Introduction

Sexually transmitted infections (STIs) present a unique public health problem. Approximately 20 million new STIs are diagnosed in the US each year, and a large number of cases remain undiagnosed or unreported.¹ And while appropriate treatment options exist for many STIs including syphilis, gonorrhea, and chlamydia,² the number of new cases continues to increase each year.¹ These infections increase the risk of chronic health issues such as complications in reproductive and fetal health as well as increase risk of acquiring other STIs such as human immunodeficiency virus (HIV).¹

Certain groups have been identified as having a higher risk of acquiring particular STIs and/or developing serious long-term complications associated with STIs.¹ Approximately 50% of patients diagnosed with an STI are between the ages of 15 and 24 years of age.³ Women of childbearing age are at high risk of long-term complications; the CDC estimates that approximately 20,000 women become infertile annually due to undiagnosed and/or untreated STIs.⁴ Importantly, increasing rates of syphilis in women of childbearing age has led to an increase in congenital syphilis, which leads to significant morbidity and mortality in infants.⁴ Another group with significant STI risk is men who have sex with men (MSM), and cases of reportable STIs among this population are also consistently increasing year to year.¹

Many behavioral and socioeconomic factors also influence the spread of STIs.⁵ Hispanics, African Americans, and American Indians have higher rates of STIs compared to white patients as these groups are also linked to decreased access to care, poverty, and communities/sexual networks with higher rates of STIs.⁵ According to Healthy People 2020, STIs affect marginalized and indigent patients disproportionately due to decreased access to care and/or social networks with higher risk behaviors.⁵ Patients with substance abuse disorders are also at a higher risk of acquiring an STI due to an increased likelihood of engaging in high-risk behaviors.⁵ An important aspect of decreasing the societal burden of STIs is the likelihood of patients to seek treatment for these infectious diseases; however, the stigma associated with STIs including HIV may limit patients from accessing diagnosis and care.⁵

Education, prevention measures, and prompt diagnosis and treatment are of utmost importance in controlling the STI epidemic in the US as rates of chlamydia, gonorrhea, and syphilis have consistently increased each year from 2013-2017.¹ Funding has also been cut from state resources including health departments; therefore, evaluating patients for sexual history and risky behaviors at any point of contact with the healthcare system is needed.¹ Prevention efforts should be coordinated between community, public health, and medical services. In addition, system-level obstacles should be reevaluated to allow for expedited partner therapy (EPT) for certain types of STIs as well as community-based test and treat programs. Pharmacists are easily accessible to many patients who otherwise may not seek medical care and are in a position to provide much needed patient education, counseling, and linkage to care for those patients who may benefit from STI evaluation and/or treatment.

Case

CC: “I have a crazy rash that covers most of my body. I am really worried about it because I don’t know where it came from.”

Patient: JB is a 20-year-old African American male who is a senior art major at New York University (NYU). JB presents to clinic complaining of a rash that covers a large portion of his body, including the soles of his feet. He does not have a primary care physician in the city and was referred to the clinic by a friend.

HPI: New onset rash that covers ~60% of his body, including the soles of his feet. No fever, chills, or systemic signs of infection. No complaints of pain or trouble urinating.

PMH: No significant history or surgeries

FH:

• Father: unknown
• Mother: hypertension and hyperlipidemia
• One younger sister with no significant medical history

SH:

• Drinks socially (7-8 vodka drinks) on weekend nights
• Denies cigarette smoking
• Occasional drug abuse when “partying with friends” in the city
• Sexually active with multiple male partners (reports condom use ~60% of the time), states that he is typically the receptive partner

SDH: American-born student at NYU with a part-time job at an art studio, full scholarship to NYU with on-campus housing and meals provided, raised by a single mother in rural, upstate New York with minimal access to healthcare service

Medications:

• Acetaminophen PRN for headaches
• Melatonin PRN for sleep
• Multivitamin daily

Allergies: NKDA

Vaccinations: No documentation available, patient states that he thinks he has received all routine childhood vaccines but is unsure

Vitals:

• BP 116/70 mmHg
• HR 70 bpm

Labs: None available at this time

Case Questions

1. Is JB considered to be a patient at high risk for acquiring STIs? Why or why not?

JB would be considered high risk for acquiring STIs because he is an African American MSM, has multiple sexual partners, and does not consistently protect himself using barrier methods of contraception. Additionally, JB reports some unspecified substance abuse and limited access to healthcare which are other risk factors for STIs.

2. Without further laboratory data, which STI does JB most likely have? What is the appropriate therapy for JB at this time (include appropriate follow-up)? Without proper treatment, which additional STI is JB at high risk for?

JB most likely has secondary syphilis (rash) which should be treated with benzathine penicillin G 2.5 million units IM as a single dose. The CDC STD treatment guidelines also recommend testing for HIV infection in all patients with primary or secondary syphilis. JB should follow up at 6 and 12 months post-therapy to be evaluated for clinical and serologic response. Approximately 89 percent of cases of primary/secondary syphilis were reported in male patients in 2016, and of these, 81% were reported in gay, bisexual, or other MSMs.¹ Without proper treatment of his syphilis, JB is at an increased risk of acquiring HIV.

3. JB is extremely upset with his diagnosis and wants to know more about how to avoid STIs in the future. What non-pharmacologic recommendations can you provide JB with at this time?

JB should be counseled on prevention measures such as using barrier contraception (male condoms) consistently when engaging in anal, vaginal, or oral sex, minimizing the number of sexual partners (ideally limiting sex acts to a monogamous relationship), as well as eliminating additional risky behaviors such as illegal drug use and binge drinking. Additionally, JB is very upset with his diagnosis and could be referred to a psychologist or support group. He may also be worried about others finding out about his diagnosis or being judged for having an STI due to the stigma that exists in society. Counseling JB on the ways to prevent future STIs and moving forward in relationships with an awareness and openness to discuss STIs will be of utmost importance.

4. Which screening tests should be performed at least every year in MSMs who are sexually active?

More frequent testing (every 3-6 months) should occur in patients with ongoing risk behaviors or if sexual partners have multiple partners, however the following screening tests should be conducted at least annually in all MSM:

• >HIV serology, if status unknown or previously negative and patient (or sexual partners) had more than one sex partner since the previous HIV test
• Syphilis serology to determine untreated, partially treated, serologic response to previous therapy, or serofast patients
• Test for N. gonorrhoeae and C. trachomatis urethral infection for those who had insertive intercourse
• Test for N. gonorrhoeae and C. trachomatis rectal infection for those who had receptive anal intercourse
• Test for N. gonorrhoeae pharyngeal infection for those who had receptive oral intercourse (test for C. trachomatis pharyngeal infection not recommended)

5. According to the CDC & the 2015 STD Treatment Guidelines, what are the five major strategies for preventing and controlling the spread of STIs?

The five major strategies are:

• >Assessment of risk and education/counseling on avoidance of STIs by changing sexual behaviors and using prevention services for at risk patients
• Vaccination for preventable STIs prior to exposure
• Identification of symptomatic and asymptomatic patients
• Appropriate diagnosis, treatment, follow up, and education of patients
• Follow up with sexual partners of patients diagnosed with STIs for evaluation, treatment, and education

6. JB wants to know if there are any vaccinations available to protect patients against STIs. What information can you provide JB with at this time? What are the recommended age and dosing schedule for each of these vaccinations?

Without knowing more details about JB’s immunization status, JB can be educated about vaccination for hepatitis A & B as well as human papilloma virus (HPV). If he received all recommended childhood vaccines, JB may have already received each of these. Documentation and/or serologic testing would be needed to confirm. General age and dosing recommendations are as follows:

• >Hepatitis A
  • >Recommended during routine childhood vaccination at 1-2 years of age
  • Also recommended for all MSM patients who have no previous history of infection or documentation of vaccination
• Hepatitis B
  • >Recommended during routine childhood vaccination to be started at birth and completed at 6-18 months of age
  • Also recommended for all MSM patients who have no previous history of infection or documentation of vaccination
• Human papilloma virus (HPV)
  • >Recommended in all children aged 11 or 12 years
  • HPV vaccine is recommended through age 26 years in MSM who have not previously received it

Author Commentary

STIs are on the rise despite available education, prevention strategies, and antibiotic treatment. For the fourth consecutive year (2013-2017), STI rates, including chlamydia, gonorrhea, and primary/secondary syphilis, have increased based on CDC reports.¹ Resources for testing and treating STIs are limited, especially among groups who are at highest risk for infection. Without appropriate diagnosis and treatment, patients are at risk for long-term health consequences as well as transmitting the infection to others, increasing the societal burden. Partner services are often limited due to lack of appropriate health department resources and/or state laws that prevent EPT. Pharmacists may be one resource that can bridge the gap between patients and health departments/clinics by counseling patients on the importance of being tested and treated for STIs.

Patient Approaches and Opportunities

Patients often do not understand that STIs can be transmitted by anal and oral sex; therefore, patient education at points of contact within the healthcare system is of utmost importance. Additionally, taking a thorough sexual history is necessary to assess the patient for STI risk factors and to recommend routine screening. Ensuring that the patient never feels “judged” by any healthcare worker is an imperative aspect of building a strong relationship. Pharmacists in community and/or ambulatory care settings have a unique opportunity to educate patients about STI transmission, the importance of partner screening, and available prevention measures such as vaccines and barrier contraceptives. In addition, pharmacists can link patients to the nearest health department or local clinics to be tested and treated for STIs. When discussing STIs and sexual health, it is imperative to keep in mind cultural differences and the health literacy of the individual patient.