Sexually Transmitted Diseases Update M. Winston Tilghman, M.D. January 19th, 2018 UCSD HIV & Global Health Rounds

2. SEXUALLY TRANSMITTED
DISEASES UPDATE
M. Winston Tilghman, M.D.
Medical Director, HIV, STD, & Hepatitis Branch
PUBLIC HEALTH SERVICES

3. DISCLAIMERS
 I have no conflicts of interest to disclose.
 I will discuss off-label use of diagnostic tests.

4. PRESENTATION OUTLINE
 Clinical overview of reportable STDs
 Local and state epidemiology
 Current state of STD control
 Role of public health department
 Role of healthcare providers

5. SYPHILIS NATURAL HISTORY
30-50%Exposure Primary 30% TertiaryLatentSecondary
25%
Neurosyphilis can occur at any stage
Incubation
Period
3-4 weeks
2-6 weeks
After 3-8 weeks
lesions disappear
spontaneously
2-20 years
Possible
relapse

6. PRIMARY SYPHILIS
 Characterized by one or more painless ulcers
(chancres) at the site of inoculation
 Appears 10-90 days after infection
 Modest, rubbery and non-tender inguinal LAD
may be present.
 Serologies are negative in 10-25% of patients
with early primary syphilis.

7. PRIMARY SYPHILIS
STD Atlas, 1997
Raguse et al, Ann Int Med 2012

8. T. PALLIDUM ON DARKFIELD
MICROSCOPY

9. SECONDARY SYPHILIS
 Usually occurs 3-6 weeks after primary chancre
 Rash (75-90%), involving palms/soles (60%)
 Generalized lymphadenopathy (70-90%)
 Constitutional symptoms (50-80%)
 Mucous patches (5-30%)
 Condylomata lata (5-25%)
 Patchy alopecia (10-15%)
 Symptoms of neurosyphilis (1-2%)
 Less common: meningitis, hepatitis, arthritis, nephritis

10. SECONDARY SYPHILIS
Photo: CDC
Courtesy: Gregory Melcher, UC Davis, Susan Philip,
SF DPH & UCSF

11. SECONDARY SYPHILIS
Courtesy: Gregory Melcher, UC Davis, Susan Philip,
SF DPH & UCSF

12. LATENT SYPHILIS
 No signs or symptoms of active disease
 Categorized into early and late disease:
 Early: < 1 year duration
 Late: ≥ 1 year or unknown duration
 Most relapses to secondary syphilis occur during first
year of infection.
 Patients are considered non-infectious after first year
of infection (not true for mother-to-child transmission).

13. NEUROSYPHILIS
CAN OCCUR AT ANY STAGE OF SYPHILIS
 All patients with syphilis should be evaluated for neurologic symptoms and
signs.
 Asymptomatic CNS invasion is common in early syphilis.
 Early symptomatic forms (months to a few years):
 Acute syphilitic meningitis (CN VI, VII, VIII)
 Hearing loss
 Ocular syphilis
 Meningovascular (stuttering stroke)
 Altered mental status
 Late symptomatic forms (>2 years):
 General paresis and tabes dorsalis

14. CRITERIA FOR CSF EXAMINATION*
 Neurologic or opthalmic symptoms/signs:
 Auditory disease, cranial nerve dysfunction, meningitis,
stroke, altered mental status, loss of vibration sense,
iritis, uveitis
 Evidence of tertiary disease:
 Aortitis, gumma
 Serologic treatment failure
In HIV infection, unless neurologic symptoms, there is no evidence
that CSF exam is associated with improved outcomes, so not
recommended. *CDC 2015 STD Treatment Guidelines
Guidelines for Prevention and Treatment of OI in HIV+ 2013

15. Ocular Syphilis
Manifestations:
• Conjunctivitis, scleritis, and episcleritis
• Uveitis: anterior and/or posterior
• Elevated intraocular pressure
• Chorioretinitis, retinitis
• Vasculitis
Symptoms:
• Redness
• Eye pain
• Floaters
• Flashing lights
• Visual acuity loss
• Blindness
Diagnosis:
• Ophthalmologic exam
• Serologies: RPR, VDRL, treponemal tests
• Lumbar puncture
Wender, JD et al. How to Recognize Ocular Syphilis. Review of Ophthalmology. 2008
Slide courtesy of Sarah Lewis, MD

16. OCULAR SYPHILIS
WHAT DO CLINICIANS NEED TO KNOW?
 Test for syphilis in patients with visual or ocular symptoms/signs.
 Ask patients with syphilis about changes in their vision.
 Patients with positive syphilis serology and visual complaints
should receive immediate ophthalmologic evaluation.
 Patients with suspected ocular syphilis should receive LP and
treatment for neurosyphilis.
 Test for HIV.
 Report cases of syphilis to the health department within 1 day.
*Moradi Am J Ophthal 2015

17. CONGENITAL SYPHILIS
Photos courtesy of Public Health
Image Library, CDC and Drs.
Norman Cole, Susan Lindsley,
Robert Sumpter, and J. Pledger

18. CONGENITAL SYPHILIS…..
IS COMPLETELY PREVENTABLE THROUGH:
 Timely diagnosis of maternal syphilis:
 Syphilis screening during first prenatal visit (required by law)
 Repeat screening during third trimester (28 weeks) and at delivery for high-risk
women
 No newborn should be discharged from the hospital if the mother’s syphilis status
has not been determined.
 Appropriate and timely treatment of maternal syphilis:
 CDC-recommended penicillin-based therapy
 Initiation of treatment at least 30 days prior to delivery
 Ensuring that partner(s) are managed appropriately to prevent repeat
infection during pregnancy

19. SYPHILIS DIAGNOSIS
BOTH NON-TREPONEMAL AND TREPONEMAL
TESTS ARE NEEDED TO ESTABLISH A NEW
DIAGNOSIS!
 Non-treponemal testing (RPR, VDRL, TRUST):
 Non-specific but correlates with disease activity
 May be negative in ~25% of patients with early primary syphilis
 Semiquantitative (reactive results expressed as titer)
 Treponemal testing (EIA, CIA, TPPA, MHA-TP, FTA-ABS,
MBIAs):
 Specific for T. pallidum; usually positive for life after initial infection
 Usually positive in primary syphilis (90%), invariably positive in secondary
syphilis

20. SYPHILIS STAGING
YES
Chancre Rash, etc.
NO
PRIMARY SECONDARY
LATENT
ANY IN PAST YEAR?
• Negative syphilis serology
• Known contact to an early case
• Good history of typical signs/symptoms
• 4-fold increase in titer
• Only possible exposure was this year
NOYES
EARLY LATENT
(< 1 year)
LATE LATENT or UNKNOWN
DURATION
SIGNS OR SYMPTOMS?

21. SYPHILIS TREATMENT
Primary, Secondary & Early Latent:
Benzathine penicillin G 2.4 million units IM in a single dose
Late Latent and Unknown Duration:
Benzathine Penicillin G 7.2 million units total, given as 3 doses
of 2.4 million units each at 1 week intervals
Neurosyphilis:
Aqueous Crystalline Penicillin G 18-24 million units IV daily
administered as 3-4 million IV q 4 hr for 10 -14 d
Only one dose of PCN Is recommended for early syphilis in HIV-
infected persons, extra doses not needed

22. SYPHILIS TREATMENT
PRIMARY, SECONDARY & EARLY LATENT
Alternatives (non-pregnant penicillin-allergic adults):
Doxycycline 100 mg po bid x 2 weeks
Tetracycline 500 mg po qid x 2 weeks
Ceftriaxone 1 g IV (or IM) qd x 10-14 d
Azithromycin 2 g po in a single dose*
* Do NOT use azithromycin in MSM or pregnant women
In pregnancy, benzathine penicillin is the only
recommended therapy. No alternatives

23. SYPHILIS CLINICAL PEARLS
 For suspected primary syphilis, order both
treponemal and non-treponemal testing (unless pt
has a previous history of syphilis).
 Always obtain an RPR titer on the day of
treatment initiation.
 Beware of the prozone effect.
 Counsel patients regarding the Jarisch-
Herxheimer reaction.

24. SYPHILIS GREY AREAS
 When to perform lumbar puncture in HIV-infected
individuals
 Current recommendation: only if neuro or
ocular symptoms/signs are present.
 Management of patients who do not have the
expected four-fold decline in RPR titer
 Maximal acceptable interval between BPG doses
in non-pregnant patients

25. STD Control Branch
24
Primary & Secondary Syphilis, California versus
United States Incidence Rates, 1941–2016
Rev. 6/2017

26. STD Control Branch
25
Congenital Syphilis Cases versus Female Early Syphilis*
Incidence Rates, California, 2007–2016
* Includes primary, secondary, and early latent syphilis.
Rev. 6/2017

27. Primary & Secondary Syphilis Cases by Year
San Diego County, 1988 - 2016
47 25 33 12 20 10 16 5 11 5 1 10 13 14 26 94 111 144 201 290 269 227 253 236 282 288 282 428 432
424
310
323
284
112 106 98
52
35
23 23 25 27 27
38
109
137
193
234
346 346
263
277
289
333
347
369
490
523
0
100
200
300
400
500
600
1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
NumberofCases
Year
Men who have sex with men Other
Note: The green area represents the proportion of cases who are not men who have sex with men.
The number above the columns represents the total number of primary and secondary syphilis cases per year.

28. Primary & Secondary Syphilis Cases and
Rates by Year
San Diego County, 1988 - 2016
424
310
323
284
112 106 98
52
35
23 23 25 27 27
38
109
137
193
234
346 346
263
277
289
333
347
369
490
523
17.8
12.5
12.9
11.1
4.3 4.1 3.8
2.0
1.3
0.9 0.9 0.9 1.0 0.9
1.3
3.7
4.6
6.3
7.6
11.2 11.0
8.6 8.9
9.3
10.6
11.0
11.6
15.2
15.9
0.0
5.0
10.0
15.0
20.0
25.0
0
100
200
300
400
500
600
1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Rateper100,000Population
NumberofCases
Year
Cases Rate per 100,000 population

29. Primary & Secondary Syphilis Rates by
Gender and Year
San Diego County, 1997 - 2016
1.2*
30.5
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
RatePer100,000Population
Year
Females Males
* Between 2015 and 2016, the female primary and secondary syphilis rate
increased by 33%, and the number of cases increased by 27%.

30. Primary & Secondary Syphilis Rates by
Gender and Age
San Diego County, 2016
0.0 0.0
2.0
5.1 4.5
1.6 0.9 0.20.0 0.0
17.3
45.1
57.7
67.1
57.2
20.3
0
10
20
30
40
50
60
70
80
<10 10-14 15-19 20-24 25-29 30-34 35-44 45+
Rateper100,000Population
Age Group
Female Male

31. Primary & Secondary Syphilis Rates by
Gender and Race/Ethnicity
San Diego County, 2016
0.0 0.0
8.4
0.9 0.8
1.9
27.5
14.2
56.3
35.3
25.5
18.7
0
10
20
30
40
50
60
Native American/
Alaskan Native
Asian/Pacific Islander Black Hispanic White Other/Mixed Race
Rateper100,000Population
Race/Ethnicity
Female Male
Note: Rates exclude 28 cases missing race/ethnicity information.

32. MSM* Primary & Secondary Syphilis Cases
Co-Infected with HIV by Year
San Diego County, 2007 - 2016
44%
0
10
20
30
40
50
60
70
80
90
100
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
PercentwithHIVCo-Infection
Year *MSM: Men Who Have Sex With Men

34. Slide courtesy of Heidi Bauer, MD, MS, MPH

35. Slide courtesy of Heidi Bauer, MD, MS, MPH

36. PUBLIC HEALTH RESPONSE
SYPHILIS
 Surveillance
 Disease investigation/partner Services
 Females of childbearing age
 1°/2° Syphilis, some EL cases
 HIV prevention
 Safety net clinical services
 Community engagement
 Support for community providers (syphilis histories, consultations)

38. PUBLIC HEALTH CHALLENGES OF
SYPHILIS PREVENTION & CONTROL
PRE-AIDS
 Occult/asymptomatic infection
 Multiple partners
 Anonymous partners
 “Poppers”
 Mistrust of medical community
 Stigma
 Prejudice
 Health inequity
POST-AIDS
 Occult/asymptomatic infection
 Multiple partners
 Anonymous partners
 Methamphetamine, ED medications
 Mistrust of the medical community
 Stigma
 Prejudice
 Health inequity
Adapted from slide produced by Anne Rompalo, MD

39. PUBLIC HEALTH CHALLENGES OF
STD PREVENTION & CONTROL
WHAT’S NEW?
 Changes in sexual practices:
 Less condoms?
 More oral sex?
 Biomedical HIV prevention tools:
 ART, TasP
 PrEP
 Internet: geosocial networking apps
 Closure of STD clinics in many areas
 Not enough disease investigators
The Lancet HIV
CDC
Adapted from slide produced by Anne Rompalo, MD

40. GONORRHEA
 Urethritis:
 Incubation period: 2-5 days in most (1-14 days)
 Frequently symptomatic (dysuria, discharge, meatal swelling/erythema)
 Cervicitis:
 More variable incubation period, symptoms usually within 10 days
 50-70% asymptomatic
 PID
 Epididymitis
 Conjunctivitis
 Pharyngitis
 Proctitis
STD Atlas, 1997

41. DISSEMINATED GONOCOCCAL
INFECTION (DGI)
 0.5-2% of mucosal infections
 Triad of polyarthralgia, tenosynovitis,
dermatitis
 Frank arthritis in 30-40%:
 Wrist, MCP, ankle, and knee joints
most commonly affected
 Meningitis, endocarditis (rare)
Photo Credit: CDC

42. CHLAMYDIA
 Urethritis
 Cervicitis
 PID
 Epididymitis
 Pharyngitis (?)
 Proctitis
 Often asymptomatic
 Compared to gonorrhea, symptoms tend to be less abrupt in
onset and milder.
Holmes K, et al. STD, 4th ed.

43. • < 25 annually, 25+ if at risk
• Pregnant <25, if at riskFemales
• At least annually
• Exposed sites: genital, rectal, throatMSM
• High prevalence settingsHetero males
• At least annually
• All exposed sitesHIV +
• Every 3 monthsPatients on PrEP
• All patients, 3 months after treatmentPost-Tx
Who Should be Screened for CT/GC?
CDC 2015 STD Tx Guidelines www.cdc.gov/std/treatment
Plus: Guidelines for HIV care and PrEP

44. Major conclusions
NAATs recommended for detection of genital tract infections in men and
women – with and without symptoms
- highly sensitive and specific compared to culture
- less dependent on specimen collection and handling
Optimal specimen types are:
First catch urine for men
Self collected vaginal swabs from women
NAATs recommended for detection of rectal and oropharyngeal infections

45. • HIV
• Syphilis
• Urethral GC and CT
• Rectal GC and CT (if anal sex)
• Pharyngeal GC (if oral sex)
• HSV-2 serology (consider)
• Hepatitis B (HBsAg, frequency not specified)
• Hepatitis C (HIV+ MSM at least annually)
* At least annually, more frequent (3-6 months) if at high risk
(multiple/anonymous partners, drug use, high risk partners)
CDC 2015 STD Treatment Guidelines
*
Anal Cancer in HIV+ MSM: Data insufficient to recommend
routine screening, some centers perform anal Pap and HRA

46. MAJORITY OF RECTAL INFECTIONS IN
MSM ARE ASYMPTOMATIC
Chlamydia
n=316
Gonorrhea
n=264
Chlamydia
n=315
Gonorrhea
n=364
Rectal Infections
Urethral
Infections
Asymptomatic
Symptomatic
Kent, CK et al, Clin Infect Dis July 2005
86% 84%
42%
10%

47. High Proportion of Extragenital CT/GC
Associated with Negative Urine Test,
STD Surveillance Network (n=21994)
Patton et al CID 2014

48. PROPORTION OF CT/GC MISSED IF SCREENING
ONLY PERFORMED AT URETHRAL SITE (URINE),
SAN FRANCISCO, 2008-2009
N=3398 PATIENT VISITS
Chlamydia Gonorrhea
Marcus et al, STD Oct 2011; 38: 922-4
Among asymptomatic MSM
CT or GC was found in at least one anatomical site
at 16% of these patient visits

50. Gonorrhea Dual Therapy
Uncomplicated Genital, Rectal,
or Pharyngeal Infections
Ceftriaxone 250 mg IM
in a single dose
Azithromycin
1 g orally
CDC 2015 STD Treatment Guidelines
www.cdc.gov/std/treatment
PLUS*
• Regardless of CT test result

51. ALTERNATIVE CEPHALOSPORINS:
 Cefixime 400 mg orally once
PLUS
 Azithromycin 1 g, regardless of CT co-infection
IN CASE OF SEVERE ALLERGY:
Gonorrhea Treatment Alternatives
Anogenital Infections
Gentamicin 240 mg IM + azithromycin 2 g PO
OR
Gemifloxacin 320 mg orally + azithromycin 2 g PO
CDC 2015 STD Treatment Guidelines www.cdc.gov/std/treatment

52. Alternative Urogenital GC Regimens:
AVOID MONOTHERAPY
 NIH-sponsored non-comparative randomized trial in
adults with urethral or cervical gonorrhea
1. gentamicin 240 mg IM + azithromycin 2 g PO, or
2. gemifloxacin 320 mg PO + azithromycin 2 g PO
 Per-protocol efficacy:
 gentamicin + azithromycin = 100% (202/202)
 gemifloxacin + azithromycin = 99.5% (198/199)
Kirkcaldy, CID 2014;59:1083-91.

53. Any downside to the alternative
regimens?
Gentamicin
Regimen
Gemifloxacin
Regimen
Route IM or IV Oral
Nausea 27% 37%
Vomiting (<1 hour) 3% 7%
Availability OK FDA reported
shortage in May
2015
Volume Need 6 cc
(40mg/cc)

54. Who needs a test of cure for GC?
• Patients with pharyngeal GC treated with an
alternative regimen
– Obtain test of cure 14 days after treatment, using
either culture or NAAT
• Cases of suspected treatment failure (culture
and simultaneous NAAT)
• Consider if using non-recommended or
monotherapy
CDC 2015 STD Treatment Guidelines www.cdc.gov/std/treatment

55. Suspected GC Treatment Failure
• If GC culture not available, call your local health department
TEST WITH CULTURE AND NAAT:
• Gemifloxacin 320 mg + AZ 2g OR Gentamicin 240 mg IM + AZ 2g
• If reinfection suspected, repeat treatment with CTX 250 + AZ 1g
REPEAT TREATMENT:
• To your local health department within 24 hours
REPORT:
• Treat all partners in last 60 days with same regimen
TEST AND TREAT PARTNERS:
• TOC 7-14 days with culture (preferred) and NAAT
TEST OF CURE (TOC):

56. Chlamydia Treatment
Adolescents and Adults
Recommended regimens (non-pregnant):
 Azithromycin 1 g orally in a single dose
 Doxycycline 100 mg orally twice daily for 7 days
Recommended regimens (pregnant*):
Azithromycin 1 g orally in a single dose
* Test of cure at 3-4 weeks only in pregnancy
CDC 2015 STD Treatment Guidelines www.cdc.gov/std/treatment

57. Chlamydia Treatment
Changes in 2015 CDC Tx Guidelines
New Alternative Regimen (non-pregnant):
Doxycycline (delayed release) 200 mg QD x 7 d
• Equally efficacious to doxycycline BID, ↓ GI side effects
• More $$$
Moved to Alternative Regimen (pregnant*):
Amoxicillin 500 mg po TID x 7 days
• CT persistence documented in vitro after treatment
prompted removal from recommended to alternate

58. The Effectiveness of Expedited Partner
Treatment on Re-Infection Rates
11%
3%
13%
11%
0%
5%
10%
15%
20%
Usual Care EPT Usual Care EPT
Golden M, et al. N Engl J Med 2005 Feb 17;352(7):676-85.
GONORRHEA
P=.02
CHLAMYDIA
P=.17

59. LEGAL STATUS OF EPT IN U.S.
http://www.cdc.gov/std/ept

60. Gonorrhea Cases and Rates by Year
San Diego County, 1997 - 2016
1505
1587 1560
1797
1875
2128
1972
2376
2606
2767
2385
2016
1843
2019
2166
2597
2865
3391
3695
4992
56.7 58.7 56.7
63.9 65.5
72.9
66.4
78.9
85.7
90.3
77.0
64.2
60.1
65.2
69.5
83.0
90.9
106.2
114.5
151.8
0
20
40
60
80
100
120
140
160
180
200
0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Rateper100,000Population
NumberofCases
Year
Cases Rate per 100,000 population

62. Gonorrhea Rates by Gender and Age
San Diego County, 2016
1.5
14.8
208.7
386.1
240.6
147.0
98.1
12.3
0.5 4.1
163.1
489.2
548.0
427.8
288.8
98.2
0
100
200
300
400
500
600
<10 10-14 15-19 20-24 25-29 30-34 35-44 45+
Rateper100,000Population
Age Group
Female Male
Note: Rates exclude 21 cases missing gender or age information.

63. Gonorrhea Rates by Gender and
Race/Ethnicity
San Diego County, 2016
0.0 9.1
200.8
52.2
34.7
119.7123.7
45.4
437.8
115.1 106.4
482.2
0
100
200
300
400
500
600
Native American/
Alaskan Native
Asian/Pacific Islander Black Hispanic White Other/Mixed Race
Rateper100,000Population
Race/Ethnicity
Female Male
Note: 40.9% of cases are missing race/ethnicity and are not included in the rates above.

64. Chlamydia Rates by Gender and Age
San Diego County, 2016

65. Slide courtesy of Heidi Bauer, MD, MS, MPH

66. Slide courtesy of Heidi Bauer, MD, MS, MPH

67. PUBLIC HEALTH RESPONSE
GONORRHEA
 Surveillance
 Disease intervention
 HIV-negative rectal GC cases
 HIV prevention
 Monitoring of antimicrobial susceptibility (GISP):
 Male urethral isolates
 Coming soon: endocervical, pharyngeal, rectal isolates
 Safety net clinical services: dual treatment
 Community engagement
 Home testing program for young women
 Clinical consultation services

68. Chlamydia Cases and Rates by Year
San Diego County, 1997 - 2016
6360
7006
7576
8637
9168
10225 10249
10822 11001
11980
12692
14073 14266
15336 15349
16538
16042
15626
17418
18904
239.7
259.2
275.4
306.9
320.1
350.1 344.9
359.5 361.9
390.8
409.9
447.9
465.5
495.5 492.6
528.6
509.2
489.2
539.7
574.8
0
100
200
300
400
500
600
700
800
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
20000
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Rateper100,000Population
NumberofCases
Year
Cases Rate per 100,000 Population

69. Chlamydia Rates by Gender and Year
San Diego County, 1997 - 2016
713.6
434.7
0
100
200
300
400
500
600
700
800
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Rateper100,000Population
Year
Females Males

70. 6.4 48.5
2352.2
4130.3
1814.8
816.3
330.4
34.33.8 5.1
509.2
1520.1
1159.8
776.2
416.9
114.9
0
400
800
1200
1600
2000
2400
2800
3200
3600
4000
4400
<10 10-14 15-19 20-24 25-29 30-34 35-44 45+
Rateper100,000Population
Age Group
Female Male
Note: Rates exclude 79 cases missing gender or age information.
Chlamydia Rates by Gender and Age
San Diego County, 2016

72. Slide courtesy of Heidi Bauer, MD, MS, MPH

73. PUBLIC HEALTH RESPONSE
CHLAMYDIA
 Surveillance
 Screening in juvenile detention facility
 Safety net clinical services
 Home testing program for young women
 TA for STD prevention education in local schools
 Clinical consultation services

74. WHAT PROVIDERS CAN DO
 Test test test!
 3-site testing for GC/CT in MSM
 At least annually, more frequent if high-risk or on PrEP
 Normalize STD testing
 Offer options for expedited or “express” testing.
 Verify pregnancy status of all female syphilis cases, and ensure prompt
treatment of pregnant cases.
 Provide dual treatment to all gonorrhea cases.
 Report STD cases to local health department.
 Treat partners; consider EPT when feasible.

75. FUTURE DIRECTIONS
 Research: drivers of increasing STD morbidity in MSM, vaccines,
new treatment options for GC
 POC testing
 Express visits, opt-out testing, validate GC/CT tests for self-collected
specimens
 Utilize STD prevention opportunities provided by increased PrEP
interest/uptake
 Better utilize existing resources:
 Disease investigators
 Community agencies/clinics
 Dedicated STD clinics

76. ACKNOWLEDGEMENTS
 California STD/HIV Prevention Training Center
 Heidi Bauer, MD, MS, MPH (CA Dept of Public Health)
 Anne Rompalo, MD (Johns Hopkins University SOM)
 Juliet Stoltey, MD (CA Department of Public Health)

77. THANK YOU!
 Myres Winston Tilghman, MD
 Winston.Tilghman@sdcounty.ca.gov
 Office Phone: (619) 692-8394
 Consultation Pager: 877-217-1816
 STD Field Services (syphilis histories): (619) 692-8501
 www.stdsandiego.org
On May 17, 2016, the County of San Diego Health and Human Services Agency Division
of Public Health Services received accreditation from the Public Health Accreditation Board.