Serovars L1,2,3 *For suspected LGV cases, please contact the Provincial STI/HIV Clinic Physician for further management. The diagnosis of LGV is not always straightforward and symptoms often overlap with other STIs. A diagnosis of LGV is often based on history and clinical presentation which is later confirmed by laboratory testing. LGV strains of C. trachomatis are more invasive, preferentially affecting the lymph tissue. If a patient presents with a painless genital papule, proctitis (especially hemorrhagic proctitis), painful inguinal/femoral lymphadenopathy AND has had a positive C. trachomatis CT/GC NAAT (nucleic acid amplification test) swab from a lesion or the rectum, please arrange for confirmatory LGV testing by contacting your laboratory or the Provincial STI/HIV Clinic Physician. Empiric treatment may be warranted. REPTABLE - Pregnancy/Lactation Follow Up A test of cure (TOC) should be A TOC for C. trachomatis performed 3-4 weeks after initiation of Body Copy: Ut wisi enim ad minim veniam, IS NOT quis RECOMMENDED nostrud etre exerci when: tation treatment for all pregnant or lactating the standard treatment regimen for ullamcorper women. suscipit lobortis nisl ut aliquip ex chlamydia ea commodo has been consequat. completed Duis Fluoroquinolones, autem vel eum doxycycline iriure dolor and in hendrerit signs in vulputate and symptoms velit esse have resolved molestie estolate consequat, preparations vel of illum erythromycin dolore eu feugiat there nulla is no facilisis re-exposure at vero to an untreated eros et accumsan are contraindicated et iusto for odio pregnant dignissim and qui blandit partner praesent luptatum zzril lactating women. delenit augue duis dolore te feugait nulla facilisi. Lorem ipsum dolor sit A TOC for C. trachomatis amet, consectetuer IS RECOMMENDED nonummy nibh when: euismod tincidunt ut laoreet dolore compliance is uncertain All partners/contacts in the last 60 days, patient was not initially treated regardless of symptoms or signs, should Ut wisi enim ad minim veniam, quis nostrud exerci with a tation recommended ullamcorper regimen be tested and treated with one of the patient is pregnant suscipit recommended lobortis regimens. nisl ut aliquip If there is ex no ea commodo eu feugiat nulla facilisis at Repeat screening is recommended at vero partner eros during et accumsan this period, et then iusto the last odio blandit praesent 6 months post-treatment as chlamydia luptatum partner should be tested augue and treated. duis dolore te feugait re-infection nulla risk facilisi. is high. Patients and contacts should abstain from sexual activity for 7 days after initiation of treatment and should be advised to avoid exposure to any untreated partner(s). eleifend option congue nihil imperdiet doming id quod mazim placerat facer possim assum. tincidunt ut laoreet dolore Duis autem vel eum iriure dolor in hendrerit in vulputate velit esse molestie consequat, vel feugiat nulla facilisis at vero eros et accumsan REPTABLE et iusto odio blandit praesent luptatum augue duis dolore te nulla facilisi. Patients should abstain from sexual activity Doxycycline 100 mg PO bid for 21 days (B-П) until 3 weeks after initiation of treatment tincidunt ut laoreet and dolore should be magna advised aliquam to avoid exposure erat to Alternate treatment any untreated partner(s). Azithromycin 1g PO in a single dose, once weekly for 3 weeks (C-Ш) Contacts should abstain from sexual activity for 7 days after initiation of treatment. Erythromycin 500 mg PO qid for 21 days (C-Ш) Treatment of Contacts to LGV (Patients are less likely to be compliant with Duis Erthromycin autem x 3 vel weeks eum duration) iriure dolor in hendrerit Doxycycline vulputate 100 mg velit PO bid esse for 7 days (A-Ι) molestie consequat, vel feugiat Azithromycin 1g PO in a single dose (A-Ι) nulla facilisis at vero eros et All partners/contacts within 60 days prior accumsan et iusto odio Treatment of Contacts dignissim to LGV qui with to symptom initiation should be tested Name and here blandit treated praesent as a contact. luptatum symptoms and/or lab If there is no partner zzril tests delenit consistent with LGV augue during duis this period, dolore then te the last partner Date here nulla should facilisi. be tested and treated. Doxycycline 100 mg PO bid x 21 days tincidunt ut laoreet 2 dolore Chlamydia & Lymphogranuloma Venereum

4 Gonorrhea - Neisseria gonorrhoeae The treatment regimen recommended by BCCDC differs from the Canadian STI Guidelines treatment guidelines for Neisseria gonorrhoeae. BC recommendations continue to be updated according to provincial surveillance data. Uncomplicated Infection DID (Urogenital/Rectal/Pharyngeal YOU KNOW CAPTIONS: sites) Lorem All regimens ipsum dolor require sit amet, concomitant consectetuer empiric adipiscing treatment elit, for sed chlamydial diam nonummy and other nibh non-gonoccoccal infections. euismod tincidunt ut laoreet dolore magna aliquam Recommended erat Regimen Cefixime 800 mg PO in a single dose (A-Ι) Ceftriaxone 250 mg IM in a single dose (A-Ι) PULL (The QUOTES: preferred diluent for this dose of ceftriaxone is 0.9 ml of 1% lidocaine without epinephrine to reduce discomfort.) Lorem PLUSipsum dolor sit Azithromycin 1 g PO in a single dose (A-Ι) amet, (If vomiting consectetuer occurs more than one hour postadministration, a repeat dose is not required.) Doxycycline 100 mg PO bid for 7 days (A-Ι) Alternate Treatment tincidunt ut laoreet dolore effects.) Azithromycin 2 g PO in a single dose (A-Ι) (Taking medication with food may minimize adverse Spectinomycin 2 g IM in a single dose (A-Ι) (Consult Provincial STI/HIV Clinic Physician to order and access this medication. Test of cure (TOC) is recommended.) PLUS Co-treatment for chlamydia REPTABLE Assess for pelvic inflammatory All partners/contacts in the last 60 days, Body disease Copy: (PID) Ut wisi or epididymitis enim ad minim and treat veniam, regardless quis nostrud of symptoms etre or exerci signs tation should accordingly. be tested and treated with one of the ullamcorper suscipit lobortis nisl ut aliquip ex ea commodo consequat. Obtaining cultures for N. gonorrhoeae recommended regimens. If there is no Duis is autem important vel for eum monitoring iriure dolor antibiotic in hendrerit partner in vulputate during this velit period, esse then the last molestie resistance. consequat, Clinicians vel are illum encouraged dolore to eu feugiat partner nulla should facilisis be tested at and vero treated. eros et accumsan perform a culture et iusto for odio N. gonorrhoeae, dignissim in qui blandit Patients praesent and contacts luptatum should abstain zzril from addition to a CT/GC NAAT (nucleic acid delenit augue duis dolore te feugait nulla sexual facilisi. activity Lorem for 7 ipsum days after dolor initiation sit of amplification test) test, for any patient amet, consectetuer treatment with obvious cervical, urethral or rectal nonummy and should nibh be euismod advised to avoid exposure to any untreated partner(s). tincidunt discharge. ut laoreet dolore Cultures for N. gonorrhoeae should be Follow Up Ut wisi performed enim ad in all minim cases veniam, of: quis nostrud TOC exerci by culture tation is ullamcorper recommended for suscipit lobortis suspected nisl pelvic ut aliquip inflammatory ex ea commodo gonorrhea eu feugiat positive nulla patients facilisis 3 7 at days disease (PID) after initiation of treatment when: vero eros et accumsan et iusto odio blandit praesent treatment failure patient is diagnosed with a luptatum augue duis dolore te feugait gonococcal nulla facilisi. pharyngeal infection sexual contacts outside of Canada or from areas with recognized patient is treated with a antimicrobial resistance non-recommended regimen sexual assault treatment failure is suspected eleifend option antimicrobial congue nihil resistance imperdiet to therapy doming Pregnancy/Lactation is documented id quod mazim placerat facer possim assum. compliance is uncertain Cefixime 800 mg PO as a single dose (A-Ι) re-exposure to an untreated partner is suspected nonummy Ceftriaxone nibh 250 mg euismod IM in a single tincidunt dose (A-Ι) ut laoreet dolore PID or disseminated gonococcal PLUS Duis autem vel eum iriure dolor in hendrerit infection vulputate is diagnosedvelit esse Amoxicillin molestie 500 consequat, mg PO tid for 7 vel days illum (A-Ι) dolore eu feugiat patient nulla is pregnant facilisis at vero eros et accumsan et iusto odio If blandit NAAT is used praesent for gonorrhea luptatum TOC, Azithromycin 1 g PO in a single dose (B-Ι) augue duis dolore te it nulla should facilisi. be done 2-3 weeks after Alternate Treatment initiation of treatment. Spectinomycin 2 g IM in a single dose Repeat screening is recommended at 6 Lorem (Consult ipsum Provincial dolor STI/HIV sit Clinic amet, Physician consectetuer to access months for all N. gonorrhoeae positive nonummy this medication.) nibh euismod tincidunt ut laoreet cases. dolore PLUS Co-treatment for chlamydia (See Chlamydia section: Pregnancy/Lactation) - Pregnancy/Lactation Duis A autem test of vel cure eum (TOC) iriure by culture dolor is in hendrerit in vulputate velit esse molestie recommended consequat, for all vel pregnant and lactating patients at 3-7 days after feugiat initiation nulla of facilisis treatment. at vero eros et accumsan et iusto odio Name here blandit praesent luptatum augue duis dolore te Date here nulla facilisi. tincidunt ut laoreet 3 dolore Gonorrhea

5 Bacterial Vaginosis (BV) Bacterial vaginosis is not usually considered - Pregnancy/Lactation a sexually transmitted infection. Metronidazole 500 mg PO bid for 7 days (A-Ι) Systemic rather than intravaginal treatment is recommended in pregnancy Symptoms noted by either the clinician Body Metronidazole Copy: Ut gel wisi 0.75% enim x one ad applicator minim (5 veniam, g) quis as intravaginal nostrud treatment etre exerci alone tation has not during a pelvic examination, or reported by ullamcorper once a day intravaginally suscipit lobortis for 5 days nisl (A-Ι) ut aliquip ex been ea shown commodo to decrease consequat. the risk of the patient, may include abnormal vaginal Duis autem vel eum adverse pregnancy outcomes. iriure dolor in hendrerit in vulputate velit esse discharge and/or abnormal vaginal odour Clindamycin cream 2% x one applicator (5 g) Intravaginal clindamycin cream has (i.e., amine odour). molestie consequat, vel feugiat nulla facilisis at vero eros intravaginally once a day for 7 days (A-Ι) been associated with adverse outcomes et accumsan et iusto odio blandit in the praesent neonate and luptatum should only zzril be used Abnormal vaginal odour may be noticeable Alternate Treatment delenit augue duis dolore te feugait nulla facilisi. when alternatives Lorem ipsum are not dolor possible. with or without potassium hydroxide (KOH) sit Metronidazole 2 g PO in a single dose (A-Ι) Test and treat symptomatic pregnant assessment and vaginal ph is usually amet, consectetuer women. elevated greater than 4.5. An elevated tincidunt Clindamycin ut laoreet 300 mg dolore PO bid for magna 7 days aliquam (A-Ι) erat Routine screening for BV is not vaginal ph in peri-menopausal or post recommended during pregnancy unless menopausal women in the absence of other Ut wisi enim ad minim veniam, quis nostrud it exerci is a high vaginal symptoms may not indicate a BV tation risk pregnancy. ullamcorper Individuals taking metronidazole should If considered a high risk pregnancy, infection. suscipit not lobortis drink alcohol nisl or ut take aliquip alcohol-based ex ea commodo eu feugiat nulla facilisis at screen at weeks. When the laboratory report (e.g., Nugent vero eros medications et accumsan for 12 hours et before iusto odio and dignissim BV qui during blandit pregnancy praesent is associated Score) is intermediate or positive and the luptatum 24 zzril 48 hours delenit after augue treatment duis because dolore te feugait with premature nulla facilisi. rupture of membranes, client is asymptomatic, treatment would not of possible disulfiram-like (Antabuse) chorioamnionitis, preterm labour, be recommended unless: reaction. preterm birth and post-cesarean patient is pregnant and at high risk for Clindamycin cream is oil-based and may endometritis. pre-term delivery weaken latex condoms or diaphragms. Testing should be repeated after one patient is scheduled to have any upper Nam Single liber tempor dose oral cum metronidazole therapy eleifend month option to congue ensure therapy nihil imperdiet was effective. reproductive tract instrumentation doming has id a higher quod relapse mazim rate placerat at one month. facer possim assum. (e.g., gynaecological surgery, D&C or therapeutic abortion) There is not enough current evidence to Lorem Pregnancy/Lactation Treatment of male sexual partners is not ipsum dolor sit amet, consectetuer indicated adipiscing and does elit, not sed prevent diam recurrence. support routine screening for BV at the time nonummy Recommended nibh euismod Regimentincidunt ut laoreet dolore of IUD insertion in asymptomatic women. Metronidazole 500 mg PO bid for 7 days (A-Ι) Offer female partners of women diagnosed with Duis autem vel eum iriure dolor BV, in hendrerit assessment, in testing, vulputate and possible velit treatment esse Alternate molestie Treatment consequat, vel illum dolore if eu the female feugiat partner(s) nulla facilisis tests are positive. at vero (D-Ι) Clindamycin 300 mg PO bid for 7 days (A-Ι) eros et accumsan et iusto odio blandit praesent luptatum Follow Up augue duis dolore te nulla facilisi. Follow up is not considered necessary unless symptoms recur. tincidunt ut laoreet dolore Trichomoniasis - Trichomonas vaginalis DID YOU KNOW CAPTIONS: nonummy nibh euismod tincidunt ut laoreet dolore magna aliquam erat PULL QUOTES: Lorem ipsum dolor sit amet, consectetuer tincidunt ut laoreet dolore Metronidazole 2 g PO in a single dose (A-Ι) Metronidazole 500 mg PO bid for 7 days (A-Ι) Individuals taking metronidazole should not drink alcohol or take alcohol-based medications for 12 hours before and hours after treatment because of possible disulfiram-like (i.e., Antabuse) reaction. Pregnancy/Lactation Trichomoniasis may be associated with Partners/contacts should be treated with premature rupture of membranes, preterm birth the same therapy recommended for the Duis and autem low birth weight. vel eum It is iriure not known dolor whether in hendrerit patient. in vulputate It is not necessary velit esse to screen sexual molestie treatment consequat, will improve pregnancy vel outcomes. partners. The majority illum of men dolore infected eu with feugiat Asymptomatic nulla facilisis pregnant at women do not Trichomonas vaginalis vero are eros asymptomatic, et accumsan need to be et treated iusto (D-Ι). although occasionally men will report odio Name here having mild urethritis. blandit Recommended praesent Regimen luptatum - augue Symptomatic duis dolore Pregnant te Women Date here Follow Up Metronidazole 2 g PO in a single dose for nulla facilisi. Follow up is not considered necessary symptom relief (A-Ι) unless recurring symptoms are presumed to Alternate Regimen - be due to re-infection. Symptomatic Pregnant Women eleifend Metronidazole option 500 congue mg PO bid nihil for imperdiet 7 days (A-Ι) doming id quod mazim placerat tincidunt ut laoreet 4 dolore Vaginosis & Trichomoniasis

6 Vulvovaginal Candidiasis - Candida albicans Vulvovaginal candidiasis is not usually DID considered YOU KNOW a sexually CAPTIONS: transmitted infection Lorem and treatment ipsum dolor is sit not amet, necessary consectetuer for adipiscing asymptomatic elit, sed patients. diam nonummy (D-Ι) nibh euismod Recommended tincidunt ut laoreet Regimen dolore magna aliquam Over-the-counter erat (OTC) treatments: Clotrimazole or miconazole, intravaginal azole ovules and/or creams (A-Ι) PULL Fluconazole QUOTES: 150 mg PO in a single dose. (A-Ι) Lorem ipsum dolor sit Pelvic Inflammatory Disease (PID) a polymicrobial infection with multiple etiologies. amet, The BCCDC consectetuer recommended regimen differs from the Canadian STI Guidelines treatment guidelines for PID. Outpatient Treatment nonummy Recommended nibh Regimen euismod is not necessary to remove the IUD Cefixime 800 mg PO in a single dose (A-Ι) during treatment unless there is no tincidunt ut laoreet dolore clinical improvement after 72 hours of Ceftriaxone 250 mg IM in a single dose (A-Ι) (The preferred diluent for this dose of ceftriaxone is 0.9 ml of 1% lidocaine without epinephrine to reduce discomfort.) PLUS Doxycycline 100 mg PO bid for days (A-П) Azithromycin 1g PO in a single dose, once weekly for 2 weeks WITH or WITHOUT Metronidazole 500 mg PO bid for days (B-Ш) Alternate Treatment Levofloxacin 500 mg PO bid for 14 days (A-Ι) (The alternate antibiotic treatment above will cover enteric organisms, but may not cover N.gonorrhoeae or C.trachomatis.) WITH or WITHOUT Metronidazole 500 mg PO bid for 14 days (A-Ι) Metronidazole is recommended for additional anaerobic coverage and when bacterial vaginosis is suspected. (B-Ш) Individuals taking metronidazole should not drink alcohol or take alcohol-based medications for 12 hours before and hours after treatment because of possible disulfiram-like (i.e., Antabuse) reaction. : Oil based ovules and creams may Routine screening and treatment of male Body weaken Copy: latex Ut wisi condoms enim or ad diaphragms. minim veniam, partners quis is nostrud not indicated. etre (D-Ι) exerci However, tation if Candida balanitis is present, consider ullamcorper suscipit lobortis nisl ut aliquip ex ea commodo consequat. Pregnancy/Lactation treatment of male sexual partners with a Duis Fluconazole autem vel is contraindicated eum iriure dolor in pregnancy. in hendrerit topical in azole vulputate cream twice velit a esse day for 7 14 days. molestie Only topical consequat, azoles are vel recommended illum dolore for eu feugiat nulla facilisis at vero eros et treatment accumsan of vulvovaginal et iusto odio candidiasis dignissim during qui blandit Follow praesent Up luptatum zzril pregnancy. Treatment for 7 days may be No follow up necessary unless symptoms delenit augue duis dolore te feugait nulla facilisi. Lorem ipsum dolor sit necessary. persist or recur in which case repeat amet, consectetuer assessment nonummy is advised. nibh euismod tincidunt ut laoreet dolore Ut wisi enim ad minim veniam, quis nostrud exerci tation ullamcorper suscipit lobortis nisl ut aliquip ex ea commodo eu feugiat nulla facilisis at vero eros et accumsan et iusto odio blandit praesent In treating mild to moderate PID, it luptatum augue duis dolore te All feugait partners/contacts nulla facilisi. in the last 60 days regardless of symptoms or signs should be tested and treated for gonorrhea and recommended antibiotic treatment. chlamydia. If there is no partner during Consider hospitalization when the this period, then the last partner should be Nam patient: liber tempor cum eleifend tested, option treated congue and advised nihil to imperdiet abstain from doming id is quod pregnant mazim placerat facer possim sexual assum. activity for 7 days after initiation of treatment. is severely ill with nausea and Lorem ipsum vomiting dolor and/or sit amet, high fever consectetuer Patients adipiscing should elit, abstain sed from diam sexual activity nonummy has nibh a suspected euismod tubo-ovarian tincidunt ut laoreet until dolore treatment magna is completed aliquam (i.e., erat days) abscess and should be advised to avoid exposure to Duis autem vel eum iriure dolor in hendrerit in vulputate velit cannot tolerate oral medication any untreated partner(s). esse molestie consequat, vel feugiat nulla facilisis at vero May have a surgical emergency eros et accumsan et iusto odio dignissim Follow qui blandit Uppraesent luptatum such as appendicitis or an ectopic pregnancy augue duis dolore te Patients nulla treated facilisi. for PID as outpatients need careful follow-up and should be reevaluated hours after therapy has Lorem Pregnancy/Lactation ipsum dolor sit amet, consectetuer been adipiscing initiated. If elit, no clinical sed diam improvement nonummy Consultation nibh with euismod a obstetrical/gynaecology tincidunt ut laoreet has dolore occurred, magna hospital aliquam admission erat for specialist is recommended. Pregnant patients with suspected PID should be hospitalized for evaluation and treatment with parenteral therapy. Duis Fluroquinolones autem vel eum (e.g., levofloxacin), iriure dolor in hendrerit in vulputate velit esse doxycycline and estolate preparations molestie of erythromycin consequat, are contraindicated vel for feugiat pregnant nulla and facilisis lactating women. at vero eros et accumsan et iusto odio If patient is HIV positive a consultation Name with here blandit HIV praesent specialist is luptatum advised see: augue BC Women s duis dolore Hospital te & Healthcare Date Centre here nulla Oak facilisi. Tree Clinic - Providing Care to Women & Families Living with HIV/AIDS tincidunt ut laoreet 5 dolore Vulvovaginal Candidiasis & Pelvic Inflammatory Disease parenteral therapy and observation may be required.

7 Urethritis Urethritis is a disgnosis based on DID presenting YOU KNOW urethral CAPTIONS: symptoms in the absence of microscopic assessment. The recommended regimen covers both nonummy nibh N. gonorrhoeae and C. trachomatis. euismod tincidunt ut laoreet dolore magna aliquam Recommended erat Regimen Cefixime 800 mg PO as a single dose (A-Ι) Ceftriaxone 250 mg IM in a single dose (A-Ι) PULL (The QUOTES: preferred dliuent for this dose of ceftriaxone is 0.9 ml of 1% lidocaine without epinephrine to reduce discomfort) Lorem PLUSipsum dolor sit Doxycycline 100 mg PO bid for 7 days (A-Ι) amet, consectetuer Azithromycin 1 g PO as a single dose (A-Ι) tincidunt Persistent ut laoreet Recurrent dolore Urethritis magna Presistent aliquam or Recurrent erat Urethritis is defined as: persistent urethral symptoms co-treatment for N. gonorrhoeae and C. trachomatis was more than 2 weeks ago there has been no re-exposure to an untreated or new sexual partner Nongonococcal Urethritis (NGU) NGU is a diagnosis based on immediate laboratory microscopy (i.e.,urethral smear) showing inflammatory/pus cells as greater than or equal to 5 PMNs (i.e., polymorphonuclear leukocytes) in the absence of typical intracellular diplococci (i.e., N. gonorrhoeae). Causative organisms may include: Chlamydia trachomatis Mycoplasma genitalium Ureaplasma urelyticum Trichomonas vaginalis (occasionally) Viruses: HSV, VZV, or Adenovirus Follow Up If a male patient presents with urethral If symptoms persist or recur after therapy symptoms (e.g., urethral discharge, has been completed, (i.e. 14 days or more after Body Copy: Ut wisi enim ad minim veniam, quis nostrud etre exerci tation dysuria, intermittent urethral itching/ the initiation of treatment) the patient should be ullamcorper tingling or suscipit meatal erythema) lobortis and nisl Gram ut aliquip re-evaluated. ex ea commodo consequat. Duis stain autem results vel are eum unavailable, iriure dolor test in and hendrerit in vulputate velit esse See Persistent or Recurrent Urethritis Section. molestie treat consequat, empirically for vel both illum gonorrhea dolore and eu feugiat Symptoms nulla alone facilisis are not at sufficient vero eros for chlamydia. et accumsan et iusto odio blandit re-treatment praesent in the absence luptatum of laboratory zzril Full resolution of symptoms can take up delenit augue duis dolore te feugait nulla findings facilisi. or Lorem clinical signs. ipsum dolor sit to 14 days or longer after therapy has amet, been consectetuer initiated. tincidunt ut laoreet dolore Ut Patients wisi enim and contacts ad minim should veniam, abstain quis from nostrud exerci tation ullamcorper sexual activity for 7 days after initiation of suscipit lobortis nisl ut aliquip ex ea commodo eu feugiat nulla facilisis at treatment and should be advised to avoid vero exposure eros et to any accumsan untreated et partner(s). iusto odio blandit praesent luptatum augue duis dolore te feugait nulla facilisi. eleifend option congue nihil imperdiet If Doxycycline was the initial treatment consider Other Potential Causes: doming Azithromycin id quod 1 mazim g PO in a placerat single dose facer (A-Ι) possim assum. organisms not covered by the original treatment Lorem Erythromycin ipsum dolor 500 mg sit PO amet, qid for consectetuer 7-14 days adipiscing (e.g., elit, Trichomonas sed diam vaginalis) nonummy If Azithromycin nibh was euismod the initial treatment tincidunt consider ut laoreet dolore antimicrobial magna aliquam resistant erat organisms Doxycycline Duis 100 autem mg PO vel bid eum for 7 days iriure (A-Ι) prostatitis dolor in hendrerit in vulputate velit non-infectious inflammatory syndromes esse molestie consequat, vel feugiat nulla facilisis at vero Erythromycin 500 mg PO qid for 7-14 days Patients who have been appropriately eros et accumsan et iusto odio blandit praesent luptatum treated for urethritis and continue to augue duis dolore te have nulla urethral facilisi. symptoms in the absence of a known STI infection may benefit adipiscing from the anti-inflammatory elit, sed diam properties of either doxycycline or erythromycin. tincidunt ut laoreet dolore If there is no resolution of symptoms after treatment, consider referring the patient to a urologist. Duis autem vel eum iriure dolor in hendrerit in vulputate velit esse molestie consequat, vel feugiat nulla facilisis at All partners/contacts vero in the eros last 60 et days Doxycycline 100 mg PO bid for 7 days (A-Ι) should be tested and treated to cover for accumsan et iusto odio Name here chlamydia. blandit Azithromycin praesent 1g PO luptatum as a single dose (A-Ι) Patients and their contacts should abstain augue duis dolore te Date here form sexual activity until 7 days after nulla facilisi. initiation of treatment and be advised to avoid exposure to any untreated partner(s). tincidunt ut laoreet 6 dolore Urethritis & Persistent or Recurrent Urethritis & Nongonococcal Urethritis

8 Epididymitis The BCCDC recommended regimen differs from the Canadian STI Guidelines treatment guidelines for Epididymitis. C. trachomatis and N. gonorrhoeae account DID for YOU two-thirds KNOW of CAPTIONS: the epididymitis cases in men under 35 years of age. adipiscing Coliform elit, bacteria sed diam account nonummy for many nibh euismod epididymitis tincidunt cases ut laoreet in men dolore 35 years magna of age aliquam or older. erat To cover C. trachomatis and N. gonorrhoeae PULL Cefixime QUOTES: 800 mg PO in a single dose (A-Ι) Ceftriaxone 250 mg IM in a single dose (A-Ι) Lorem ipsum dolor sit (The preferred diluent for this dose of ceftriaxone is 0.9 ml of 1% lidocaine without epinephrine to reduce amet, discomfort) consectetuer PLUS adipiscing Doxycycline 100 elit, mg PO sed bid for diam days (A-Ι) tincidunt Herpes ut Simplex laoreet dolore Virus (Genital) Primary/First Episode Acyclovir 400 mg PO tid for 7 10 days (A-Ι) Famciclovir 250 mg PO tid for 5 7 days (A-Ι) Valacyclovir 1 g PO bid for 7 10 days (A-Ι) Recurrent Episodes (Episodic Therapy) Acyclovir 400 mg PO tid for 5 days (A-Ι) or Acyclovir 800 mg PO tid for 2 days (C-Ι) Famciclovir 125 mg PO bid for 5 days or Famciclovir 1000 mg PO bid x 1 day (B-Ι) Valacyclovir 500 mg PO bid for 3 days or Valacyclovir 1 g PO OD for 3 days (B-Ι) Suppressive Therapy Recurring outbreaks - 6 to 9 / year Acyclovir 400 mg PO bid daily for 6 12 months (A-Ι) Famciclovir 250 mg PO bid daily for 6 12 months (A-Ι) Valacyclovir 500 mg PO once daily for 6 12 months (A-Ι) Recurring outbreaks - more than 10 / year Valacyclovir 1 g PO daily for 6 12 months (A-Ι) Alternate treatment Levofloxacin 500 mg PO once daily for days (B-П) Body Copy: Ut wisi enim ad minim veniam, symptom quis nostrud onset or date etre of exerci diagnosis tation should be tested and treated for gonorrhea and ullamcorper Ciprofloxacin suscipit 500 mg PO lobortis bid x nisl ut days aliquip ex ea commodo consequat. chlamydia. Duis (The autem alternate antibiotic vel eum treatments iriure listed dolor above in hendrerit will in vulputate velit esse cover enteric organisms, but may not cover Patients and contacts should be advised molestie N. gonorrhoeae consequat, or C. trachomatis.) vel feugiat nulla facilisis at vero eros to not have sexual activity for 7 days after et accumsan et iusto odio blandit initiation praesent of treatment. luptatum zzril delenit augue duis dolore te feugait nulla facilisi. Lorem ipsum dolor sit Consider non-infectious causes of amet, consectetuer Follow nonummy Up nibh euismod scrotal pain and swelling Patients should be advised to be tincidunt (i.e. trauma, ut laoreet tumors or dolore testicular magna torsion). aliquam erat reassessed within 48 to 72 hours after Testicular torsion is a surgical emergency diagnosis to ensure there has been an and needs to be considered with acute Ut wisi enim ad minim veniam, quis nostrud adequate exerci response tation ullamcorper to treatment. If there onset of testicular pain. suscipit lobortis nisl ut aliquip ex ea commodo has been eu no feugiat clinical nulla improvement, facilisis refer at to a urologist. vero eros et accumsan et iusto odio blandit praesent luptatum augue duis dolore te feugait nulla facilisi. Nam liber tempor cum eleifend Pregnancy/Lactation option congue nihil imperdiet doming Oral id acyclovir, quod mazim famciclovir placerat and facer possim Consultation assum. with an obstetrician / valacyclovir are comparatively gynaecologist experienced in the efficacious. management of genital HSV infections is Topical acyclovir is not effective for recommended. nonummy systemic nibh symptoms, euismod and tincidunt should not ut be laoreet dolore used Duis for that autem purpose. vel eum iriure dolor in hendrerit in vulputate velit Herpes is not a reportable infection. esse A molestie shorter course consequat, of acyclovir vel 800 illum mg dolore PO eu feugiat nulla facilisis at vero eros tid et for accumsan 48 hours appears et iusto as odio efficacious dignissim Supportive qui blandit counseling praesent is an luptatum essential part as the approved 5 day regimen. of management and patients will need augue duis dolore te nulla facilisi. Start famciclovir preferably less than 6 guidance on how they will inform present hours and valacyclovir preferably less and/or future sexual partners. Lorem than ipsum 12 hours dolor after sit the amet, first symptoms consectetuer Patients should be advised that even nonummy appear. nibh euismod tincidunt ut laoreet though dolore transmission magna can aliquam occur in erat the Patient-initiated therapy at the onset of absence of a lesion (i.e., asymptomatic prodromal symptoms has been proven shedding), transmission is more likely to to be effective. occur during an active outbreak. It is recommended that individuals have medications on hand and be provided Positive HSV education and public health Duis with autem specific vel information eum iriure on dolor when in to messaging emphasizing genital herpes as hendrerit in vulputate velit esse molestie initiate consequat, treatment. a manageable, albeit a chronic infection, vel is important to help reduce stigma, lack Having genital herpes simplex (HSV) feugiat nulla facilisis at of understanding and vero subsequent eros et anxiety can increase the risk of acquiring and accumsan transmitting et iusto HIV. odio experienced by patients dignissim receiving qui a new Name here genital herpes diagnosis. blandit Physicians praesent may luptatum order HSV-TSS augue (type duis specific dolore serology) te via LifeLabs Please refer to the following Date here feugait websites etre for nulla although facilisi. this is not covered by BC genital HSV information: Medical Services Plan. CDC Manual, Chapter 5 Non-certified STI soluta DSTs nobis eleifend option congue nihil imperdiet doming id quod mazim placerat tincidunt ut laoreet 7 dolore Epididymitis & Herpes Simplex Virus All partners in the last 60 days prior to

9 Syphilis - Treponema pallidum Contact the Provincial STI/HIV Physician for management, support and to order long acting (Bicillin LA) medication. Early Syphilis DID YOU KNOW CAPTIONS: Primary Lorem Symptoms ipsum dolor can include sit amet, chancre, consectetuer and /or adipiscing regional elit, lymphadenopathy. sed diam nonummy nibh euismod Secondary tincidunt ut laoreet dolore magna aliquam Symptoms erat can include rash, fever, malaise, lymphadenopathy, mucus lesions, condylomata lata, and/or alopecia. Early Latent PULL Asymptomatic QUOTES: and has had a negative syphilis test in the last year. Lorem ipsum dolor sit amet, Benzathine consectetuer penicillin G (i.e., Bicillin LA) 2.4 million units in a single dose (A-Ι) units given IM into each buttock at the same visit.) NOTE: tincidunt ut laoreet dolore is the appropriate treatment for syphilis. It achieves detectable serum levels of (Bicillin LA is administered in divided doses of 1.2 million Long-acting benzathine penicillin G (Bicillin-LA) penicillin for 2-4 weeks and is required to adequately treat infectious syphilis. Short-acting benzathine penicillin G or benzyl penicillin G has a similar name to the long-acting penicillin (i.e., Bicillin-LA), but does not provide adequate treatment for syphilis. Jarisch-Herxheimer Reaction (i.e., fever, chills, headache, and myalgia) occurs 2 12 hour after treatment of early infectious syphilis and usually resolves within 24 hours. Antipyretics may be needed. to Early Syphilis All sexual contact/partners within 90 days of the patient s diagnosis and/or symptom onset, should be tested and treated with Bicillin 2.4 million units IM regardless of test results to treat incubating syphilis. Sexual contacts/partners greater than 90 days only need to be tested or as per instructions from the BCCDC Provincial STI/HIV Clinic physician or syphilis nurse. For partner/contact follow up, please consult Provincial STI/HIV Syphilis Nurse REPTABLE Late Latent Syphilis HIV and Syphilis Co-infections > 1 year duration or of unknown duration Syphilis positive patients co-infected with HIV Body Copy: Ut wisi enim ad minim veniam, require quis syphilis nostrud serology etre every exerci 3 months. tation ullamcorper Tertiary suscipit Syphilis lobortis nisl ut aliquip ex ea commodo consequat. (cardiovascular and other syphilis not involving the Duis autem vel eum iriure dolor in hendrerit Neurosyphilis central nervous system) in vulputate velit esse Neurosyphilis symptoms can occur at molestie consequat, vel feugiat nulla facilisis at vero eros any syphilis stage. It is usually seen in et Benzathine accumsan penicillin et iusto G (Bicillin odio dignissim LA) qui blandit the late praesent latent stage luptatum although zzril recently delenit 2.4 million augue units duis given dolore weekly te for feugait 3 weeksnulla facilisi. some Lorem cases of ipsum neurosyphilis dolor have sit been amet, to a total consectetuer of 7.2 million adipiscing units diagnosed in the secondary syphilis elit, sed diam stage. (Bicillin LA is administered in divided doses of 1.2 million tincidunt ut laoreet dolore units given IM into each buttock at the same visit.) Ut Alternate wisi enim treatment ad minim (if allergic veniam, to Penicillin) quis nostrud vertigo, exerci ataxia, tation uveitis, ullamcorper retinitis, auditory suscipit Doxycycline lobortis 100 mg nisl PO ut BID aliquip for 28 days ex ea (B-П) symptoms such as hearing loss or commodo tinnitus, eu feugiat meningitis, nulla personality facilisis changes, at vero eros et accumsan to et Late iusto Syphilis odio dignissim and qui dementia), blandit consider praesent syphilis as a luptatum Test all long zzril term delenit sexual augue partners duis and dolore te feugait differential nulla diagnosis facilisi. and complete children (i.e., 18 years of age or younger) of syphilis serology screening. an infected mother. (Bicillin LA is administered in divided doses of 1.2 million units given IM into each buttock at the same visit.) adipiscing In most cases, elit, Treponema sed diam pallidum nonummy Additional doses may be necessary nibh euismod tincidunt ut laoreet antibodies dolore magna persist aliquam for the life erat of a patient depending on the duration of the infection. and therefore the EIA test will detect a If there is a penicillin allergy, greater number of old syphilis cases. desensitization to penicillin is The EIA treponeme-specific test is recommended as the recommended similar to the TPPA and FTA-Abs tests alternate treatment with doxycycline is used for confirmatory syphilis testing. contraindicated in pregnancy. Duis autem vel eum iriure dolor in hendrerit Confirmatory in vulputate tests velit will esse no longer need to be ordered by a physician as they will be molestie Follow consequat, Up vel automatically done by the BC-PHMRL feugiat Syphilis nulla serology facilisis should be at monitored every 6 as appropriate. vero eros et accumsan months after et treatment iusto odio until a suitable response Name here EIA testing allows for automated, high blandit is observed. praesent A four fold luptatum drop in the RPR titre volume syphilis screening for within 6-12 months and an RPR titire of less augue duis dolore te BC residents. Date here than 1:8 within one to two years after treatment, nulla is considered facilisi. adequate response to therapy. Syphilis When unexplained neurological symptoms are present (e.g., headaches, Further testing and possible referral to an infectious disease specialist may be Pregnancy/Lactation warranted. Nam Please liber tempor consult with cum Provincial STI/HIV eleifend Please option consult congue Provincial nihil imperdiet STI/HIV doming Clinic id Physician quod mazim at placerat facer possim Clinic assum. Physician at for All pregnant women should be screened management and treatment. for syphilis during the first trimester of pregnancy and repeated later in EIA Syphilis Serology Algorithm nonummy pregnancy nibh for euismod women with tincidunt ongoing ut risk laoreet In dolore July 2014 magna the BC aliquam Public Health erat of syphilis Duis exposure. autem vel eum iriure dolor in hendrerit Microbiology in Reference vulputate Laboratory, velit esse Recommended molestie consequat, Regimen vel (BC-PHMRL) feugiat nulla switched facilisis the preliminary at vero screening test for syphilis from the Rapid eros Benzathine et accumsan penicillin et G iusto (Bicillin odio LA) blandit praesent luptatum Plasma Reagin (RPR) antibody test zzril 2.4 delenit million units augue in a single duis dolore dose (A-Ι) te nulla facilisi. to an Enzyme Immunoassay (EIA), a Treponema pallidum specific antibody test. For more information contact the Provincial STI/HIV Clinic Physician at Once adequate response to therapy has been Nam achieved, liber a tempor two-dilution cum rise in RPR titre may eleifend indicate re-infection. option congue nihil imperdiet doming id quod mazim placerat tincidunt ut laoreet 8 dolore

10 HIV - Human Immunodeficiency Virus REPTABLE British Columbia guidelines on HIV DID testing YOU are KNOW intended CAPTIONS: to support healthcare providers by offering routine HIV testing as well as enhanced HIV testing to priority nonummy nibh populations. euismod tincidunt ut laoreet dolore magna aliquam HIV Testing erat Guidelines for the Province of British Columbia Public Health recommends that healthcare providers be aware of the HIV status of all PULL patients QUOTES: under their care. Specifically it is recommend that providers Lorem offer an HIV ipsum test: dolor sit Routinely, every five years, to all amet, patients consectetuer aged years Routinely, every year, to all patients aged years who belong to infection tincidunt ut laoreet dolore HIV status is not known populations with a higher burden of HIV Once at age 70 or older if the patient s Offer an HIV test to patients including adults 18 70, youth and the elderly whenever: they present with a new or worsening medical condition that warrants laboratory investigation they present with symptoms of HIV infection or advanced HIV disease their providers identify a risk for HIV acquisition they request an HIV test they are pregnant : Obtaining informed consent for HIV testing is the same as for any other diagnostic test. If the pretest probability of a positive HIV test is high, then a more extensive discussion may be warranted. Positive HIV results are reported to public health via the Medical Health Officer (MHO) or the HIV designate nurse (HIV- DN). An HIV-DN will contact the ordering clinician to offer assistance with reporting forms, partner notification, counseling and referrals. Testing and Management of Benefits of HIV Treatment Potential HIV Exposures Individuals may benefit from initiation of Body Probable Copy: low Ut risk wisi HIV enim exposure, ad minim veniam, quis HIV as nostrud early as etre possible. exerci tation test at 6 weeks post exposure Benefits include improvement to patient ullamcorper suscipit lobortis nisl ut aliquip ex ea commodo consequat. re-test at 3 months health and decreased risk of HIV Duis autem vel eum iriure dolor in hendrerit transmission in vulputate to velit sexual esse partners, known molestie Recent high consequat, risk exposures vel illum or when dolore HIV eu feugiat in BC nulla as Treatment facilisis as at Prevention vero eros or seroconversion is suspected, et accumsan et iusto odio blandit TasP. praesent luptatum zzril test soon as the patient presents delenit augue duis dolore te feugait nulla facilisi. Acute Lorem HIV infection ipsum is diagnosed dolor sit indicate Query Acute HIV on by special laboratory testing and is amet, requisition consectetuer as the laboratory adipiscing may elit, sed diam supported by the BC Public Health tincidunt perform ut laoreet specific HIV dolore tests magna if indicated aliquam erat Microbiology and Reference Laboratory (BC-PHMRL) at BCCDC. Point-of-care (POC) rapid tests for HIV Ut antibodies wisi enim are ad widely minim available. veniam, quis nostrud For exerci questions tation please ullamcorper contact the suscipit All positive lobortis HIV nisl POC ut tests aliquip require ex ea commodo Provincial eu feugiat STI/HIV nulla Clinic facilisis Physician at at vero confirmatory eros et accumsan HIV testing et iusto odio blandit praesent HIV treatment and primary care luptatum Post-exposure prophylaxis augue (PEP) duis dolore te feugait resources nulla can facilisi. be found at the Antiretroviral therapy may be offered BC Centre for Excellence in HIV/AIDS within 72 hours of a high risk exposure by contacting: BC Centre for Excellence in HIV/AIDS Pregnancy/Lactation Nam St. liber Paul s tempor Hospital cum Pharmacy eleifend option congue nihil imperdiet HIV testing should be offered to all doming Accidental quod Exposure mazim placerat Program at facer possim pregnant assum. women as part of routine prenatal care. adipiscing Antiretroviral elit, therapy sed (ARV) diam is available, St. Paul s Hospital switchboard at nonummy nibh euismod Ask for the tincidunt Infectious ut laoreet and dolore significantly magna decreases aliquam the erat risk of mother-to-child transmission. Disease Duis physician autem on-call vel eum iriure dolor in hendrerit in vulputate velit Repeat testing later in pregnancy may esse molestie consequat, vel be feugiat recommended nulla facilisis if risk of exposure at vero is eros Referral/Follow et accumsan et Up iusto odio high. blandit praesent luptatum Newly diagnosed HIV positive individuals augue duis dolore te HIV nulla positive facilisi. women are advised not to often require specialized medical care breastfeed, but rather to use formula or including emotional and psychological donated breast milk. Lorem support ipsum for their dolor new diagnosis. sit amet, Timely consectetuer nonummy referral and nibh follow euismod up recommended. tincidunt ut laoreet dolore The MHO or the HIV-DN can provide assistance to clients and help arrange follow up and ongoing community suport when requested. Please contact your local public health department. Duis autem vel eum iriure dolor in hendrerit in vulputate velit esse Medical support is also available through: molestie BC Centre consequat, for Excellence vel in HIV/AIDS: feugiat et iusto odio nulla facilisis at vero eros et accumsan blandit REACH praesent (Rapid luptatum Expert Advice & Name here Consultation for HIV): augue Toll duis free dolore at te or Date here nulla facilisi. BC Women s Hospital & Healthcare Centre Nam Oak liber Tree tempor Clinic - cum Providing Care to Women & Families Living with HIV/AIDS tincidunt ut laoreet 9 dolore HIV

11 STI/HIV Resources BCCDC Provincial STI/HIV Clinic Clinical Prevention Services 655 West 12th Avenue Vancouver, BC V5Z 4R4 General Inquires: Provincial STI/HIV Clinic Phone: Provincial STI/HIV Clinic Fax: Provincial STI/HIV Physician: Provincial STI/HIV Nurse: BC STI Treatment Guidelines and the BC Physician STI Treatment Guideline Summary (printable copy or updates) available at: Public Health STI clinics, services, programs and health files are available at: Health Authorities in BC Fraser Health Authority Interior Health Authority Northern Health Authority Island Health Authority Vancouver Coastal Health Authority Provincial Health Services Authority First Nations Health Authority