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This document provides information on common sexually transmitted diseases that affect HIV-infected women, including herpes, syphilis, chlamydia, gonorrhea, and trichomoniasis. It describes the clinical presentations, diagnosis, and treatment considerations for each disease. Providing culturally competent care for screening and diagnosis is discussed. The conclusion emphasizes that STD screening and treatment should be a standard of care for all health care settings.

Career◦

Common Sexually Transmitted
Diseases (STDs) and
HIV-Infected Women
October 2007

2
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
2

3
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

4
Common STDs in HIV-Infected Women
1. Herpes Simplex Virus (HSV)
2. Syphilis
3. Chlamydia
4. Gonorrhea
5. Trichomoniasis

6
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

7
Herpes Simplex in Women with AIDS
Credit: Jean R. Anderson, MD

8
HSV: Diagnosis
 Clinical presentation
 Viral culture
 Tzanck smear/Giemsa smear
 Skin biopsy

9
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

11
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

12
Primary Chancre
Primary
Chancre
Credit: Centers for Disease Control and Prevention (CDC)

13
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

14
Syphilitic Rash
Credit: Dr. Gavin Hart and CDC
Credit: Connie Celum and Walter Stamn
and Seattle STD/HIV Prevention Training Center

15
Condyloma lata
Credit: CDC
Condyloma
lata

16
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

17
Syphilis: Clinical Presentation (continued)
Tertiary Stage:
 Cardiovascular: Aortic valve disease, aneurysms
 Neurological: Meningitis, encephalitis, tabes
dorsalis, dementia
 Gumma formation: Deep cutaneous
granulomatous pockets
 Orthopedic: Charcot’s joints, osteomyelitis
 Renal: Membranous Glomerulonephritis

18
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)

19
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

20
Syphilis: Treatment Considerations
 Primary/ secondary/ latent stage: Benzathine
penicillin
 Neurosyphilis: Penicillin G
 Ask about penicillin allergy before treatment
 Jarisch-Herxheimer reaction may occur

22
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

23
Cervicitis
Credit: University of Washington and
Seattle STD/HIV Prevention Training Center

24
Chlamydia: Diagnosis
 Chlamydia culture
 New tests include:
 Direct immunofluorescence assays (DFA)
 Enzyme immunoassay (EIA)

25
Chlamydia: Treatment Considerations
 Antibiotics
 Azithromycin
 Evaluate and treat sexual partners
 Avoid sex for seven days after completion of
treatment

27
N. gonorrhoeae-gram negative
diplococci
Diplococci
Credit: Negusse Ocbamichael and Seattle STD/HIV Prevention Training Center

28
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

29
Gonorrhea: Diagnosis
 Clinical exam
 Cervical culture
 Polymerase chain reaction (PCR) or ligase
chain reaction (LCR)
 Gram stain–polymorphonucleocytes with
gram negative intracellular diplococci

30
Gonococcal Isolate Surveillance Project (GISP) — Percent
of Neisseria gonorrhoeae isolates with resistance or
intermediate resistance to ciprofloxacin, 1990–2005
Percent
Resistant
Intermediate resistance
0.0
3.0
6.0
9.0
12.0
1990 91 92 93 94 95 96 97 98 99 2000 01 02 03 04 05

31
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

33
Trichomoniasis: Clinical Presentation
Signs and symptoms:
 Vulvar irritation
 Dysuria
 Dyspareunia
 Pale yellow, malodorous - gray/green frothy
discharge
 Strawberry cervix, inflamed and friable

34
Strawberry Cervix
Credit: Claire E. Stevens and Seattle STD/HIV Prevention Training Center

35
 Flagellated, motile trichomonads on wet mount
 Vaginal pH > 4.5
 Diagnosis confirmed by microscopy
 Other FDA approved tests:
 OSOM Trichomonas Rapid Test
 Affirm VP III
Trichomoniasis: Diagnosis

36
Trichomoniasis: Treatment Considerations
 For HIV-infected women: same treatment as
non-HIV infected women
 Metronidazole or Tinidazole
 Sex partners have to be treated

37
Providing Culturally Competent Care
The following factors can influence a woman’s
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

38
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.

39
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.

40
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/

41
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-STD&HIV.htm#WhatIs
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-principles.doc
US Preventive Services Task Force. Screening for gonorrhea:
recommendation Statement. Ann Fam Med 2005;3:263-7.

std-module.ppt

1.
Common Sexually Transmitted Diseases(STDs) and HIV-Infected Women October 2007
2.
2 This slide setwas 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 2
3.
3 Learning Objectives 1. Identifythe 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
4.
4 Common STDs inHIV-Infected Women 1. Herpes Simplex Virus (HSV) 2. Syphilis 3. Chlamydia 4. Gonorrhea 5. Trichomoniasis
5.
5 Herpes Simplex Virus(HSV)
6.
6 HSV: Clinical Presentation PrimaryInfection  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
7.
7 Herpes Simplex inWomen with AIDS Credit: Jean R. Anderson, MD
8.
8 HSV: Diagnosis  Clinicalpresentation  Viral culture  Tzanck smear/Giemsa smear  Skin biopsy
9.
9 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
10.
10 Syphilis
11.
11 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
12.
12 Primary Chancre Primary Chancre Credit: Centersfor Disease Control and Prevention (CDC)
13.
13 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
14.
14 Syphilitic Rash Credit: Dr.Gavin Hart and CDC Credit: Connie Celum and Walter Stamn and Seattle STD/HIV Prevention Training Center
15.
15 Condyloma lata Credit: CDC Condyloma lata
16.
16 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
17.
17 Syphilis: Clinical Presentation(continued) Tertiary Stage:  Cardiovascular: Aortic valve disease, aneurysms  Neurological: Meningitis, encephalitis, tabes dorsalis, dementia  Gumma formation: Deep cutaneous granulomatous pockets  Orthopedic: Charcot’s joints, osteomyelitis  Renal: Membranous Glomerulonephritis
18.
18 Syphilis: Diagnosis Requires demonstrationof:  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)
19.
19 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
20.
20 Syphilis: Treatment Considerations Primary/ secondary/ latent stage: Benzathine penicillin  Neurosyphilis: Penicillin G  Ask about penicillin allergy before treatment  Jarisch-Herxheimer reaction may occur
21.
21 Chlamydia
22.
22 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
23.
23 Cervicitis Credit: University ofWashington and Seattle STD/HIV Prevention Training Center
24.
24 Chlamydia: Diagnosis  Chlamydiaculture  New tests include:  Direct immunofluorescence assays (DFA)  Enzyme immunoassay (EIA)
25.
25 Chlamydia: Treatment Considerations Antibiotics  Azithromycin  Evaluate and treat sexual partners  Avoid sex for seven days after completion of treatment
26.
26 Gonorrhea
27.
27 N. gonorrhoeae-gram negative diplococci Diplococci Credit:Negusse Ocbamichael and Seattle STD/HIV Prevention Training Center
28.
28 Gonorrhea: Clinical Presentation Areasof Infection  Urethra  Endocervix  Upper genital tract  Pharynx  Rectum Signs and Symptoms  Frequently asymptomatic  Vaginal discharge  Abnormal uterine bleeding  Dysuria  Mucopurulent cervicitis  Lower abdominal pain
29.
29 Gonorrhea: Diagnosis  Clinicalexam  Cervical culture  Polymerase chain reaction (PCR) or ligase chain reaction (LCR)  Gram stain–polymorphonucleocytes with gram negative intracellular diplococci
30.
30 Gonococcal Isolate SurveillanceProject (GISP) — Percent of Neisseria gonorrhoeae isolates with resistance or intermediate resistance to ciprofloxacin, 1990–2005 Percent Resistant Intermediate resistance 0.0 3.0 6.0 9.0 12.0 1990 91 92 93 94 95 96 97 98 99 2000 01 02 03 04 05
31.
31 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
32.
32 Trichomoniasis
33.
33 Trichomoniasis: Clinical Presentation Signsand symptoms:  Vulvar irritation  Dysuria  Dyspareunia  Pale yellow, malodorous - gray/green frothy discharge  Strawberry cervix, inflamed and friable
34.
34 Strawberry Cervix Credit: ClaireE. Stevens and Seattle STD/HIV Prevention Training Center
35.
35  Flagellated, motiletrichomonads on wet mount  Vaginal pH > 4.5  Diagnosis confirmed by microscopy  Other FDA approved tests:  OSOM Trichomonas Rapid Test  Affirm VP III Trichomoniasis: Diagnosis
36.
36 Trichomoniasis: Treatment Considerations For HIV-infected women: same treatment as non-HIV infected women  Metronidazole or Tinidazole  Sex partners have to be treated
37.
37 Providing Culturally CompetentCare The following factors can influence a woman’s 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
38.
38 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.
39.
39 Conclusion  STD screeningand 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.
40.
40 Helpful Resources  AETCNational 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/
41.
41 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-STD&HIV.htm#WhatIs 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-principles.doc US Preventive Services Task Force. Screening for gonorrhea: recommendation Statement. Ann Fam Med 2005;3:263-7.

Editor's Notes

#2 Speaker notes: This slide set with speaker notes is intended to be used to train providers in family practice, primary care, and other clinical settings. The goal of this slide set is to provide an introduction to the five most common sexually transmitted diseases (STDs) in HIV-infected women. The slides can be adapted based upon the learning needs of the audience. NOTE: When printing this slide set, please be sure to select either color or gray scale. When the slides are printed in black and white, some of the graphics are compromised.
#3 Speaker notes: Each year, the AIDS Education and Training Centers (AETC) National Resource Center (NRC) coordinates workgroups on topics identified through needs assessment activities. For the 2006-07 grant year, the topic of women's health was selected for an AETC workgroup. This workgroup was charged with the task of facilitating collaboration among the AETCs, and other federal training partners, in the identification, development, and/or dissemination of resources and tools, which address a gap or area of emerging need, for AETC clinicians and/or trainers.With Dr. Laura Armas from the Texas/Oklahoma AETC as the Workgroup Leader, the AETC NRC coordinated the Women's Health and Wellness Workgroup. As a subset of this Workgroup, the Cervical Cancer Screening Subgroup developed this training slide set, which is part of the Clinical Issues Training of Trainers (TOT) package. A slide set on cervical cancer screening with a focus on Pap smears and pelvic examinations and a slide set on human papillomavirus (HPV) infection in HIV-infected women is also included in the package. A System Issues Technical Assistance (TA) package was also developed by the Cervical Cancer Screening Subgroup to assess and remedy system barriers to cervical cancer screening. The package includes a training slide set titled Using a Fishbone Diagram to Assess and Remedy Barriers to Cervical Cancer Screening in Your Healthcare Setting. This is accompanied by a Guidebook.
#4 Speaker notes: Upon completing this training, participants will be better able to: Identify the five most common STDs affecting HIV-infected women Discuss clinical presentations associated with the five common STDs Recall methods for diagnosing the five common STDs
#5 Speaker notes: This presentation will focus on the five most common STDs found in HIV-infected women. This includes: 1. Herpes Simplex Virus (HSV) 2. Syphilis 3. Chlamydia 4. Gonorrhea 5. Trichomoniasis Information will be presented on the clinical presentations, diagnosis, and treatment of each STD listed on this slide.
#6 Speaker notes: NOTE: The next five slides will focus on HSV. HSV outbreaks may be more frequent, prolonged, and/or severe in HIV-infected women, particularly as their immunity declines. Also, HSV infection increases the risk for transmission or contraction of HIV.
#7 Speaker notes: Primary Infection HSV-1 (oral) and HSV-2 (genital) cause both oral and genital primary infection and recurrent disease. Prodrome phase: This phase occurs immediately prior to the appearance of the vesicles and usually presents as tingling/itching of the skin. The prodrome phase is followed by appearance of painful vesicles in clusters on an erythematous base. These vesicles then ulcerate, forming crusts (usually golden in color), and then usually heal within 7-14 days. HIV-infected individuals with low CD4 cell count have more frequent occurrences and more extensive ulcerations. Vesicles may coalesce then become chronic and non-healing. Viral Shedding Explanation of viral shedding: The herpes simplex virus lies dormant in the cells. Once this latent period is over, the virus may reactivate and multiply, causing the virus to spread and be transmissible. This viral shedding may be asymptomatic, but the patient can still transmit the virus to others, particularly during sexual activity. Viral shedding increases with: Oral-contraceptive use Depo-Provera use Women with severe Vitamin A deficiency Recurrent Disease After primary infection, virus migrates to sacral dorsal root ganglion in the spinal cord and lies dormant. Reactivation of the herpes simplex virus occurs due to various triggers such as: stress, decreasing CD4 cell counts, increasing viral loads, or concomitant infections. Recurrent episodes are usually milder and shorter in duration and tend to be more localized. Persistent HSV eruptions (>1 month) is an AIDS defining illness.
#8 Speaker Notes: The above picture shows Herpes simplex in woman with AIDS, CD4 cell count <50. Again note the coalescence of the lesions and consequent ulcer formation, this particularly occurs in patients who are severely immunocompromised.
#9 Speaker notes: Clinical presentation: The diagnosis of HSV is usually based on clinical appearance and symptoms, without laboratory testing. Viral culture: If diagnosis is uncertain, obtain specimen from a freshly opened vesicle or the base of an ulcer and send for viral culture. Note that vesicles that are more than 2-3 days old may not show HSV in the culture specimen. Polymerase chain reaction (PCR) is also a sensitive diagnostic test for detection of herpes DNA in ulcerative lesions, but it is more expensive test and less widely available than viral culture. Tzanck smear/ Giemsa smear: If a culture is not available, perform a Tzanck smear, or Giemsa smear, by staining scrapings from the base of the lesion with Giemsa or methylene blue to reveal the typical multinucleated giant cells. Note: this test is fairly insensitive and not widely used. Skin biopsy: If cultures are negative and there is a high suspicion of HSV, skin biopsy may be taken from edge of the ulcer for biopsy. The biopsy material may also be cultured. Single serologic tests that detect HSV-1 and HSV-2 antibodies can determine if the patient has ever been infected with HSV. A 4-fold or greater rise in antibody titer between the acute and convalescent serum specimens may diagnose primary HSV. However, only 5% of persons with recurrences will develop a 4-fold rise in titer.
#10 Speaker notes: Antiviral Therapy Initial episode: Acyclovir (Zovirax) 400mg po tid x 7-10 days Acyclovir (Zovirax) 200mg po 5 x day x 7-10 days Famciclovir (Famvir) 250mg po tid x 7-10 days Valacyclovir (Valtrex) 1 gm bid x 7-10 days Empiric treatment for suspicious lesions is often initiated in the absence of laboratory confirmation. In some instances treatment can be started empirically and, if no response is seen within 7-10 days, laboratory studies can be undertaken. If possible, do a follow-up call during treatment period to assess response to treatment. B. Recommended regimens for episodic outbreak in HIV-infected persons: Acyclovir (Zovirax) 400mg po tid x 5 days Acyclovir (Zovirax) 800mg po bid x 5 days Acyclovir (Zovirax) 800mg po tid x 2 days Famciclovir (Famvir) 125mg po bid x 5 days Famciclovir (Famvir) 1gm po bid x 1 day Valacyclovir (Valtrex) 500mg po bid x 3 days Valacyclovir (Valtrex) 1 gm po od x 5 days Acyclovir OR Famiciclovir OR Valacyclovir C. Severe disease: Treat initially with IV Acyclovir. D. Acyclovir resistant HSV: Confirmed with culture and sensitivities. Cross-resistance to Famiciclovir / Valcyclovir and Ganciclovir will be present. Usual alternative is IV Foscarnet. May also use topical Cidofovir gel applied to lesions. E. Regimens for chronic suppressive therapy in HIV-infected persons (>6 outbreaks/year) Acyclovir (Zovirax) 400mg po bid Famciclovir (Famvir) 250mg po bid Valacyclovir (Valtrex) 500mg po od Valacyclovir (Valtrex) 1 gm po od Treatment may be continued indefinitely. Suppressive therapy may reduce the risk of HSV transmission. Localized Treatment Consideration Lesions may be bathed in mild soap and water. If the crusting is severe, and causing discomfort, bathing with mild soap and water tends to soften the hard crusts, alleviating some of the discomfort. Sitz baths may also provide some soothing relief of the lesions. Updated treatment information: For more updated and in-depth information on HSV treatment, please visit: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5511a1.htm
#11 Speaker notes: The next 10 slides will focus on syphilis. This is an important topic to discuss since there is an estimated 2-to 5-fold increased risk of acquiring HIV infection when syphilis is present. Ulcerative STDs that cause sores, ulcers, or breaks in the skin or mucous membranes, such as syphilis, disrupt barriers that provide protection against infections. The genital ulcers caused by syphilis can bleed easily. When they come into contact with oral and rectal mucosa during sex, it increases the infectiousness of and susceptibility to HIV. Keep in mind that atypical manifestations of the disease may be seen in HIV-infected patients.
#12 Speaker notes: Syphilis is an infection that is characterized by sequential stages and is caused by spirochete Treponema pallidum. The three main stages of syphilis are: Primary (infectious or early stage): There are 2 PHASES in the primary stage: primary and secondary Secondary (latent) stage Tertiary stage This slide focuses on the primary phase of the primary stage. The primary phase involves the formation of a chancre. Chancre description: It begins as papule and erodes into a painless ulcer with a hard edge and clean base. It is usually in the genital area. The chancre appears within 9-90 days after exposure. The median is three weeks. Chancre may be solitary lesions or they may be multiple lesions, also known as kissing lesions. In a kissing lesion, two surfaces touch each other such as on the labia or between the buttocks. Chancre heals within 3-6 weeks, however scarring may be present. Seventy five percent of patients may show no further symptoms. Chancre may proceed to latent stage if untreated. Chancre may include neurosyphilis (central nervous system (CNS) involvement).
#13 Speaker notes: The picture above is that of a primary syphilitic chancre on labia. As mentioned earlier, the characteristic of syphilitic chancre is that it presents as a painless ulcer with a hard edge and a clean base. Especially in the areas such as the labia, the provider may see ‘kissing lesion’ on the opposite surface. For example, if primary chancre is on the left labia, a kissing lesion may be found on right labia, due to close proximity of the two surfaces. (The picture above does not show a kissing lesion).
#14 Speaker notes: This slide focuses on secondary phase of the primary stage of syphilis. This phase occurs at 6 weeks to 6 months after the appearance of the chancre and lasts several weeks. It may be accompanied with: fever, malaise, generalized lymphadenopathy, patchy alopecia on the scalp, eyebrows, and beard. Maculo-papular rash usually appears on palms and soles. Another characteristic lesion of this phase is Condyloma lata. This is a flat, pink, warty lesions on perianal or vulval areas. Mild hepatosplenomegaly may be present on physical exam. May proceed to latent stage if untreated. Neurosyphilis should be considered in HIV-infected patients who present with neurological signs and symptoms due to increased central nervous system (CNS) involvement in these patients.
#15 Speaker notes: This slide shows a syphilitic rash which occurs in the secondary phase of the primary stage. Remember these rashes can be highly infectious so please wear gloves. Left view: Rash has covered the back, representing systemic spread of Treponema pallidum. Right view: papulosquamous rash of secondary syphilitic lesions on the soles of patient’s feet.
#16 Speaker notes: Picture above demonstrates condyloma lata lesions on the vulva and anal regions. Note the typical flat, wart-like appearance of the lesions.
#17 Speaker notes: The secondary stage is also known as latent stage. During this stage, serology is positive (ie, Rapid Plasma Reagin (RPR) or Venereal Disease Research Lab (VDRL)). These tests are discussed in more detail on slide 18 titled Syphilis: Diagnosis in the speaker notes. Patients are asymptomatic. They are also not infectious after first year, but may relapse to infectious secondary stage if untreated. One-third will convert to sero-negative status, one-third will stay sero-positive but asymptomatic, and one-third will develop tertiary syphilis.
#18 Speaker notes: The tertiary stage is characterized by complications of the following body systems: Cardiovascular: Aortic valve disease or aneurysms Neurological: Meningitis, encephalitis, tabes dorsalis, dementia Gumma formation: Deep cutaneous granulomatous pockets Orthopedic: Charcot’s joints, osteomyelitis Renal: Membranous glomerulonephritis
#19 Speaker notes: This slide presents the diagnostic tests for syphilis. There are non-specific tests and specific tests. Non-Specific Treponomal Tests: These are inexpensive, primary screening titer tests. Tests are positive within 7 days of exposure. A titer of > 1:64 is probably diagnostic of syphilis or other treponemal infection. These titers are used to monitor therapy and they decrease with time and treatment. Two non-specific tests are: 1) VDRL - Venereal Disease Research Laboratory (VDRL) and, 2) Rapid Plasma Reagin (RPR). VDRL / RPR monitoring: 4-fold rise in titer (eg, 1:8 to 1:32) indicates new infection. Failure to decrease 4-fold within 3 months of treatment for primary/secondary syphilis or 6 months-1 year of treatment for latent syphilis is indicative of treatment failure. Titers usually become negative after treatment, but they may remain present as low titers (eg, 1:2, 1:4). An increase from this baseline will indicate a new infection or treatment failure. False negatives occur if: 1) blood is drawn too early in infection (< 2 week old) or 2) Prozone phenomena - in secondary syphilis where there are high concentration of antibodies which mask the infection. All dilutions must be tested to declare specimen negative. False positives are common and may occur in the following diseases or conditions: 1) rheumatoid arthritis, 2) collagen vascular disease, 3) mononucleosis, 4) drug addiction, 5) pregnancy, 6) febrile illness, 7) malaria, or 8) leprosy.
#20 Speaker Notes: Specific Treponemal Test: These are used to confirm diagnosis. They are reported as reactive or non-reactive. They are usually positive for life after treatment. Due to unusual, non-specific results in HIV patients, they are absolutely needed to rule out syphilis. Two specific tests are: Fluorescent Treponomal Antibody absorption (FTA-ABS) and Microhemagglutination- Treponema pallidum (MHA-TP) Other Diagnostic Tests: Lumber Puncture: Should be performed for Cerebrospinal fluid (CSF) serology Used in latent syphilis where duration of infection is unknown, or non-penicillin treatment is planned, or when neurological symptoms are present. Special note to remember when performing various diagnostic tests using CSF: VDRL, not RPR, used on CSF, may be negative in neurosyphilis Negative FTA-ABS or MHA-TP on CSF excludes neurosyphilis
#21 Speaker notes: Primary/secondary/early latent stage: Benzathine penicillin (Bicillin) 2.4mu IM x 1 dose Late latent: Bicillin 2.4mu IM 1 dose weekly x 3 weeks Neurosyphilis: 3-4million units Penicillin G IV q4 x 10-14 days HIV-infected women often need longer treatment and higher doses, especially as HIV advances. When a Penicillin allergy exists, Erythromycin, Tetracycline, Ceftrioxone (Rocephin), or Doxycycline may be used. Desensitization recommended for HIV and pregnant patients. Do not use other penicillin formulations. Do not use Azithromycin as it may result in rapid resistance to drug. Jarisch-Herxheimer reaction: Common within 24 hours of starting treatment due to lysis of treponemes. Symptoms include fever, chills, headache, myalgia, and new rash. Do not confuse with allergic reaction to treatment. Manage with antipyretics and antihistamines. Follow-up: Repeat serologies at 3 months, 6 months, and 1 year Updated treatment information: For more updated and in-depth treatment information on Syphilis, please visit: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5511a1.htm
#22 Speaker notes: NOTE: The next five slides will focus on chlamydia. It is to be noted that there are no significant differences in prevalence, clinical presentation, diagnosis, and treatment in HIV-infected women compared to non HIV-infected women.
#23 Speaker notes: Common clinical presentation of chlamydia include: Mucopurulent cervicitis / vaginal discharge Dysuria Lower abdominal pain Urethritis, salpingitis, proctitis Post coital bleeding – friable cervix Key considerations are that: 50% of females are asymptomatic Think of chlamydia: If a patient presents with urinary tract infection symptoms and the urine culture comes out sterile, also known as sterile pyuria.
#24 Speaker notes: Picture above depicts ectopy, edema, and discharge of the cervix due to chlamydial infection. NOTE: Ectopy refers to the area of the ectocervix lined by columnar epithelium. This area of ectopy is fragile and friable due to the blood vessels lying close to the surface and in close contact with the vaginal environment. This friability places the patient at a higher risk for HIV transmission or contraction.
#25 Speaker notes: A chlamydia culture is the gold standard for diagnosis, but this test is expensive and can take from 2-6 days to obtain results. There are two new tests available. 1) Direct immunofluorescence assays (DFA): This is a fast test and results may be obtained within 30 minutes. The test has good sensitivity and specificity. 2) Enzyme immunoassay (EIA): This is a low cost test and results may be obtained in 30-120 minutes. However, false positives may be a problem. Explanation of terms: Sensitivity refers to the probability of a positive test among patients with disease. Specificity refers to probability of a negative test among patients without disease.
#26 Speaker notes: Patients are often treated empirically based on clinical diagnosis. Treating patients prevents transmission to sex partners. Treating pregnant women usually prevents transmission to infants during birth. Co-infection with chlamydia frequently occurs in patients who have gonnococcal infection. Presumptive treatment of those patients is appropriate. Sex partners should be treated if there was sexual contact within 60 days preceding onset of symptoms. Consider partner notification if available (explained under ‘Pearls of Wisdom’, slide no. 40). Treatment: Azithromycin ( Zithromax) 1 gm po single dose OR Doxycycline 100mg po bid x 7 days Alternatives: Ofloxacin 300mg po bid x 7 days OR Levofloxacin 500mg po od x 7 days Erythromycin 500mg po qid x 7 days (use in pregnancy) or Amoxicillin 500mg po tid x 7 days Special Considerations – Pregnancy: Doxycycline, Ofloxacin and Levofloxacin are contraindicated Azithromycin or Amoxycillin are safe to use during pregnancy Follow-up testing 3 weeks after completion of regimen recommended for pregnant women, to avoid the sequale that might occur in the mother or neonate if the infection persists. Follow-up: Not recommended for persons treated with recommended or alternative regimes unless therapeutic adherence is in question, symptoms persist, or reinfection is suspected. Patients are advised to avoid all sexual contact for seven days after the completion of treatment. Updated treatment information: For more updated and in-depth treatment information please visit: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5511a1.htm
#27 Speaker notes: NOTE: The next seven slides will focus on gonorrhea. It is to be noted that there are no significant differences in prevalence, clinical presentation, diagnosis, and treatment in HIV-infected women as compared to non HIV-infected women. .
#28 Speaker notes: This slide shows the typical diplococci of N. gonorrhoeae. Gonorrhea is caused by gram-negative diplococcus, Neisseria gonorrhoeae. The incubation period is 2-14 days. It can affect the genital tract, oro-pharynx, and anal canal. There are one million new infections annually in US and gonorrhea is the second most common STD. Gonorrhea affects 20% of normal vaginal delivery neonates of infected mothers causing ophthalmic neonatorum (gonorrhea of the eyes in the neonates due to exposure during delivery through the birth canal of an infected mother). Transmission risk: -Male to Female: 70% after 1 exposure -Female to Male : 20% with 1 exposure; 60%-90% with 4 exposures
#29 Speaker notes: Areas of infection include urethra, endocervix, upper genital tract, pharynx, and rectum. Gonorrhea in women is frequently asymptomatic, and therefore frequent screening in high-risk women, particularly HIV-infected women, is recommended. Signs and symptoms include vaginal discharge, abnormal uterine bleeding, dysuria, mucopurulent cervicitis, and lower abdominal pain. It is important to also note that 20-40% of pelvic inflammatory disease (PID) is caused by gonorrhea and many infections do not produce symptoms until complications like PID occur.
#30 Speaker notes: Diagnosis is made by: 1) Clinical examination: looking at patient’s signs and symptoms 2) Cervical culture: do not refrigerate the culture, and 3) PCR/LCR: can be used with cervical, urethral, or urine specimens and it may detect gonorrhea and chlamydia simultaneously. 4) Gram stain–polymorphonucleocytes with gram negative intracellular diplococci can be seen.
#31 Speaker notes: This slide addresses the recent CDC treatment guideline update for gonorrhea due to emerging resistant patterns to fluoroquinalones, which were previously the drugs of choice for treatment Fluoroquinalones (ie. Ciprofloxacin, ofloxacin, levofloxacin) are no longer recommended for treatment of Gonoococcal infections due to widespread resistance patterns. Also use of a single, oral dose of Azithromycin is now not recommended because of concerns regarding rapid emergence of resistance. However, this may be used if person has documented sever allergy to Penicillin or cephalosporins.
#32 Speaker notes: Ceftriaxone 125mg IM single dose OR Cefixime 400mg po single dose Alternate Regimens: Spectinomycin 2gm IM single dose OR Cephalosporin single dose regimens Evaluate and treat all sexual partners Pregnant women should be given Ceftriaxone single dose but substitute Quinolones with Erythromycin. Furthermore, pregnant women should not be treated with Quinolones or Tetracyclines. For more in-depth treatment options for Gonorrhea, please visit: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5511a1.htm For CDC’s latest information on discontinued use of floroquinolones, please visit: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5614a3.htm?s_cid=mm5614a3_e
#33 Speaker notes: NOTE: The next five slides focus on trichomoniasis. Incidence, persistence, and recurrance of trichomoniasis in HIV-infected women are not significantly different compared with HIV-negative women.
#34 Speaker notes: Trichomoniasis is caused by Trichomonas vaginalis and accounts for 10% of all vaginal infections. It occurs primarily in women with normal estrogen levels. Signs and symptoms: Vulvar irritation Dysuria Dyspareunia Pale yellow, malodorous - gray/green frothy discharge Strawberry cervix, inflamed and friable
#35 Speaker notes: This slide shows the classic ‘strawberry cervix’ of trichomoniasis infection. Note the petichiae-like appearance and gray-green frothy discharge.
#36 Speaker notes: Flagellated, motile trichomonads on wet mount. Vaginal pH > 4.5. Diagnosis usually confirmed by microscopy, if available. Only 60%-70% sensitivity rate as it requires immediate evaluation of the wet-prep slide for optimum results Other FDA approved tests for “Point of Care” Testing: 1. OSOM Trichomonas Rapid Test (Genzyme Diagnostics, Cambridge , MA) Dipstick technology Results available in 10 minutes 2. Affirm VP III (Becton Dickenson, San Jose, CA) Nucleic Acid probe Results available in 45 minutes
#37 Speaker notes: Metronidazole 2gm po stat, single dose (may be used in 2nd trimester of pregnancy) OR Tinidazole 2 gm po stat, single dose Alternate or for Treatment failure: Metronidazole 500mg po bid x 7days Patients should avoid use of alcohol 24 hours after completion of Metronidazole or 72 hours after completion of Tinidazole. Metronidazole gel is less efficacious for treatment of Trich. (> 50%) and therefore is not recommended. Follow-up: Not recommended for patients who become asymptomatic. Treatment failure: Some strains of Trichomoniasis can have diminished susceptibility to Metronidazole (2-5% cases) but these are usually more susceptible to Tinidazole as it has a longer serum half-life and reaches higher levels in genitourinary tissue than Metronidazole. If failure occurs with Metronidazole 2gm single dose and re-infection can be excluded, patient can be treated with the Metronidazole 500mg po bid x 7 days or Tinidazole 2gm po single dose. For patients failing both these treatments consider treating with either drug at 2gm po daily for 5 days. If still failing treatment refer to specialist or call CDC for consultation and T. vaginalis susceptibility testing at 770-488-4115; website: http://www.cdc.gov.std. Management of sex partners: Partners should be treated with a single dose or 7 day regimen. Instruct to avoid sex until they and their partners are treated and cured (ie. when treatment has been completed and they are both asymptomatic).
#38 Speaker notes: Many women may have a different understanding of illness than western healthcare providers. It is important to be open to the women’s approach to wellness and illness and to use their belief system when educating about sexually transmitted diseases. Women from many different cultures are uncomfortable speaking about sexual health. When taking a sexual health history or explaining sexually transmitted diseases begin with less threatening and more general questions. Progress to more personal issues once trust has been established. Remind women that you ask questions about sex of everyone and they are important part of assessing one’s overall health. Many women find STD screening difficult and/or uncomfortable. It may be helpful to ask her about her previous experiences and address any concerns or anxieties. If she has never had an exam, explain the exam before it is performed and show her the instruments. This is best done before she changes into a gown for the exam when a women may feel vulnerable. All of the challenges mentioned above can be barriers to follow-up. At the end of the exam be clear with the patient about how and when you will follow-up with her. If possible, involve other members of the clinic team to help patients follow-up. Possible questions for participants: 1: Ask participants how these factors may influence the ability of the provider to obtain a complete and thorough sexual history, and also prevent the completion of a GYN exam, including STD screenings . 2: Ask participants how these factors may influence the patient to follow through with partner notification and subsequent partner screening and treatment. For more information on how to define cultural competency and frameworks for cultural interactions when caring for people infected with HIV, review the AETC Guiding Principles for Cultural Competency that is listed in the references section of this slide set (HRSA HAB, 2006).
#39 Speaker notes: It is very important to get comfortable with obtaining a good, thorough sexual history. To do so, assure confidentiality and explain why the questions you are asking are important. Do not assume anything. Ask for an explanation of sexual practices. Use direct and non-judgmental questions about specific behaviors. Patients may be more forthcoming with their responses if the behaviors are normalized. Check oral cavity if genital STD suspected because partners often engage in oral sex and infections can be transmitted from the genital area to the oral cavity. For this reason, it is important to ask patient during history-taking about sexual practices, including engagement in oral sex. It is recommended to coincide annual STD screenings with annual Pap examination. Partner notification: To inform the partner that they may be infected with an STD can be carried out by the patient. However, if patient is not comfortable in informing their partner, many States or Local Health Departments offer the services of a “Partner Notification Program”. This service will notify the partner that they may have been exposed to an STD. The source is kept confidential. It is also important to prevent reinfection between partners. Therefore, risk reduction counseling for both patient and partner is an important part of treatment and follow-up.
#40 Speaker Notes: Numerous studies have shown that aberrations in the genital tract lining or skin due to genital ulcers, cervical infections, and / or vaginal infections found in STDs increases HIV shedding and consequently increases the risk for contracting and transmitting HIV infection. Control and treatment of STDs should be considered a primary intervention to assist in the reduction of HIV transmission. STD screening and treatment may decrease HIV infectiousness among persons who do not qualify for highly active antiretroviral therapy (HAART), (eg, those with CD4 cell counts of > 350 or even those persons who are receiving HAART) since these infections may stimulate genital viral replication even in those persons with good HIV suppression.
#41 Speaker notes: NOTE: It may be helpful to print out this resource list for participants.

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