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Sexual Assault and Domestic Violence Services
Sexually Transmitted Infections/HIV Update
Wendy Goodine, PHC-NP, SANE
Jennifer Keeler, PHC-NP, SANE
March 27, 2009
Objectives:
Review the normal versus abnormal findings
Review common sexually transmitted infections (STIs)
Review the 2008 updates to the Canadian Guidelines on
STIs
Review the 2008 updates to the HIV post exposure
prophylaxis (PEP)
Assessment:
Assessment of the male and female GU systems during initial examination or during
follow-up appointments to screen for STIs may demonstrate a wide range of normal
and abnormal variations.
Nurses working in clinics need to recognize abnormal findings that may or may not
be related to the sexual assault and offer the patient recommendations for follow-up
for further assessment and treatment.
According to the Canadian Guidelines (2008) there has been a steady increase in
the three reportable STIs – chlamydia, gonorrhea, and infectious syphilis in Canada,
the US and the UK.
Possible explanations for this increase include:
Introduction of the nucleic acid amplification tests (NAATs).
Safe-sex burn-out.
Innovations in HIV therapy leading to treatment optimism and increased risk
taking.
Earlier age of sexual activity with a high rate of serially monogamous
relationships.
Assessment:
The SANE must keep the significance of this increased rate of disease
when seeing patients in the clinics in regards to:
Burden of disease.
Potential complications associated with STIs.
Examples include:
Pre-existing ulcers or inflammation from infections such as syphilis
chancre, herpes ulcers can increase risk of acquiring and transmitting
HIV.
Untreated infections in women such as chlamydia and gonorrhea can
lead to pelvic inflammatory disease, chronic pelvic pain, ectopic
pregnancy and infertility.
Persistent human papillomavirus (HPV) plays an important role in the
development of cervical dysplasia and carcinoma.
Variations of Normal:
The SANE must be aware of the variations that are possible in both the
male and female GU exam.
There must also be a sensitivity to the possible anxiety that variations
both normal and abnormal can cause in patients seen in the sexual
assault clinics.
There are many normal variations of the female cervix and the male
penis and the SANE will often need to differentiate between normal vs.
abnormal during the clinical exam.
External Genital Lesions: Cancer of the Vulva
Symptoms and Signs:
Pigmented lesions.
Bleeding.
Persistent ulceration.
Persistent pruritus.
Recalcitrant lesions.
Vaginal Discharge:
Sexual
Transmission
•Bacterial Vaginosis
•Candidiasis
•Trichomoniasis
•Not usually
•Not usually
•Yes
Predisposing
Factors
Often absent
More common if sexually active
New sexual partner
Intrauterine device use
Symptoms
Vaginal discharge
Fishy odour
50% asymptomatic
Signs
White or grey, thin, copious
discharge
Often absent
More common if sexually
active
Current or recent antibiotic
use
Pregnancy
Corticosteroids
Poorly controlled diabetes
immunocompromised
Vaginal discharge
Itch
External dysuria
Superficial dyspareunia
Up to 20% asymptomatic
White, clumpy, curdy
discharge
Erythema and edema of
vaginal and vulva
Multiple partners
Vaginal discharge
Itch dysuria
10-50% asymptomatic
Off-white or yellow frothy
discharge
Erythema of vulva and
cervix (“strawberry cervix”)
Epidemiology of STIs in Canada:
Infection
How common in clinical practice
Trends in incidence
Most affected
Chlamydia
Most commonly diagnosed and
reported.
Cases reported (preliminary data):
2002: 56 241
2006: 65 000
Steadily increasing since
1997
Young women:
15-24 years of age
Young men:
20-29 years of age
Gonorrhea
Second most commonly diagnosed
and reported.
Cases reported:
2002: 7 367
2006: 10 808
From 1997 – 2004:
94% increase
Quinolone resistance has
increased from :
1992 - <1%
2005 - 15.7%
2006 - 28%
Males:
2/3 of reported cases
Increase in MSM
Young men:
20-29 years of age
Young women:
15-24 years of age
Infectious
Syphilis
Previously rare.
Cases reported (preliminary data):
2002: 463
2006: 1 493
National increase since
1997.
MSM (both HIV + and -):
30-39 years of age
Sex workers and their
clients.
Acquisition in endemic
regions.
Regional outbreaks in
Canada.
Epidemiology of STIs in Canada:
Infection
How Common in Practice
Trends in Incidence
Most affected
Human
Papillomavirus
Very common:
70% of adult population will
have had at least one genial
HPV infection over their
lifetime.
Not reportable:
True incidence not
known.
All ages
Male and female
High prevalence in
adolescents and
young adult both
sexes.
Genital Herpes
(HSV 1 and 2)
Common
Not reportable:
True incidence not
known
Seroprevalence
studies indicate rates
of at least 20%.
Adolescents and adult
women and men,
Women are more
affected then men.
Epidemiology of STIs in Canada:
Infection
How Common in Practice
Trends in Incidence
Most affected
HIV
Rare in general practice:
2 529 cases reported in 2004.
Reportable.
2000-2004: 20% rise in
HIV+ test reports in
Canada.
MSM
Acquisition in endemic
areas.
Injection drug users.
Young women: 15-19
years of age.
Hepatitis B
In Canada:
Approximately 700 acute cases per
year
Reportable
Acute infection twice as
high for men than women.
Infants born to HBsAG +
mothers.
Injection drug users who
share equipment
Multiple sex partners
Acquisition in endemic
regions.
Sexual and household
contacts of acute or
chronic carrier.
Updated STI Statistics: Toronto Public Health
Unpublished data - December 2008
Chlamydia:
Up 5% compared to 2007.
Biggest increase is from September – December.
Gonorrhea:
Decreased 7% compared to 2007.
HIV:
Decreased 3% compared to 2007.
Infectious Syphilis:
Increased 12% - to 310 cases.
June – October were the highest months.
Common Normal and Abnormal Findings on
Genitourinary Examination
Cervicitis:
Signs and Symptoms:
Mucopurulent cervical discharge.
Cervical friability.
Vaginal discharge.
Strawberry cervix.
Possible causes:
Niesseria gonorrhoea (incubation period: 2-7 days).
Chlamydia trachomatis (incubation period: 2-3 weeks but up to 6
weeks).
Trichomonas vaginalis (incubation period: 4-28 days).
Majority sexual contacts however occasional contact by fomites.
Herpes simplex virus (incubation period: average is 6 days).
60% asymptomatic.
40% symptomatic (80% with typical genital symptoms and 20%.
atypical, including cervicitis).
Gonorrhea: Manifestations in Youth and Adults
Females
Males
Females and Males
Cervicitis
Urethritis
Pharyngeal infection
Pelvic Inflammatory
Epididymitis
Conjunctivitis
Disease
Urethritis
Perihepatitis
Bartholinitis
Proctitis
Disseminated gonococcal
infections: arthritis,
dermatitis, endocarditis,
meningitis
Disseminated Gonococcal Infections (DGI)
1 -2 % of mucosal infections will progress to DGI.
Gonorrhea enters bloodstream and is disseminated.
More common in women.
Gonorrhea often asymptomatic therefore DGI occurs before
symptoms.
Often seen shortly after menses.
Symptoms:
Arthritis dermatitis: painful macular-papular to pustular lesions, often
with hemorrhagic component of rash and nails.
Migratory polyarthralgia: knees, elbows, distal joints of fingers and
toes.
Fever: usually < then 39 degrees Celsius.
If left untreated can lead to septic arthritis (often knee), gonococcal
meningitis and endocarditis.
Diagnosis of Gonoccol Infections:
Culture of secretions on selective media is gold standard.
Urethral specimens from males: sensitivity and specificity of
95%
Endocervical specimens from adult females: sensitivity of 4565% and specificity of 90%.
Nucleic acid amplification tests (NAAT) - PCR, AC2, SDA,
GenProbe, BDProbetec:
Tests on secretions or urine
Highly sensitive and specific
Permits dual testing for chlamydia.
Generally not indicated for test of cure as may remain (+) for
at least 2-3 weeks after effective treatment.
Treatment for Gonococcal Infections:
Co-infection with Chlamydia trachomatis is common.
Treat for chlamydia unless negative test confirmed.
Due to the rapid increase in quinolone resistant Neisseria gonorrhoeae,
quinolones such as ciprofloxacin and ofloxacin are no longer preferred drugs for
the treatment in Canada.
Urethral, endocervical, rectal, pharyngeal infection (except pregnant or nursing women):
Preferred
Alternatives
Cefixime 400mg PO in a single dose
No if cephalosporin or penicillin
allergy.
Ceftriaxone 125mg IM in a single dose
No if cephalosporin or penicillin allergy
Or
Azithromycin 2g PO in a single dose
Associated with a significant incidence of GI adverse
effects – take with food or anti-emetic may help.
Or
Spectinomycin 2g IM in a single dose
Not effective for pharyngeal infection.
Chlamydia Infections:
Females
Males
Symptoms and Signs:
Often asymptomatic
Cervicitis
Vaginal discharge
Dysuria
Lower abdominal pain
Abnormal vaginal bleeding
Dyspareunia
Conjunctivitis
Proctitis (commonly asymptomatic)
Symptoms and Signs:
Often asymptomatic
Urethral discharge
Urethritis
Urethral itch
Dysuria
Testicular pain
Conjunctivitis
Proctitis (commonly asymptomatic)
Major sequelae
Pelvic inflammatory disease
Ectopic pregnancy
Infertility
Chronic pelvic pain
Reiter syndrome
Major sequelae
Epidiymo-orchitis
Reiter syndrome
Diagnosis of Chlamydia Infections:
Culture:
Preferred method for medico-legal purposes.
Culture of infected site which contains epithelial cells, not discharge.
Excellent specificity.
Low sensitivity (40-70%).
Currently, only culture is recommended for throat specimens.
NAATS:
Are the most sensitive and specific and should be used whenever
possible for urine, urethral and cervical specimens.
Blood and mucous can affect performance (increase false negatives).
Both C. trachomatis and N. gonorrhoeae can be detected from a
single specimen.
Serology is not useful in diagnosing acute infection.
Culture is recommended for pharyngeal swabs.
Epididymitis: Inflammation of the Epididymis
Usually acute onset of unilateral testicular pain and swelling.
Often with tenderness of the epididymis and vas deferens.
Occasionally with erythema and edema of the overlying skin.
May also have urethral discharge, hydrocele, erythema and/or
edema of the scrotum, fever.
Men < 35 years: 2/3 are secondary to STIs
47% Chlamydia trachomatis, 20% Neisseria gonorrhoeae
Predisposing factors: sexually transmitted urethritis
Men > 35 years: 75% of cases attributed to coliforms or
pseudomonas.
Predisposing factors: underlying structural pathology of
chronic bacterial prostatitis.
Treatment of Chlamydia Infections:
Empirical co-treatment if N. Gonorrhea is diagnosed due to the high probability of
co-infection (20-42%)
Adults (non-pregnant and non-lactating): urethral, endocervical, rectal, conjunctival
infection:
Preferred
Alternative
Doxycycline 100mg PO bid for 7 days
Or
Azithromycin 1g PO in a single dose if
poor compliance expected.
Ofloxacin 300mg PO bid for 7 days
Or
Erythromycin 2g/day PO in divided doses
for 7 days
Or
Erythromycin 1g/day PO individed doses
for 14 days
If used test of cure should be performed
3-4 weeks after completion.
External Genital Lesions: Human Papillomavirus
(HPV) Infections
One of the most common STIs
Infections are often acquired early (15-19 years of age)
Majority (>80%) of these infections clear spontaneously within 18 months.
Over 130 HPV types:
40 of them can infect the ano-genital epithelium
Infection with one HPV genotype does not protect against infection with
other types.
Most common:
6 and 11 – cause external warts
16 and 18 - associated with precancerous or cancerous cervical lesions.
Incubation period is 1 - 8 months
The average time from acquiring high risk genotype HPV to the detection of
cervical cancer is 20 years
Hepatitis B
Most common cause of sexually transmitted hepatitis.
Incubation period:
Percutaneous exposure: days
Mucous membranes: 4-8 weeks
Risk factors:
Injection drug use: 34%
Multiple heterosexual sex partners: 24%
Men who have sex with men: 7.3%
Sex with HBV-infected individuals: 12%
Hepatitis B carrier in family: 2.4%
Hepatitis B: Post Exposure Prophylaxis
NO treatment if Hepatitis B series completed.
If not immunized or status unknown:
Start Hepatitis B vaccine series.
National Advisory Committee on Immunization preferred
schedule is 0, 1, and 6 months.
Hepatitis B Immune Globulin (Human) – (HBIG)
Single dose of HBIG (0.06ml/kg) within 14 days of sexual
contact.
Recommend begin the hepatitis B vaccine series
concurrently with the HBIG.
Administration of vaccine with HBIG may improve the
efficacy of post-exposure treatment.
Serologic Markers for Hepatitis B
Stage
HBsAg
HBeAg
Anti-HBc
IgM
Anti-HBc
IgG/total
Hepatitis B
Viral DNA
Anti HBs
Acute
(early)
+
+
+
+
+
-
Acute
(resolving)
+
-
+
+
-
-
Chronic
+
+/-
-
+
+/-
-
Resolved
-
-
-
+
-
+/-*
Vaccinated
-
-
-
-
-
+*
anti-HBc=antibody to hepatitis B core antigen
anti-HBs=antibody to hepatitis B surface antigen
HBeAg=hepatitis B early antigen
HBsAg=hepatitis B surface antigen
*is some patients, anti-HBs may decline over time and become undetectable
Human Immunodeficiency Virus (HIV):
A retrovirus that causes acquired immunodeficiency syndrome (AIDS).
Different from many other viral diseases
Infects, disables and destroys cells (CD4+ T lymphocytes) of the
immune system that would ordinarily control this virus.
Chronic, progressive illness that leaves infected people
susceptible to opportunistic infections and cancers.
Classified as types 1 and 2
HIV-1 principally responsible for the global pandemic.
HIV replicates rapidly
Several billion new virus particles may be produced every day.
Makes many mistakes while copying DNA resulting in different strains
or mutations.
Without treatment a person usually develops AIDS within 10 years.
HIV:
Men who have sex with men represent the largest number and proportion.
Heterosexual exposure has now surpassed injection drug use as the second
largest exposure category.
Increase proportion of persons migrating to Canada from HIV endemic
countries.
Women:
Over 25% of the HIV (+) reports in Canada were women compared with 10%
prior to 1995.
Highest group aged 15-19 years.
Nearly 50% of Aboriginal peoples were women compared with 20% of
Caucasian.
Canadians of African ancestry:
Heterosexual exposure accounts for more than 80% of HIV (+) test
50% are women.
Believed that 30% of people with HIV infection are unaware of their HIV status.
HIV Laboratory Diagnosis:
Must have informed consent
Nature of the test with pre and post test counselling.
3 main tests:
HIV antibody test:
Shows whether a person has been infected with HIV.
Also known as ELISA (Enzyme-Linked Immunosorbent Assay) tests.
(+) test requires confirmatory testing (Western blot) using the same specimen.
Antigen test:
Early in infection P24 is produced in excess and can be detected in serum.
Once HIV established in the body it will fade to undetectable levels.
Detect HIV earlier than standard antibody tests.
Some modern tests combine P24 with antibody identification to enable earlier and
more accurate.
PCR tests:
come in two forms: DNA PCR and RNA PCR.
Babies born to HIV positive mothers are usually tested using a DNA PCR because
they retain their mother's antibodies for several months (antibody test inaccurate).
Blood supplies in most developed countries are screened for HIV using an RNA PCR
test, which can produce positive results several days before a DNA test.
PCR tests are not often used to test for HIV in adults, as they are very expensive and
more complicated to administer than a standard antibody or P24 test.
HIV Laboratory Diagnosis:
Point-of-care rapid tests for HIV antibodies are
available.
All (+) tests require a confirmatory test such as
Western blot analysis.
Negative tests do not require repeat tests.
Most people develop detectable HIV antibodies within
6-12 weeks of infection.
Rare cases may take up to 6 months.
HIV Treatment:
Highly active retroviral treatment therapy (HAART) has been effective in
reducing the viral load.
HIV levels remain suppressed and the CD4 count remain greater than
200
Quality of life can be improved and prolonged.
Women are more likely to develop AIDS and die at higher CD4 counts
than men
Decision to start HAART must take into account the gender of the
patient
Initial physiologic events after HIV exposure suggests that it can take
several days for infection to become established in the lymphoid and
other tissues.
During this time interruption in viral replication could be possible to
prevent the exposure from becoming an established infection.
HIV Post Exposure Prophylaxis (PEP):
Because of the highly mutating nature of the HIV a
combination of antiviral drugs is recommended to
attack the virus at different points in its life cycle to
prevent development of drug resistance.
HIV PEP 28 day course of antiviral drugs
Optimally started within an hour of being exposed,
no longer than 72 hours.
Ontario Network HIV PEP Programme:
The overall scope of the HIV PEP program remains the same as that of
the HIV PEP Study which is: “to universally counsel on HIV risk and to
offer HIV PEP medications to all clients at-risk of HIV.”
Here are the core elements of the program:
All clients receive counselling about potential HIV risks
All clients at any risk of HIV infection are offered HIV PEP
HIV PEP begins within 72 hours of exposure
HIV PEP is taken for a period of 28 days
For those who choose HIV PEP, an intensive follow-up schedule is in
place to assist them to cope with side effects and complete the
treatment
HIV PEP is provided at no cost to clients
HIV PEP: Combivir
Combivir = zidovudine (300mg) and lamivudine (150mg) 1 tablet
twice a day:
Contains 2 Reverse Transcriptase Inhibitor.
Works by blocking the conversion of RNA into DNA.
Well tolerated with main side effects being headache, nausea and
fatigue.
Serious side effect – anemia.
Contraindicated;
Patients who have taken myleosuppressive or hemotoxic.
drugs within 2 weeks of starting HIV PEP.
History of bone marrow insufficiency or severe anemia.
And/or acute pancreatitis..
HIV PEP: Kaletra
Kaletra = lopinavir (200mg) and ritonavir (50mg) 2
tablets twice a day:
1 protease inhibitor (prevents viral replication of
HIV-1 protease).
With ritonavir to boost the level of the drug and
maximise its efficacy.
Well tolerated with main side effect – diarrhea.
Contraindicated:
Acute or advanced liver failure.
Drug Interactions and Contraindications:
Combivir and Kaletra
Both have possible drug interactions and
contraindications that must be identified, monitored
and altered if necessary.
Per Incident Probabilities of HIV Transmission:
Number and Prevalence of 18 year and older
HIV (+) Residents in Ontario (2006):
Insert graph
Revised list of all HIV Endemic Countries:
THANK YOU
For more information contact:
Jennifer Keeler/ Wendy Goodine
100 Queensway West
Mississauga, L5B 1B8
Phone: 905 848 7580 x.2548
Email: [email protected]/ [email protected]
References:
AIDS.org. (2003). Educating – Raising Awareness – Building Community.
Retrieved http://www.aids.org/factsheets.html
Bayer Corporation. (March 2002). Hepatitis B Immune Globulin (Human)BayHepB Product Monograph / product insert.
Canadian AIDS Society (June, 2005). HIV Transmission: Guidelines for
Assessing Risk. Canada: Canadian AIDS Society, 5th Edition.
Cleghorn, F., Reitz, M., Popovic, M. & Gallo, R. (2005). Human
Immunodeficiency Viruses. In Mandell, G., Dolin, R., & Bennett, J. (Eds).
Mandell, Douglas, and Bennett’s Principles and Practice of Infectious
Diseases, 6th Edition (pp. 2119-2131.). U.S.A.: Elsevier Inc
Drezett J. Post-exposure prophylaxis in raped women. In: IV International
Conference on HIV infection in women and children. Rio de Janeiro: Livro
de Resumos. Universidade, Federal do Rio De Janeiro e Institute of
Virology of Maryland; 2002.
Health Canada (2005). HIV/AIDS EPI Updates, Surveillance and Risk
Assessment Division. http://www.hcsc.qc.ca/english/diseases/aids.html
References:
Joint United Nations Programme on HIV/AIDS (2004). 2004 report
on the global AIDS epidemic. Switzerland: WHO Library
Cataloging-in-Publication data
Kaede V., Jamieson, F., Fisman D., K. Jones , Tamari I, Lai-King N.,
Towns, L., Prasad P., Di Prima, A., Wong, T. Richardson, S.
(2009). Prevalence of and risk factors for quinolone-resistant
Neisseria gonorrhoeae infection in Ontario, CMAJ, 180(3).
National Institute of Health, U.S. Department of Health and Human
Services (2004). HIV Infection in Women.
http://health.yahoo.com/centers/hiv_aids/712
Ontario Network of Sexual Assault/ Domestic Violence Treatment
Centres -HIV PEP program (Updated 2008). Retrieved from
http://www.satcontario.com
Public Health Agency of Canada (2008). Canadian Guidelines of
Sexually Transmitted Infections available at:
www.publichealth.gc.ca/sti
References:
Public Health Agency of Canada (2006). Canadian Immunization
Guide, 7th Edition; Ottawa, Canada.
Rote, N. (2002). Infection and Alterations in Immunity and
Inflammation. In McCance, K. & Huether, S. (Eds).
Pathophysiology The Biologic Basis for Disease in Adults &
Children, 4th Edition (pp.227-271). Missouri: Mosby.
Sterling, T., Vlahov, D., Astemborski, J. & Hoover, D. (2001). Initial
plasma HIV-1 RNA levels and progression to AIDS in women and
men. The New England Journal of Medicine. 344 (10), 720.
Wang SA, Panlilio AL, Doi PA, White AD, Stek M Jr, Saah A; HIV
PEP Registry Group. Experience of healthcare workers taking
postexposure prophylaxis after occupational HIV exposures:
findings of the HIV Postexposure Prophylaxis Registry. Infect
Control Hosp Epidemiol 2000;21:780--5.
Photography References:
Public health slides:
http://www.phac-aspc.gc.ca/slm-maa/slides/other/index-eng.php
Genital warts slides:
http://www.health-science-report.com/alotek/topics3/article19
STI pictures:
http://depts.washington.edu/nnptc/online_training/std_handbook/gall
ery/index.html
Cervix Photos:
http://www.gfmer.ch/Books/Cervical_cancer_modules/Unaided_visua
l_inspection_atlas.htm