Sexually-Transmitted Diseases: HIV

Genital herpes in adolescents is most often caused by herpes simplex virus 1 (HSV 1). HSV 1 recurs less, sheds less, and is therefore less likely to be transmitted. Appropriate testing is described, as well as psychological ramifications and counseling interventions. Human papillomavirus (HPV) is a common sexually-transmitted infection with the highest prevalence rates in adolescent and young women. HPVs that infect mucosal epithelium are classified as high- or low-risk based on their causal association with clinical outcomes. The majority of HPV infections clear without causing any clinical disease. However, persistent infection with one or more of the 13 high-risk HPV types puts women at risk for high-grade dysplasia (a precursor for cervical cancer) and cervical cancer. HPV 16 and HPV 18 cause approximately 70% of cervical cancers and the majority of HPV-associated anal, vulvar, vaginal, and oral cancers. HPV 6 and HPV 11 cause approximately 90% of genital warts. Diagnosis of genital warts is typically based on physical exam. Genital warts usually present as painless papules and occasionally become large and disfiguring, especially in immunocompromised patients. Multifocal lesions are common; therefore, inspection of the entire genital area is warranted during a physical exam. HPV DNA testing is not appropriate for the diagnosis of warts, but may be useful in screening for cervical dysplasia and cancer in adults. Treatment options for genital warts include topical patient-applied therapy, topical provider-applied therapy, ablative therapy, and surgical excision. Treatment decisions are based on patient preference, provider experience, and size and location of warts. Chlamydia trachomatis (CT) is the most common bacterial sexually-transmitted infection (STI) in the US with the highest prevalence rates reported amongst adolescent and young adult females. Symptoms and signs of chlamydia infection may include vaginal discharge and cervicitis; however, the majority of female chlamydial infections are asymptomatic. Therefore, annual screening of all sexually-active females aged 25 years or younger is the standard of care. If untreated, chlamydial infection may progress to pelvic inflammatory disease (PID) and the associated morbidities of ectopic pregnancy, infertility, and chronic pelvic pain. Women often seek care for sexually-transmitted infections (STIs) from their gynecologist. Adolescent and young adult women are disproportionately affected by STIs. Gonorrhea is a common STI of the urethra, cervix, fallopian tubes, rectum, and pharynx. Presenting symptoms vary by anatomic site, and may include vaginal or anal discharge, pharyngitis, and tenosynovitis. Infection with gonorrhea may be asymptomatic and has serious sequelae if left untreated. Treatment for gonorrhea includes a combination of antibiotics such as ceftriaxone and azithromycin or doxycycline. All patients presenting for STI screening or gonorrhea treatment should be tested for other STIs, such as chlamydia, trichomonas, and HIV, and counseled on contraception. Trichomonas vaginalis (TV) is a sexually-transmitted infection that is as common as chlamydia in adolescent women. It is a vaginal pathogen that causes inflammation and breakdown of the vaginal mucosal barrier. Many infections are asymptomatic, and untreated infections can have serious health consequences. Point-of-care testing and treatment are highly effective. Providers who care for at-risk teens should have a low threshold for screening for TV. Adolescents are at risk for HIV both though risk-taking behavior as well as biologic mechanisms, and should be routinely screened for HIV infection. Medical providers should be aware of the gynecologic conditions that may indicate concurrent HIV infection. HIV-positive adolescents have unique gynecologic needs requiring modified guidelines for STI and cervical cancer screening, as well as attention to reproductive health, including preconception, contraceptive concerns, and prenatal care. Sexually-transmitted infections (STIs) may go unnoticed or present with a rash or bump. Lack of awareness of the presentations of the less common disease means lack of accurate diagnosis and treatment. Awareness of both common and obscure STIs will allow you to treat all STIs appropriately, speedily, and safely.