7.1 Sexually Transmitted Infections

Abstinence

Abstinence is the only way to 100 percent prevent STIs. This includes not having vaginal, anal, or oral sex (Centers for Disease Control and Prevention [CDC], 2022). Not all people will practice abstinence, so it is important that they know all other options that are available.

Sexual Behaviors

Some sexual behaviors can increase the risk of STIs. For adolescents, biologic factors may increase this risk. Younger females with immature cervical epithelia have higher levels of cytokines and chemokines. The immature epithelium is thought to be more susceptible to STI pathogens, especially N. gonorrhoeae, C. trachomatis, and human papillomavirus (Fortenberry, 2023). The following is a list of other sexual behaviors that increase the risk for STIs:

• multiple partners
• new partners
• partners with multiple partners
• for transgender adolescents, penile penetration
• inconsistent condom use
• alcohol and drug use
• rectal douching or enemas before receiving anal sex
• sex with a partner who recently had an STI
• trading sex for money or drugs, including oral, anal, penile, or vaginal, with a sex worker
• men who have sex with men

(Fortenberry, 2023; Rietmeijer, 2023)

Incidence

Gonorrhea is on the rise in the United States, with 583,405 cases reported in 2018. This is a rate of 171.9 cases per 100,000 population, compared to a rate of about 100 cases per 100,000 population in 2012 (U.S. Department of Health and Human Services, 2020). In 2020, there were approximately 82 million cases of gonorrhea worldwide (World Health Organization [WHO], 2023). The bacterium Neisseria gonorrhoeae infects the mucous membranes in the reproductive tract, mouth, throat, eyes, and rectum (U.S. Department of Health and Human Services, 2020).

Screening and Diagnosis

All sexually active people assigned female at birth who are less than 25 years old and all persons assigned male at birth having intercourse with persons assigned male at birth should be screened for gonorrhea every year. People assigned female at birth who are older than 25 years should be screened if they have a new sex partner, have more than one sex partner, have a sex partner who has other sex partners, or have a sex partner with an STI. Other high-risk populations, such as those with multiple anonymous partners, those in which either partner has a substance use disorder, or those at risk for HIV acquisition, should be screened at all anatomic sites of exposure every 3 to 6 months. Screening for gonorrhea is not recommended for cisgender heterosexual persons less than 25 years of age who are at low risk for infection (CDC, 2021a).

Cultures or polymerase chain reaction (PCR) tests are used to diagnose gonorrhea. In people with a vagina, endocervical swabs are used; and in people with a penis, urethral swabs are used. Rectal, oropharyngeal, and conjunctival cultures or PCR tests using a swab can also be done to check for infection. Urine cultures for gonorrhea can also be performed (CDC, 2021a).

Management and Treatment

Gonorrhea is one STI that must be reported to the Department of Health in every state in the United States (CDC, 2021a). Drug-resistant strains of gonorrhea are resistant to fluoroquinolone, cefixime, and extended-spectrum cephalosporins, and these strains have been seen throughout the world. The standard treatment for gonorrhea is ceftriaxone (Rocephin) 500 mg IM in a single dose for persons weighing < 150 kg (330 lb) and ceftriaxone 1,000 mg IM for persons weighing ≥ 150 kg (330 lb). If the patient has a cephalosporin allergy, they can take gentamicin (Garamycin) 240 mg IM in a single dose PLUS azithromycin (Zithromax) 2 g orally in a single dose. If ceftriaxone is not available, the patient can take cefixime (Suprax) 800 mg orally in a single dose (CDC, 2021a).

Complications

Untreated gonorrhea can lead to pelvic inflammatory disease (PID), which can cause chronic pelvic pain, infertility, and ectopic pregnancy due to scarring in the reproductive tract. There is an increased risk of HIV infection. Gonorrhea can also cause a disseminated infection, which can lead to skin lesions, arthralgias, and arthritis (CDC, 2021a).

Patient Education

Recent sex partners (within the past 60 days) should get referred for evaluation, testing, and presumptive treatment. If greater than 60 days, then the most recent partner should be treated. If access to care is limited and the partner does not seek their own evaluation, the patient’s provider or a local pharmacy can provide treatment to the partner or partners if they live in a state where this is permitted (CDC, 2021a).

Symptoms should subside with treatment, but if symptoms persist, repeat testing should be performed. The patient should abstain from sexual activity until 7 days after treatment and until all sex partners are treated. People with gonorrhea should get tested for other STIs, including chlamydia, syphilis, and HIV (CDC, 2021a). The CDC (2021) recommends a test of cure (TOC), a retesting to determine that the treatment was successful, in 3 months for uncomplicated gonorrhea that has been treated.

Incidence

Chlamydia is the most common bacterial STI in the United States, with 1,758,668 cases reported in 2018 (U.S. Department of Health and Human Services, 2020). There were more than 129 million reported cases of chlamydia worldwide in 2020 (WHO, 2023).

Screening and Diagnosis

All sexually active persons assigned female at birth < 25 years old should be screened every year. Those ≥ 25 years old should be screened if they have a new sex partner, have more than one sex partner, have a sex partner who has other sex partners, or have a sex partner with an STI. Routine screening of persons assigned male at birth is not recommended unless they are in a setting where there is a high incidence of chlamydia, such as a correctional facility or if they are part of a high-risk population, such as persons assigned male at birth having sex with other persons assigned male at birth (CDC, 2021a). A diagnosis can be made by obtaining a vaginal or cervical swab, a Papanicolaou (Pap) test, or a first-void urine for those assigned female at birth. In persons assigned male at birth, the diagnosis can be made by a first-catch urine or a meatal or urethral swab (CDC, 2021a).

Management and Treatment

Chlamydia is a reportable STI in every state in the United States. The provider or lab must report cases to the Department of Health (CDC, 2021a). Treatment for chlamydia is usually doxycycline (Vibramycin) 100 mg orally 2 times a day for 7 days. Alternative treatments are azithromycin (Zithromax) 1 g orally once or levofloxacin (Levaquin) 500 mg orally once a day for 7 days. Repeat testing is not recommended. For pregnant persons, doxycycline is contraindicated in the second and third trimesters, but azithromycin is safe. Follow-up testing for pregnant persons should be done about 4 weeks after treatment to ensure there is no more infection. Pregnant persons who are < 25 years old or who have a new sex partner, have more than one sex partner, have a sex partner who has other sex partners, or have a sex partner with an STI should be tested at the first prenatal visit and again in the third trimester (CDC, 2021a).

Complications

Chlamydia that is untreated can cause serious complications. Persons assigned female at birth are at risk for developing pelvic inflammatory disease (PID), which can cause chronic pelvic pain, infertility, and ectopic pregnancy due to scarring of the reproductive tract. Chlamydia can increase the risk of transmitting or acquiring HIV. In pregnant persons, chlamydia can cause preterm birth and serious complications in the neonate, such as ophthalmia neonatorum or pneumonia (CDC, 2021a).

Patient Education

Recent sex partners (within the past 60 days) should get referred for evaluation, testing, and presumptive treatment. If greater than 60 days, then the most recent partner should be treated. If access to care is limited, the patient or local pharmacy can provide treatment to the partners (CDC, 2021a). Persons receiving treatment should abstain from sexual activity for 7 days after the single-dose regimen or until completion of a 7-day regimen and resolution of any symptoms. Pregnant persons who receive treatment need to have a TOC at approximately 4 weeks after treatment; nonpregnant persons do not need a TOC if they completed their treatment (CDC, 2021a).

Incidence

Trichomoniasis is one of the most prevalent nonviral STIs in the world. It is thought to affect approximately 2.6 million people in the United States (CDC, 2021a). It is not a reportable STI, so estimates may be inaccurate. Trichomonas is a protozoan that can survive on fomites, such as towels and toilet seats, but transmission via fomites has not been proven. Persons AFAB can transmit trichomoniasis to any partner regardless of sex. Persons AMAB normally acquire this only from persons assigned female at birth (Sobel & Mitchell, 2023).

Screening and Diagnosis

Routine screening for trichomoniasis is not recommended. Up to 70 percent of the population who have it may not have symptoms, so screening for it is recommended only for patients who have HIV or who are in high-prevalence settings, such as STI clinics and correctional facilities, or for patients with new or multiple sex partners, with a history of sex work, or with a history of STIs (Sobel & Mitchell, 2023). Urine specimens and Pap smears in persons AFAB are acceptable for trichomoniasis testing. A vaginal or urethral swab using nucleic acid amplification tests (NAATs) is the best way to diagnose trichomoniasis; however, microscopic and pH testing can be used if necessary (Sobel & Mitchell, 2023).

Management and Treatment

The treatment for persons AFAB is metronidazole (Flagyl) 500 mg 2 times a day for 7 days; for persons AMAB, the treatment is metronidazole 2 g orally in a single dose.

Complications

For persons who are pregnant, trichomoniasis is associated with adverse outcomes such as premature rupture of membranes, preterm delivery, and delivery of a small for gestational age infant (CDC, 2021a). Trichomoniasis is also associated with increased risk of HIV transmission and pelvic inflammatory disease (CDC, 2021a).

Patient Education

Persons should be instructed that their partners need treatment and that they should abstain from sexual activity for approximately 7 days after they and their partners have completed treatment and no longer have symptoms. Retesting is recommended for all persons assigned female at birth at approximately 3 months after treatment, even if partners have received treatment, because of the high rate of reinfection (CDC, 2021a).

Symptoms and Incidence

Syphilis is a treatable STI, caused by the bacterium Treponema pallidum, that affected approximately 115,045 people in the United States in 2018. This was a 71 percent increase in the number of cases of syphilis in the United States since 2014, when the number of cases was approximately 67,000. There were approximately 7.1 million cases of syphilis worldwide in 2020 (WHO, 2023). Untreated syphilis progresses in stages. Primary syphilis presents as a chancre, a genital sore or lesion where syphilis pathogens enter the body (Figure 7.6). It is usually painless and may go unnoticed.

Figure 7.6 Syphilis Chancre A chancre is a syphilis lesion that presents at the site where the bacteria enter the body, here on the tongue. (credit: “Primary stage syphilis sore (chancre) on the surface of a tongue.” by Division of STD Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention/ Centers for Disease Control and Prevention, Public Domain)

Secondary syphilis presents as a rash or lesions away from the primary site. This can begin when the initial site is healing or healed. It usually is not itchy and may be faint. It can occur anywhere on the body, although the hands and feet are common sites (Figure 7.7). Other symptoms associated with secondary syphilis are myalgia, pharyngitis, swollen lymph nodes, headaches, patchy hair loss, muscle aches, or fatigue (Tudor et al., 2023).

Figure 7.7 Secondary Syphilis Secondary syphilis often presents as a rash on the hands or feet. (credit: “Secondary stage syphilis sores (lesions) on the palms of the hands. Referred to as ‘palmar lesions’” by Division of STD Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention/Centers for Disease Control and Prevention, Public Domain)

Latent stage syphilis occurs when there are no signs and symptoms, but syphilis remains in the body. Early latent syphilis is when infection occurred within the past 12 months, and late latent syphilis is when the infection occurred more than 12 months previously. Tertiary syphilis is rare, but it can affect many body organs, including the cardiac and neurologic systems. It can invade any organ (Tudor et al., 2023). It can occur 10 to 30 years after the initial infection and can be fatal. Neurosyphilis occurs when the infection invades the nervous system, causing headaches, muscle weakness, paralysis, trouble with movement, numbness, or changes in mental status. Ocular syphilis invades the visual system and can cause eye pain, redness in the eye, floaters, sensitivity to light, and changes in vision. Otosyphilis occurs when the infection invades the auditory and/or vestibular system and can cause hearing loss, ringing in the ears, difficulty with balance, and dizziness. Congenital syphilis occurs when a pregnant person transmits the infection to a fetus during pregnancy (U.S. Department of Health and Human Services, 2020).

Screening and Diagnosis

All pregnant persons should be screened for syphilis at their first prenatal visit and again in the third trimester, as mandated by most states. For pregnant patients who live in communities with high rates of syphilis or who have a risk of acquiring syphilis during pregnancy, testing should be done twice in the third trimester, at 28 weeks and at the time of delivery (CDC, 2021a). Persons at an increased risk, such as sex workers, persons who are incarcerated, persons assigned male at birth having sex with other persons assigned male at birth, and persons with HIV, should be screened annually (CDC, 2021a).

Darkfield examinations and molecular tests for detecting syphilis directly from a lesion or tissue are the definitive methods for diagnosing early syphilis and congenital syphilis; however, they can have a false-negative result if the patient has applied a topical antibiotic (Tudor et al., 2023). A presumptive diagnosis of syphilis requires two laboratory serologic tests: a nontreponemal test such as the Venereal Disease Research Laboratory (VDRL) or the rapid plasma reagin (RPR) test and a treponemal test such as the T. pallidum passive particle agglutination (TP-PA) assay, various enzyme immunoassays (EIAs), chemiluminescence immunoassays (CIAs) and immunoblots, or rapid treponemal assays (CDC, 2021a). Nontreponemal tests are easy to perform and inexpensive, but they are not specific for syphilis. There is the possibility of false-negative results in patients during primary syphilis and possible false-positive results in patients without syphilis or with previously treated syphilis. The nontreponemal tests can give false-positive results in patients with HIV, some autoimmune conditions, vaccines, injectable drug use, pregnancy, and older age. A confirmatory treponemal test is required. The treponemal test will confirm the positive if it is a true positive test (CDC, 2021a; Tudor et al., 2023).

Management and Treatment

Syphilis is a reportable STI in every state in the United States. The provider or lab must report cases to the Department of Health (CDC, 2021a). Treatment of latent, primary, and secondary syphilis is penicillin G benzathine (Bicillin L-A) 2.4 million units IM in a single dose. Later phases of syphilis should be treated with 1 injection per week for 3 weeks (WHO, 2023). Patients with neurosyphilis, ocular syphilis, or otosyphilis should be treated with penicillin G aqueous (Pfizerpen) 18 to 24 million units per day, administered as 3 to 4 million units IV every 4 hours or continuous infusion for 10 to 14 days (CDC, 2021a). Pregnant women with all phases of syphilis should receive the same penicillin treatment. If they are allergic, they should be desensitized and treated with penicillin because it is the only medication with documented efficacy in pregnancy (CDC, 2021a).

Complications

Treatment of syphilis can sometimes be too late to prevent permanent damage to the patient. Once this damage occurs, treatment will not reverse these problems. The spread of syphilis can cause permanent damage to the brain and neurologic system, causing pain, heightened or loss of sensations, visual problems that can lead to blindness, and stroke. Permanent cardiovascular changes can lead to aortic aneurysm, a weakening of the aorta causing a bulging area that can rupture. Some patients will have gastric changes that lead to weight loss, pain, and vomiting.

Untreated syphilis during pregnancy can lead to miscarriage, stillbirth, or preterm delivery. Infants born with congenital syphilis may be asymptomatic at birth but can suffer from hepatomegaly, jaundice, rash, nasal discharge, lymphadenopathy, and skeletal abnormalities. They can develop fetal hydrops (abnormal accumulation of fluid in the fetal tissues), myocarditis, pneumonia, sepsis, and central nervous system dysfunction that can lead to hydrocephalus, cranial nerve palsies, optic atrophy, blindness, deafness, neurodevelopmental regression, seizures, and fetal death (Arrieta, 2023). These problems can be prevented with adequate treatment during the prenatal period.

Patient Education

Patients should get tested at 6 months and 12 months after treatment. All patients testing positive for syphilis should get tested for HIV. All sex partners within 90 days prior to diagnosis should receive treatment for syphilis (CDC, 2021a).

Incidence

Data on the incidence of PID are limited because signs and symptoms vary between people infected and there is no diagnostic test that can easily detect PID.

Screening and Diagnosis

There is no screening for PID because it is caused by multiple organisms, and diagnosis can be difficult because the symptoms vary. Laparoscopy can be used to make an accurate diagnosis of inflammation in the fallopian tubes and pinpoint bacteria but cannot identify endometritis and may also miss mild inflammation in the fallopian tubes. This test is not readily available and may not be justified for mild symptoms (CDC, 2021a). No history, physical, or laboratory finding can make a definitive diagnosis. Persons assigned female at birth most often present with lower abdominal pain. It is usually bilateral, can occur suddenly, and can last up to a few weeks. Pain can be subtle, and the patient could notice worsening pain with coitus or with sudden, jarring movement. The onset of pain is more likely to occur during or shortly after menses. Abnormal uterine bleeding, urinary frequency, and abnormal vaginal discharge are possible symptoms. During a physical exam, there may be abdominal tenderness with palpation, worse in the lower quadrants. Rebound tenderness, fever, and decreased bowel sounds may be present in patients with severe cases (Ross & Chacko, 2022).

A presumptive diagnosis of PID should be used for persons assigned female at birth who are young and sexually active and all others who are at risk for STIs if they are experiencing pelvic or lower abdominal pain, if no other cause for the illness can be identified, and if one or more of the following three minimum clinical criteria are present on pelvic examination: cervical motion tenderness, uterine tenderness, or adnexal tenderness. This is the most common way that PID is diagnosed (CDC, 2021a). More than 85 percent of cases of PID are caused by STIs; therefore, all patients with possible PID should be tested for STIs. A negative STI result does not rule out PID, but a positive one warrants treatment. Some persons assigned female at birth do not have symptoms of PID and may never be diagnosed with this disease until they have tubal-related fertility issues due to scarring of the fallopian tubes (Ross & Chacko, 2022).

Management and Treatment

Parenteral treatment for PID has improved effectiveness over oral treatment. Intramuscular or oral treatment could be considered for patients with mild to moderate acute PID. Table 7.2 summarizes PID treatment options.

Complications

Pelvic inflammatory disease during pregnancy places a pregnant person at risk for maternal morbidity and preterm delivery. Pregnant persons with PID may need to be hospitalized and treated with IV antibiotics (ACOG, 2022). They may require a consultation with an infectious disease specialist (CDC, 2021). Persons with PID are at risk for reoccurrence. They are also at risk to develop hydrosalpinx, where the fallopian tube gets blocked, fills with fluid, and gets enlarged; chronic pelvic pain; infertility; ectopic pregnancy; and ovarian cancer (Peipert & Madden, 2021).

Infertility is a serious complication of PID because PID can often reoccur and can cause tubal and epithelial destruction, which can affect fertility. PID can cause permanent injury to the fallopian tube, including loss of ciliary action, fibrosis, and occlusion of the tube. After PID resolves, hydrosalpinx can occur and cause difficulty with implantation of the blastocyte (Peipert & Madden, 2021). Table 7.3 summarizes bacterial and protozoan STIs and PID.

Patient Education

Patients should experience clinical improvement in less than 3 days after initiation of treatment; if not, they should be hospitalized for possible change in medication and possible laparoscopy. Sex partners should be tested for gonorrhea and chlamydia. People with an IUD who get PID need treatment but do not need to have the IUD removed (CDC, 2021a).

Incidence

Human papillomavirus is the most common sexually transmitted infectious organism in the United States and the world (Garcia et al., 2023). Approximately 79 million Americans are infected with HPV (U.S. Department of Health and Human Services, 2020). Globally in 2020, about 300 million patients had HPV (WHO, 2023). There are 150 types of HPV, and at least 40 of them affect the genital area. Many types of HPV do not cause any symptoms and are self-limiting. However, types 6 and 11, as well as some others, cause about 90 percent of all anogenital warts. Anogenital warts can be painful and itchy, or they can be asymptomatic. HPV types 16 and 18 cause most cervical, penile, vulvar, vaginal, anal, and oropharyngeal cancers and precancers (CDC, 2021a). Globally, cervical cancer is the most common cancer in persons assigned female at birth and is most often caused by HPV (Palefsky, 2022).

Screening and Diagnosis

During cervical cancer screening, HPV testing can be performed using the same sample. However, annual cervical cancer screening is not recommended for all patients with a vagina who are at average risk. This includes patients with no previous cervical cancer or high-grade precancer, those who are not currently under close follow-up for abnormal results, those not immunocompromised, and those who had no exposure to diethylstilbestrol in utero. For patients 21 to 29 years old, a study of cells, or cytology test (in this case, a Pap smear) to detect abnormal cells is recommended every 3 years. For patients aged 30 to 65 years, a cytology test every 3 years, an HPV test every 5 years, or a cytology plus HPV test every 5 years is recommended (CDC, 2021a). FDA-approved tests for HPV are approved only for cervical specimens and are used to detect oncogenic types of HPV (CDC, 2021a).

Management and Treatment

There is no cure for HPV. Treatment can be done on genital warts or precancerous lesions caused by the virus (CDC, 2021a). For patients with genital warts, the warts may resolve on their own, but treatment may be preferred for cosmetic reasons. Cryotherapy and/or external medication may be used for treatment. Medications that are self-applied include imiquimod (Aldara), podofilox (Condylox), or sinecatechins (Veregen). A provider can perform cryotherapy with liquid nitrogen, or they can apply trichloroacetic acid or bichloroacetic acid or surgically remove the warts. For patients who test positive for HPV types 16 or 18, a colposcopy should be performed, even if the cytology is normal. For patients with abnormal cytology and a positive HPV, a loop electrosurgical excision procedure (LEEP) of the cervix is often recommended (CDC, 2021a).

The HPV vaccine is recommended for all youth aged 11 to 12 and for adults up to age 26 who have not been vaccinated. The vaccine can prevent infection with the types of HPV that cause most genital warts and cancers (U.S. Department of Health and Human Services, 2020). Adults aged 27 to 45 can get the HPV vaccine if they have not been vaccinated and they are at risk for HPV. Less benefit is shown at this age because most adults by this point have been exposed to HPV already (CDC, 2023a). The vaccine has been proven safe and effective, but the rates of vaccination are still low; around 50 percent of youth aged 13 to 17 had completed the vaccine series in 2018 in the United States (U.S. Department of Health and Human Services, 2020).

Complications

Human papillomavirus infection may present with no signs or symptoms; at other times it can cause genital warts. This infection can also cause cervical cancer, anal cancer, vulvar or vaginal cancer, penile cancer, or oropharyngeal cancer (U.S. Department of Health and Human Services, 2020). Human papillomavirus is the number 1 cause of cervical cancer, the fourth most common cancer worldwide in people with a cervix. Approximately 570,000 cases are diagnosed each year, and around 311,000 people die of cervical cancer each year (Palefsky, 2022). In the United States, there were 11,542 new cases of cervical cancer and 4,272 deaths from this cancer in 2020 (CDC, 2023b).

Patient Education

Nurses should educate patients that HPV often goes unnoticed but can have severe health consequences. The vaccine can prevent HPV, but there is no cure once the person has contracted it. Nurses can encourage patients who have tested positive for HPV to address their immune health by decreasing stress, taking multivitamins, exercising, and engaging in overall healthy habits. Sexual partners can unknowingly share HPV, making it impossible to know where it started (CDC, 2021a). In addition, a person can have HPV for a long time prior to having genital warts or changes on their cervix. Therefore, patient education should include that having a new diagnosis of HPV does not mean their partner is having sex with another person; the virus could have been contracted many years prior (CDC, 2021a).

Incidence

Herpes simplex virus (HSV) is a global health issue. From 2005 to 2010, approximately 16 percent of the U.S. population aged 14 to 49 acquired HSV-2 (Albrecht, 2022). There are two types of herpes simplex virus: type 1 and type 2. Both can cause genital herpes. HSV can be found in mucous membranes as well as in the lesions or skin affected by the virus. This type of virus can be spread through oral to oral, oral to genital, or genital to genital contact (Johnston & Wald, 2023). Transmission occurs when there is an outbreak or at periods of subclinical shedding, when the patient has no symptoms, making this an easily spread virus (Albrecht, 2022).

Screening and Diagnosis

Screening for and diagnosis of HSV can be performed depending on where the virus is in the cycle of a lesion. If a lesion is new and has yet to start healing, an HSV NAAT assay test is available. A serum PCR test is available and is the preferred method to diagnose HSV if the infection affects the central nervous system (CNS). This blood test should not be used to detect a genital herpes infection, unless neurologic involvement is suspected (CDC, 2021a). HSV NAAT tests are run on a swab with a specimen from the lesions. This test is the most sensitive but could be negative on older lesions. A viral culture, which is a swab with a specimen from the lesion, may be the only test available but has low sensitivity (CDC, 2021a).

Management and Treatment

The primary infection is the first time the patient has HSV, and the symptoms are often severe and include painful genital ulcers, dysuria, fever, tender lymphadenopathy, and headache (Albrecht, 2022). Medication should be initiated with the start of an outbreak to maximize effectiveness and reduce the duration of the episode (CDC, 2021a). For the first episode of genital herpes, the preferred treatment is acyclovir (Zovirax) 400 mg orally 3 times a day for 7 to 10 days OR famciclovir (Famvir) 250 mg orally 3 times a day for 7 to 10 days OR valacyclovir (Valtrex) 1 g orally 2 times a day for 7 to 10 days. The virus intermittently sheds, and recurrent episodes can occur. Suppressive treatment can be used to prevent outbreaks. Patients who have HSV may have prodromal symptoms prior to an outbreak, which include tingling, paresthesias, or pruritis (Albrecht, 2022). Treatment taken during the prodromal period can include:

• acyclovir 400 mg orally 2 times a day OR
• valacyclovir 500 mg orally once a day OR
• valacyclovir 1 g orally once a day OR
• famciclovir 250 mg orally 2 times a day.

If an outbreak occurs, the following can be used and are most effective if started within 1 day of the outbreak:

• acyclovir 800 mg orally 2 times a day for 5 days OR
• acyclovir 800 mg orally 3 times a day for 2 days OR
• famciclovir 1 g orally 2 times a day for 1 day OR
• famciclovir 500 mg once, followed by 250 mg 2 times a day for 2 days OR
• famciclovir 125 mg 2 times a day for 5 days OR
• valacyclovir 500 mg orally 2 times a day for 3 days OR
• valacyclovir 1 g orally once daily for 5 days (CDC, 2021a).

Pregnant patients who have an active herpes lesion must have a cesarean birth to avoid infecting the newborn. Therefore, patients with recurrent genital herpes should receive suppressive therapy beginning at 36 weeks’ gestation to prevent an outbreak at birth. The therapy should be acyclovir 400 mg given orally 3 times a day or valacyclovir 500 mg given orally 2 times a day until delivery (CDC, 2021a).

Complications

Most often, HSV causes oral infection or genital lesions, but more severe cases can lead to disseminated infection, pneumonitis, hepatitis, or CNS complications such as meningitis or encephalitis. Immunocompromised patients, such as those with HIV, can have longer and more severe episodes. HSV is one disease in a group of infectious diseases, called TORCH, which can be passed from the pregnant person to the fetus (CDC, 2021a). Approximately 2 percent to 3 percent of all congenital anomalies are attributed to perinatal infection (Jaan & Rajnik, 2023). Intrauterine infection due to maternal primary infection can cause the placenta to necrotize and cause inflammation of the umbilical cord, leading to hydrops fetalis or even fetal demise. This is more common if the HSV infection occurs in the second half of pregnancy (Jaan & Rajnik, 2023). A neonate born after intrauterine infection can have skin vesicles, eye damage, and severe central nervous system problems including microcephaly. Neonates that acquire HSV during delivery can develop localized skin, eye, and mouth diseases (SEM), CNS disease, or disseminated disease (Demmler-Harrison, 2022). Neonates with SEM can progress to CNS or disseminated disease if not treated. Neonates with SEM can have skin lesions, eye watering and pain, and ulcerative lesions of the mouth and tongue. Infants with CNS disease can exhibit seizures, lethargy, irritability, tremors, poor feeding, and temperature instability, where neonates with disseminated virus can have dysfunction of multiple organs, including the liver, lungs, heart, kidneys, and neonatal death (Demmler-Harrison, 2022).

Patient Education

Herpes simplex virus outbreaks can come and go. Suppressive medication can be used to decrease the severity, duration, and/or frequency of outbreaks. Current and future sexual partners should be informed of a person’s HSV status before engaging in sexual activity, and patients should abstain from sexual activity when lesions are present. Condoms can help reduce transmission of genital herpes; however, the virus can still be spread through lesions in the genital or anal area that are not covered with the condom. Sexual activity should be avoided during an outbreak (WHO, 2023). Immunocompromised patients, such as those with HIV, could have longer or more severe episodes. Pregnant people with genital herpes can take acyclovir to prevent active lesions at the time of delivery (CDC, 2021a).

Incidence

There are about 1.5 million cases of hepatitis A in the world each year, more common in areas of lower socioeconomic status and less access to clean drinking water. There are rarely relapses, and hepatitis A does not lead to chronic infection (Mehta & Reddivari, 2022). Hepatitis B virus (HBV) is a global health problem, with an estimated 250 million HBV carriers in the world. HBV can be spread through blood and body fluids, perinatally; percutaneously, such as in intravenous drug use; and through sexual contact (Lok, 2023). Hepatitis B can spread from a pregnant person to the newborn. High-risk populations include those having unprotected sex with infected partners, those having sex with multiple partners, those with history of other STIs, and those who inject drugs (CDC, 2021a). Hepatitis C is prevalent in 0.5 percent to 2 percent of the population in the world, with approximately 71 million cases of chronic hepatitis C worldwide. Those who use intravenous drugs and persons who have hemophilia have the highest number of cases (Mehta & Reddivari, 2022).

Screening and Diagnosis

During the acute phase of HBV infection, serum lab work shows increased levels of alanine and aspartate aminotransferase (ALT and AST, respectively). Serologic testing can determine the acute or chronic phase of HBV infection. Table 7.4 summarizes different tests for HBV and what they indicate.

All pregnant persons should be tested for hepatitis B surface antigen (HBsAg) and high-risk patients should be tested again at delivery so that the infant can be treated right after birth (CDC, 2021a).

Management and Treatment

There is no treatment for acute HBV infection. However, therapeutic agents can be used with chronic HBV to help achieve suppression and remission of liver disease (CDC, 2021a). Two products are available to prevent HBV. The first is hepatitis B immune globulin (HBIG), which is used for postexposure prophylaxis. HBIG is prepared from plasma with high concentrations of anti-HBs and provides short-term (3 to 6 months) protection from HBV. This is usually used in combination with the hepatitis B vaccine for people who have not been vaccinated or did not respond to the vaccination (CDC, 2023a). This, along with the hepatitis B vaccine, is also given to infants born to persons who are HBsAG positive (Drutz, 2023). The hepatitis B vaccine is available and is a three- or four-dose scheduled vaccine. It is recommended for all infants and should be given at any time if the person has not been vaccinated (CDC, 2023a).

Complications

Hepatitis B virus infection can lead to serious complications, including the development of cirrhosis of the liver, liver disease, hepatocellular carcinoma, and death. Alcoholics with HBV often have accelerated liver disease (Lok, 2023).

Patient Education

The nurse should teach the patient with HBV infection to avoid alcohol and get vaccinated for hepatitis A and other diseases, such as flu. Family and close friends should get tested and receive the HBV vaccine (Lok, 2023). It is important to complete the whole hepatitis B vaccine series (CDC, 2021a). The person with HBV should always use a latex condom when having sex.

The patient should use caution to prevent spreading the virus through blood, such as avoiding needle sharing. People with HBV infection should cover any cuts or lesions to prevent spread and should not share household articles that can be contaminated with blood, such as razors or toothbrushes. Patients with HBV should not donate blood, plasma, body organs or tissue, or semen (CDC, 2021a). Blood used for transfusions is tested for HBV in the United States. Pregnant patients are tested for HBV during pregnancy; those with HBV will need their newborn to receive hepatitis vaccine and hepatitis B immunoglobulin within 12 hours to prevent transmission of the virus (Mehta & Reddivari, 2022) after birth.

Incidence

As of 2021, 38.4 million adults and 1.7 million children are living with HIV or AIDS worldwide (Quinn, 2022). In the United States, there are about 1.2 million people with HIV. In 2015, there were 37,800 new cases reported, compared with a decline to 34,800 cases in 2019 (HIV.gov, 2022). HIV is a virus that enters the body through the anogenital mucosa or by binding to dendritic cells found in the cervicovaginal epithelium as well as in the tonsils and adenoids. This means HIV can be transmitted through anal-genital, genital-genital, or oral-genital sex (Sax, 2022a). HIV can also be spread through blood and specific body fluids, including breast milk (WHO, 2023). HIV-infected cells in the body fuse with CD4+ T cells, which then spread the virus. During initial infection, the patient has a large number of CD4+ T cells and no HIV immune response, leading to rapid viral replication. The populations most at risk for HIV are persons AMAB having sex with other persons AMAB, people who inject drugs, blood product recipients, and health-care workers with needlestick exposure (Sax, 2022a).

After the primary infection, the patient develops antibodies against HIV antigens, and seroconversion occurs. As the virus stabilizes, a viral set point level is reached. This is variable in patients who are not on treatment, but for patients on treatment, the viral load can remain low. Patients then enter the phase of chronic HIV without AIDS. Without treatment, the patient will usually progress to AIDS within 5 to 10 years. However, with treatment, patients with HIV can often have a near-normal lifespan (Wood, 2023). AIDS is the outcome of chronic HIV infection with a consequent depletion of CD4 cells. AIDS is defined as a CD4 count < 200 cells/microL or the presence of any AIDS-defining conditions, which include the following:

• bacterial infections, multiple or recurrent
• candidiasis of bronchi, trachea, or lungs
• candidiasis of esophagus
• cervical cancer, invasive
• coccidioidomycosis, disseminated or extrapulmonary
• cryptococcosis, extrapulmonary
• cryptosporidiosis, chronic intestinal, > 1 month
• cytomegalovirus disease (other than liver, spleen, or nodes), onset at age >1 month
• cytomegalovirus retinitis
• encephalopathy, HIV related
• herpes simplex—chronic ulcers (>1 month) or bronchitis, pneumonitis, or esophagitis, onset at age >1 month
• histoplasmosis, disseminated or extrapulmonary
• cystoisosporiasis (formerly known as isosporiasis) chronic intestinal (>1 month)
• Kaposi sarcoma
• lymphoma, Burkitt
• lymphoma, immunoblastic
• lymphoma, primary, of brain
• Mycobacterium avium complex or Mycobacterium kansasii, disseminated or extrapulmonary
• Mycobacterium tuberculosis of any site
• Mycobacterium, other species, disseminated or extrapulmonary
• Pneumocystis jirovecii pneumonia
• pneumonia, recurrent
• progressive multifocal leukoencephalopathy
• Salmonella septicemia, recurrent
• toxoplasmosis of brain, onset at age >1 month
• wasting syndrome attributed to HIV (Wood, 2023)

Screening and Diagnosis

Patients at higher risk for HIV acquisition, including sex workers and AMAB persons who have sex with others AMAB, should be screened for HIV at least annually. Anyone seeking testing for another STI should also be tested for HIV. All pregnant persons should be screened for HIV as well. Written consent is not needed, and the CDC recommends the opt-out process for testing so that all pregnant persons are tested, unless they decline. Testing rates have been shown to be higher with this method. (CDC, 2021a).

Testing for HIV requires a blood sample. Initial positive results should be confirmed using the supplemental HIV-1/HIV-2 antibody differentiation. Any rapid positive results should also be followed up with RNA testing (CDC, 2021a).

Management and Treatment

HIV and AIDS are reportable conditions in every state in the United States. Reporting should be done by the provider or lab according to state and local mandates. These reports are confidential (CDC, 2021a). Early detection and treatment of HIV can improve outcomes and reduce new cases, so all sex partners and needle-sharing partners should be notified as soon as possible (CDC, 2021a).

Antiretroviral therapy (ART) consists of medications that suppress HIV. They should be given during the acute phase to decrease severity and transmission (CDC, 2021a). ART should be administered to all HIV-positive patients, regardless of the severity of the disease. ART has been proven to reduce AIDS and non-AIDS morbidity and mortality. ART is effective at suppressing serum viral RNA levels and increasing CD4 levels, possibly to near-normal levels. Low viral levels are thought to reduce the risk of transmission. ART should be started as soon as possible and should be managed by a provider who is experienced with HIV management (Sax, 2022b). The ART should be chosen based on drug-resistance testing but will be a combination of medications.

ART is continued indefinitely (Sax, 2022b). Pregnant patients should receive these combination treatments as well (ACOG, 2024).

Currently, no vaccine exists to prevent HIV, but HIV preexposure prophylaxis (PrEP) is available. The daily oral antiretroviral PrEP is a medication that can reduce the rate of HIV acquisition, especially in those persons assigned male at birth who have intercourse with other persons assigned male at birth. All sexually active patients should be educated about PrEP because it is 99 percent effective in preventing HIV. PrEP is available as an oral therapy taken at home or an injectable therapy given in a clinic setting every 8 weeks. Compliance with taking the medication is important when deciding which treatment to use. PrEP is recommended for certain populations, especially those who have injected drugs and have shared a needle or equipment in the past 6 months or patients who engage in sexual behavior that increases their risk of HIV. This includes

• patients who have sexual partners with HIV,
• persons assigned male at birth who have sex with persons assigned male at birth if there has been condomless anal sex within 6 months,
• heterosexual persons assigned male at birth from regions where HIV is epidemic who have condomless sex,
• heterosexual cisgender persons assigned female at birth who have engaged in condomless sex in the past 6 months with partners assigned male at birth who are at high risk of HIV infection, or
• heterosexual persons assigned male at birth who have been diagnosed with a bacterial STI or have engaged in condomless sex with partners from areas of low general HIV prevalence but who are at high risk of HIV infection (Krakower, 2023).

Complications

Early ART treatment can reduce the severity and chance of transmission of HIV. Patients without ART can have a large viral load and are highly infectious. These patients can also spread HIV perinatally if they are pregnant. Pregnant patients should be tested at the first prenatal visit and again in the third trimester. Knowing about a person’s positive HIV status can help to maintain that patient’s health and reduce the risk of transmission to the fetus by taking ART. Transmission to the fetus without ART is about 30 percent, but that risk is decreased to < 2 percent with ART and obstetric interventions (ACOG, 2024). A patient with HIV and a viral load of ≤ 1,000 copies/mL can wait for spontaneous labor and have a vaginal delivery without increased risk of transmission to the fetus. Patients with a viral load > 1,000 copies/mL should be offered an elective C-section at 38 weeks with intravenous zidovudine (Retrovir) given 3 hours preoperatively (ACOG, 2024). Ideally, this will take place before the onset of labor and rupture of membranes to reduce the risk of transmission to the fetus. Breast-feeding should be discussed with the provider. HIV can be transmitted through breast milk, but the risk is less than 1 percent with ART (HIV.gov, 2023). Breast-feeding may be necessary in countries without safe water sources. Getting treatments to people in these areas is important (WHO, 2023).

If an HIV infection continues without ART, the patient’s CD4 cell count decreases. This causes the patient to become immunocompromised. Once the patient is immunocompromised, they can develop complications such as oropharyngeal or vulvovaginal candidiasis, seborrheic dermatitis, bacterial folliculitis, and methicillin-resistant Staphylococcus aureus (MRSA). Streptococcus pneumonia can also occur (Wood, 2023).

The patient is at higher risk of other STIs. HIV can progress to acquired immunodeficiency syndrome (AIDS), which is defined as a CD4 cell count < 200 cells/microL or the presence of any AIDS-defining conditions. These conditions include, but are not limited to, bacterial infections, multiple or recurrent; cervical cancer; Pneumocystis jirovecii pneumonia; encephalopathy; Kaposi sarcoma; lymphomas; and wasting syndrome. Death will likely occur (Wood, 2023).

Patient Education

Patients with HIV infection who take antiretroviral therapy (ART) can suppress the virus to undetectable levels, which can reduce morbidity, increase lifespan, and prevent sexual transmission to others. Patients diagnosed with HIV should be sent to an HIV specialist and may also need counseling. Pregnant patients should be tested because treatment with ART can significantly decrease the risk of spread to the fetus (CDC, 2021a). Table 7.5 summarizes sexually transmitted infections caused by viruses.