Sexually Transmitted Infections in Adults & Pediatrics (FL INITIAL Autonomous Practice- Differential Diagnosis)

The sexual health assessment is an important part of prevention. Sexual orientation and gender identification questions can lead to more specific questions. There are screening tools available such as the “5 Ps” that can help practitioners to ask difficult questions in a nonjudgmental way. The “5 Ps” tool asks (Rietmeijer, 2022):

1. Partners:
   • Is the patient having sex?
   • Gender(s) of the partners?
2. Practices:
   • Vaginal sex?
   • Anal sex?
   • Oral sex?
3. Protection from STIs:
   • Does the patient and partner(s) discuss the prevention of HIV and STIs?
   • Does the patient and partner(s) discuss getting testing?
   • What kind of protection do the patient and partner use?
4. Past history of STIs:
   • Has the patient ever been tested?
   • Has the patient ever been diagnosed?
   • Have any partners had STIs?
5. Pregnancy intention:
   • Does the patient think they will have children in the future?
   • How important is pregnancy protection until then?
   • Is the patient or partner using contraception?
   • Would the patient like to know about ways to prevent pregnancy?

It may be beneficial to discuss ways to prevent STIs rather than focusing on risk because of the stigma surrounding STIs. It is always important to speak in a positive, non-judgmental manner that makes the patient comfortable and willing to talk, rather than feel ashamed and try to keep information to themselves. Open-ended questions using understandable language is a good way to facilitate good communication (Centers for Disease Control and Prevention [CDC], 2022). The provider should never make the patient feel ashamed because they will be less likely to communicate what their needs are.

Behavior modification is another important part of prevention. Behavior counseling is recommended for all sexually active adolescents, as well as other high-risk populations. These behavioral modifications should include patient education about STI transmission as well as behaviors that increase the risk of exposure to STIs. Safe sexual practices should be emphasized. Proper condom use should also be reviewed as part of behavior modification (Rietmeijer, 2022).

Behavior modification can be provided in any outpatient setting and with a variety of sources, such as in-person counseling, telephone calls, and different types of media such as websites, hand-outs, videos, etc. It is important that when teaching behavior modification, the educator is nonjudgmental and offers realistic guidance. If the educator judges the patient or treats them like they are doing something wrong, these patients may not listen or come back for care. Group counseling about behavior modification has also been shown to be effective.

Effective antiretroviral treatment is an effective means of prevention because it reduces the HIV viral load in blood, semen, vaginal fluid, and rectal fluid to very low or even undetectable levels. This reduces the risk of transmission by about 95%. Individuals who are HIV negative but have a high risk of HIV exposure may receive pre-exposure antiretroviral prophylaxis (PrEP) to prevent HIV (Rietmeijer, 2022).

Antiviral suppression of HSV is also part of prevention because it is effective at preventing the spread to partners (Rietmeijer, 2022).

There are vaccines available for a number of sexually transmitted infections. Hepatitis A vaccine is recommended for (Rietmeijer, 2022):

• Men who have sex with men
• People who use injectable and non-injectable drugs
• People with HIV
• People with chronic liver disease
• People who have close contact to people with Hepatitis A
• People who live in countries where Hepatitis A is endemic

Hepatitis B vaccine is recommended for all people with the first dose given during birth hospitalization. There are several HPV vaccines available, and it is recommended that all individuals aged 9 to 26 receive the vaccination, although only about half receive vaccination (Rietmeijer, 2022).

Condom use is one of the most effective ways of preventing STIs. Both the Centers for Disease Control and Prevention and the World Health Organization recognize condom use as an essential part of prevention (Rietmeijer, 2022). Condoms must be used consistently and correctly in order to provide the fullest protection. Latex condoms are the type most commonly used, and they are shown to be the most effective. Patients should be instructed on how to use condoms including (Workowski et al., 2021; Campos-Outcalt, 2021):

• Do not use five years after the manufacturing date or any time after the expiration date
• If using lubricant – it must be water-based
• A new condom should be used for each sex act
• The condom should be handled carefully to prevent tears
• The condom should be placed after the penis is erect but before any genital, oral, or anal contact with the partner
• The penis should be withdrawn while erect and the condom should be held firmly against the base of the penis during removal

It is important to note that it is difficult to make changes and encourage patients to change behaviors. Some barriers to preventing STIs include (WHO, 2023):

• Lack of public awareness
• Lack of healthcare worker training
• Stigma surrounding STIs

Patients needing screening and treatment may lack resources, have high out-of-pocket expenses, and poor quality of care available (WHO, 2023).

It is recommended for females younger than age 25 to be screened for (Stöppler, 2022):

• Genital chlamydia: Annually
• Genital gonorrhea: Annually
• Human Immunodeficiency Virus (HIV): At least once
• Hepatitis C Virus (HCV): At least once (if older than 18)

If the patient is at an increased risk, also screen for (Stöppler, 2022):

• Syphilis
• Trichomoniasis
• Hepatitis B Virus (HBV)

It is recommended for females aged 25 years and older to be screened for (Stöppler, 2022):

• HIV: At least once
• HCV: At least once

If the patient is at an increased risk, also screen for (Stöppler, 2022):

• Genital chlamydia and gonorrhea
• Syphilis
• Trichomoniasis
• HBV

It is recommended for all pregnant individuals to be screened for (Stöppler, 2022):

• Genital chlamydia: In the first trimester
• Genital gonorrhea: In the first trimester
• HIV: In the first trimester
• HBV: In the first trimester
• Syphilis: In the first trimester

Repeat screening for each of these infections is recommended if the patient is at an increased risk in the third trimester.

Additional screening that can be done at the first prenatal visit (Stöppler, 2022):

• HCV for those at risk (or if ≥ 18 years with no prior screening)
• Trichomoniasis for those with HIV

It is recommended that females with HIV infection be screened for (Stöppler, 2022):

• Genital gonorrhea: Annually
• Genital trichomoniasis: Annually
• Syphilis: Annually

It is recommended that men who have sex with women (MSW) without HIV infection be screened for (Stöppler, 2022):

• HIV: At least once
• HCV: At least once (if age ≥ 18 years)

It is recommended that men who have sex with men (MSM) without HIV infection be screened for (Stöppler, 2022):

• Genital chlamydia: At least annually
• Rectal chlamydia (if exposed): At least annually
• Genital gonorrhea: At least annually
• Rectal gonorrhea (if exposed): At least annually
• Pharyngeal gonorrhea (if exposed): At least annually
• Syphilis: At least annually
• HIV: At least annually
• Hepatitis A Virus (HAV): At the first visit
• HBV: At the first visit
• HCV: At least once

More frequent screening (every three months) is recommended for those with risk factors for chlamydia, gonorrhea, and syphilis (Stöppler, 2022). More frequent screening for HIV and HCV may also be warranted.

It is recommended that men who have sex with women (MSW) with HIV infection be screened for (Stöppler, 2022):

• Genital chlamydia: Annually
• Genital gonorrhea: Annually
• Syphilis: Annually
• HBV: At the first visit
• HCV: At the first visit

It is recommended that men who have sex with men (MSM) with HIV infection be screened for (Stöppler, 2022):

• Genital chlamydia: At least annually
• Rectal chlamydia (if exposed): At least annually
• Genital gonorrhea: At least annually
• Rectal gonorrhea (if exposed): At least annually
• Pharyngeal gonorrhea (if exposed): At least annually
• Syphilis: At least annually
• HAV: At the first visit
• HBV: At the first visit
• HCV: At least annually

More frequent screening (every three months) is recommended for chlamydia, gonorrhea, and syphilis in those with risk factors (Stöppler, 2022). More frequent screening for HCV may also be warranted.

Screening for STIs should be based on an individual's birth gender and sexual practices (Stöppler, 2022).

Recommendations for genital gonorrhea, chlamydia, and cervical cancer screening in cisgender women should be extended to all transgender men and gender-diverse individuals with a cervix (Stöppler, 2022). 

Screening for other STIs should be based on risk factors and exposures (Stöppler, 2022; Ghanem & Tuddenham, 2022).

HIV infection is a serious, non-curable illness.Acute infection may cause a brief flu-like illness that can include fever, malaise, lymphadenopathy, pharyngitis, arthritis, or rash. People who are infected usually experience one symptom but may not recognize that they are sick.

Acute infection progresses and can lead to acquired immunodeficiency syndrome (AIDS). Testing for HIV requires a blood sample. Initial positive results should be followed up with supplemental HIV-1/HIV-2 antibody differentiation. Any rapid positive results should also be followed up with RNA testing. Treatment should be initiated as soon as possible to improve individual health and prevent spread. Antiretroviral treatment (ART) should be given to all HIV positive patients. The patient should also be referred to an HIV specialist.

There is a stigma involved with HIV and it is important to keep these patients engaged in their own care so that they follow treatment regimens (CDC, 2022). When HIV was first recognized, it usually led to a quick death. HIV positive patients can now live long lives when under treatment.

All pregnant women should be tested. It is crucial for their own health, as well as to decrease the risk of HIV spreading to the fetus. The risk of spreading to a neonate without treatment is about 30%. If the woman is on ART, the chance of spread is less than 2%. HIV positive patients should not breastfeed, as the virus can be passed through breastmilk.

Genital, anal, or perianal ulcers are usually caused by genital herpes or syphilis. Patients with ulcers should have a syphilis serology test and darkfield exam from the lesion, nucleic acid amplification test (NAAT) or culture for genital herpes, and serology testing for type specific HSV antibodies (CDC, 2022).

Treatment for syphilis is an antibiotic. Genital herpes can be treated with antivirals. Treatment controls the symptoms and prevents reoccurrence. But reoccurrence can happen if the patient is not taking medication (CDC, 2022).

Syphilis is caused by T. pallidum. T. pallidum can infect the central nervous system, which can occur at any stage of syphilis and result in neurosyphilis (CDC, 2022; Workowski et al., 2021).

Darkfield examinations and molecular tests from lesion exudate or tissue are the only definitive methods for diagnosing early syphilis and congenital syphilis (CDC, 2022; Workowski et al., 2021). If a patient is thought to have syphilis, a diagnosis requires the use of two laboratory serologic tests (CDC, 2022; Workowski et al., 2021):

• A nontreponemal test (i.e., Venereal Disease Research Laboratory [VDRL] or rapid plasma reagin [RPR] test)

AND

• A treponemal test

The standard treatment for syphilis is penicillin (CDC, 2022).

Urethritis is inflammation of the urethra and can be caused by infectious or noninfectious conditions. Symptoms can include itching and discharge.

Infectious causes include N. gonorrhoeae, C. trachomatis, M. genitalium, and N. meningitidis(CDC, 2022; Workowski et al., 2021). Gram stain, methylene blue (MB), or gentian violet (GV) microscopy can be used to diagnose these infections (CDC, 2022). An antibiotic should be prescribed for each of these conditions (CDC, 2022). 

Cervicitis can be determined by a purulent discharge in the endocervical canal and sustained endocervical bleeding easily induced with a cotton swab. C. trachomatis or N. gonorrhoeae is the most common cause of cervicitis and should be tested with a NAAT test. Patients with cervicitis should also be evaluated for bacterial vaginitis and trichomoniasis. An antibiotic is the treatment of choice for these infections (CDC, 2022).

Chlamydia is caused by the C. trachomatis bacteria. Many patients are asymptomatic, but it can cause pelvic inflammatory disease (PID), ectopic pregnancy, and infertility. Screening should be done per guidelines. Vaginal or cervical swabs or urine can be used to diagnose chlamydia. An antibiotic is used to treat chlamydia (CDC, 2022).

Gonorrhea is caused by the N. gonorrhoeae bacteria and is common in the United States. Many men experience urethral infections and women may have no symptoms until it has caused pelvic inflammatory disease (PID).

Screening should be done per guidelines. Specific microbiologic diagnosis of N. gonorrhoeae infection should be performed by culture or NAAT (CDC, 2022; Workowski et al., 2021). Antibiotics are used to treat gonorrhea (CDC, 2022).

There are about 150 different types of HPV. HPV vaccines are recommended per guidelines. These guidelines state (CDC, 2022; Workowski et al., 2021):

• HPV vaccination is indicated for all adolescents at age 11 or 12 years
• Administering the HPV vaccine should start at age 9 years
• Catch-up vaccination through age 26 years for those not vaccinated previously
• Not using HPV vaccination for all adults aged > 26 years
• A 2-dose vaccine schedule is recommended for persons who initiate vaccination before their 15th birthday (the second dose should be given 6–12 months later)
• A 3-dose vaccine schedule is recommended for those who get the first dose on or after their 15th birthday and for immunocompromised persons regardless of age of initiation (the second dose should be given 1-2 months after the first dose, and the third dose should be given 6 months after the first dose)

The only treatment for HPV is treating the genital warts or precancerous lesions. There is no medication to cure HPV (CDC, 2022).

There are 3 main types of hepatitis. They are caused by a virus.

Hepatitis A is self-limiting and is transmitted by the fecal-oral route, by person-to-person contact, food, or water (CDC, 2022; Workowski et al., 2021). A vaccine is available for at-risk populations who did not receive it during childhood.

Hepatitis B infection can be self-limiting or chronic (CDC, 2022). HBV is spread through sexual contact or injected drug use (CDC, 2022). Diagnosis is made through serum testing. Vaccines should be given during childhood. Chronic HBV can cause liver damage. There is no treatment.

Hepatitis C is a chronic bloodborne infection that is primarily transmitted though sharing drug-injecting needles. It can be transmitted in health care settings through bodily fluids. There is some data to suggest that it can be spread through sexual contact. Diagnosis is made through serum testing. There is medication available that can cure HCV and the patient should see a specialist for treatment (CDC, 2022).

It is important to recognize that victims of sexual assault and abuse are at risk for STIs and need appropriate screening and treatment. Examination of the patient should be done by someone who has training and is experienced in managing sexual assault victims. These patients should be monitored closely to ensure compliance and to help manage the side effects of their treatments.

Trichomoniasis, BV, gonorrhea, and chlamydia are the most frequently diagnosed infections in women who have been sexually assaulted. The victim should receive NAAT testing and serum testing for STIs (CDC, 2022; Workowski et al., 2021). Women who have been sexually assaulted should receive antibiotics for chlamydia, gonorrhea, and trichomonas and men should receive antibiotics for chlamydia and gonorrhea (CDC, 2022; Workowski et al., 2021). If the patient is tested, they can refuse the antibiotic while waiting for results, but often there is poor medical follow up, so empirical treatment may be the best option.

Emergency contraception may also be considered. If the patient has not received the HBV vaccine, they should get the vaccine as well as immunoprophylaxis. HIV PEP, or HIV post-exposure prophylaxis, is a 28-day course of zidovudine and should be decided on a case-by-case basis (CDC, 2022).

Sexual assault or abuse of a child is reportable in all states. Most STIs acquired after the postnatal period are the result of sexual contact, but there are exceptions. A careful exam to minimize pain and trauma should be performed by a qualified examiner. STI testing should be considered in the following conditions (CDC, 2022; Workowski et al., 2021):

• A child has evidence of penetrative injury or has experienced penetration of the genitals, anus, or oropharynx
• A child has a sibling, relative, or another person in the household with an STI
• A child has been abused by a person they do not know
• A child has been abused by an assailant known to be infected with or at high risk for STIs
• A child lives in an area with a high rate of STIs in the community
• A child has signs or symptoms of STIs
• A child or parent requests STI testing
• A child is unable to verbalize details of the assault

Testing should be performed before treatment, so it does not interfere with the results. The risk of children getting an STI is lower, so empirical treatment is not recommended. These children can be at risk of performing risky sexual behavior in the future because of the trauma they have experienced. It is important to always provide counseling (CDC, 2022).

STIs during pregnancy can have severe consequences for the woman, the fetus, and the partner. All pregnant women and their partners should be asked about STIs and receive counseling (Workowski et al., 2021). These individuals should have access to screening and treatment if indicated. State laws have some control over screening and may have requirements. But regardless of the state laws, all pregnant women who are at risk should be tested for STIs. Some women may refuse testing because they have been with the same partner and have no symptoms. It is important to teach these individuals that they could have an STI without knowing it and that there is always the possibility that a partner can have other sex partners.

Every pregnant woman should be tested for HIV at the first prenatal visit, even if they have been tested before (Workowski et al., 2021). Prompt identification and treatment can prevent spread to the fetus. A pregnant woman should see an HIV specialist to determine antiretroviral medication protocols during pregnancy and labor. Breastfeeding is not recommended for an HIV positive mom because HIV can be passed into breastmilk. With proper treatment of medication and not breastfeeding, the chance of passing HIV to the fetus or infant is only 2%. Third trimester retesting is recommended for women at high risk of acquiring HIV (Workowski et al., 2021). This includes women who inject drugs, have STIs during pregnancy, have a new sex partner during pregnancy, or have partners with HIV (Workowski et al., 2021). Women who are incarcerated or live in areas with high rates of HIV, or who have signs of acute HIV infection should also be retested. Some states require third trimester screening (Workowski et al., 2021). For any patient who arrives to labor and delivery and has not been tested for HIV during pregnancy, a rapid HIV test should be performed (CDC, 2022).

Congenital syphilis rates have increased in the United States. Between 2012 and 2019, the rate increased by over 477%. All pregnant women should be tested for syphilis in the first trimester, even if they have been tested before (Workowski et al., 2021). Most states have prenatal syphilis testing requirements. Testing again in the third trimester and at delivery can prevent congenital syphilis (Workowski et al., 2021). It is recommended that newborns are not discharged from the hospital without having at least one syphilis result during pregnancy recorded (CDC, 2022).

All pregnant women should be tested for hepatitis B surface antigen (HbsAg) (Workowski et al., 2021). If this is positive, they should receive counseling and medical management. Women who are negative but at risk should receive the vaccination. Women who are high risk should be retested at time of admission for delivery. Any positive HbsAg result should be reported to the local or state government. Infants born to mothers with HBV should receive immunoprophylaxis at the time of birth (CDC, 2022). The infant should receive a bath immediately after birth to prevent transmission and receive Hepatitis immunoglobulin, as well as the 1st dose of the HBV vaccine.

Pregnant women who are less than 25 years old or are at high risk for chlamydia and gonorrhea should be screened during the first prenatal visit and again during the third trimester. High risk behaviors include a new sex partner, a sex partner who also has other sex partners, or a sex partner with an STI. Pregnant women who remain high risk should be tested again in the third trimester. Any pregnant patient who tests positive for gonorrhea or chlamydia should be tested immediately (CDC, 2022).

Because of the rise of hepatitis C among pregnant women, they should be screened during each pregnancy. The patients at highest risk for hepatitis C include those that have had (CDC, 2022; Workowski et al., 2021):

• Any history of or current use of injected drugs
• Blood transfusions
• Organ transplants prior to 1992
• Clotting factor infused prior to 1987
• An unregulated-ink tattoo
• Long-term hemodialysis
• HIV

All women with the infection should receive counseling and supportive care (CDC, 2022).

Pregnant, asymptomatic women do need routine screening for bacterial vaginosis, trichomoniasis, or genital herpes. Testing should be done if the patient complains of any symptoms. Genital herpes is self-limiting but recurrent. If genital herpes is visible, they should be tested by NAAT or a culture. Antiviral medication can be used to treat symptoms and prevent a reoccurrence. Genital herpes can be spread to the fetus if there is an outbreak at the time of delivery. If the patient has active lesions during labor, a cesarean section should be performed to decrease the risk of infection to the fetus. Acyclovir is thought to be safe during pregnancy and may prevent an outbreak (CDC, 2022).

STIs are highest in adolescents in the United States. Adolescents who begin having sex earlier in life are a higher risk of having STIs. They make up half of all cases of STIs in the world. All adolescents should receive counseling and screening as indicated. It is important to maintain confidentiality with these patients. Adolescents living in detention facilities or exchanging sex for drugs, food, or money are also at high risk. Transgender adolescents, adolescents with disabilities, substance abuse, or mental health disorders are also at higher risk. Factors that further increase the risk are (CDC, 2022; Workowski et al., 2021):

• Having multiple sex partners
• Failing to use condoms
• Having lower socioeconomic status
• Facing obstacles to health care 

All 50 states and the District of Columbia allow minors to consent for their own STI services (Workowski et al., 2021). Parental consent is not required for diagnosing and treating STIs. The age at which consent is needed varies by state. Providers need to know the laws in the state where they practice. It is important that all providers discuss STIs with their adolescent patients and make sure that they talk about confidentiality and make the patient feel safe. Minors may not seek screening or treatment because of their fear of having to tell their parents or guardians (Fortenberry, 2022). Patient portals that hold patient medical information are a concern because unless there are systems in place to block the information, parents can see the minor’s information. Another area where confidentiality could be broken is through the insurance provider. A bill or explanation of benefits (EOB) could disclose services that the minor received. It is an area that still needs improvement for adolescents so that their care remains confidential and they continue to seek care. Some states allow (but none require) providers to notify parents that the adolescent received treatment for an STI, even though consent was not required (CDC, 2022). Iowa requires that parents are notified if a minor receives a positive HIV screen. Reporting of STIs (to the state) is mandatory in every state for syphilis, gonorrhea, and HIV. Some states may require more STIs to be reported (Fortenberry, 2022).

In adolescents, a speculum or bimanual pelvic exam can be anxiety-provoking and cause discomfort. An external genital exam can evaluate for lesions that can be caused by herpes, syphilis, or HPV, without performing an internal exam.

A pelvic exam should be done if the patient is experiencing abdominal and pelvic pain or tenderness, for menstrual irregularities such as amenorrhea or prolonged or heavy bleeding, for evaluation of vaginal discharge if there is a suspected retained foreign body such as a tampon or condom, or for cervical cancer screening, which is not usually recommended for patients less than 21 years old unless they are immunocompromised. Traditionally, pelvic exams were done to obtain specimens for testing, but urine testing and patient-collected vaginal swabs are usually effective (Fortenberry, 2022). If a pelvic exam is needed, the procedure should be completely explained to the patient so that they know what to expect. Any specimens being collected should also be explained to the patient. If the patient is too anxious or uncomfortable, the exam should be stopped (Carusi, 2022).

HPV vaccination is recommended for all adolescents at age 11 or 12 and can be given up to age 26. Hepatitis B vaccine series should be given to all adolescents who have not received it. Hepatitis A vaccine series should be offered to adolescents who have not received it. CDC recommends HIV PrEP for adolescents weighing more than 35 kg who are at a significant risk for HIV. Providers should always discuss STIs in a safe, non-judgmental setting with adolescents (CDC, 2022).

Children who are prepubescent and have STIs can indicate sexual assault or abuse and may indicate a need for child-protection authorities to investigate. There are reporting laws in every state. Gonorrhea, syphilis, HIV, chlamydia, and trichomoniasis infections are high indicators of sexual contact, unless the infection was acquired in the neonatal period. HSV, HPV and anogenital warts, as well as vaginitis, may suggest sexual contact, but the association is not as clear (CDC, 2022).

How could communication be improved and what are this patient’s needs?

Open-ended questions in a non-judgmental manner could improve communication with this patient. Some possible questions include:

• What is your sexual orientation?
• What is your gender orientation?
• Tell me about your recent sexual activity.
• How many partners have you had recently?
• Do you have sex with males, females, or both?
• What are your sexual practices?
• Have you or your partner(s) been tested or talked about testing?
• Do you use protection and what kind?
• Have you or your partner(s) ever tested positive in the past?
• Do you plan on having children in the future?

After further conversation, the patient tells you that they have oral, anal, and vaginal sex with 1 female and 2 male partners. He has used a condom most of the time. He has never been tested and he is afraid to ask his partners. He has never had an STI in the past.

What are the needs of this patient?

This patient needs education about prevention, including condom use and instructions on how to use a condom. He should also receive screening for HIV, chlamydia, gonorrhea, syphilis, and hepatitis A, B, and C. It is important to make this patient feel that you are listening and willing to help without being judgmental.