4 Drawing the line: preventing sexually transmitted infections

Lindsey M. Childs-Kean, PharmD, MPH, BCPS

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 Hispanic, Black, and American Indian patients have higher rates of STIs compared to white patients as these groups also experience 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?

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?

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?

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

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

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?

Author Commentary

STIs are on the rise despite available education, prevention strategies, and antibiotic treatment. For the fifth consecutive year (2013-2018), 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.