Dealing with HIV and other STIs

in the
Adolescents

Rosemarie Santana-Arciaga, M.D.

Fellow, Philippine Pediatric Society, Inc.
Fellow, Pediatric Infectious Disease Society of the Philippines
Fellow. Philippine Society for Microbiology and Infectious Diseases

PIDSP Annual Convention, Feb 2013

 Epidemiology of Adolescent HIV/STI’s

 STI is a common worldwide

occurrence
 Adolescents*: highest burden of
STI’s
 Probability of STIs:
 12.5% at age 15 years
WHODEFINITION:
1.2% at age 24 years
*Adolescents: 10-19 years; Youth: 15-24 years.
 Prevalence of STIs Among the Different Groups RTI/STI
Prevalence Survey in Selected Sites in the Philippines
February to May 2002 (n = 300)

Wi TEC, Saniel OP, Ramos ER et al. RTI/STI Prevalence in Selected Sites in the Philippines . Department of
Health, Women’s Health and Safe Motherhood Project, National AIDS/STI Prevention and Control Program and
Philippine National AIDS Council Secretariat in collaboration with Family Health International. 2002
 Sexually Transmitted Infections
among Filipino Sex Workers
n=484

Prevalence of
Number of infections

STIs Females =
51.7%
Males = 10%

Monzon OT, Santana RT, Paladin FJ et al. The Prevalence of Sexually Transmitted Diseases (STDs)
and HIV Infection among Filipino Sex Workers. Phil J Microbiol Infect Dis 1991; 20(2):41-44
 Estimated Youth STI Incidence, 2000
Sexually Experienced Population STI Incidence

is

Weinstock et al., Persp Sex Repro Health,

 STI Care: Young Adolescents
Physician Offices

OB-Gyn
* *
*
Percen

* FP/GP
t

* Pedia

* * *
Age Group
Hoover et. al., J Adol Health
2010
 Adolescents: Psychosocial
and Cognitive Transition

 Dependent child  independent, decision-

making
adults
 Peer influences  own individual beliefs
Resistance to STI care due to:
 embarrassment (stigma)
 confidentiality issue
 concerns about pelvic exams
 Taking a Sexual History

 Interview the patient alone.

 Make no assumptions.
 Start with safe questions.
 Don’t act surprised.
 Use easily understood language.
 Avoid lecturing.

The more you do it, the more you develop your own technique.
 STI History

5 P’s Symptoms:
 Partners  Vaginal/penile discharge

 Rash, sore throat, fever

 Sexual Practices
 Painful defecation
 Past history of
STIs  Dysuria, hematuria

 Pregnancy  Dyspareunia

 Protection from
STIs Good screening practices require
Good ASKING practices.
 HIV/STIs in
ADOLESCENTS
 Epidemiology

 Approach to teens: Sexual History

Taking
 STI Screening Recommendations
 HIV/STI Management
Recommendations
 HIV/AIDS
 Genital Ulcers
 Urethritis and cervicitis
 Vaginal discharge
HIV/AIDS Cases in the Philippines

Dec 2012, Philippine HIV/AIDS Registry. National Epidemiology Center, Department of Health
 HIV Transmission by Age Group, 2012
(n=3,338)

Dec 2012, Philippine HIV/AIDS Registry. National Epidemiology Center, Department of Health
 Adolescent HIV/AIDS

 Rates lowest in adolescents, but have increased almost 4x in

the last decade.
 HIV diagnosis in teens often reflects a newly acquired
infection.

 Most new adult HIV: Later stages of disease

Acquisition during older adolescence/young adult.

 The HIV-Infected Adolescent

Recognize the different biomedical and psychosocial

needs of perinatally-infected vs behaviorally-
infected youth.

 Most acquired HIV behaviorally

 Many with recent HIV infection

 Some infected perinatally or via blood products

 Usually heavily treatment-experienced
Recommendations for Initiating ART

“ART is recommended for

all HIV-infected individuals.

Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and

Adolescents
http://aidsinfo.nih.gov/guidelines 2012
 Anti-Retroviral Therapy (ART)

 Improves/preserves immune function  better clinical outcomes

 Reduces risk of HIV transmission
 ARV combinations are effective and well tolerated
 Adult ART guidelines: appropriate for post-pubertal adolescents

 Early puberty: Dosing should be based on Tanner stages

Tanner stages 1-2: Pediatric dose
Tanner stages 3-5: Adult dose
 HIV/STIs in
ADOLESCENTS
 Epidemiology

 Approach to teens: Sexual History

Taking
 STI Screening Recommendations

 HIV/STI Management
 HIV/AIDS Recommendations
• Syphilis
 Genital Ulcers
 Urethritis and cervicitis
• Herpes
 Vaginal discharge • Chancroid
 Other STIs • Donovanosis
 Diagnosis of Syphilis
 Dark field microscopy
 Non-treponemal: RPR/ VDRL
 Quantitative
 Follow titers to assess treatment response

 Treponemal: FTA-ABS,
TPHA
 Qualitative
 Very sensitive
 Used to confirm syphilis diagnosis EIA
 Remains positive after treatment
Clinical Signs of Syphilis

 Primary: chancre, painless ulcer

 Secondary: 1-2 month post infection
 rash, condyloma lata, lymphadenopathy, fever,
splenomegaly, headache, arthralgia, neurologic ssx
 Latent: seropositive but no symptoms.
 Early latent (1 year after infection)
 Late latent (after one year or of unknown duration)

 Tertiary: gumma lesions (skin, bones, internal organs)

and cardiovascular disease (aortitis)
 Genital Herpes

 Most genital HSV are caused by HSV-2,

but 30% are caused by HSV-1

 Adolescents make up 25% of new

diagnoses.

 Diagnosis:
 serologic testing for type-specific HSV
antibody
 culture for HSV or PCR testing for HSV
 HIV/STIs in
ADOLESCENTS
 Epidemiology

 Approach to teens: Sexual History

Taking
 STI Screening Recommendations
 Management
Recommendations  Non-GC urethritis

 HIV/AIDS  Chlamydia
 Urethritis
Genital Ulcers
and  Gonorrhea
cervicitis
 Vaginal discharge Pelvic
 Other STIs Inflammator
 Urethritis

 Mucopurulent or purulent urethral discharge

 Urethral secretions ≥5 WBC/oif

 + Leukocyte esterase test on first-void urine

or
≥10 WBC / hpf

Screen for
Gonorrhea and Chlamydia
 Cervicitis

 Purulent or mucopurulent endocervical exudate

 Sustained endocervical bleeding easily induced by gentle
passage of a cotton swab through the cervical os

 Test for Gonorrhea and Chlamydia

 Evaluate for BV and Trichomonas
 Assess for Pelvic Inflammatory
Disease
 Diagnosis of Urethritis & Cervicitis

Laboratory Tests Microscopy Culture NAAT*

Cervical swab X X X
Urethral swab,
Urethral discharge X X X
Urine X X
Pharyngeal swab X X X
Rectal swab X
*Nucleic Acid
Amplification Test
Chlamydia and Gonorrhea:
New Testing Option

 Nucleic acid amplification tests (NAATs)

 most sensitive CT laboratory tests
 Vaginal swabs: preferred female specimen
 Urine: preferred male specimen
 Rectal and oropharyngeal swab NAATs
 Rectal swabs: for GC and CT NAATs
 Oral swabs: for GC NAATs

SchachterJ, et al. Sex Transm Dis. 2008;35:637-42

 Chlamydia Infections

 NGU is caused by C. trachomatis in 15-40% of

cases.
 Majority (60 – 80%) are asymptomatic.
 May present with urinary symptoms
 Female: 20-50% leads to PID
20% of PID patients become infertile
 Male: Symptoms can progress to epididymitis or orchitis
 Management of
Non-gonococcal Urethritis
 Recommended Regimens
 Azithromycin 1g orally single dose
or
 Doxycycline 100 mg BID for 7 days
 Alternative Regimens
Erythromycin 500 mg QID for 7 days

or
 Levofloxacin 500 mg OD for 7 days
NO SEX for 7 days after single dose Azithromycin,
orcompleted regimen AND until all partners
or until 7 day
 Ofloxacin 300 mg
are treated BID for 7re-infection.
to minimize days
*2010 STD Treatment Guidelines. Centers for Disease Control and Prevention
 Gonorrhea

 50% of women are asymptomatic

 Rates highest in teens and young women

 Often a co-infection with Chlamydia and other

STI’s.

 Increasing fluoroquinolone resistance

 Treatment for Gonorrhea

 Gonococcal antimicrobial resistance remains an issue

 Penicillin, tetracycline or quinolones are no longer

gonorrhea treatment options ! ! !

 CDC recommends DUAL THERAPY regardless

of anatomic sites

*2010 STD Treatment Guidelines. Centers for Disease Control and Prevention
Update to CDC’s Sexually Transmitted Diseases Treatment
Guidelines, 2010:Oral Cephalosporins No Longer a
Recommended Treatment for Gonococcal Infections

MMWR 2012;61:590-594
JAMA. 2012;308(18):1850-1853.
 Gonorrhea Develops Rapid Resistance
to Azithromycin*

 Azithromycin monotherapy is not

recommended because of concerns about
rapid emergence of macrolide resistance

 Azithromycin-resistant variant of
gonorrhea developed in just 12 days*

*Olusegun Soge, PhD. 2012 National STD Prevention Conference, March 14, 2012
 HIV/STIs in
ADOLESCENTS
 Epidemiology

 Approach to teens: Sexual History

Taking
 STI Screening Recommendations

 HIV/STI Management Recommendations

 Genital
HIV/AIDS Ulcers
 Urethritis and cervicitis  Bacterial Vaginosis
 Vaginal discharge  Trichomoniasis
 Other STIs  Candidiasis
Vaginal Discharge Diagnostic Tests

 pH of vaginal
secretions
 Wet mount with NSS
 KOH smear
 Gram’s stain
microscopy
Diagnostic Opportunities
Point-of-Care Rapid test
 Trichomoniasis:
Recommended Regimen

 Metronidazole 2 g orally in a single dose

or
 Tinidazole 2 g orally in a single dose

Alternative Regimen
 Metronidazole 500mg po bid x 7 days
 HIV/STIs in
ADOLESCENTS
 Epidemiology

 Approach to teens: Sexual History

Taking
 STI Screening Recommendations
 Management Recommendations
 HIV/AIDS
 Genital Ulcers
 Urethritis and cervicitis
 Vaginal discharge
 Other STIs
 HPV: Genital Warts

 Common STI
 6.2 million new infections annually

 Preventable
through HPV
immunization
 Hepatitis A/B/C
 All 3 viruses can be transmitted sexually
 Hepatitis A / B : vaccine preventable

 Hepatitis C:

Rates rising dramatically in

adolescence.
Risk factors:
 IVDU sex partner
 HCV-infected sex partner
 HSV positive
 Expedited Partner Therapy

“Treatment of sex partners without prior health provider

examination or assessment.”

Patient-Delivered Partner Therapy

 Give index case medication intended for partners
or
 Write prescription for partner

Golden, NEJM, 2005

When dealing with HIV / STIs in the
Adolescents….

Adolescence: unique and vulnerable

time.

An Integrated Approach to STI Care should address

the emotional and psychosocial needs of all
adolescents.