There have been some recent developments in sexually transmitted infection (STI) treatment and prevention that are worth reviewing now, including:

1. New recommendations for treatment of gonorrhea and chlamydia
2. Expanding opportunities for prevention of HIV
3. Recent recommendation for hepatitis C, a “sometimes” STI

STIs caused by the bacteria Neisseria gonorrhoeae, have increased by 63% since 2014. These infections have important sequelae such as pelvic inflammatory disease, ectopic pregnancy and infertility and can increase transmission of HIV. Since 2010, the CDC-recommended treatment has been a single dose of ceftriaxone 250 mg IM with 1 gm of azithromycin. The recommendation for combination therapy was intended to reduce the development of resistance to ceftriaxone and treat chlamydia.

Since that time, several things have been observed that have resulted in reconsideration of this treatment. First, increased resistance has not been seen with ceftriaxone to any degree. On the other hand, gonorrheal resistance has been increasing briskly to azithromycin. Other STIs such as Mycoplasma genitalium and non-STI bacteria such as Streptococcus pneumonia have also developed increased resistance to azithromycin. Finally, studies have increased our understanding of the pharmacology of ceftriaxone in the body and what dosing is needed to kill gonorrhea in tough places such as the pharynx. Based on these considerations, the CDC published new treatment recommendations for gonorrhea and chlamydia in December of 2020. They are as follows:

• Uncomplicated gonococcal infections of cervix, urethra, pharynx and rectum, 500 mg IM ceftriaxone as single dose, 1 gm IM for persons weighing more than 150 kg without azithromycin
• Uncomplicated gonococcal infections of cervix, urethra and rectum in cephalosporin allergic patients, gentamicin 240 mg IM as a single dose (no alternative regimen available for this) with 2 gm of azithromycin
• For patients in whom chlamydia is not ruled out, doxycycline 100 mg BID for 7 days, azithromycin 1 gm for pregnant patients
• For partners not present on evaluation, cefixime 800 mg as a single dose and doxycycline 100 mg BID for 7 days can be provided

Despite tremendous strides in the treatment of HIV, 35,000 to 40,000 new HIV cases are diagnosed every year in the United States. Transmission is now principally due to new cases spreading infection before diagnosis and treatment. HIV-negative patients who engage in risky sexual behavior (multiple sexual partners, limited use of barrier precautions among others) or who use injectable drugs are at risk for acquiring HIV in this fashion.

Daily anti-retroviral use in HIV-negative patients, known as Pre-Exposure Prophylaxis or PrEP, has been shown to be effective in preventing HIV transmission in populations at risk. The two approved drugs for this are Truvada and Descovy, each dosed at one pill daily. Until this year, cost has been a major barrier for widespread use of PrEP. Starting in January 2021, PrEP medications are defined by the US Preventive Services Task Force as category A drugs. Under the ACA, such drugs must be covered by most private health plans without out-of-pocket costs to their subscribers. PrEP can be prescribed by any provider but HIV testing is required at the beginning of therapy and at least every three months while on treatment to be sure the patient is not undertreating an active HIV case (HIV acquisition can occur if the patient is not compliant with taking their PrEP medication). The Infectious Disease clinic here at VMC is also willing to help with the use of PrEP for the appropriate patients; just send a consultation.

Although sexual transmission is not a common way to get Hepatitis C, new recommendations for screening from 2020 are worth mentioning here. The CDC is now recommending that all pregnant patients and all adults over age 18 be screened at least once for antibodies to Hepatitis C. Patients at risk, including persons with HIV, persons who inject drugs or who have persistently abnormal alanine aminotransferase (ALT) test results, and persons with known exposure to hepatitis C should be screened at any age.

Curative therapy is available for this potentially deadly disease but it cannot be offered unless it is diagnosed and there continues to be a large population of patients who don’t know they have it. The Infectious Disease clinic can assist in treatment of newly diagnosed patients, again, just send a consultation.