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révention en pratique médicale MALADIES INFECTIEUSES We thought we had won the battle Bacterial STIs make a comeback! After decreasing progressively for years, STIs are making a strong comeback. This worrisome rebound requires an energetic and coordinated response: promote the adoption of safe sexual behaviours, recognise the presence of risk factors and perform appropriate screening tests, treat infected people without delay, evaluate and treat all their sexual partners without delay. Chlamydia Young women aged 15 to 19 years are still the most affected In Montreal, from 1990 to 1996, the number of reported cases of chlamydia decreased by 65%; from 1996 to 2001, there was a 75% increase in the number of cases reported every year. (Outside Montreal, in the rest of the province, there was a 45% increase STIs: the globalisation of STDs STIs are sexually transmitted diseases, renamed to match international nomenclature. STI stands for Sexually Transmitted Infections. It is more accurate to use the word “infection” rather than “disease” since not all people who are infected are sick. during the latter period.) Women continue to be the most affected (70% of all cases), especially women aged 15 to 24 years: the rate of incidence was 1488 cases per 100 000 among 15 to 19-year-old women and 1228 cases per 100 000 among those aged 20 to 24-year-old. These rates are 2 to 3 times higher than the targets set in Canada for the year 2000 for women in these age groups. Recent studies conducted by the Montreal Public Health Department have shown that the prevalence rate among street youth is 6.6% (prevalence is significantly higher among women with a history of pregnancy than in those without such a history: 10.4% versus 3.6%), and 3.8% among people consulting in various types of clinics (CLSCs, private clinics, etc.) (prevalence is significantly higher among women with a history of abortion than in those without such a history: 5.1% versus 2.7%). continued on page 4 “STIs make a comeback” Number of cases of STI, Montreal region, 1990-2001 Diseases 4544 2495 1718 1832 2066 2598 2990 Chlamydia 1209 306 350 308 Gonorrhea 381 443 559 32 6 Infectious syphilis 1990 August 2002 4 1 3 6 11 1996 1997 1998 1999 2000 2001 1 Infections with severe consequences The probability of developing pelvic inflammatory disease (PID) following C. trachomatis or N. gonorrhoeae endocervical infection is about 20% to 25%, whereas the probability of having chronic pelvic pain, an ectopic pregnancy, or tubal infertility after untreated PID is 15%, 5%, and 15% respectively (the probability of tubal infertility could be as high as 60%, depending on the number of episodes of PID). For syphilis, it is estimated that 30% of those untreated will develop latent syphilis (cardiovascular, neurological or ophthalmic lesions, or gumma which can affect any organ). It was already known that the human papilloma virus (HPV) contributes to the development of squamous cell cancer of the cervix. Recent studies have demonstrated that infection from C. trachomatis can act as a co-factor, increasing the risk of cancer associated with HPV infection. Interaction with HIV infection Ulcerative (e.g.: syphilis, chancroid, herpes) and inflammatory STIs (e.g.: gonorrhea, chlamydia) are factors of HIV transmission. The presence of these STIs may enhance infectiousness in people with HIV and increase susceptibility to HIV infection in those who are HIV negative. Moreover, having HIV infection alters the evolution of syphilis, and can result in atypical presentation and early signs of neurological disease. Screening Currently we do not know enough to define, for each STI, all the specific contexts in which systematic screening is appropriate. However, we believe that people in the following risk groups should be offered screening tests. People who have had unprotected sex with someone in one of these groups should also undergo the same tests as the person in the group itself. A pregnant women who has a risk factor or whose partner has a risk factor should have the three tests listed in the table below. Of course, sexual partners of known cases of STI should be evaluated and tested (including newborns with a parent who has an STI or who is at risk). Openly discuss the presence of risk factors with each patient Bacterial STIs to test for, based on identified risk factors (for guidance) PEOPLE AT RISK AND THEIR SEXUAL PARTNERS STI TO TEST FOR Chlamydia Someone < 25 years who has had a new sexual partner in the last two months Someone < 25 years who has had more than 2 sexual partners in the last year Someone < 25 years who has contracted an STI in the last year Street youth Woman asking for an abortion Someone with multiple sex partners Man who has sex with men Hard drug user, whether injection drug or not Someone who has had sexual relations with a new partner who has recently been to ✔ a country where STI and HIV are highly endemic Gonorrhea Syphilis ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ STI and HIV are highly endemic ✔ ✔ ✔ Sex worker Someone who asks to be tested, even if he or she has no risk factors ✔ ✔ ✔ ✔ ✔ ✔ Someone who has had sexual relations with a partner from a country where Source: Adapted from: “Canadian STD Guidelines”, 1998 Edition, Health Canada, “Sexually Transmitted Diseases Treatment Guidelines ”, 2002 edition, Centers for Disease Control, USA, and “Recommandations de dépistage des MTS”, Comité MTS, MSSS, 2000. Chlamydia and gonorrhea Note that systematic testing for chlamydia among all sexually active youth under the age of 25 is not recommended (it could be recommended in particular clinical contexts, for example in a youth clinic where prevalence of the infection is unusually high). The same recommentation applies to gonorrhea. We recommend that you wait for 3 weeks after the end of any antibiotic treatment before taking a sample. In men, it is important to wait one hour between last urination and taking a urethral specimen. In women, a sample taken from the endocervix can be done even when the woman is menstruating, if bleeding is not too abundant. When testing for gonorrhea, it is important to obtain pharyngeal and rectal specimens, if these sites might have been exposed, even if the person is asymptomatic. Waiting a few days between the time of sexual contact at risk and the time when the specimen is taken increases the probability of detecting a germ, thus avoiding a false-negative result. Few data are available on this subject. It is not necessary to adhere to this time frame if the person is symptomatic or if he or she may be exposed to an STI regularly. Syphilis Since transmission can occur by simple oral-genital contact without penis-rectum or penis-vagina penetration, and since a person often develops atypical and transitory symptoms, you may not readily suspect syphilis. It is important to offer the test to all individuals who have a risk factor. During recent outbreaks, a high proportion of men who have sex with men (MSM) who had infectious syphilis also had HIV infection. Therefore, we recommend offering an HIV test to MSM who have infectious syphilis. 2 In some people with HIV infection, a syphilis serology is difficult to interpret because of abnormally high, low, or fluctuating titres, or a false “non reactive” test. Frequency of tests The frequency for repeating screening tests has not been established. People with repeated STI or who have multiple sex partners could be evaluated regularly, every 3 to 6 months, for example. Prévention en pratique médicale, August 2002 Tests Nucleic Acid Amplification Testing (NAAT) Screening for C. trachomatis Over the last few years, most laboratories in Montreal hospitals have been offering Chlamydia trachomatis (CT) screening by nucleic acid amplication test using the PCR (polymerase chain reaction) method. Other NAAT methods are also available, such as LCR (ligase chain reaction) or TMA (transcript mediated assay). best choice. A urinary sample test should only be considered when taking a genital specimen is not praticable or unacceptable to the patient and could be an obstacle to testing. The urine test is especially pertinent for men, who are more reluctant to being tested. The anus and throat cannot be tested using the NAAT; the only appropriate test is a cell culture. Increased sensitivity and specificity The sensitivity (proportion of infected people identified through testing) and specificity (proportion of uninfected people identified through testing as noninfected) of NAAT in detecting CT are higher than for antigen detection tests such as direct immunofluorescence (DIF) and enzyme immunoassay (EIA). Test Chlamydia Genital EIA Genital PCR Urinary PCR Sensitivity % Men Women 60.0 65.1 99.1 96.5 94.4 95.1 Procedures for obtaining a urine specimen The patient must not have urinated for 2 hours before obtaining a urine specimen. The patient collects the first 10 mL of urine. The urine is refrigerated (between 2oC and 8oC); if need be, the specimen can remain at room temperature for a maximum of 24 hours. Specificity % Men Women 75-95 95.9 98.5 99.4 100.0 99.8 Screening for N. gonorrhoeae Gonorrhea may also be detected by a genital or urine specimen using NAAT. When using NAAT instead of a culture (with sensitivities), it is impossible to establish an antibiotic resistance profile for the strain of N. gonorrhoeae. Testing a urine sample for N. gonorrhoeae using NAAT is especially advantageous when screening people at risk of infection who are reached outside usual clinical settings (sauna or bath houses, prisons...). Possibility of analysing a urine sample NAAT can be used not only to test genital secretions (cervix in women, urethra in both men and women) but also urinary specimens. However, for complete evaluation, a genital and pelvic examination and genital specimen are still the Treatment Treatment of choice Alternatives Doxycycline 100 mg PO BID X 7 days Azithromycin 1g PO in 1 dose or Ofloxacin 300 mg PO BID X 7 days Azithromycin 1g PO in 1 dose Ceftriaxone 125 mg IM in 1 dose Cefixime 400 mg PO in 1 dose or or Ciprofloxacin 500 mg PO in 1 dose Plus chlamydia treatment Ceftriaxone 125 mg IM in 1 dose Plus chlamydia treatment Primary, secondary, and latent syphilis (less than a year)(2) – adolescents and adults Benzathine penicillin G 2.4 million UI IM in 1 dose Amoxicillin 500 mg PO TID X 7 days or Gonorrhea – adolescents and adults - Urethral, endocervical, pharyngeal, rectal infection Cefixime 400 mg PO in 1 dose (1) Plus chlamydia treatment Pregnant or breastfeeding woman Chlamydia – adolescents and adults - Urethral, endocervical, rectal infection If allergic to penicillin: Doxycycline 100 mg PO BID X 14 days Benzathine penicillin G If allergy to penicillin: desensitization Latent syphilis of more than a year(2) – adolescents and adults Benzathine penicillin G 2.4 million UI IM/week X 3 doses If allergic to penicillin: Doxycycline 100 mg PO BID X 28 days Benzathine penicillin G If allergy to penicillin: desensitization (1) Cefixime and ceftriaxone should not be administered to people allergic to cephalosporin or who have ever had an immediate or anaphylactic reaction to penicillin. (2) People with HIV may require treatment for a longer period of time and/or higher doses of medication. Source: Adapted from: “Canadian STD Guidelines”, 1998 edition, Health Canada, and “Sexually Transmitted Diseases Treatment Guidelines”, 2002 edition, Centers for Disease Control, USA. Up to 25% of cases of gonorrhea reported in Montreal in 2001-2002 were treated with fluoroquinolone (ciprofloxacin or ofloxacin) although the treatment of choice is cefixime. Post-treatment follow-up test Usually, a test is not repeated when following-up on treatment for urethral or endocervical CT or NG infection. However, we recommend repeating the test when compliance with treatment is difficult to verify or when the prescribed treatment is not optimal Prévention en pratique médicale, August 2002 3 (e.g.: if cefixime or ceftriaxone is not used, or when treating a gonococcal infection) and if the patient is a child or a pregnant woman, or if there is a history of treatment failure. However, all cases of syphilis must be closely followed after treatment, especially people with HIV. “STIs make a comeback” continued from page 1 Gonorrhea Back after a 20-year decline In Montreal, the annual number of cases of gonorrhea among men has increased by 120% since the lowest levels were attained in 1996. (In the rest of the province, the number rose by 65% during the same period.) Although a large increase has also been observed among women, men continue to make up the majority of cases by far; in fact among reported cases, the proportion of men has grown from 75% in 1996 to 85% in 2001. Among men, the proportion of men having sex with men (MSM) has climbed from 53% in 1996 to 66% in 2001. Of the cases reported in 2001, most of the men were 25 to 39-year-old whereas most women were aged 20 to 24-year-old; almost 80% are French-Canadian; just over 5% reported using hard drugs; and 7% had given or received money in exchange for sex. Strains of fluoroquinolone-resistant N. gonorrhoeae In Montreal in 1994, a strain showing reduced sensitivity to ciprofloxacine was isolated for the first time. Subsequently, 1 to 4 strains were identified every year. In 2001, 15 were discovered. The continuous activity of floroquinolone-resistant gonococcal infections highlights the importance of prescribing cefixime as the treatment of choice for gonococcal disease. Infectious syphilis Outbreak in the gay community The annual number of reported cases of infectious syphilis (SPC) in Montreal had been decreasing over the last several years; the rate declined from 32 in 1990 to 1 in 1998. However, between 11 September 2000 and 31 July 2001, a total of 15 cases of infectious syphilis, 14 men and 1 woman, were reported. Among the men, 12 (85.7%) were men who have sex with men (MSM); the average age of these MSM was 39 years, 8 (66.6%) were French-Canadians, 6 (50.0%) said they had had sex with partners living outside Québec, and 6 (50.0%) had had sex in saunas with anonymous partners. None reported having taken hard drugs or having given or received money in exchange for sex. As of 2 July 2002, there were 9 cases of infectious syphilis in 2002, all in MSM, an indication that the trend is continuing. In Québec, outside Montreal, 4 cases of infectious syphilis were reported in 2001 and 4 in 2002 (as of 2 July). From 2000 to 2001 in New York City, the number of cases more than doubled, and 50% of cases were among MSM. Regional service for the supply Vaccination against hepatitis of benzathine penicillin G Hepatitis B vaccination should be offered to for the treatment of syphilis people presenting an STI and those at risk of At this time, benzathine penicillin G is available only through the Special Access Programme (SAP) at Health Canada’s Therapeutic Products Directorate. To make it easier to have access to benzathine penicillin G through the SAP, the Montreal Health Department has set up a regional service to supply the medication. To order doses from the Public Health Department, contact (514) 528-2400, extension 3887 during regular working hours. Delivery takes 2 to 24 hours, depending on the time at which the Public Health Department receives the order. Medication and delivery are free. When placing your order, you should have the following information on hand: indication for the medication, and the patient’s initials, date of birth and sex. being exposed to an STI. Free vaccination in Montreal In Montreal, hepatitis B vaccination is free for people who have contracted gonorrhea or infectious syphilis and their sexual partners, and for all people aged 18 years and under. Moreover, hepatitis A and B vaccination is free for specific populations including MSM, people who use injection drugs, and street youth. Partner Notification Service, Public Health Department For doctors who wish to refer a patient: 528-2400, extension 3840 For Patients and their partners: 528-2464 (direct, confidential telephone line) Prescribe condoms! A person usually goes through different stages before adopting new behaviours and condom use is no exception. Physicians can help their patients by developing a helping relationship and a one of trust: create or strengthen the need for your patient to use condoms, discuss the patient’s risk factors that support or obstruct this behaviour, encourage the patient to start changing gradually, using solutions that suit him or her, support and monitor the efforts required to maintain this behaviour. Condoms are not effective if they are not used properly! The spermicide nonoxynol-9 can increase the risk of HIV transmission through mucosal irritation. If condoms are used for HIV and STI prevention, they should be those without nonoxynol-9 www.santepub-mtl.qc.ca révention en pratique médicale a twice-monthly column on the Web 4 The #9-STI fact sheets (August 2002) included with this bulletin are an up-date of the #9-STD fact sheets (February 2000) from the "Prévention en pratique médicale" binder. révention en pratique médicale A publication of the Direction de santé publique de Montréal-Centre in collaboration with the Association des médecins omnipraticiens de Montréal, as part of the Prévention en pratique médicale programme coordinated by Doctor Jean Cloutier. This issue is produced by the Infectious Disease Unit Head of the unit: Dr. John Carsley Editor-in-chief: Dr. Monique Letellier Editor: Blaise Lefebvre Graphic designer: Paul Cloutier Translator: Sylvie Gauthier Texts by: Dr. Gilles Lambert Dr. Marc Steben Contributors: Dr. Jean-Pierre Villeneuve Dr. Mark A. Miller Dr. Jean Vincelette 1301 Sherbrooke East, Montreal, Québec H2L 1M3 Telephone: (514) 528-2400, fax: (514) 528-2452 http://www.santepub-mtl.qc.ca email: [email protected] Legal deposit – 3rd trimester 2002 Bibliothèque nationale du Québec National Library of Canada ISSN: 1481-3734 Agreement number: 40005583 Association des Médecins Omnipraticiens de Montréal Prévention en pratique médicale, August 2002 STIs révention Sexually Transmitted Infections en pratique médicale Notification of partners The infection rate is high among the partners (men or women) of individuals suffering from a sexually transmitted infection. Many of these partners remain asymptomatic. At least 30% to 35% of all sexual partners are unaware that they have been exposed to the infection: • 5% of regular partners, • 30% of occasional partners, • up to 60% of casual partners. The notification of sexual partners is the process through which all sexual partners, not just the regular partner, are promptly identified, located, assessed, treated and advised on prevention measures in order to reduce the risk of sequellae among the partners and avoid spreading the infection in the community. The medical treatment of an STI includes the notification of the partners. Notification must be discussed at the time of the first medical evaluation 1. Provide the patient with complete information on the STI and explain that it is relevant and necessary to inform the partners. 2. Establish with the patient a list of all sexual partners to be contacted, bearing in mind the STI’s incubation and contagious periods. 3. Discuss ways of notifying the partners. • If the patient wishes to personally notify the partners, discuss how he will do so. Present possible problems and solutions. Suggest to the patient that a third party such as a friend, a physician or a public health professional be present when a partner is informed. If • the patient does not wish to personally notify the partners, suggest that a third party such as a physician, a nurse or a public health professional notify the partners without revealing the patient’s identity. Collect the information needed to retrace the partners that the patient refuses to contact and in respect of whom he agrees to have a third party intervene: name, sex, address, telephone numbers (home and work), date and type of exposure, age or date of birth, place of work or study. 4. Ensure follow-up. Set a deadline within which the patient promises to notify his partners. Notification should take place promptly, ideally within 48 hours. Plan a follow-up telephone call or visit. It is useful to make note of at least the partners’ first names in order to ascertain whether the patient has indeed taken the necessary steps to notify each one of them. Provide special assistance when notification occurs in the following situations When the index case: • • • • • • • had two or more partners during the infection period is reluctant to personally inform certain of his partners fears violence or reprisals is suffering from pelvic inflammatory disease has suffered from STIs repeatedly or has undergone several abortions has been exposed through sexual abuse is under 20 years of age and suffering from a chlamydial infection. When the partner: • • • • • • is a casual or occasional partner appears to play a key role in the transmission process or appears to be the source of the patient’s infection also has several partners is hard to locate is likely to be unaware of the exposure is pregnant. When the infection is: • • • • • • • a contagious syphilis a gonococcal infection (especially if the strain is resistant to quinolone) a chancroid a venereal lymphogranuloma an inguinal granuloma an HIV infection a chlamydial infection in someone less than 20 years old. Notification is recommended even in the case of a clinical syndrome that is compatible with an STI: a clinical diagnosis of pelvic inflammatory disease, urethritis, mucopurulent cervicitis or proctitis made when samples cannot be taken or test results are negative. Direction de santé publique de Montréal-Centre August 2002 ISSN: 1481-3742 9 STIs Dealing with sexual partners* Partners to be contacted ** STI Chlamydial infections or compatible syndromes, including pelvic inflammatory disease Gonococcal infections or compatible syndromes, including pelvic inflammatory disease Hepatitis A Fecal-oral transmission frequent among men who have sexual relations with men Hepatitis B • All sexual partners : • • - during the 60 previous days prior to the appearance of symptoms or, if the patient is asymptomatic, before the diagnosis was made - up to the seventh day after adequate treatment was effected. In the absence of a partner during this period, go back to the most recent partner. In the case of an infected newborn, assess the mother and her sexual partners. • All sexual partners : • • - during the 60 previous days prior to the appearance of symptoms or, if the patient is asymptomatic, before the diagnosis was made - up to the seventh day after adequate treatment was effected. In the absence of a partner during this period, go back to the most recent partner. In the case of an infected newborn, assess the mother and her sexual partners. • All sexual partners during the two weeks preceding and the week following either jaundice or the acute phase of the illness. Clinical procedures *** Preventive measures • Clinical evaluation including samples. • Treatment even if the analysis • Patient and partners should abstain • Clinical evaluation including samples. • Treatment for gonococcal infection and • Patient and partners should abstain • Clinical evaluation. • Serology if necessary (AntiHAV-IgM). • Immunization as quickly as possible with: • Wash hands frequently. • Monitor the appearance of symptoms • Depending on whether the cases are acute • Never share syringes, needles, razors or toothbrushes. • During the six months following of the samples is negative. for chlamydial infection even if the analysis of the samples is negative. from sexual relations or use a condom until seven days after the end of the treatment. from sexual relations or use a condom until seven days after the end of the treatment. among food handlers or day-care workers. - Hepatitis A vaccine within 7 days of the last infectious contact (add immunoglobulin (IG) if immunodeficient). - IG only if between 7 and 14 days of last infectious contact. • • Acute cases: - All sexual partners during the six months preceding the appearance of symptoms. Chronic cases: - All regular or current sexual partners - All sexual partners since the likely time of infection. or chronic and the partners regular or new: - serology (HBsAg and anti-HBs) at 0 and six months - vaccination against hepatitis B - administration of specific hepatitis B immune globulin (HBIG) if contact less than 14 days. the last exposure: - abstain from sex or use a condom - do not breast feed or donate blood, sperm or organs - discuss risks if pregnancy is considered. Herpes simplex • All current or regular sexual partners. from sex during symptomatic • Risk of transmission especially to newborn • Abstain periods of index case. if primary infection occurred during pregnancy. • Use a condom between symptomatic phases. • Explanation of possible contagiosity Syphilis • All sexual partners during the period • Clinical and serological assessment: (VDRL and TP-PA). • Preventive treatment of all partners during asymptomatic phase. specific to each stage of development: - Primary syphilis: 3 months ➤ - Secondary syphilis: 6 months Contagious phase - Early latent syphilis: 1 year ➤ - Late latent syphilis: assess spouse or longstanding partners and children - Congenital syphilis: examine the mother and sexual partners. Both parents of infected newborns. Trichomoniasis • • All sexual partners during HIV • • Abstain from sex or use a condom until cured. of contagious syphilis cases: - during the past 90 days even if the serology is negative - over 90 days if follow-up is uncertain or the results are not available quickly. • Abstain from sex or use a condom • Clinical microscopy. • Treatment of symptomatic or asymptomatic until cured. the 60 previous days. sexual partners even if results are negative. All current and previous sexual partners since the likely time of infection determined according to the history of exposure and the clinical evaluation. • Clinical and serological evaluation (anti-HIV) • Human papilloma virus (HPV) • All current or regular sexual partners. at time 0, then at three, and if need be, six months after the last exposure because of variable delays in seroconversion (diagnostic window). Pre-and post-test counselling. • Simple visual examination. • Cytology of the cervix for women when it goes back more than one year. • Treatment solely of macroscopic lesions. • Never share syringes, needles, razors or toothbrushes. • During the six months following the last exposure: - abstain from sex or use a condom - do not breast feed or donate blood, sperm or organs - discuss risks if pregnancy is considered. • Use of condom recommended with new or occasional partners (variable protection depending on location of lesions). ***Depending on the history, sampling for STIs other than that of the index case may be recommended. * Only factors concerning sexual partners have been incorporated into this table.The physician may have to take into account other exposed individuals, e.g. the newborn child of a mother - Vaccination against hepatitis B is recommended for anyone with an STI and all of the individual’s sexual infected by HBV. partners. It is free of charge for cases of gonorrhea and syphilis in the contagious stage and for their partners, regardless of age. ** Depending on the exposure history of the index case, the reference period could be broadened in respect of the inclusion of partners to be contacted. - Vaccination against hepatitis A and B is recommended and is free of charge for all men who have sexual relations with other men, injection drug users, street youths and chronic carriers of HCV. Association des Médecins Omnipraticiens de Montréal STIs esources Sexually Transmitted Infections Direction de santé publique de Montréal-Centre: (514) 528-2400 1. Notification of partners - NoPa STIs/HIV Specialized regional support service pertaining to the notification of the partners of individuals suffering from STIs or HIV infection. Confidentiality is assured. (514) 528-2400, ext. 3840 • Service for physicians wishing to refer patients (514) 528-2464 (direct, confidential line) • Direct service for patients and their partners 2. Reporting of STIs by the physician (compulsory reportable diseases) STIs should be reported promptly by telephone at (514) 528-2400, ext. 3840, by mail, or through the fax line devoted to reportable diseases at (514) 528-2461. Confidentiality is assured. Use the appropriate form or a copy of the laboratory report, as the case may be, for the following infections: • gonococcal infection • inguinal granuloma syphilis • • venereal lymphogranuloma • chancroid • Chlamydia trachomatis infection viral hepatitis A and B • • HIV (The Laboratoire de santé publique du Québec will directly contact the physician) 3. Epidemiological data The Epidemiological Surveillance Bureau (Bureau de surveillance épidémiologique) is responsible for receiving, verifying, compiling, analysing and archiving reports on reportable diseases. To obtain epidemiological data, call (514) 528-2400, ext. 3858 or visit the Web site of the Direction de santé publique: http://www.santepub-mtl.qc.ca, infectious diseases section. For physicians who prefer to refer their patients Clinics - Adapted from a list distributed by the Centre québécois de coordination sur le sida Name Address Clinique 30 St-Joseph Clinique médicale des Jeunes St-Denis Clinique médicale l’Alternative Clinique médicale 1851 Clinique médicale GLR Clinique médicale l’Actuel Clinique médicale La Cité Clinique médicale de l’Ouest Clinique médicale du Quartier Latin Head and Hands Inc. Telephone (514) 30, boul. St-Joseph Est, local 100, Montréal (Québec) H2T 1G9 CLSC des Faubourgs, 1250, rue Sanguinet, 3e étage, Montréal (Québec) H2X 3E7 2034, rue St-Hubert, Montréal (Québec) H2L 3Z5 1851, rue Sherbrooke Est, bureau 101, Montréal (Québec) H2K 4L5 3545, chemin de la Côte-des-Neiges, bureau 023, Montréal (Québec) H3H 1V1 1001, boul. de Maisonneuve Est, bureau 1130, Montréal (Québec) H2L 4P9 300, rue Léo Pariseau, bureau 900, case postale 933, Place du Parc, Montréal (Québec) H2W 2N1 4647, rue Verdun,Verdun (Québec) H4G 1M7 905, boul. René-Lévesque Est, Montréal (Québec) H2L 5B1 2304, avenue Old Orchard, Montréal (Québec) H4A 3A8 845-4240 844-9333 281-9848 524-7564 935-1197 524-1001 281-1722 765-3600 285-5500 481-0277 CLSC - Refer patients to youth or family medicine clinics EAST (514) Montréal-Est/PAT 642-4050 Rivière des Prairies 494-4924 Montréal-Nord 327-0400 Mercier-Est/Anjou 356-2572 Olivier-Guimond 255-2365 Saint-Léonard 328-3460 Saint-Michel 374-8223 De Rosemont 524-3541 Hochelaga-Maisonneuve 253-2181 CENTRE Plateau Mont-Royal Saint-Louis du Parc Des Faubourgs Métro Côte-des-Neiges René-Cassin NDG/Mtl-Ouest (514) 521-7663 286-9657 527-2361 934-0354 731-8531 488-9163 485-1670 Hospitals - Refer patients to family medicine clinics Direction de santé publique de Montréal-Centre August 2002 ISSN: 1481-3742 WEST Pierrefonds Lac Saint-Louis du Vieux La Chine (514) 626-2572 697-4110 639-0650 SOUTHWEST Saint-Henri Pointe Saint-Charles Verdun/Côte St-Paul LaSalle 933-7541 937-9251 766-0546 364-2572 NORTH Ahuntsic Parc Extension La Petite Patrie Villeray Bordeaux-Cartierville Saint-Laurent (514) 381-4221 273-9591 273-4508 376-4141 331-2572 748-6381 9 STIs Community services ACTION SÉRO-ZÉRO • Prevention and intervention aimed at men who have sexual relations with other men STELLA • • • • • • Prevention and intervention aimed at women working in the sex industry:moral support,referrals,and so on (514) 285-8889 GAP-VIES CRISS RUBAN EN ROUTE (514) 521-7665 Prevention, support and intervention aimed at the Caribbean and African Communities (non restrictive) (514) 722-5655 Centre de Ressources et Intervention en Santé et Sexualité : Prevention, support and intervention for women living with HIV Prevention and management of STIs Individual, couple, and group counselling (condylomas and herpes) (514) 855-8991 (514) 725-6425 Telephone support lines STI • Support and information line dealing with condylomas, herpes and other STIs GAI-ÉCOUTE • Free telephone service offering information and resources for gays, lesbians and bisexuals INFO-SIDA • • Service of CPAVIH (Comité des Personnes Atteintes du VIH - People living with HIV) Referral line, help line and info (514) 855-8995 1-888-505-1010 (no charge) (514) 521-7432 1-866-521-7432 (regions) Documentation • • Canadian STD Guidelines, 1998, Health Canada, Health Protection Branch, Laboratory Centre for Disease Control (LCDC). Highlights of the Canadian STD Guidelines, 1998, Health Canada, Health Protection Branch, Laboratory Centre for Disease Control (LCDC). Summary of Canadian guidelines concerning the most frequent STIs. Both documents are available free of charge to physicians. To obtain a copy, call (514) 528-2400, ext. 3953 (Direction de santé publique de Montréal-Centre). Both publications are also available at the following Web address: http://www.hc-sc.gc.ca/hpb/lcdc/bah • • Sexually Transmitted Diseases, Holmes K.K., Mardh P.E. et al. McGraw Hill, 3rd ed., 1999. • Canadian Immunization Guide, 6th ed., 2002, Health Canada, Population and Public Health Branch, Centre for Infectious Disease Prevention and Control. Publication: Canadian Medical Association, (613) 731-8610, ext. 2307. Protocole d’immunisation du Québec, 1999 and updates, MSSS, Direction générale de santé publique. Distribution: Direction de santé publique de Montréal-Centre, (514) 528-2400, ext. 3863. Québec program, administered by RAMQ, to provide free drugs to treat sexually transmitted infections Under this program, anyone covered by the Québec health insurance plan and suffering from a bacterial STI (chlamydial infections, gonococcal infections, syphilis, inguinal granuloma, chancroid and venereal lymphogranuloma) and the individual’s partners can obtain drugs free of charge from private pharmacies. The physician must write out a prescription for each patient, using his own prescription form (it is not necessary to use a special form). In addition to the usual information, the physician must note one of two codes used in the free-drug program, depending on the situation: • • Code K : Treatment of individuals suffering from STIs Code L : Treatment of the partners of individuals suffering from STIs Association des Médecins Omnipraticiens de Montréal