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SCREENING, DIAGNOSIS, AND TREATMENT OF SEXUALLY TRANSMITTED DISEASES IN PRIMARY CARE SETTINGS (14HC03)

Bonnie Richards, DO, BSN, Patricia Mason, BS, PHA and Sindy M. Paul, MD, MPH, FACPM

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Case Studies
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CASE STUDIES

CASE STUDY 1: Presumptive HIV positive male referred from a “Rapid-Rapid HIV testing” site

History and clinical presentation

A 17 year old African American male referred from a New Jersey needle exchange program with a report of a presumptive positive from a site that uses the “Rapid-Rapid HIV testing” algorithm. His mother — who knew he had a history of unprotected sex — escorted him to the HIV testing site because he had a rash on his body. He had received an HIV test a month previously at an agency in another state, but had not returned for results. He also reported that he had a scant penile discharge two weeks ago, but that had resolved, however he still complained of some meatal irritation and itching.

Social History

Lives in apartment with his mother and younger brother. He has smoked tobacco approximately 7 cigarettes per day ‘for several years’. Reports marijuana and alcohol use in the past. Denies any other illicit drug use. He dropped out of school at age 16 years.

Sexual history (using CDC’s “5 P” approach)

Partners: His first sexual encounter was at the age of 15 years. He has had approximately 40-50 sexual encounters in the last 2 years and about 5 in the last 2 months. All of the partners were male. He has never had sex with a female. He has a current boyfriend, but also has sex with other partners. His last sexual encounter was 3 days ago with his current boyfriend. He meets his partners mainly through internet chat-lines. These encounters are anonymous, single encounters with no contact after sex. He denies receiving money for sex and denies any physical or sexual abuse.

Prevention of pregnancy: not applicable at this time.

Protection from STDs: He occasionally uses condoms if he has them, or if any of his partners insist. He did use one in the encounter 3 days ago. He is knowledgeable about risk reduction practices, having attended the Many Men, Many Voices trainings, a CDC-approved group HIV prevention intervention for MSMs.

Practices: He reported that he practices insertive and receptive anal intercourse and oral sex.

Past history of STDs: He denies any history of STDs or being tested for STDs in the past.

INITIAL VISIT
  • Given this patient’s social and sexual history, what would be the focus of your physical exam?
  • Keeping in mind that this patient was just diagnosed as presumptive HIV positive at a counseling and testing site, which laboratory tests would you request?
  • What education and counseling would you provide?

Physical exam

Fit and healthy looking teenager with an unremarkable physical exam. Vital signs within normal limits. No fever or headaches. No rashes or other dermatological findings. Normal genitalia. 1cm right inguinal non-tender, node. No sign of a penile discharge or genital/rectal lesions.

Initial management

Laboratory testing: A full HIV, STD workup was conducted, including syphilis screen; nucleic acid amplification tests (NAATs) for oral, anal and genital gonorrhea and chlamydia screening; hepatitis B and C screens; TB screen.

Patient education and counseling: The patient was engaged in a discussion about HIV infection and potential STD infection, including transmission risk, spectrum of disease, treatment options. Risk reduction techniques were reviewed and condoms provided. A psycho-social assessment was performed by the social worker. A discussion regarding partner notification resulted in the patient stating that he had already informed his current boyfriend of his own HIV status and the partner was also going to get tested. He had no contact information for most of his other partners.

SECOND VISIT
Given the following laboratory results, how would you manage this HIV-infected patient?
  • HIV Western Blot—reactive
  • HIV PCR RNA—32,534 copies
  • CD4—absolute 589; percent 22.6
  • CBC—WNL
  • CMP—WNL
  • FTA abs—reactive
  • RPR titer—1:256
  • GC—negative anal, oral, urine
  • Chlamydia—negative anal, oral
  • Chlamydia—positive urine
  • Hep C Ab—negative
  • HBsAg—negative, AHBc—negative, AHBs—positive
  • HIV genotype—no resistance detected
  • Toxicology screen—negative
  • Serum TB test—negative

Management and clinical course

Second visit: The patient was contacted immediately upon receiving the lab results and was scheduled to return the next day for care and treatment. He was treated for:

  • Syphilis infection with benzathine penicillin G 2.4 million units IM as single dose
  • Chlamydia infection with azithromycin 1 gram by mouth, single dose

Health education and risk reduction messages were reinforced. The patient stated that the diagnosis of syphilis had scared him more than the HIV diagnosis and that he was going to abstain from sex for a while. A discussion regarding starting ARV therapy to treat the HIV infection resulted in the patient requesting to hold off on medication at this time, despite the fact that — as per current guidelines — he does meet the criteria to start ARV therapy. He submitted an application for the AIDS Drug Distribution Program (ADDP); he enrolled in financial counseling to qualify for charity care. He agreed to inform his boyfriend of his exposure to syphilis and chlamydia.

Subsequent visits: At subsequent visits, the patient received the first dose of a two dose regimen of Hepatitis A vaccine and Pneumococcal vaccine. Follow up serologies for syphilis were drawn every 3 months and the titers went from 1:256 to 1:4 in a nine month period. The second Hepatitis A vaccine dose was given after six months. HIV treatment continues to be discussed and his HIV infection monitored every 3 months. It is expected that he will be ready to start ARV therapy in the near future. The patient reported that he had resumed sexual activity and remains monogamous with his boyfriend. The boyfriend had tested positive for syphilis and received treatment for both syphilis and chlamydia. The boyfriend was also tested for HIV, but the patient was unaware of his boyfriend’s HIV status at this time. He reported using condoms 100% of the time for anal sex however occasionally did not use a condom for oral sex.

Current status: At this time, he is employed part time and is going back to school to get his GED; he is interested in entering the hotel/ hospitality business. The patient is currently engaged in his health care and to date has kept all of his scheduled visits for his ongoing HIV care. Behavior change is very difficult to implement and maintain and health education and risk reduction conversations need to take place with the patient at every visit.

COMMENTS:

The National HIV/AIDS Strategy recommends ongoing prevention education, early screening for and identification of STDs and HIV infection, referral and linkage to care and treatment services, and maintenance of patients in care. This case study addresses a number of these recommendations.

The focus of the case study is a high risk young man who has sex with men (YMSM). Like other YMSM, particularly YMSM of color, he needs access to quality prevention and care and treatment services. This case highlights the collaboration between HIV testing sites and care and treatment services, and the impact this collaboration can have on a patient’s short- and long-term health outcomes. It also emphasizes the need to take a sexual history for all new patients, as the sexual history provides guidance on laboratory testing, physical examination and health education.


CASE STUDY 2: Female with trichomonas

History and clinical presentation

“Gail” is a 33 year old African American female who was diagnosed with HIV during her first pregnancy in 1990. She now has 3 children ages 22, 20 and 19 years. All children were born HIV-negative. After the third child in 1993 she received a bilateral tubal ligation. Since 2007, Gail has been not only fully engaged in HIV care, but also on ARV therapy and very adherent. Prior to 2007 she received intermittent care from a number of providers. Her HIV PCR RNA (viral load) at the time of starting ARV therapy was 114,000 copies, and her CD4 count was 304. She has remained virally suppressed for several years, but her current HIV PCR RNA is < 20 copies. Her CD4 absolute count increased over time and has remained between 550 and 650. Gail is fit and healthy and has no other chronic illnesses. She has received regular GYN care since 2009 and her PAP smears have remained within normal limits.

Social history

Gail lives in an apartment with her mother and 3 children. She has a full time job working as a receptionist. She has used marijuana, alcohol and tobacco in the past, but denies current use.

Clinical presentation

Gail presented to the office following a phone call during which she stated that she had recently had sex but the condom had broken, so she wanted to be seen. Upon arrival Gail appeared nervous and was tearful. She explained that she had met a man 3 weeks ago; they had sexual intercourse for the first time 3 days ago, during which time the condom had broken. The next day she had received a call from him during which he stated that he had unprotected sex with another female prior to their encounter, and that she had informed him that she had an STD. Gail denied any pain, tenderness, vaginal discharge, or itching.

Sexual history (using CDC’s “5 P” approach)

Partners: Her first sexual encounter was at the age of 17 years. The number of encounters in the previous two years was approximately 5. In the last 2 months she has had 1 encounter. All of her partners were male. Her last sexual encounter was 3 days ago with a partner she had met 3 weeks ago. Gail stated that “she always seemed to pick the wrong guy” and that “men just want one thing, then they move on.”

Prevention of pregnancy: She received a bilateral tubal ligation in 1993 and stated that she has no desire to have any more children.

Protection from STDs: She always tries to get her partner to use condoms, but admits that sometimes she has unprotected sex. She stated that she always tries to douche before and after sex, and that she puts a little bleach in her bath water to “keep herself clean and odor free”. Both are practices that her mother had taught her.

Practices: She reported that she practices only vaginal intercourse and denies ever having oral or anal sex as “that is nasty.”

Past history of STDs: She has been treated for trichomonas 3 times in the past six years, the last time being in October 2010, she was also treated for chlamydia at that time. She denies a history of syphilis or gonorrhea. She has been screened annually for syphilis since receiving HIV care: all have been negative.

INITIAL VISIT
  • Given this patient’s social and sexual history, what would be the focus of your physical exam?
  • Which laboratory tests would you request?
  • What education and counseling would you provide?

Physical exam

Her vital signs were WNL and her physical exam unremarkable. Her pelvic exam was also unremarkable, with no sign of redness, bleeding, lesions, vaginal discharge, no adnexal or cervicalmotion tenderness and no lymphadenopathy. Vaginal pH was 5.

Initial management

An STD workup was conducted, including:

  • Syphilis screen
  • Endocervical cultures for chlamydia, gonorrhea and trichomoniasis

Gail was engaged in a discussion about safer sex practices, condom use and negotiation. The healthcare provider also broached the topic of douching and use of bleach in the bath water. The patient was educated about the health implications of these practices, including the risk that douching will increase susceptibility to infection because it causes inflammation of, or damage to, the mucous membranes and changes the pH of the vaginal secretions. At this point in the discussion, the patient also spoke about her disappointment in her choice of partners and how they often rejected her after developing a sexual relationship. She commented that she often felt “dirty” after being rejected by her partners. This conversation prompted a referral to the licensed clinical social worker for a more in depth psycho-social assessment.

SECOND VISIT

Given the following laboratory results, how would you manage this patient?

  • FTA abs — non-reactive
  • RPR — negative
  • GC — culture negative
  • Chlamydia — culture positive
  • Trichomoniasis — culture positive

Management and clinical course

Second visit: The patient was contacted immediately upon receipt of the laboratory test results and prescribed:

  • Azithromycin 1 gm po x 1 dose
  • Metronidazole 500mg po bid x 7 days
  • In addition, Gail was linked to regular mental health counseling to address her relationship issues

She was instructed to refrain from any sexual activity until the treatment was completed, in one week’s time. It was also recommended that she refer her sexual partner for treatment. A follow-up phone call the next day confirmed that she had taken the prescribed azithromycin dose and was taking the metronidazole. A follow-up appointment was made for 3 months hence.

Current status: Gail is currently engaged in weekly counseling. In a follow up phone call to her, it was learned that she is working with a counselor on low self-esteem issues; she feels she is making progress. She is not ready to engage in any relationships in the near future.

COMMENTS:

This case study highlights not only the importance of STD screening and follow-up, but also the importance of conducting a thorough sexual health history. Guided by CDC’s “5 P” approach, and using compassionate, non-judgmental interviewing skills, the healthcare provider was able to get an accurate sexual history and gain an understanding of some of this patient’s relevant health beliefs and practices. This patient had learned from her mother that douching and the use of bleach in the bath water would help to stop infections and also “keep her clean”. The discussion around relationships gave insight into her choice of partners and her overall mental health.



 
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