Common Sexually Transmitted Diseases (STDs) and HIV-Infected Women

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Common Sexually Transmitted Diseases (STDs) and
HIV-Infected Women
October 2007
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• This slide set was developed by members of the
  Cervical
• Cancer Screening Subgroup of the AETC Women's
  Health
• and Wellness Workgroup
• Laura Armas, MD Texas/Oklahoma AETC
• Kathy Hendricks, RN, MSN François-Xavier Bagnoud
  Center
• Supriya Modey, MBBS, MPH AETC National Resource
  Center
• Andrea Norberg, MS, RN AETC National Resource
  Center
• Peter Oates, RN, MSN, ACRN, NP-C François-Xavier
  Bagnoud Center
• Jamie Steiger, MPH AETC National Resource Center
• Other subgroup members and contributors include
• Abigail Davis, MS, ANP, WHNP Mountain Plains
  AETC
• Lori DeLorenzo, MSN, RN Organizational Ideas
• Rebecca Fry, MSN, APN François-Xavier Bagnoud
  Center
• Pamela Rothpletz-Puglia, EdD, RD François-Xavier
  Bagnoud Center
• Jacki Witt, JD, MSN, WHNP Clinical Training
  Center for Family Planning

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Learning Objectives

1. Identify the five most common STDs affecting
   HIV-infected women
2. Discuss clinical presentations associated with
   the five common STDs
3. Recall methods for diagnosing the five common STDs

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Common STDs in HIV-Infected Women

1. Herpes Simplex Virus (HSV)
2. Syphilis
3. Chlamydia
4. Gonorrhea
5. Trichomoniasis

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• Herpes Simplex Virus (HSV)

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HSV Clinical Presentation

• Primary Infection
• Prodrome phase Tingling/itching of skin
• Appearance of painful vesicles in clusters on an
  erythematous base
• Vesicles ulcerate then crust over and heal within
  7-14 days
• Viral shedding continues for up to 2-3 weeks

• Recurrent Disease
• After primary infection, virus migrates to sacral
  ganglion and lies dormant
• Reactivation occurs due to various triggers
• Reoccurrence is usually milder and shorter in
  duration

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Herpes Simplex in Women with AIDS
Credit Jean R. Anderson, MD
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HSV Diagnosis

• Clinical presentation
• Viral culture
• Tzanck smear/Giemsa smear
• Skin biopsy

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HSV Treatment Considerations

• Antivirals
• Lesions may be bathed in mild soap and water
• Sitz baths may provide some relief
• Sex partners may benefit from evaluation and
  counseling
• Transmission is possible when lesions not present
  due to viral shedding

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• Syphilis

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Syphilis Clinical Presentation

• Primary / Infectious / Early Syphilis Stage
• Primary Phase
• Primary chancre
• Begins as papule and erodes into painless ulcer
  with a hard edge and clean base
• Usually in the genital area
• Appears 9-90 days after exposure
• Can be solitary or multiple (eg. kissing lesions)
• Heals with scarring in 3-6 weeks and 75 of
  patients show no further symptoms

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Primary Chancre
Primary Chancre
Credit Centers for Disease Control and
Prevention (CDC)
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Syphilis Clinical Presentation (continued)

• Primary / Infectious / Early Syphilis Stage
• Secondary Phase
• Occurs 6 weeks 6 months after chancre
• Lasts several weeks
• Accompanied with fever, malaise, generalized
  lymphadenopathy, and patchy alopecia
• Maculo-papular rash usually on palms and soles
• Condyloma lata on perianal or vulval areas
• Possible mild hepatosplenomegaly

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Syphilitic Rash
Credit Dr. Gavin Hart and CDC
Credit Connie Celum and Walter Stamn and Seattle
STD/HIV Prevention Training Center
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Condyloma lata
Condyloma lata
Credit CDC
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Syphilis Clinical Presentation (continued)

• Secondary / Latent Stage
• Positive serology
• Rapid Plasma Reagin (RPR)
• Venereal Disease Research Lab (VDRL)
• Patients are asymptomatic and not infectious
  after first year, but may relapse
• One-third will convert to sero-negative status
• One-third will stay sero-positive but
  asymptomatic
• One-third will develop tertiary syphilis

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Syphilis Clinical Presentation (continued)

• Tertiary Stage
• Cardiovascular Aortic valve disease, aneurysms
• Neurological Meningitis, encephalitis, tabes
  dorsalis, dementia
• Gumma formation Deep cutaneous granulomatous
  pockets
• Orthopedic Charcots joints, osteomyelitis
• Renal Membranous Glomerulonephritis

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Syphilis Diagnosis

• Requires demonstration of
• Organisms on microscopy using dark field
• Positive serology on blood or cerebrospinal fluid
  (CSF)
• Non-Specific Treponemal Tests
• 1. Venereal Disease Research Laboratory
• (VDRL)
• 2. Rapid Plasma Reagin (RPR)

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Syphilis Diagnosis (continued)

• Positive serology on blood or CSF
• Specific Treponemal Test
• 1. Fluorescent Treponemal Antibody Absorption
• (FTA-ABS)
• 2. Microhemagglutination-Treponema pallidum
  (MHA-TP)
• Organism may not be cultured but diagnosis cannot
  be determined by clinical findings only

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Syphilis Treatment Considerations

• Primary/ secondary/ latent stage Benzathine
  penicillin
• Neurosyphilis Penicillin G
• Ask about penicillin allergy before treatment
• Jarisch-Herxheimer reaction may occur

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• Chlamydia

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Chlamydia Clinical Presentation

• Mucopurulent cervicitis/vaginal discharge
• Dysuria
• Lower abdominal pain
• Urethritis, salpingitis, and proctitis
• Post coital bleeding friable cervix

• Key Considerations
• 50 of females are asymptomatic
• Sterile pyuria with urinary tract symptoms
  should
• trigger you to think chlamydia

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Cervicitis
Credit University of Washington and Seattle
STD/HIV Prevention Training Center
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Chlamydia Diagnosis

• Chlamydia culture
• New tests include
• Direct immunofluorescence assays (DFA)
• Enzyme immunoassay (EIA)

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Chlamydia Treatment Considerations

• Antibiotics
• Azithromycin
• Evaluate and treat sexual partners
• Avoid sex for seven days after completion of
  treatment

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• Gonorrhea

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N. gonorrhoeae-gram negative diplococci
Diplococci
Credit Negusse Ocbamichael and Seattle STD/HIV
Prevention Training Center
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Gonorrhea Clinical Presentation

• Areas of Infection
• Urethra
• Endocervix
• Upper genital tract
• Pharynx
• Rectum

• Signs and Symptoms
• Frequently asymptomatic
• Vaginal discharge
• Abnormal uterine bleeding
• Dysuria
• Mucopurulent cervicitis
• Lower abdominal pain

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Gonorrhea Diagnosis

• Clinical exam
• Cervical culture
• Polymerase chain reaction (PCR) or ligase chain
  reaction (LCR)
• Gram stainpolymorphonucleocytes with gram
  negative intracellular diplococci

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Gonococcal Isolate Surveillance Project (GISP)
Percent of Neisseria gonorrhoeae isolates with
resistance or intermediate resistance to
ciprofloxacin, 19902005
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Gonorrhea Treatment Considerations

• Intramuscular Ceftriaxone
• For pregnant women only
• Ceftriaxone single dose but substitute Quinolones
  with Erythromycin
• Do not treat with Quinolones or Tetracyclines
• Evaluate and treat all sexual partners

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• Trichomoniasis

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Trichomoniasis Clinical Presentation

• Signs and symptoms
• Vulvar irritation
• Dysuria
• Dyspareunia
• Pale yellow, malodorous - gray/green frothy
  discharge
• Strawberry cervix, inflamed and friable

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Strawberry Cervix
Credit Claire E. Stevens and Seattle STD/HIV
Prevention Training Center
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Trichomoniasis Diagnosis

• Flagellated, motile trichomonads on wet mount
• Vaginal pH gt 4.5
• Diagnosis confirmed by microscopy
• Other FDA approved tests
• OSOM Trichomonas Rapid Test
• Affirm VP III

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Trichomoniasis Treatment Considerations

• For HIV-infected women same treatment as non-HIV
  infected women
• Metronidazole or Tinidazole
• Sex partners have to be treated

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Providing Culturally Competent Care

• The following factors can influence a womans
  understanding of STDs and need for screening
• Language and literacy level
• Cultural and social background and its impact
  on her
• understanding of health, illness, and the
  female anatomy
• Comfort with discussing sexual health issues
• Comfort and previous experience with STD
  screening or testing
• History of sexual abuse and/or domestic
  violence may cause anxiety and exam refusal

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Pearls of Wisdom

• Get comfortable with obtaining a thorough sexual
  history
• Check oral cavity if genital STD suspected
• Minimum of annual screening for STDs is
  recommended, with more frequent screening if high
  risk behaviors are reported
• Partner notification and risk reduction
  counseling for both patient and partner is an
  important part of treatment and follow-up.

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Conclusion

• STD screening and treatment should be a primary
  intervention and a standard of care in all health
  care settings.
• Women infected with STDs have increased chances
  of contracting HIV.
• Studies show STD and HIV co-infection increases
  HIV virus shedding in the patients genital
  secretions.
• If co-infection is present, proper diagnosis and
  treatment of STDs will decrease the chances of
  transmitting HIV.

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Helpful Resources

• AETC National Resource Center (NRC),
  www.aidsetc.org
• Clinical Manual for Management of the
  HIV-Infected Adult
• AIDSMAP,http//www.aidsmap.com
• Centers for Disease Control and Prevention,
  http//www.cdc.gov/std
• STD Treatment guidelines 2006
• HIV / AIDS and STDs
• Health Resources and Services Administration
  HIV/AIDS Bureau, http//hab.hrsa.gov/
• A Guide to the Clinical Care of Women with
  HIV/AIDS
• HIVInsite, http//hivinsite.ucsf.edu
• Transgender Awareness Training Advocacy
• http//www.tgtrain.org/

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References

• Anderson, J.R, ed. (2005). A Guide to the
  Clinical Care of Women with HIV. Health Resources
  and Services Administration HIV/AIDS Bureau.
• Centers for Disease Control and Prevention.
  Sexually Transmitted Diseases Treatment
  Guidelines 2006. MMWR, Aug 4, 2006, 55.
• Centers for Disease Control and Prevention.
  Sexually Transmitted Diseases Treatment
  Guidelines 2006. MMWR, April 13, 2007, 56
• Centers for Disease Control and Prevention. The
  Role of STD Detection and Treatment in HIV
  Prevention. Retrieved on September 16, 2007 from
  http//www.cdc.gov/std/hiv/STDFact-STDHIV.htmWha
  tIs
• Health Resources and Services Administation,
  HIV/AIDS Bureau, AETC National Resource Center.
  (2006). Guiding Principles for Cultural
  Competency. Retrieved on September 20, 2007 from
  http//www.aidsetc.org/doc/workgroups/cc-principle
  s.doc
• US Preventive Services Task Force. Screening for
  gonorrhea recommendation Statement. Ann Fam Med
  20053263-7.