1. 
   

   Which hospitalized patients should be screened for sexually transmitted infections?

   
   
2. 
   

   How should patients with vaginal or urethral discharge be diagnosed?

   
   
3. 
   

   What are the common causes of genital ulcers?

   
   
4. 
   

   What are the benefits of universal HIV screening in health care settings?

In the United States, there are 15 million cases of sexually transmitted infections (STIs) yearly, including 4 million cases of Chlamydia trachomatis alone, and the current seroprevalence of herpes simplex virus type 2 (HSV-2) is 22%. Most, but not all, cases of STIs occur in young people, who may be oblivious or indifferent to health risks, including pelvic inflammatory disease, infertility, cervical cancer, an increased risk of HIV acquisition, and cardiac and neurologic complications of syphilis. Up to 40% of sexually active females aged 15 to 19 in the United States have an STI. The prevalence of genital chlamydia and HSV-2 is thought to be similar in Europe and in other developed nations. Worldwide, there are an estimated 90 million new cases of genital chlamydia per year, and 60 million cases of gonorrhoea per year. Syphilis has recently reemerged in many regions where it had become uncommon, including the United States, Europe, and China. All STIs increase the risk of HIV acquisition.

There are many barriers to care for patients with STIs. These include privacy concerns, fear of disclosure, lack of health care access and affordability, ongoing mental health or substance abuse problems, and denial. Adolescents are a particularly vulnerable group: symptomatic females may take up to 10 days before seeking medical attention, and many more do not present because of the absence of symptoms. For many patients, an emergency room visit or hospitalization, often for a reason other than an STI, may be the only opportunity for medical personnel to screen for HIV and other STIs, and provide point-of-care diagnosis and treatment and sexual risk reduction counselling.

The most important element in the diagnosis of an STI is a complete sexual history. The sexual history should be obtained in a professional, nonjudgmental, and thorough fashion. The interview should be in a private setting, with the patient physically comfortable and at eye level with the physician. The physician should emphasize the confidential nature of the information obtained, and that the questions asked are part of routine medical care. There should be no physical barrier, such as a desk, between the patient and physician, and the physician’s body language should suggest acceptance, with arms and legs uncrossed. The physician should make eye contact with the patient, nod encouragement, and employ strategic pauses when necessary. The physician should use terminology that the patient understands, and assess for comorbid mood disorders, alcohol, and drug abuse that may increase the patient’s risk of STIs. A useful format for the sexual history interview is the five Ps: partners, prevention of STIs (if any), prevention of pregnancy (if any), practices, and previous STI history.

HIV Seroconversion Illness

Acute HIV infection can present to the emergency room as a mononucleosis-like syndrome. Patients have high-level viremia and are highly infectious. Clinical features may include fever, sweats, malaise, lymphadenopathy, pharyngitis, aphthous ulcers, maculopapular rash on the trunk and extremities, and aseptic meningitis. Patients may also be asymptomatic. Benefits of early diagnosis include establishment of ongoing HIV care and prevention of opportunistic infections (Table 202-1). The role of early antiretroviral therapy (ART) in these patients remains undefined. Knowledge of HIV-positive status also discourages risky behaviour and facilitates partner testing. Although the possibility of acute HIV syndrome is an indication for obtaining HIV serology (and viral load testing as well), clinicians should note that current guidelines recommend HIV screening in all health care settings in an opt-out capacity.

Postexposure Prophylaxis of HIV

Postexposure prophylaxis (PEP) with a 28-day course of ART is recommended in sexual contacts of HIV-positive persons presenting within 72 hours of exposure. Receptive and insertive anal intercourse has an especially high risk of HIV acquisition. If the patient’s contact is of unknown HIV status, as in sexual assault or anonymous sex, then the risk is weighed on individual basis. The possibility of surreptitious sexual assault should also be considered in patients who are brought to the hospital with alcohol or drug intoxication. A full medical and medication history should be obtained prior to commencement on PEP. Monitoring of complete blood counts and renal function on ART and outpatient HIV clinic follow-up are recommended. A full STI screen should also be performed.

Universal HIV Testing

Every person presenting with a STI or suspected STI should have an HIV test. This is particularly true for high-risk groups such as sex workers, drug users, MSM, and people with multiple sexual contacts or contacts from countries of high prevalence. The benefit of screening for HIV before symptoms develop include decreased transmission, a greater likelihood of starting antiretroviral treatment in a timely manner, and a decreased risk of opportunistic infection. In 2006, the Centers for Disease Control and Prevention recommended that HIV screening be performed as part of routine medical care on all patients aged 13 to 64. The demographics of HIV in the United States have changed over the past 20 years, with a higher prevalence in persons younger than 20 years, women, racial or ethnic minorities, and heterosexual men and women. As a result, the effectiveness of risk-based testing to identify HIV-infected persons has diminished.

Sexually Acquired Viral Hepatitis

Sexual transmission of hepatitis B represents a major mode of acquisition, particularly among men who have sex with men (MSM). In the United States and other developed countries, hepatitis B vaccine is a routine childhood vaccination. Nonimmune groups who are potentially vulnerable to hepatitis B include persons who have not been vaccinated due to lack of health care access, vaccine nonresponders, or those with waning immunity to vaccine. Acute hepatitis B can present as an influenza-like illness with anorexia, fatigue, nausea, right upper quadrant pain, and jaundice. Blood tests can show very elevated ALT and AST (often > 1000 IU/L), with or without an elevated bilirubin. Fulminant disease with hepatic failure is unusual (0.1–0.5%); risk factors include concomitant acetaminophen and alcohol intake. Initial treatment is supportive, although antiviral therapy may be considered in fulminant disease. Vaccination of household members and partners and screening of contacts is also important.

STIs that May Masquerade as Other Conditions

Syphilis is known as the great pretender because of its protean manifestations and ability to mimic a wide variety of other diseases. Clinical findings may include ulcerations or heaped-up lesions (condylomata lata) involving the genitals, oropharynx, or rectum, a wide variety of psoriasiform skin rashes, lymphadenopathy, alopecia, aseptic meningitis, uveitis, hearing loss, visual loss, bone pain (periostitis), aortic regurgitation, stroke, psychiatric disease, gait disorder, and dementia. Diagnosis and treatment are discussed in further detail below.

Lymphogranuloma venereum (LGV) is caused by serovars L1, L2, and L3 of C trachomatis. It is endemic in Central and South America, Southeast Asia, Africa, and the Caribbean. It is uncommon in the United States and Europe, where most cases occur in MSM. Clinical manifestations include a primary stage, leading to a small, painless genital or anorectal ulcer that may not be recognized by the patient. The secondary stage of infection, occurring days to weeks later, may lead to fever and tender inguinal and femoral lymphadenopathy, which may lead to formation of abscesses (buboes) with drainage. Alternatively, patients may develop a painful anorectal syndrome with scanty rectal discharge, bleeding, pruritis, or constipation. Hemorrhagic proctitis due to LGV may be mistaken for inflammatory bowel disease, and biopsy findings in LGV proctitis may actually be similar to those of Crohn disease. Laboratory diagnosis is difficult. It is traditionally based on C trachomatis serology, although most tests lack specificity for the serovars causing LGV. Reference laboratories may be able to perform nucleic acid amplication tests (NAATs) on genital or rectal swab specimens. LGV is treated with doxycycline 100 mg twice daily for three weeks. When LGV is likely, presumptive treatment is recommended.