Download Hot Topics in Sexually Transmitted Infections and Associated

A Quick Reference Guide for Clinicians®
Hot Topics in Sexually Transmitted
Infections and Associated Conditions
Introduction 2
Counseling Patients about Sexually Transmitted Infections
3
Management of Sex Partners 4
Bacterial Vaginosis 6
Chlamydia 7
Gonorrhea9
Genital Herpes 11
HIV 16
Human Papillomavirus 19
Syphilis 24
Trichomoniasis 26
References 28
Appendix: Additional Resources 32
Publication Information 33
Introduction
Despite decades of available prevention methods and treatment for most sexually transmitted
infectionsi (STIs), these infections continue to affect large numbers of youth and adults. More than
400 million cases of treatable STIs occur worldwide every year.1 In the United States, there are
about 20 million new infections each year, with a total prevalence of about 110 million, estimated
from 2008 data.2 These infections cost the US health care system almost $16 billion each year in
direct medical costs.3 In addition to financial costs, STIs exact an enormous personal toll on quality
of life, sexual health, and reproductive health—and increase the risk of infection with human
immunodeficiency virus (HIV).4
Significant racial and ethnic disparities persist in STI rates in the United States. For example, almost
half of Black adolescents had one or more STIs, compared with only one in five White or Mexican
American adolescents, even when adjusted for income level and the number of sexual partners, and
the rates of chlamydial infection, gonorrhea, and syphilis are several fold higher in Blacks than in
Whites or Asian Americans.2
Many STIs remain undiagnosed and therefore untreated.5 In some cases, the gap exists because
the STI is asymptomatic, as is often the case with chlamydial infection in women. In other cases,
it is because providers have not considered the possibility of STI or are unaware of the guidelines
for screening of asymptomatic individuals. Other STIs, such as genital infection with human
papillomavirus (HPV) and herpes simplex virus (HSV), are incurable, although symptoms can
be controlled and serious outcomes prevented. Untreated STIs can result in chronic pelvic pain,
infertility, pregnancy complications, cancer, and death. It is estimated that untreated STIs are
responsible for infertility in more than 24,000 women each year.6
This Quick Reference Guide provides a focused, clinically oriented resource for managing the
aspects of STIs that practicing clinicians often find difficult or perplexing. It provides essential
practical information, or “clinical pearls,” about screening, diagnosis, and treatment of the
most common STIs: chlamydial infections, gonorrhea, genital herpes, HIV infection, genital HPV
infections, syphilis, and trichomoniasis. The Guide also discusses bacterial vaginosis (BV), a
common sexually associated condition. This Guide is not meant to be a comprehensive resource for
STI treatment and management. Its guidance is based largely on recommendations of the Centers
for Disease Control and Prevention’s (CDC’s) Sexually Transmitted Diseases Treatment Guidelines.
Abbreviations and acronyms used in this Guide:
• ASC-US: atypical squamous cells of undetermined significance
• BCA: bichloroacetic acid
• BV: bacterial vaginosis
• CDC: Centers for Disease Control and Prevention
• CIN: cervical intraepithelial neoplasia
• CT: Chlamydia trachomatis
• ELISA: enzyme-linked immunosorbent assay
• EPT: expedited partner therapy
• GC: Neisseria gonorrhoeae or gonococcus
• HIV: human immunodeficiency virus
______________________
i
The term sexually transmitted infection is used; in this Guide it is synonymous with sexually transmitted disease,
with no intended significant difference in meaning.
Hot Topics in Sexually Transmitted Infections and Associated Conditions
2
• HPV: human papillomavirus
• HSV: herpes simplex virus
• HSV-1: herpes simplex virus type 1
• HSV-2: herpes simplex virus type 2
• LSIL: low-grade squamous intraepithelial lesion
• MSM: men who have sex with men
• NAAT: nucleic acid amplification test
• PID: pelvic inflammatory disease
• POCT: point-of-care test
• STI: sexually transmitted infection
• USPSTF: United States Prevention Services Task Force
Counseling Patients about Sexually Transmitted Infections
• The National Network of STD/HIV Prevention Training Centers recommends these steps for
providing patient-centered counseling on STIs:7
• Speak with, rather than to, the patient.
• Ask questions that focus on issues that the patient identifies, accept the patient’s ideas about
changing his or her behavior, and acknowledge the patient’s feelings as important.
• Maintain a nonjudgmental attitude.
• Use open-ended questions (e.g., “What are your concerns about condom use?” rather than
“Are you concerned about asking your partner to use condoms?”).
• Support positive risk-reduction behaviors the patient has taken.
• Assist the patient in identifying barriers to risk reduction.
• Set a realistic risk-reduction plan, with steps that are acceptable to the patient, explicit, and
achievable.
• Offer options, not directives.
• Other steps include the following:
• Provide key counseling messages about specific STIs as relevant, and provide basic
information about STIs. (For downloadable fact sheets about specific STIs in English and
Spanish, see www.cdc.gov/std/healthcomm/fact_sheets.htm.)
• Focus on the positive aspects of sexual health, and share counseling messages that
normalize sexual health.
• Encourage the evaluation of sex partners, and arrange for therapy of partners with
treatable STIs.
• Do not make assumptions about a patient’s sexual orientation.
Hot Topics in Sexually Transmitted Infections and Associated Conditions
3
• Counseling tips for the adolescent patient8 include the following:
• Become familiar with slang terms that adolescents use to talk about sex.
• Dispel common myths, such as “only vaginal sex spreads STIs” and “the pill protects against
STIs.”
• Address STIs and their importance to sexual health during annual well-adolescent exams,
sports physicals, and evaluations for amenorrhea or dysmenorrhea, and include evaluation
for possible STIs.
• Consider talking about sexual health in general with the adolescent with his or her parent
present, but then meet with the adolescent alone to discuss sexual habits, activity, and
preferences.
Management of Sex Partners
• The goals of partner management in STI clinical services include the following:9
• Increasing the number of individuals with STIs who access treatment
• Preventing re-infection of the index patient
• Interrupting transmission networks
• Partner notification is a central but often neglected aspect of STI management and is carried
out either by the care providers of the index patient or public health authorities. It includes
identification of sex partners of the index patient and arranging for their evaluation and
treatment.
• Traditionally, partner management for treatable STIs has involved treatment of the index patient’s
partner(s) in a clinical setting.
• Clinicians should encourage individuals with treatable STIs to notify their sex partners and urge
them to seek treatment. Clinicians can also request that patients bring their partners when they
return for treatment or follow-up.
• Expedited partner therapy (EPT) is the treatment of the sex partners of index patients with STIs
outside of the clinical setting, that is, without medical evaluation or prevention counseling. When
partner referral is not likely to be successful, EPT may be helpful. EPT is meant to supplement
other partner management strategies, such as provider-assisted referral, which may be limited
by available resources. EPT should be considered a routine practice when it is the best option to
ensure partner treatment for gonorrhea or chlamydial infection and where legally permissible.9
• EPT is used most commonly for partners of patients diagnosed with Chlamydia trachomatis
(CT) or Neisseria gonorrhoeae (GC) and may also be considered for the partners of patients
with trichomoniasis.
• EPT is legally permitted in most states but still prohibited by law in some. To check on the
legal status by state, see www.cdc.gov/std/ept/legal.
• EPT should be accompanied by instructions and warnings about the medication (including
allergy or pregnancy), general health counseling, and the advice that partners seek
medical evaluation themselves, especially in the presence of STI symptoms.
• Generally EPT should not be used for men who have sex with men (MSM), because of the
high risk for coexisting STIs, including undiagnosed HIV infection.
Hot Topics in Sexually Transmitted Infections and Associated Conditions
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Table 1: Recommended Management of Sex Partners by STI or Associated Condition9
STI or Associated Condition
BV
Heterosexual men or
women with CT or GC
Genital herpes
HIV
HPV
Syphilis
Trichomoniasis
Cervicitis
Women with pelvic
inflammatory disease (PID)
Recommended Partner Management
Treatment of sex partners is not recommended.
All sex partners within preceding 60 days should be evaluated and
treated. EPT should be considered, where allowable by law, if the
sex partner is unlikely to present for treatment.
Providers should ask symptomatic sex partners about previous
history of genital lesions and should offer type-specific HSV serologic
testing.
Partners not previously diagnosed with HIV should be tested and
counseled; selected partners may be candidates for post-exposure
prophylaxis (PEP) with antiretroviral drugs (see CDC guidelines at
www.cdc.gov/mmwr/preview/mmwrhtml/rr5912a1.htm).
Patients should be encouraged to inform partners, and counseling
about communication with sex partners may be helpful in the
adoption of prevention strategies; clinical evaluation is optional for
asymptomatic partners.
Patients should receive a clinical exam and serologic testing;
partners of patients with syphilis less than a year in duration should
be treated without awaiting diagnostic test results (for specific
regimens, (see CDC guidelines at www.cdc.gov/mmwr/preview/
mmwrhtml/rr5912a1.htm).
Male partners of infected women should be treated; EPT may be
considered where legally permissible.
Partners should receive treatment for the same STI(s) as the index
patient.
Sex partners should be treated with regimens that are effective
against both CT and GC, regardless of the etiology of PID.
Hot Topics in Sexually Transmitted Infections and Associated Conditions
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Bacterial Vaginosis
• Key facts about the condition
• It is not clear whether BV is sexually acquired, but the condition is associated with STI risk
factors and with elevated risk for other STIs.9
• BV involves loss of indigenous Lactobacillus species with overgrowth of anaerobes.
• BV is the most common cause of abnormal vaginal discharge or odor.10
• BV is linked to premature rupture of membranes, preterm labor, preterm birth, and
complications after gynecologic surgery.9,11,12
• Typical symptoms
• Vaginal malodor, often more prominent following vaginal intercourse
• Increased vaginal discharge, typically thin, white or gray, usually without itching or
irritation
• Screening and diagnosis
• Screening for BV is not recommended in asymptomatic women, even in pregnancy.
• In symptomatic women, BV can be diagnosed clinically by the presence of at least three of
the following:9
• Homogeneous, thin, white discharge that smoothly coats the vaginal walls
• Clue cells on microscopic examination of vaginal fluid
• Positive “whiff” or amine test (characteristic fishy odor after the addition of 10 percent
potassium hydroxide)
• pH > 4.5
• In lieu of wet mount microscopy, Gram stained vaginal fluid can be examined
microscopically by experienced and trained clinicians to identify clue cells and evaluate
vaginal bacteria.
• Treatment and management
• See the following recommended regimens.
Table 2: Recommended Regimens for the Treatment of Bacterial Vaginosis9
Medication
Metronidazole
tablets
Metronidazole
gel 0.75%
Clindamycin
cream 2%
Dosage
500 mg twice daily by mouth
Duration
7 days
one full applicator (5 g)
5 days
intravaginally, once a day
one full applicator (5 g) intravaginally 7 days
at bedtime
Hot Topics in Sexually Transmitted Infections and Associated Conditions
Comments
Avoid alcohol
consumption
May weaken latex
condoms
6
• Patients should be advised to avoid the consumption of alcohol while taking metronidazole and
for 24 hours after completing treatment.
• Clindamycin cream is oil based and might weaken latex condoms and diaphragms for 5 days
after use (refer to clindamycin product labeling for additional information).
• Treatment of asymptomatic sex partners has not been demonstrated to prevent recurrent BV and
is not recommended.
Chlamydia
• Key facts about infection
• Genital infections caused by CT are the most frequently reported infectious disease in the
United States, with 1.4 million cases reported in 2011.13
• Chlamydial infection can cause urethritis and cervicitis but is often asymptomatic in both
men and women.
• Genital chlamydial infections are associated with several adverse consequences, including
PID, ectopic pregnancy, infertility, and chronic pelvic pain.9
• Co-infection with gonorrhea is common.14,15
• Screening and diagnosis
• Routine laboratory screening is recommended in asymptomatic sexually active women who
have the following risk factors:
• Age ≤ 25 years
• Age ≥ 26 years with
• New sex partner
• Multiple sex partners
• Inconsistent use of condoms (unless in monogamous relationship)
• New diagnosis of other STI
Table 3: Testing Options for Chlamydia9,16
Nucleic Acid Amplification Test (NAAT)
Test method of choice—higher sensitivity than
culture
Allows the widest variety of testing sites, but
specific test kits vary in the specimen types
for which they are FDA cleared
Culture
Not routinely done—may be useful for evaluating
and managing suspected treatment failure
Used only in research situations to assess possible
trends in antimicrobial susceptibility
• Anatomical sites for testing
• In women
• Vaginal swab is the preferred site for NAAT screening and may be collected by either
clinician or patient; vaginal swab detects more infections than endocervical swab,
which is no longer recommended for routine screening or diagnostic testing.
Hot Topics in Sexually Transmitted Infections and Associated Conditions
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• A urine specimen (“first catch” rather than midstream “clean catch”) is acceptable
when logistical considerations preclude vaginal swab (e.g., screening in nonclinical
settings).
• Rectal swab is recommended if anal sexual exposure has occurred.
• CT testing of the pharynx is generally not recommended, even in women who perform
oral sex, but is usually bundled with GC testing by NAAT.
• In men
• Either a first-catch urine specimen or a urethral swab can be used for screening and
diagnostic testing.
• Specimens from the rectum should be tested if sexual exposure has occurred.
• Pharyngeal CT testing is not recommended, but bundled testing may accompany GC
testing by NAAT.
• NAATs are not FDA cleared for nongenital sites such as the pharynx, although some
laboratories have created performance specifications that allow NAATs to be used for these
sites. Clinicians should check product inserts or check with their laboratories for specific
information.
• Laboratories may require different types of swabs for different collection sites (e.g., vaginal,
male urethral, pharyngeal) for NAATs. Clinicians should ensure use of the correct collection
kits.
• Treatment and management
Table 4: Recommended Regimens for the Treatment of Uncomplicated Genital Chlamydial
Infection*9
Medication
Dose and Duration
Azithromycin
Doxycycline
1 g orally, single dose
100 mg orally twice
daily for 7 days
Levofloxacin
500 mg orally once
daily for 7 days
Comment
The usual treatment of choice
For patients who do not tolerate
azithromycin or who are likely to comply
with 7 days’ treatment; contraindicated in
pregnancy
When neither azithromycin nor doxycycline
can be used; contraindicated in pregnancy
*For alternative regimens or for treatment of children or individuals with complicated infection, coexisting HIV infection,
or infection at nongenital sites, see CDC treatment guidelines.
• Treatment is recommended for all opposite-sex partners within the preceding 60 days. EPT
is a routine option when the partner may not seek clinical treatment and where allowed by
local/state regulations.
• Clinicians should report cases of confirmed chlamydia to the local or state health
department as required by law.
Hot Topics in Sexually Transmitted Infections and Associated Conditions
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Gonorrhea
• Key facts about infection
• Gonorrhea, or gonococcal infection, is the second most common reportable infection in the
United States, with 321,849 cases reported in 2011, although the actual number of cases
is estimated to approximate 600,000.9,13
• Almost all men with urethral gonorrhea (> 95 percent) are symptomatic, typically with
prominent urethral discharge and often dysuria. However, infection is disproportionately
transmitted by the minority who are without symptoms, who ignore symptoms, or whose
symptoms begin after transmission.9
• In contrast, women may develop urethritis or cervicitis but often are asymptomatic until PID
or other complications have developed.9
• Chlamydial co-infection is present in 20 to 40 percent of patients with GC.14,15
• Drug resistance in N. gonorrhoeae is a growing problem.16
• Screening and diagnosis
• No official criteria for GC screening have been proposed.
• CDC does not recommend widespread screening of asymptomatic women; however,
targeted screening of women ages ≤ 25 years with risk factors is suggested.
• Risk factors for GC recognized by the United States Prevention Services Task Force
(USPSTF) include the following:17
• History of GC infection
• Other STIs
• New sex partner
• Multiple sex partners
• Inconsistent condom use
• Transactional sex
• Testing options
Table 5: Testing Options for Gonorrhea9,16
NAAT
Higher sensitivity than culture—the usual test
of choice
Allows the widest variety of testing sites, but
specific test kits vary in the specimen types
for which they are FDA cleared
Culture
Preserves isolate for potential antimicrobial
sensitivity testing—useful for evaluating and
managing suspected treatment failure
Used to assess trends in antimicrobial susceptibility
Hot Topics in Sexually Transmitted Infections and Associated Conditions
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• Anatomical sites for testing
• In women
• Vaginal swab is the preferred site for NAAT screening and may be collected by either
clinician or patient.
• Endocervical swab is an acceptable alternative source for NAAT for either gonorrhea
or chlamydia.
• A urine specimen (first catch rather than midstream clean catch) is acceptable for
screening when vaginal or endocervical testing are impractical (e.g., in nonclinical
settings).
• Specimens from the pharynx and rectum should be tested if sexual exposure has
occurred.
• In men
• Either a first-catch urine specimen or a urethral swab can be used for testing.
• Specimens from the pharynx and rectum should be tested if sexual exposure has
occurred.
• NAATs are not FDA cleared for nongenital sites such as the pharynx, although some
laboratories have created performance specifications that allow NAATs to be used for these
sites. Clinicians should check product inserts or check with their laboratories for specific
information.
• Laboratories may require different types of swabs for different collection sites (e.g., vaginal,
male urethral, oropharyngeal) for NAATs. Clinicians should ensure use of the correct
collection kits.
• Treatment and management
Table 6: Recommended Regimens for Treatment of Uncomplicated Genital or Oropharyngeal
Gonorrhea Infection in Adults*9
Medication
Ceftriaxone PLUS
Azithromycin
Ceftriaxone PLUS
Doxycycline
Dose and Duration
Comment
250 mg intramuscular, single All patients should receive dual therapy
dose
with ceftriaxone plus either azithromycin
or doxycycline, whether or not CT co1 g orally, single dose
infection is documented or suspected
250 mg intramuscular, single
dose
100 mg orally twice daily
Contraindicated in pregnancy
for 7 days
For severe cephalosporin allergy
Azithromycin
2 g orally, single dose
Perform test of cure at 1 week**
*For alternative regimens or for treatment of children or individuals with complicated infection, coexisting HIV infection,
or infection at other sites, see CDC treatment guidelines and update.
www.cdc.gov/mmwr/preview/mmwrhtml/rr5912a1.htm
www.cdc.gov/mmwr/preview/mmwrhtml/mm6131a3.htm?s_cid=mm6131a3_w
**NAAT may remain positive for up to three weeks despite successful treatment; for earlier test-of-cure, culture is
recommended.
Hot Topics in Sexually Transmitted Infections and Associated Conditions
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• Treatment is recommended for all sex partners within the preceding 60 days. EPT is a routine
option when the partner may not seek clinical treatment and where allowed by local/state
regulations.
• Clinicians should report cases of confirmed gonorrhea to the local or state health department as
required by law.
• Drug-resistant GC
• Because of increasing resistance of GC, CDC no longer recommends cefixime at any
dose as a first-line regimen for treatment of confirmed gonorrhea. However, cefixime plus
azithromycin remains the recommended regimen for EPT.16
• If a clinician suspects treatment failure due to antimicrobial resistance, cultures of relevant
clinical specimens with antimicrobial susceptibility testing should be requested.
• Following apparent treatment failure, most patients will respond to repeat treatment with
ceftriaxone plus azithromycin or doxycycline. However, clinicians also should consult an
infectious disease specialist, a STD/HIV Prevention Training Center consultant (www.nnptc.
org), or CDC (telephone: (404) 639-8659).
• Report all drug-resistant cases to the local or state health department within 24 hours of
diagnosis.
• Following suspected treatment failure, ensure that all the patient’s sex partners from the
preceding 60 days are evaluated (with culture, in addition to NAAT, with antimicrobial
sensitivity testing if culture is positive) and treated with ceftriaxone (unless a severe
cephalosporin allergy is suspected) plus azithromycin or doxycycline.
Genital Herpes
• Key facts about infection
• HSV causes mucocutaneous infection, retrograde infection along sensory nerves, latent
infection in cranial nerve or dorsal spinal ganglia, and mucocutaneous recurrences.9
• Herpes simplex virus type 1 (HSV-1)
• HSV-1 causes mostly orolabial infection with recurrences (“cold sores,” “fever
blisters”).
• Owing to rising frequencies of oral-genital sexual exposures, HSV-1 has grown to
account for 50 to 70 percent of initial genital herpes infections in the United States.18
• The frequency of overt recurrent outbreaks and asymptomatic viral shedding, and
therefore the risk of sexual transmission, is substantially lower for HSV-1 than for
herpes simplex virus type 2 (HSV-2).19,20,21 Suppressive therapy is less likely to be
necessary or helpful in the management of genital herpes due to HSV-1 compared
with HSV-2.
Hot Topics in Sexually Transmitted Infections and Associated Conditions
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• HSV-2
• Infections are almost always in the genital area; oral HSV-2 is relatively uncommon.
• In the United States, more than 24 million individuals have HSV-2 infection.2
• The prevalence of HSV-2 infection varies by race/ethnicity. A national survey found an
HSV-2 seroprevalence rate for non-Hispanic Blacks that was approximately three times the
rate for non-Hispanic Whites and nearly four times that for Mexican Americans.22
• Most people with HSV-2 are unaware that they are infected, owing to asymptomatic
infection and failure to recognize or understand mild symptoms.9
• Asymptomatic viral shedding, the potential for sexual transmission, and recurrences are
more common with HSV-2.20,21
• Timeline for genital herpes infection
Figure 1: Timeline of Primary HSV-2 Infection19,23,24
• If lesions develop, they appear 2 to 14 days after exposure and last about 3 weeks if
antiviral therapy is not used.19
• Viral shedding lasts an average of 12 days (but duration varies widely), stopping a few
days before lesions heal, if they are present.19
• Seroconversion (i.e., the development of measurable HSV antibodies) usually will occur
within 2 to 12 weeks after the infection.19
• Research suggests that by six weeks, more than 60 percent of patients with new HSV-2
infections will have developed antibodies and by 12 weeks more than 70 percent will have
seroconverted.23,24
• Although the antibody response is lifelong, it does not protect against local recurrence.19
• Most cases of genital herpes are due to transmission from a partner who is asymptomatic at
the time of transmission or is unaware he or she is infected.
Hot Topics in Sexually Transmitted Infections and Associated Conditions
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• The classic presentation of primary infection begins with papules, which transform into
vesicles, pustules, and ulcers over the course of 1 to 2 weeks.
• Most individuals do not have the classic presentation but may have pain at the location of
lesions and adenopathy.
• Women may have cervicitis or urethritis; pharyngitis can occur with oral infection.
• Diagnosis
• Test all patients with genital ulcers, including those that seem atypical for herpes, unless
there is another definitive diagnosis.
• Because of the important differences between HSV-1 and HSV-2 in clinical course,
transmission risk, and management, virus type should be determined in all patients with
genital herpes.*
• Two basic types of tests are available for genital herpes diagnosis:
• Virologic (direct) tests of mucocutaneous lesions
• NAAT (usually polymerase chain reaction) to detect HSV DNA: the test of
choice, substantially more sensitive than culture; readily distinguishes HSV-1
from HSV-2, often routinely (without specific request); now widely available
• Viral culture: less sensitive than NAAT (more false negative results), longer
turnaround time, may require specific request and higher cost to determine
virus type
*Your laboratory may require a specific request to distinguish HSV-1 from HSV-2, sometimes at increased cost.
Table 7: Virologic Tests for Genital Herpes9,25,26
Viral culture
Reference standard for diagnosis of
genital herpes—can be used if NAAT
is unavailable
High specificity but poor sensitivity
More stringent requirements for
specimen management, i.e. transport
medium, refrigeration
Yield is best early in course: requires
swab from base of vesicular lesion
NAAT
Preferable due to higher sensitivity
Sensitivity is 98–100% and specificity is 80–97%
(sensitivity and specificity vary depending on the clinical
setting, specimen type, and other factors)
Polymerase chain reaction–based tests are most
commonly used
Results in 2 hours compared with 1–5 days for culture
• Serologic tests
• Detect the presence of antibodies to HSV and can indicate past exposure
• Are useful in symptomatic individuals to determine whether lesions represent
initial infection or recurrence, to assess past infection with both virus types, and
to diagnose in the presence of a false negative culture (e.g., in patients with
recurrent genital herpes or healing lesions in whom culture is less sensitive)
• Are useful for selective screening of an asymptomatic individual at high risk
or the partner of a person with HSV infection (although specific criteria for
screening are controversial)
Hot Topics in Sexually Transmitted Infections and Associated Conditions
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• Are useful if neither NAAT nor culture is performed or if one is performed but is
negative
• Include three types
• Enzyme-linked immunosorbent assay (ELISA)–based serologic assays
• Point-of-care tests (POCTs) or rapid serologic assays
• Western blot
Table 8: Serologic Tests for Genital Herpes9,25,26,27,28
ELISA-based assays
Sensitivity of 94–100% and
specificity of 94–98%
Cross-reactivity between types
can be an issue and may result
in incorrect typing (HSV-1 vs.
HSV-2)
POCTs or Rapid Serologic Assays
Provide rapid results with
sensitivity of at least 91% and
specificity of at least 94%
Detect viral antigen
Western Blot
Useful for confirmation in
selected cases (only available
in research applications)
More expensive than ELISA
tests
• Older serologic tests (e.g., enzyme immunoassay) could not differentiate between types 1
and 2 and should not be used.
• Useful serologic tests measure immunoglobulin G (IgG) antibody to HSV-1 and HSV-2.
• Immunoglobulin M (IgM) antibody tests are discouraged, even when routinely offered by
laboratories:
• There is a high rate of false positive results.
• Theoretically IgM antibody develops before IgG and indicates recently acquired
infection, but in fact it performs poorly in distinguishing early from late HSV infection.
• Currently available tests do not distinguish the HSV-1 from HSV-2 antibody.
• Treatment and management
• Initial genital herpes
• Antiviral therapy speeds resolution of initial genital herpes.
• It is recommended for all patients with an initial genital herpes unless healing is well
under way at presentation.
• Intravenous therapy can be used for severe infection requiring hospitalization.
Hot Topics in Sexually Transmitted Infections and Associated Conditions
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Table 9: Recommended Treatment for Primary Genital Herpes*9
Medication
Acyclovir
Famciclovir
Valacyclovir
Dosage
400 mg orally three
times a day
250 mg orally three
times a day
1 g orally twice a day
Duration
7 to 10 days or longer as needed until
healing of lesions
*For guidance on therapy for patients with HIV infection or women who are pregnant, see CDC treatment guidelines.
www.cdc.gov/mmwr/preview/mmwrhtml/rr5912a1.htm
• Recurrent genital herpes
• Ongoing suppressive therapy reduces the frequency of recurrences and of
asymptomatic viral shedding and decreases the risk of transmission to partners.
• Self-initiated episodic therapy of recurrent episodes, if started early, modestly speeds
resolution. Episodic therapy should be initiated as soon as symptoms begin or during
the prodrome that some patients experience before lesion outbreaks.
• Topical antivirals are minimally effective and not recommended.
• See CDC guidelines for information about treatment in pregnancy and for individuals
with coexisting HIV infection.
Table 10: Suppression Therapy for Recurrent Genital Herpes*9
Medication
Acyclovir
Valacyclovir
Valacyclovir
Dosage
400 mg orally twice
daily
500 mg orally once
daily
1 g orally once daily
Comments
The higher dose is recommended for
patients with frequent outbreaks (≥ 9 per
year) and is preferred by some experts for
all patients.
*Examples of suggested regimens are shown. For additional options, see CDC treatment guidelines.
www.cdc.gov/mmwr/preview/mmwrhtml/rr5912a1.htm
Table 11: Self-Initiated Episodic Therapy for Recurrent Genital Herpes*9
Medication
Valacyclovir
Acyclovir
Dosage
500 mg orally twice
daily
400 mg orally three
times a day
Duration
3 days
5 days
*Examples of suggested regimens are shown. For additional options, see CDC treatment guidelines.
www.cdc.gov/mmwr/preview/mmwrhtml/rr5912a1.htm
Note: All regimens shown are for HSV-2 infection. HSV-1 is less susceptible to these drugs than HSV2 and may require higher doses, although no specific studies or recommendations are available.
Hot Topics in Sexually Transmitted Infections and Associated Conditions
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HIV
• Key facts about infection
• Prevalence
• Over the past 30 years, more than 25 million people in the world have died from
HIV/AIDS.29
• As of 2011, about 34 million people were living with HIV worldwide.29
• In the United States, more than one million individuals ages 13 and older have HIV
infection; approximately one fifth are unaware they have been infected.30
• The number of new infections in the United States has remained stable over the past
decade, although the rate of new infection has increased substantially among certain
populations and the total number of people living with HIV in the United States has
increased.30
• Risk
• By risk group
• MSM of all racial/ethnic groups remain the population at highest risk for HIV
infection.30 MSM comprise approximately 4 percent of the male population
in the United States but account for 63 percent of all new infections and 52
percent of people living with HIV.31,32,33
• New infections in women are primarily related to heterosexual contact (84
percent); the remainder is related to injection drug use (16 percent).30
• By race/ethnicity
• Blacks/African Americans have experienced the greatest burden of disease
from HIV. Although approximately 12 percent of the US population, Blacks/
African Americans represent 44 percent of people with HIV infection.31,32
• An even smaller proportion of the US population, Native American/Alaska
Native women are almost three times as likely to be diagnosed with HIV
infection than Caucasian women.34
• Recent research shows that the risk of acquiring HIV and other STIs for a
specified level of risky behaviors varies across social-sexual networks. Using
data from a national survey of 18- to 26-year-olds, researchers divided
individuals into 16 risk categories based on degree of risk of sexual behaviors
and substance use. For Blacks, the prevalence of HIV and other STIs was
higher than the average prevalence for the population in every one of the
16 categories, even those with the least risky behaviors. For Whites, the
prevalence was lower than the average for all except the 4 highest risk
categories.35
Hot Topics in Sexually Transmitted Infections and Associated Conditions
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Figure 2: Estimated Rate of New HIV Infections, 2009, by Gender and Race/Ethnicity36
Source: Adapted from Prejean 2011
• By age
• Individuals ages 50 and older account for 15 percent of new HIV/AIDS diagnoses.37
Many do not perceive themselves to be at risk and are less likely to use condoms and
obtain HIV testing.38,39
• Older women may be at greater risk because of age-related thinning of the vaginal
wall, which may increase the chance of viral acquisition through tears in the
mucosa.40
• Young people ages 15 to 29 account for about 39 percent of new HIV infections
in the country, although they constitute only 21 percent of the population.41 Of the
high school youth reporting sexual intercourse in the previous three months, almost
40 percent did not use a condom the last time they had sex.42 Youth with older sex
partners and those who have experienced sexual abuse are at higher risk.41
• With comorbid STIs
• Both non-ulcerative STIs (such as chlamydia) and ulcerative STIs (such as genital
herpes and chancroid) increase the risk of HIV infection through mechanisms that
appear to increase both infectiousness and susceptibility.43 When individuals are
exposed to HIV, those with other existing STIs are two to five times more likely to
acquire HIV infection than individuals without STIs. In addition, an individual with HIV
infection and another coexisting STI is more likely to transmit HIV than an individual
with HIV but without an additional STI.44
• Ulcerative STIs create breaks in the skin than can serve as portals for entry of HIV.
Both ulcerative and non-ulcerative STIs cause local inflammation, which can increase
the number of cells in genital secretions that can be targeted by HIV.45
Hot Topics in Sexually Transmitted Infections and Associated Conditions
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• Screening and diagnosis
• Some populations are known to be at greater risk; however, clinicians should consider the
possibility of HIV infection in patients who fall outside these high-risk groups rather than
assume that a patient is HIV free because of history or demographics (e.g., young woman
who reports a monogamous relationship, 80-year-old woman).
• Clinicians should avoid “siloed” thinking regarding HIV and other STIs; they should
consider HIV when seeing patients with other STIs and associated infections (both the
common infections, such as BV and multiple bouts of candidiasis, and the less common
infections, such as chancroid).
• USPSTF now recommends that all adolescents and adults ages 15 to 65 years be screened
for HIV; in addition, younger and older individuals who are at increased risk should be
screened.46 USPSTF recommends that all pregnant women be screened for HIV, even if they
present in labor without prior screening.46
• CDC recommends opt-out HIV testing, meaning that unless a patient who meets the criteria
for screening specifically declines, he or she should be informed about and undergo
testing.47
• For specific information about screening and diagnosis, see
www.cdc.gov/hiv/testing/clinical.
• Treatment and management
• Guidelines for the treatment of HIV change rapidly. For current recommendations see
www.aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-arv-guidelines/0.
• Refer individuals newly diagnosed with HIV infection to an experienced facility or provider
for comprehensive HIV care, and assist them in navigating access issues.
• Educate and counsel patients about the infection and how to reduce the risk of transmitting
the infection. For downloadable patient education materials available in a number of
languages, see www.aids.gov/hiv-aids-basics.
• Obtain initial lab studies. The National Institutes of Health recommends the following tests
for individuals newly diagnosed with HIV infection:48
• HIV antibody testing (if prior documentation is not available or if HIV RNA is below
the assay’s limit of detection)
• CD4 T-cell count (CD4 count)
• Plasma HIV RNA (viral load)
• Complete blood count, chemistry profile, transaminase levels, blood urea nitrogen,
and creatinine
• Urinalysis
• Serologies for hepatitis A, B, and C viruses
• Fasting blood glucose and serum lipids
• Genotypic resistance testing at entry into care, regardless of whether antiretroviral
therapy will be initiated immediately
Hot Topics in Sexually Transmitted Infections and Associated Conditions
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• Use screening questions to assess for risk of domestic or partner abuse. For example,49
• “Do you ever feel unsafe at home?”
• “Are you in a relationship in which you have been physically hurt or felt threatened?”
• “Have you ever been or are you currently concerned about harming your partner or
someone close to you?”
• If a patient reveals a concern about domestic violence, express support and concern and
help him or her access support services. Express concern with statements such as the
following:
• “I believe you.”
• “I am concerned about your safety and well-being.”
• “I imagine this situation must be very difficult for you.”
• “You are not alone.”
• “There are options and resources available.”
• Take steps to engage the patient and increase the chance of retention in treatment.
• Be aware of the patient’s emotional state—he or she is likely to be upset, frightened,
and aware of the stigma associated with HIV infection.
• Ensure cultural sensitivity of care providers and staff to increase the patient’s comfort
with accessing care services.
• Ensure that all care providers and staff treat the patient with dignity and respect,
respond to questions with language he or she can understand, demonstrate interest in
the patient as a person, and take time to listen to his or her concerns.
Human Papillomavirus
• Key facts about infection
• There are >100 types of HPV, of which >40 can cause genital infection and are sexually
transmitted.9
• Within 2 years, about 90 percent of HPV infections are cleared by the immune system,
although viral DNA may persist for prolonged periods, with risk of later reactivation. The
remaining 10 percent of infections with high-risk types that persist are strongly linked to a
high risk of a precancer diagnosis.50,51
• HPV infection is ubiquitous; nearly all sexually active men and women will be infected with
at least one type of HPV at some point in their lives.52
• Of low-risk HPV types, two (HPV 6 and HPV 11) cause 90 percent of external genital and
anal warts, with low-grade cervical lesions.53
• High-risk types, such as HPV 16, HPV 18, and several others, are associated with cervical,
anorectal, vulvovaginal, and penile cancers and may be cofactors in oropharyngeal, skin,
and other cancers.9
• The most prevalent high-risk types are HPV 16 and HPV 18; together they cause 60 to 70
percent of cervical and anal cancers. HPV 16 causes some pharyngeal cancers.54
Hot Topics in Sexually Transmitted Infections and Associated Conditions
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• Prevention
Table 12: Comparison of HPV Vaccines55–66
Quadrivalent (Gardasil)
Bivalent (Cervarix)
Targeted HPV types
6, 11, 16, 18
16, 18
HPV-related diseases potentially
prevented
Cervical cancer and precancer, vulvar
and vaginal cancer and precancer,
penile, anal, and oropharyngeal
cancers, low-grade lesions.
Cervical cancer and precancer, vulvar
and vaginal cancer and precancer,
penile, anal, and oropharyngeal
cancers, low-grade lesions.
External genital warts.
Indication
Females ages 9 to 26 for prevention
of cervical cancer; cervical, vaginal,
vulvar, and cancer precursors; and
genital warts related to the four HPV
types targeted by the vaccine.
Females ages 9 to 25 for prevention
of cervical cancer and cervical
cancer precursors.
Males ages 9 to 26 years for
prevention of anal cancer and anal
cancer precursors and genital warts.
Data are not available on the
efficacy for prevention of penile and
oropharyngeal cancers.
Dosing and administration
Intramuscular injection of three
separate 0.5-mL doses at 0, 2, and 6
months.
Intramuscular injection of three
separate 0.5-mL doses at 0, 1, and 6
months.
Efficacy
Among young women (ages 16–26
years) who previously had not been
exposed to any of the four HPV types
in the vaccine:
Among young women (ages 15–25
years) who previously had not been
exposed to either of the two HPV
types in the vaccine:
• 100% efficacy in preventing
• 98% efficacy in preventing
CIN3+ caused by the targeted
CIN2/3 caused by the targeted
HPV types
HPV types
• 100% efficacy in preventing
vulvar and vaginal precancers
caused by the targeted HPV types
• 99% efficacy in preventing
genital warts caused by the
targeted HPV types
In men (ages 16 to 26 years) not
previously exposed to the four HPV
types in the vaccine, there was 90%
vaccine efficacy in preventing genital
warts and 75% efficacy in preventing
anal precancers.
Most common adverse events
Syncope (fainting), injection site pain
and redness, dizziness, nausea,
headache. Itchiness at the injection
site and mild or moderate fever have
also been reported.
To reduce fainting, prescribing
information recommends that patients
remain seated for 15 minutes after
vaccination.
Other adverse events
Rates of serious adverse events similar
between placebo and treated groups
in clinical trials; vaccine-related
serious adverse events occurred in
0.1% of more than 29,000 female
and male participants.
Since 2006, 6% of all reports
described serious adverse events.
No current evidence suggests that
the HPV vaccine caused the adverse
events.
Hot Topics in Sexually Transmitted Infections and Associated Conditions
Syncope (fainting), injection site pain
and redness, dizziness, nausea,
headache.
To reduce fainting, prescribing
information recommends that patients
remain seated for 15 minutes after
vaccination.
Low rates of events in more than
30,000 females in clinical trials.
Rates of serious adverse events
similar between placebo and treated
groups in clinical trials; no subject
withdrawals due to serious adverse
events.
20
• The primary indication for males is prevention of penile and anal cancer.
• Immunization of men contributes to protection of women and male partners, although this is
not a formal indication for immunization.
• Brief education about HPV and the vaccine can increase acceptance rates.67
• Male latex condoms reduce but do not completely eliminate transmission; even with
consistent condom use, most sexually active men and women can expect to acquire one or
more anogenital HPV infections.68
• Screening and diagnosis
• HPV tests
• Available tests detect viral nucleic acid (DNA or RNA) or capsid protein.
• Tests are FDA approved for women only, for testing of cervical and vaginal
specimens.
• Age > 30 years undergoing cervical cancer screening
• Age > 21 years with ASC-US result on Pap test (Note: HPV reflex testing for
ASC-US is optional for women ages 21 to 24 years)
• HPV testing is not recommended for women ≤ 20 years of age, as a general test for
STIs, or to determine HPV status before vaccination.69
Table 13: FDA-Cleared Tests for High-Risk HPV
Test
Manufacturer
Aptima HPV
Hologic
Cervista HPV High-Risk
Hologic
Cobas HPV
Hybrid Capture II HighRisk HPV
Roche
Qiagen
Genotyping
If requested, subtyping for 16/18 and/or
45 can be added
If requested, Cervista HPV 16/18 can be
added
Includes subtyping for 16 and 18
Subtyping cannot be added
• Clinicians should know which tests are available at the laboratories from which they obtain
HPV testing and should understand the process for ordering genotyping when needed.
• Cytology
• Screening guidelines are available for specific guidance on the use of Pap tests,
colposcopy, and cervical biopsy and the management of abnormal cytology results
(see the algorithms at www.asccp.org/Portals/9/docs/Algorithms%207.30.13.pdf
• Important recent changes to screening recommendations:70
• HPV testing is no longer recommended in women 21 to 24 years old due to the
high prevalence of HPV infection and because management is based solely on
cytology or histology, regardless of HPV test result.
• The recommended age for an initial Pap test is 21, regardless of sexual history
and timing of sexual debut; this change will avoid the attendant harm of
overtreatment of abnormal cytology related to HPV infection in young women.
Hot Topics in Sexually Transmitted Infections and Associated Conditions
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• The recommended frequency of Pap testing is every three years as long as
results are normal.
• Alternatively, women ages 30 to 65 may be screened with cytology combined
with HPV (co-testing) every five years.
• Women with certain risk factors may need more frequent screening or to
continue screening beyond age 65.
• See guidance for specific details
www.asccp.org/Portals/9/docs/Algorithms%207.30.13.pdf.
• Evaluation for genital warts
• Visual examination, sometimes aided by a hand-held magnifier, usually is sufficient for
reliable diagnosis by experienced clinicians.
• Acetic acid (3–5 percent) to highlight HPV-infected tissues (acetowhitening) is
nonspecific, insensitive, and generally not recommended.
• Treatment and management
• HPV vaccines are among the most biologically effective of all vaccines, with nearly 100
percent efficacy in preventing infection with the types included in the vaccine; they have no
effect on established infection and no role in therapy.
• Treatment is not recommended for9
• Subclinical genital HPV infection whether diagnosed by colposcopy, acetic acid
application, or laboratory tests for HPV DNA
• Mild cytological or histological findings on Pap smear (ASC-US, LSIL) or cervical
biopsy (CIN1)
• For management of cervical cytology abnormalities, see the algorithms at
www.asccp.org/Portals/9/docs/Algorithms%207.30.13.pdf.
• For management of genital warts, see the following available treatments:
Hot Topics in Sexually Transmitted Infections and Associated Conditions
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Table 14: Available Treatments for Genital Warts*9
Medication
Provider administered (clinic based)
Patient applied (prescription)
Podofilox 0.5% solution or gel
Imiquimod 5% cream
Comments
Patient should apply to visible warts twice a day for 3 days,
followed by 4 days of no therapy; cycle can be repeated for
up to four cycles if needed. Safety during pregnancy has not
yet been established.
Patient should apply once daily at bedtime, three times a
week for up to 16 weeks. Treated area should be washed
with soap and water 6 to 10 hours after application.
May weaken condoms and diaphragms. Safety during
pregnancy has not yet been established.
Sinecatechins 15% ointment
Patient should apply three times daily for no longer than
16 weeks. When medication is on the skin, the patient
should avoid sexual contact. May weaken condoms and
diaphragms. Safety during pregnancy has not yet been
established.
Cryotherapy with liquid
Repeat applications every 1 to 2 weeks. Adequate
nitrogen or cryoprobe
training required, as over- and under-treatment can lead to
complications or low efficacy.
Podophyllin resin 10% to 25%
Apply to each wart and allow to dry before any contact with
in compound tincture of benzoin clothing; can be repeated weekly, if necessary. Application
should be limited to < 0.5 mL of podophyllin or an area
of < 10 cm2 of warts per session. Area treated should not
contain any open lesions or wounds. Instruct the patient to
thoroughly wash area 1 to 4 hours after application to reduce
local irritation. Safety during pregnancy has not yet been
established.
Bichloroacetic acid (BCA) 80% Apply a small amount only to the warts and allow area to
to 90%
dry before the patient sits or stands. If needed for pain, BCA
can be neutralized with soap or sodium bicarbonate. Can be
repeated weekly, if necessary.
Trichloroacetic acid (TCA) 80% Same comments as for BCA, plus
to 90%
TCA has a low viscosity and can spread rapidly to
surrounding areas if applied excessively.
Surgical removal with tangential For patients with a large number or area of warts. This usually
scissor excision, tangential
eliminates warts in one visit but requires substantial training,
shave excision, curettage, or
additional equipment, and longer office visit than other
electrosurgery
modalities.
*For specific guidance regarding the use of these therapies or for treatment of vaginal, cervical, anal, or urethral
meatus lesions, see CDC guidelines.
www.cdc.gov/mmwr/preview/mmwrhtml/rr5912a1.htm
• Treatment choice should be based on the preference of the patient, available resources,
and the experience of the provider with the different treatment regimens.
• Research has not shown any treatment to be superior to the others, and more than one
type of treatment may be required to eradicate warts.9
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Syphilis
• Key facts about infection
• Syphilis is caused by the spiral-shaped bacterium Treponema pallidum.
• The clinical course is divided into four stages, which may overlap.
Table 15: Four Stages of Syphilis9
Stage
Primary stage
Secondary stage
Neurosyphilis
Tertiary stage
Major Manifestations
Duration (Untreated)
Ulcer or chancre at infection site,
1–3 months
regional lymphadenopathy; onset
typically 2–4 weeks after exposure
Skin rash, mucocutaneous lesions,
1–12 months, sometimes recurrent
generalized lymphadenopathy; onset
typically 1–3 months after resolution of
primary stage
May occur at any stage: early (1–12
Months to years
months) usually meningovascular,
with meningitis, stroke, altered mental
status, cranial nerve deficits, and eye
involvement; late (1–30 years) may
include dementia, gait disturbances, and
death
Cardiac or gummatous lesions, typically
of the skin, bones, or liver
• Patients may also present without symptoms (i.e., diagnosed via serology), which is defined
as latent infection.
• Early syphilis refers to primary syphilis, secondary syphilis, and latent syphilis of less than 1
year’s duration.
• The incidence of infection is increasing among MSM, who now account for more than 70
percent of all cases; up to 4 percent of HIV-infected MSM acquire syphilis annually.13
• The risk of acquiring HIV is two to five times higher among individuals with syphilis
infection.71
• Screening and diagnosis
• Treponema pallidum cannot be cultured in the laboratory, which makes diagnostic testing
for syphilis challenging.
• Direct testing
• Includes dark-field microscopy examination and tests to detect T. pallidum in lesion
exudate or biopsied tissue.
• Direct testing is the main method for diagnosing syphilis with mucocutaneous lesions
(primary syphilis, occasional secondary syphilis).
Hot Topics in Sexually Transmitted Infections and Associated Conditions
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• Serologic testing
• Serologic testing can be used to make presumptive diagnosis, based on the detection
of antibodies to the bacterium.
• A newly positive serology is strong evidence for infection with syphilis. Thus, it is
helpful to know whether a patient has been tested previously and determine the results
of prior testing if possible.
• The use of two types of tests is necessary because each type has limitations, including
false positive results.
Table 16: Serologic Testing for Syphilis9
Test Type
Examples
Comments
Nontreponemal
tests
Rapid Plasma Reagin;
Sensitive but nonspecific (risk of false positive results);
Venereal Disease
all positives need confirmation by a treponemal test;
Research Laboratory test titer (strength of positive result) indicates disease
activity, declines with effective treatment and used to
follow success of therapy
Treponemal tests Fluorescent treponemal Once positive, usually remain positive for life and thus
antibody-absorbed test; cannot be used to assess treatment response; when
used for initial screening, follow-up testing should
T. pallidum particle
be performed by a nontreponemal test so treatment
agglutination assay and
response can be followed
others;
enzyme immunoassay;
chemiluminescence
immunoassays
• Treatment and management
• Penicillin is the preferred antibiotic for all stages of syphilis.9 The formulation and dose
depend on the stage and duration of infection and whether the central nervous system is
involved.
• For adults with early syphilis: benzathine penicillin G 2.4 million units IM in a single
dose.
• Alternative for severely penicillin-allergic patients: Doxycycline 100 mg orally twice
daily for 2 weeks.
• For treatment of other stages and of pregnant women, children, or individuals with
penicillin allergy, see CDC treatment guidelines.9
www.cdc.gov/mmwr/preview/mmwrhtml/rr5912a1.htm
Hot Topics in Sexually Transmitted Infections and Associated Conditions
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Trichomoniasis
• Key facts about infection
• It is caused by the protozoan Trichomonas vaginalis.
• It is one of the most common STIs in the United States, with an estimated 148,000 new
cases each year and a prevalence of about 500,000.2
• Typical symptoms in women include a diffuse, malodorous, yellow-green vaginal discharge
with vulvar irritation; however, infection is common.
• Men are generally asymptomatic but may have nongonococcal urethritis (NGU).
• Screening and diagnosis
• Women presenting with vaginal discharge should be tested for T. vaginalis.
• Asymptomatic women at high risk for infection should be considered for screening,
especially in pregnancy.
• Risk factors include9,72
• new or multiple sex partners
• current diagnosis of or suspicion of any STI
• history of transactional sex
• injection drug use
• African American race/ethnicity
• Oral infection and isolated rectal infection are rare; testing of extragenital sites is not
recommended.9,73
• Testing options for women include the following:
• NAATs are maximally sensitive and are the preferred method for both screening and
diagnostic testing. Two assays are currently available:
• Polymerase chain reaction (Amplicor, Roche)
• Transcription-mediated amplification (APTIMA T. vaginalis, Hologic Gen-Probe)
• Preferred samples: vaginal swab in women, urine in men
• Same-day or next-day result
• Culture
• Previously the gold standard; misses 20 to 30 percent of vaginal infections.
• Vaginal swab or fluid, very insensitive for male urine.
• Results take up to five days.
Hot Topics in Sexually Transmitted Infections and Associated Conditions
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• Saline microscopy (wet prep)
• Historically the most common test, but only 50 to 60 percent sensitive, that is,
misses half of all symptomatic infections in women and almost all asymptomatic
ones
• Useful for rapid diagnosis by clinicians (where microscopy is CLIA-approved)
• Not suitable for testing males
• POCT
• Antigen tests
• Example: OSOM (Sekisui Diagnostics), uses immunochromatographic
capillary flow dipstick technology
• Results available in about 10 minutes
• Nucleic acid probe tests
• Example: Affirm VP III (Becton Dickenson), simultaneously evaluates
for T. vaginalis, Gardnerella Vaginalis (an aid to diagnosis of BV), and
Candida albicans
• Results available in about 45 minutes
• Testing options for men include the following:
• No POCTs or NAATs are currently FDA approved for use in men.
• Wet prep and culture are currently the only approved testing modalities, but they miss
most infections.
• Thus, practically speaking, there are no tests available for men that are both sensitive
and cost-effective.
• Treatment and management
• Recommended regimens include the following:
Table 17: Recommended Regimens for the Treatment of Trichomoniasis9
Medication
Metronidazole
(Flagyl® and generics)
Tinidazole (Tindamax®)
Metronidazole
Tinidazole
Dosage and Duration
Comment
2 g orally, single dose
Approximate efficacy 90–95%
2 g orally, single dose
500 mg orally twice daily for 7
days
Approximate efficacy 86–100%
Improved efficacy for patients
who will comply with complete
regimen; preferred in HIV-infected
patients
500 mg orally twice daily for 5
days
Hot Topics in Sexually Transmitted Infections and Associated Conditions
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• Multidose regimens (i.e., 5–7 days) have superior efficacy compared with single-dose
regimens. Single-dose treatment is preferred if compliance with multiple dose therapy is
uncertain.74
• Patients should be advised to avoid the consumption of alcohol while taking either drug
and for 24 hours after completing metronidazole or 72 hours after completing tinidazole.
• Note that both drugs are nitroimidazoles and allergic cross-reactivity may exist; there is no
evidence that tinidazole can be safely used in patients with metroniadazole allergy.
• Intravaginal treatment (e.g., metronidazole gel) is unreliable and not recommended.
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Appendix: Additional Resources
• CDC 2010 STI Treatment Guidelines:
www.cdc.gov/std/treatment/2010/std-treatment-2010-rr5912.pdf
• ASCCP Guidelines:
www.asccp.org/ConsensusGuidelines/tabid/7436/Default.aspx
• U.S. Preventive Services Task Force:
www.uspreventiveservicestaskforce.org/recommendations.htm
• ARHP’s HPV QRG:
www.arhp.org/ManagingHPV
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Publication Information
Clinical Review Committee
Charlotte Gaydos, DrPH, MPH, MS
Johns Hopkins University School of
Medicine
H. Hunter Handsfield, MD
University of Washington Center for
AIDS and STD
Beth Kruse, MS, CNM, ARNP
Columbia Health Center, Public Health
Seattle & King County
Jeanne Marrazzo, MD, MPH, FACP, FIDSA
University of Washington
Contributing Staff/Consultants
Aleya Horn Kennedy, MPP
Association of Reproductive Health
Professionals Program Manager
Beth Jordan Mynett, MD
Association of Reproductive Health
Professionals Medical Director
Diane W. Shannon, MD, MPH
Consulting Medical Writer
Amy M. Swann, MA
Association of Reproductive Health
Professionals Vice President
Financial Disclosure Information
The following committee members and/or contributing staff have a financial interest or affiliation
with the manufacturers of commercial products possibly related to topics covered in this Quick
Reference Guide. These financial interests or affiliations are in the form of grants, research support,
speaker support, or other support. This support is noted to fully inform readers and should not have
an adverse impact on the information provided within this publication.
Gaydos:Speaker bureau for Hologic Inc., Becton Dickinson and Company, Abbott Laboratories, and
Cepheid; Research funds from Hologic Inc., Becton Dickinson and Company, Abbott Laboratories,
Cepheid, and Roche
Marrazzo:Research funds from Hologic Inc., Medicis, and Cepheid
Handsfield, Kruse, Shannon, Horn Kennedy, Jordan Mynett, Swann: Have no affiliations to disclose
.
This publication has been made possible by
educational grants from Hologic Inc. and Merck & Co., Inc.
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