Download Prevention of genital herpes

Management and Prevention of
Viral Sexually Transmitted
Infections
Dr Wassim Chehadeh
Associate Professor
Herpes simplex virus
Prevention of genital herpes
 Herpes sores can be spread to other parts of the body by touching an open sore
and then an uninfected region. This can be particularly problematic in areas such as
the eyes which are highly sensitive.
 HSV shedding is increased in HIV-infected persons.
 Prevention of host-to-host transmission is achieved by simple hygiene, but this is
only partially effective because:
- The virus is often excreted before the appearance of overt symptoms
- Silent recurrent infections also occur.
 Condoms can reduce the chance of contracting herpes, but since the infection
can settle outside the area covered by condoms, they are not perfect protection.
 If one partner has open sores, he or she should abstain from sexual contact
 Male circumcision is partially protective against genital herpes (but not among
MSMs)
Treatment of genital herpes
 Antiviral medication can reduce the frequency of outbreaks and
the risk of transmission. There is no cure.
 Antiviral medication can also reduce the severity and duration of
symptoms.
 There are three major drugs commonly used to treat genital
herpes symptoms: acyclovir (Zovirax), famciclovir (Famvir), and
valacyclovir (Valtrex). These are all taken in pill form. Valacyclovir
and famciclovir have enhanced absorption after oral
administration.
 Severe cases may be treated with the intravenous (IV) drug
acyclovir.
 Formulas applied to the surface of the skin provide little benefit.
Treatment of genital herpes
 Initial treatment
- First diagnosed with genital herpes,
- Brief course (seven to 10 days) of antiviral therapy to relieve
sores or prevent them from getting worse.
 Intermittent treatment (Episodic therapy)
- To keep on hand in case another flare-up.
- For 2-5 days as soon as sores are noticed
- Make the symptoms less severe.
- Useful in shortening the duration of recurrent episodes.
Treatment of genital herpes
 Suppressive treatment
- For someone who has more than six outbreaks a year (recurrent genital
herpes).
- The antiviral drug is taken every day.
- Suppressive therapy can reduce the frequency of recurrences by 70% to
80%.
- Many people who take the antiviral drugs daily have no outbreaks at all.
- Suppressive antiviral therapy does not reduce the increased risk for HIV
acquisition associated with HSV-2 infection
 Management of Sex Partners
- Symptomatic sex partners should be evaluated and treated in the same
manner as patients who have genital lesions.
- Asymptomatic sex partners of patients who have genital herpes should be
questioned concerning histories of genital lesions and offered type-specific
serologic testing for HSV infection.
Human Papillomavirus
Prevention of genital warts and cervical cancers
Human Papillomavirus (HPV)
 More than 100 types of HPV exist, more than 40 of which can
infect the genital area.
 Most HPV infections are asymptomatic, unrecognized, or
subclinical.
 Women are recommended to start cervical screening with
Pap tests after 3 years of initiating sexual activity (and
repeated at 2-year intervals)
 Among women aged ≥30 years with normal Pap tests and
negative tests for high-risk HPV types, the screening interval
can be increased to 3 years.
 HPV tests are recommended for women aged ≥21 years who
have abnormal Pap test results.
Prevention of genital warts and cervical cancers
Human Papillomavirus (HPV)
 Two HPV vaccines are licensed in the United States:
- A bivalent vaccine (Cervarix) containing HPV types 16 and
18: protection against the HPV types that cause 70% of
cervical cancer
- A quadrivalent vaccine (Gardasil) vaccine containing HPV
types 6, 11, 16, and 18: protection against the HPV types that
cause 70% of cervical cancers (i.e., types 16 and 18), and
the quadrivalent HPV vaccine also protects against the types
that cause 90% of genital warts (i.e., types 6 and 11).
Prevention of genital warts and cervical cancers
 HPV vaccine is indicated for girls aged 13–26 years before
the onset of sexual activity.
 The quadrivalent (Gardasil) HPV vaccine can also be used in
males aged 9–26 years to prevent genital warts.
 Both HPV vaccines are administered as a 3-dose series of IM
injections over a 6-month period, with the second and third
doses given 1–2 and then 6 months after the first dose.
Prevention of genital warts and cervical cancers
 Women who have received HPV vaccine should continue
routine cervical cancer screening because 30% of cervical
cancers are caused by HPV types other than 16 or 18.
 Male circumcision is partially protective against genital HPV
infection since genital warts occur commonly under the
foreskin of the uncircumcised penis, but also on the shaft of
the circumcised penis.
 Male condom use might lower the chances of giving or
getting genital HPV, but such use is not fully protective,
because HPV can infect areas that are not covered by a
condom.
Treatment of genital warts
Recommended Regimens for External Genital Warts
Patient-Applied:
Podofilox 0.5% solution or gel
OR
Imiquimod 5% cream
OR
Sinecatechins 15% ointment
Provider–Administered:
Cryotherapy with liquid nitrogen or cryoprobe. Repeat applications every
1–2 weeks.
OR
Podophyllin resin 10%–25% in a compound tincture of benzoin
OR
Trichloroacetic acid (TCA) or Bichloroacetic acid (BCA) 80%–90%
OR
Surgical removal either by tangential scissor excision, tangential shave
excision, curettage, or electrosurgery.
Molluscum contagiosum virus
Prevention of Genital Molluscum Contagiosum
 The best way to avoid getting molluscum is by following good hygiene
habits:
-
Do not touch, pick, or scratch any skin with bumps or blisters
-
Wash your hands
-
Do not share towels, clothing, or other personal items.
-
Avoid sexual activities
-
To prevent the spread of molluscum to other areas of your body or to
other people, it is important to keep every blister or bump covered either
with clothing or with a watertight bandage.
-
Condoms can prevent molluscum spreading when bumps are located
only on the genital regions
Treatment of Molluscum Contagiosum
Molluscum bumps usually will disappear without treatment in 6 to 12 months
and not leave scars, but it may not go away completely for up to 4 years.
Treatment is recommended for bumps that are in the genital area.
Treatment Options in the Health Care Setting
-
Cryotherapy (freezing the molluscum growth),
Curettage (remove the fluid inside the bumps),
Lasers also can remove molluscum bumps.
Both curettage and cryotherapy methods may leave scars.
Treatment Options in the Home Setting
Creams (i.e., imiquimod, salicylic acid, podophyllin, tretinoin, Cantharidin)
HBV
Prevention of Sexually Transmitted HBV infection
• HBV is more infectious and relatively more stable in the
environment than other bloodborne pathogens like HCV and
HIV.
• The primary risk factors associated with infection among
adolescents and adults are unprotected sex with an infected
partner, unprotected sex with more than one partner, MSM,
history of other STDs, and illegal injection-drug use.
• Vaccination of previously unvaccinated children and
adolescents through age 18 years, and vaccination of
previously unvaccinated adults at increased risk for infection
(e.g., persons with more than one sex partner in the previous
6 months, MSM, and IDUs).
Prevention of Sexually Transmitted HBV infection
• In adolescents and healthy adults aged <40 years,
approximately 30%–55% acquire a protective antibody
response (anti-HBs ≥10 mIU/mL) after the first vaccine dose,
75% after the second, and >90% after the third. Vaccineinduced immune memory has been demonstrated to persist
for at least 15–20 years.
• Sex partners of HBsAg-positive persons should be
counseled to use latex condoms to protect themselves from
sexual exposure to infectious body fluids (e.g., semen and
vaginal secretions), unless they have been demonstrated to
be immune after vaccination (anti-HBs ≥10 mIU/mL) or
previously infected (anti-HBc positive).
Prevention of Sexually Transmitted HBV infection
HBsAg-positive persons also should be advised to:
- Use methods (e.g., condoms) to protect nonimmune sex
partners from acquiring HBV infection from sexual activity until
the partner can be vaccinated and immunity documented;
- Cover cuts and skin lesions to prevent spread by infectious
secretions or blood;
- Refrain from sharing household articles (e.g.,
toothbrushes, razors, or personal injection equipment) that
could become contaminated with blood.
Hepatitis C Virus
Prevention of sexually transmitted HCV infection
• Because incident HCV has not been demonstrated to occur in
heterosexual partner-pairs followed over time , condom use might not
be necessary in such circumstances.
• However, heterosexual and homosexual persons, especially those with
concurrent HIV infection or with more than one partner, should
protect themselves and their partners against transmission of HCV,
HBV, HIV, and other pathogens by use of male latex condoms.
• To reduce the risk for transmission to others, HCV-positive persons
should be advised to:
1) not donate blood, body organs, other tissue, or semen;
2) not share any personal items that might have blood on them (e.g.,
toothbrushes and razors); and
3) cover cuts and sores on the skin to keep the virus from spreading by
blood or secretions.
HIV
Prevention of HIV transmission
• A reliable way to avoid transmission of HIV is to abstain from oral,
vaginal, and anal sex or to be in a long-term, mutually monogamous
relationship with an uninfected partner.
• Male latex condoms are highly effective in preventing the sexual
transmission of HIV infection: HIV-negative partners were 80% less
likely to become HIV-infected compared with persons in similar
relationships in which condoms were not used.
• Female condom is an effective mechanical barrier to viruses,
including HIV, and to semen.
• Topical microbicides and spermicides have failed to show a
protective effect against HIV acquisition.
Prevention of HIV transmission
• Use of tenofovir gel during sexual intercourse significantly reduced
the rate of HIV acquisition (i.e., by 39%) in a study of South African
women
• Women who use hormonal contraception or cervical diaphragm, or
have intrauterine devices (IUDs), or have been surgically sterilized,
are not protected against sexually transmitted HIV infection.
• Male circumcision reduced the risk for HIV acquisition among
heterosexual men by 50%–60%.
• Male circumcision has not been demonstrated to reduce the risk for
HIV or other STDs among MSM.
• Genital hygiene methods (e.g., vaginal washing and douching) after
sexual exposure are ineffective in protecting against HIV and STD
Sexual Assault and HIV
• In USA, 13% of a national sample of adult women reported having
ever been raped (60% before age 18), and 5% reported having been
raped more than once.
• In consensual sex, the risk for HIV transmission from vaginal
intercourse is 0.1%–0.2% and for receptive rectal intercourse, 0.5%–
3%.
• Specific circumstances of an assault (e.g., bleeding, which often
accompanies trauma) might increase risk for HIV transmission
• The necessity of early initiation of Post-Exposure prophylaxis
(PEP) to optimize potential benefits (i.e., as soon as possible after
and up to 72 hours after the assault)
• A 28-day course of HAART is recommended:
- Efavirenz in combination with lamivudine/zidovudine (Combivir) or
tenofovir/emtricitabine (Truvada)
- lopinavir/ritonavir (Kaletra) and zidovudine with either lamivudine or
emtricitabine.