STI’s and HIV Risk,
Testing, and Prophylaxis in Sexual Assault
ELLEN JOHNSON BA , RN, SANE‐A , CEN
Objectives
Identify patients at increased risk for STI’s and HIV
Discuss current CDC recommendations for STI and HIV prophylaxis
Discuss the importance of follow up with regard to STI’s and HIV
STI’s
• Chancroid
• Herpes
• Syphilis
• Chlamydia
• Gonorrhea
• Trichomoniasis
Chlamydia, gonorrhea, and syphilis
• Why are these infections of particular concern?
Chlamydia, gonorrhea, and syphilis
• Why are these infections of particular concern?
• PID
• Ectopic Pregnancy
• Infertility
The rate of chlamydia in MN reached an all time high at 444 per 100,000.
The rate of gonorrhea in MN increased 28% from 2016.
The rate of primary and secondary syphilis is at 5.5 per 100,000, a decrease of 5% from
Number of reported STI’s in MN in 2017
30,981 cases reported to MDH in 2017
◦23,528 Chlamydia
◦6519 Gonorrhea
◦934 Syphilis (all stages)
Chlamydia
Most commonly reported communicable disease in MN Asymptomatic infection is common
Chlamydia disproportionately affects youth
The 15‐24 year olds make up only 14% of the population, but account for 62% of all chlamydia cases
Treatment/prophylaxis
Azithromycin 1 Gm. po in a single dose‐
preferred
◦Single dose is an advantage due to compliance concerns with multiple day Rx
Doxycycline 100 mg BID x 7 days (not if pregnant)
Chlamydia treatment/prophylaxis
Alternatives:
◦Erythromycin base 500 mg or erythromycin ethyl succinate 800 mg QID x7 days (GI upset)
◦Levofloxacin 500 mg QD x 7 days (more expensive, not if pregnant)
◦Ofloxacin 300 mg BID x 7 days (more expensive, not if pregnant)
Gonorrhea
2ndmost common reported communicable disease
MSM at higher risk
Commonly asymptomatic in women until PID
All age groups saw an increase in gonorrhea rates
30‐39 year olds had largest rate increase from 2016‐ 39%
Gonorrhea
Antimicrobial resistance is an ongoing concern
◦Antibiotic recommendations change because of this
Oropharyngeal GC is more difficult to eradicate
◦Very important for pt.. to accept recommended treatment with oral penetration
◦Need test of cure if alternate treatment given
Treatment/prophylaxis
Ceftriaxone 250 mg IM PLUS azithromycin 1 Gm. po Alternate treatment (NOT optimal!)
◦If allergic to cephalosporins or pt.. has had
anaphylaxis/angioedema with penicillin then Gentamycin 240 mg IM (must divide into 2 injections) PLUS Azithromycin 2
Why offer prophylaxis for STI’s instead of testing?
Compliance with follow up is a big concern Peace of mind when getting immediate treatment
Testing is more often ordered in children because they are much less likely to get STI
Barriers to prophylaxis
Assumption of little risk
“I hate shots”
“I don’t like to take medicine”
Fear of billing to parent’s/spouse’s insurance
Syphilis
Most prevalent in MSM Overall numbers are very low No prophylaxis recommended
Characteristics of early syphilis
†cases among MSM, Minnesota, 2016
Gay and bisexual men account for 77% of cases among men.
62% of cases among MSM are White, but a
disproportionate number of cases (17%) are African American.
44% of cases are also infected with HIV.
MSM=Men who have sex with men † Early Syphilis includes primary, secondary, and early latent stages of syphilis.
What’s being done in Minnesota?
The MDH Partner Services Program continues to follow up on early syphilis cases and their sex partners and all pregnant syphilis cases.
All HIV/Syphilis co‐infected cases are assigned to Partner Services for follow‐up.
Physicians are encouraged to screen men who have sex with men at least annually and to ask about sex partners.
All pregnant females should be screened for syphilis at first prenatal visit, 28 weeks’ gestation (at minimum 28‐36 weeks), and at delivery.
Info for our patients
Testing 6 weeks post assault No prophylaxis
Treatment is penicillin G benzathine parenterally
◦Bicillin LA 2.4 million units
◦Partners of those who test positive are treated presumptively
Trends
From 2007‐2017, the chlamydia rate increased by 71%. The rate of gonorrhea increased by 84%. Rates of reported syphilis increased in 2017 compared to 2016 by 10%.
Minnesota has seen a resurgence of syphilis over the past decade, with men who have sex with men and those co‐
infected with HIV being especially impacted. However, the number of females is near the record high for the last decade.
Persons of color continue to be disproportionately affected by STDs.
STD rates are highest in the cities of Minneapolis and Saint Paul. However, chlamydia and gonorrhea cases in the Twin Cities suburbs and Greater Minnesota account for 62% of the reported cases in 2017.
Between 2016 and 2017, early syphilis cases increased by 9%.
Men who have sex with men comprised 83% of all male cases in 2017; cases among women are continuing to rise.
Trends
Trichomoniasis
Most prevalent nonviral STI in US Caused by protozoan parasite called trichomonas vaginalis
Most have minimal or no symptoms Readily passed through penile‐vaginal sex
Risks of trichomoniasis
2‐3x increased risk for acquiring HIV If pregnant‐ increased risk for preterm birth and low birth weight
Trichomoniasis symptoms
70‐85% have minimal or no Sx
Infection may be in vagina, urethra, or both Diffuse, malodorous, frothy vaginal discharge
◦White, gray, yellow or green
Genital burning, itching, redness, swelling Frequent urge to urinate
Pain during intercourse
Untreated infections may last for months‐years
Strawberry cervix
Infection in males
Infection occurs in urethra only
Males may have urethritis, epididymitis, or prostatitis
Prophylaxis
Metronidazole (flagyl) 2 g orally in a single dose
◦Or Tinidazole 2 g orally in single dose
Alternate regimen for HIV infected persons or resistant infection
◦Metronidazole 500mg BID x7 days
Avoid alcohol for 72 hours prior and after meds
Bacterial vaginosis (BV)
Change in vaginal flora – reduction of hydrogen‐
peroxide producing lactobacilli and increase in anaerobic gram negative rods
Most common cause of vaginal discharge or malodor (fishy smell), although most are asymptomatic Associated with:
◦Multiple partners
◦New sex partner
◦Douching
BV
Increased risk for other STI’s
Increases risk of HIV to male partners Treatment of male partners not
Prophylaxis
Symptomatic BV is treated with metronidazole 500mg BID for 7 days We are not treating BV with the
Metronidazole 2g oral dose, nor are we prophylaxing for BV
◦If the pt.. develops Sx then the 7 day regimen will be indicated
Herpes
Life long viral infection
HSV‐1 and HSV‐2 can cause genital herpes
~50 million people in US infected by HSV‐2 Most people infected with HSV‐2 have not been diagnosed
Herpes
Multiple painful vesicular or ulcerative lesions
◦Not always present in person shedding virus Antivirals can decrease length and severity of first outbreak. Discuss with MD.
Counseling needed
◦Provide info re: transmission of herpes
Herpes lesions
Herpes
HPV
Most common STI
Many types of HPV infection (~100) Viral infection
May resolve on its own
HPV Genital warts
• Genital warts are usually a visual diagnosis
• May go away, stay the same, or grow in size and number
HPV
HPV vaccine
3 dose series (0, 1‐2 months, 6 months)
◦Gardasil (quadrivalent) and Gardasil 9 protect against more types of cancer and genital warts
◦2 doses needed (6‐12 months apart) if vaccinated before age 15
Vaccinate through age 26
◦Recommended for boys and girls age 11‐12, can be given as early as age 9
Not recommended in pregnancy
Candida vulvovaginitis
Overgrowth of normal yeast
◦Changes in pH
◦Weakened immune systems
◦Diabetes
◦Long term use of antibiotics Itching, burning
“Cottage cheese” discharge
Discussion item
You note a discharge coming from the cervix during your exam
What are your next steps?
Do you need to make a probable diagnosis of which acute infection may be present, if any?
Hepatitis B
Transmission
◦Blood and body fluids
◦Unprotected sex
Implications with sexual assault
◦Ask about Hep B immunization status (look up in MIC or WIR)
◦If not immunized offer 1stvaccine
◦If pt.. is unsure of immunity or immunization status offer vaccine
◦Give schedule for dose 2 and 3
◦If known Hep B+ assailant offer HBIG
Hepatitis C
No vaccine available
10% of cases are sexually transmitted
Most new cases due to illegal injection drug use
Recommend Hep C antibody testing 3 or 6 months after sexual assault
No post exposure prophylaxis
As of December 31, 2017, 34,720* persons are assumed alive and living in MN with HCV
HIV
Currently no cure Treatment advances
Prevention and education are key
HIV in MN
As of December 31, 2017 8,789* persons are
assumed alive and living in Minnesota with HIV/AIDS.
890 (10%) are co‐infected with either Hepatitis B or C
◦412 (4.7%) are living with HIV and Hep B
HIV in MN
Total HIV diagnoses for 2017 slightly lower than 2016 Men who have sex with men continue to have high rates of new HIV infections
More than half of newly reported HIV infections were among communities of color
More than one‐third of newly reported HIV infections were under 30 years of age
There is a continuing pattern of increased HIV infection among injection drug users (IDU)
Living with
HIV/AIDS by
county
Increased risk
Multiple assailants Anal penetration
Genital trauma, bleeding
Presence of infection or genital lesions for either assailant or patient
Assailant from high risk group
High risk assailants
Known HIV+
MSM, male on male assault
Assailant from location of high HIV prevalence
IVDU
Commercial sex worker
Risk
The risk of getting HIV from an HIV infected individual with one unprotected sexual encounter is very low, but varies depending on the type of assault
◦Penis inserted into mouth: 1 in 10,000
◦Penis inserted into vagina: 1 in 1000
◦Penis inserted into anus: 5 in 1000
Use tools for teaching
HIV nPEP
Be prepared to discuss your patient’s risk of acquiring HIV
Offer HIV nPEP when indicated
◦High risk assailant
HIV nPEP
NOT offered after 72 hours
Best to have baseline HIV test before starting on HIV nPEP, may test within few days
Recommended 3‐drug antiviral regimen (28 days)
◦Truvada® 1 PO Daily (2 drugs in Truvada®) AND
◦Isentress® 400 mg (Raltegravir) 1 PO BID
◦or Tivicay® 50mg (Dolutegravir) 1 PO Daily
Tivicay®
Mid 2018 study from Botswana showed women who took Tivicay® in early stages of pregnancy were at risk for neural tube birth defects
Tivicay® is available through financial assistance program from ViiV, where Isentress® is not available for uninsured pts.
How do we promote safety if pts. are placed on Tivicay ® ?
Discuss importance of not getting pregnant while on Tivicay®
◦Counsel pt. regarding risk of birth defects Encourage condom use even if on birth control
Give Rx for oral contraceptives if pt. not on birth control
Isentress ®
Isentress is preferred if pt. has insurance or just needs copay assistance because it has not been shown to cause neural tube birth defects
Isentress® is used in pts. <40 kg
Side effects
Meds are well tolerated Possible side effects
◦HA
◦Fever
◦Nausea (ask for Zofran for first 3 days)
◦Difficulty sleeping
◦Side effects often lessen or resolve in a few days
Risks of HIV nPEP
May cause kidney or liver damage or even failure, consult MD (prefer ID doc) if pt.. has baseline kidney or liver disease. Stress need for ongoing follow‐up for labs.
Must have baseline labs done to check kidney/liver function ASAP
Consider referring for PrEP risk assessment
Commercial sex worker Multiple sex partners
Inconsistent or no condom use MSM
HIV+ partner
IV drug user, sharing needles
Challenges
Lack of knowledge or awareness of HIV nPEP on the part of SANEs and providers
Disbelief that assailant could have HIV May not want to take meds
Cost
Lack of insurance
◦Not wanting to have meds put on insurance
Discussion item
How do you counsel the patient who was assaulted by a long‐term partner and is returning to this partner?
Resources
http://www.cdc.gov/std/tg2015/sexual‐assault.htm http://www.cdc.gov/hiv/pdf/programresources/cdc‐hiv‐
npep‐guidelines.pdf
http://www.health.state.mn.us/divs/idepc/diseases/hiv/
stats/2017/webinar2017.pdf
