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Tony: Hello and welcome back to another episode of Microbe Matters, presented by ID Pitstop, where we discuss, dissect and demystify topics in infectious diseases with our experts here at UPMC and the University of Pittsburgh. I’m your host, Tony Morrison, media specialist here at Pitt ID, and I’m just as curious as you may be about navigating through a world full of microscopic organisms. Please join us as we examine both the dangerous and beneficial microbial microcosms that surround us, promote public health and showcase research and treatment of modern infectious diseases.

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Tony: This week, I’d like to switch gears a little bit. Let’s talk about sex.

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Tony: I’m sure our listeners are somewhat familiar with the commonly contracted sexually transmitted infections. But people who are comfortable with their sexuality aren’t always comfortable discussing the risk factors from doing so. Though some eyes have no cure, many of them are easily treated with antibodies, sticks. But just as we have discussed previously on this show, the overuse and misuse of antibiotics has allowed for some STIs to develop antibiotic resistance. Joining me in the discussion today is Dr. Linda Nabha, clinical assistant professor of medicine here at the University of Pittsburgh and UPMC. She specializes in general infectious diseases and HIV prevention and treatment. Thanks for being here today, Linda.

Linda: Thanks for having me, Tony. This is a great topic and a very important topic to talk about today.

Tony: Also here with us is Dr. Ken Ho, associate professor of medicine here at the University of Pittsburgh as well. He is the medical director of the Pittman Studies Multicenter AIDS Cohort Study and the Prevention Committee for AIDS Free Pittsburgh, a collaborative and public health movement working to end the AIDS epidemic in Allegheny County. Ken, welcome to the show and thanks for getting down with us.

Ken: Thanks for having me. Really happy to have this discussion.

Tony: For today’s discussion. Shall we begin with an STI screening? Linda, can you tell me a little bit about a standard sexual health visit? Why is it so important to stay up to date on such screenings? And what should clinicians and patients know about taking a sexual history?

Linda: I think that this is the [Stutters] the most important question we can actually bring up today is taking inappropriate sexual history. I think that is the cornerstone to making diagnoses, treating our patients and protecting our patients. So in my opinion, I’ve seen … when you first meet a patient taking a sexual history and understanding the sexual practices of your patient is of the utmost importance. That is the way that we’re going to be able to treat them and protect them against sexually transmitted infections. And that takes actually the clinician to be comfortable with asking what are your sexual practices? Who do you have sex with and how do you have sex?

So I think just basically establishing those few points, especially on that first visit with a patient, is going to create an environment where the patient is going to be comfortable to be asking, to be answering those questions and to be forthcoming with that information. And once you are able to establish those sexual practices, then you can assess what kind of SSDI screening should I be doing for this particular patient.

Tony: I personally think it’s a great idea that people who are having sex should perform routine STI screenings, but a lot of the time patients don’t go for one unless they’re showing symptoms of an active infection. Can if someone has no symptoms at all, do they really need testing for gonorrhea, chlamydia or syphilis?

Ken; Yeah, this is something that we see a lot. I mean, when we think of your bacterial or sexually transmitted infections like gonorrhea, chlamydia, syphilis, you know, some of the symptoms that one might experience or people think you experience are like penile discharge, vaginal discharge, rectal discharge, pain, discomfort, things that would probably bring you in to see a health care provider. But the reality is the most common symptoms of those bacterial sexually transmitted infections is nothing at all. And that’s why it’s important to do regular screening. There’s [Stutters] there’s guidelines with regards to how kind of how frequently we screen different populations. I don’t know that it’s important to get into that here. I mean, for me, I tend to see a lot of gay and bisexual men.

And what I tend to do is, you know, get a sense of, you know, what the exposures are, you know, what sort of sex is happening. And then like when new partners come into the mix to try to screen kind of based on that history, which, you know, can vary per person. And so, at the end of the day, in the prep world, we do screening roughly every three months. And I sort of settled on that as kind of a reasonable amount of screening for somebody who’s sexually active with multiple partners.

Linda: I think to add on finishing is many times patients will come in and they are asymptomatic, meaning they’re not going to come in and tell you I have discharge, or I have rectal pain and the majority of these STI’s that are in the throat or the rectal area. And I, I think Ken can probably elaborate much more on this, is that they’re not going to necessarily have symptoms and it is up to the clinician to gather that information and screen appropriately.

Ken: Yeah, I think you bring up a really good point, too, because in the past, a lot of times and I think especially in in [Stutters] in men, we think, okay, the way we screen for sexually transmitted infections is just to get a urine sample. But the reality is sexually transmitted infections such as gonorrhea and chlamydia can exist in the rectal compartment, in the throat as well. And those require different testings. They actually require swaps.

Tony: With most STI screenings, there are certain organisms that aren’t typically part of the screening panel, such as herpes. Could either of you explain why that might be?

Linda: Sure, I can take this one. I certainly when we talk about herpes in particular, ah, there is such a stigma with the word herpes. And in fact the majority of the population has actually been exposed to herpes. And so when you come in and say, I want a herpes screening or herpes test, I think and I kind of cringe or see someone come in and get a herpes antibody test, right?
That’s a blood test. That test against herpes and the majority of the population is going to be positive. And so the thought here is that, [Pause] yes, you have been exposed to herpes, but that you know. But at what point is that going to be clinically important and at what point are you going to be infective or cause any significant complications in your body?

And so the real screening for herpes is really visually having a herpetic outbreak so that the clinician or the doctor sees that you’ve had a herpetic outbreak. Um, they can oftentimes diagnose herpes that way. Um, or if you see a lesion many times in the genital [Stutters] genital area, you can swab that and test that for herpes. But the idea here is that a positive antibody test in the blood for screening for herpes is not necessarily indicative of an active herpes infection and that you’re going to infect another individual.

Tony: So because so many people are exposed to herpes at some point in their lifetime, I guess it would make sense that it would only be screened in the event of a visibly active infection because there is no cure. There does seem to be a lot of stigma surrounding it, as Linda mentioned previously. Does having a herpes infection increase a person’s risk of developing other STIs? Also, how can someone protect their partner or partners?

Linda: So certainly we can start with the last person to a herpetic infection in the genital area causes a lot of inflammation in the skin. And when you sort of have that skin breakdown there, there is increased risk of other sexually transmitted infections going through that skin. Right. Breaking down that skin barrier and being able to get inside. So certainly having a herpetic outbreak can increase your risk for other sexually transmitted infections.

There are situations where one partner has herpes and one partner does not. It gets a little bit tricky because the majority of people aren’t been exposed to herpes. And so I have seen in my clinic patients coming in saying I have herpes, my partner doesn’t. How do I stop? How do I stop or prevent her herpes from spreading to my partner? Well, unfortunately, nothing is 100% except for abstinence. And we know that’s probably unlikely in this situation. And we know that consistent condom use can actually decrease the risk of this HSV-1 and HSV-2, um can decrease the risk of HSV two transmission to the uninfected partner, about 90%. Um. However, that being said, the idea that the partner doesn’t already have herpes, we will have to test it.

I think that’s a case by case basis. Certainly you want to reduce your transmission of infecting anyone else. And so obviously abstinence from sexual contact when you have a herpetic outbreak is one And then two consistent condom use would be the other way to do it. Third, thirdly, you could go on a preventative medication like Valacyclovir or Acyclovir, taking that daily depending on how often you’re breaking out, but there’s always some level of shedding. So it really complicates the matter.

Ken: Yeah. One of the challenges I think with especially when we kind of advise patients to say to use condoms consistently is a lot of times they think that refers only to vaginal sex or anal sex. But the reality is you can certainly get any of the sexually transmitted infections, including HSV and the bacterial STIs from oral sex as well, which kind of leads us well, do we recommend condoms for all oral sex? I know that’s probably good from a public health standpoint, but probably not from an acceptability standpoint in the general population. So I think we have to start thinking beyond that, like, okay, what do we do if that’s not really part of somebody’s, you know, what they’re willing to do um with regards to sexual health?

Linda: Well, to add on to the stigma, you know, of herpes here, they did a study several years ago where people get diagnosed with herpes. Right. And they’ve compared it to a death of losing a loved one, losing a house, failing an exam, and the stigma, the effect of being diagnosed with herpes is akin to failing an exam between the exam and losing a health. I mean, that is a quite a sickness account traumatic event to happen to someone. And I think one of our jobs is to really kind of [Pause] calm the person down and talk and really kind of talk [Stutters] about the clinical significance of herpes. I mean, it is much more stigmatized than the certainly the complications and the risks are for it.

Ken: I think. And Linda. Correct me if I’m wrong here, I feel like by the time you reach like middle age, like maybe all of over half of people on the planet have probably been exposed to herpes and some may have symptoms, some may not, but they all would actually have the antibody for herpes and technically, quote unquote, have herpes.

Linda: Exactly. Yeah. The majority of the population has been exposed to herpes, either type one mostly, or type two. And they may never know it because they’ve never garnered a they’ve never had a lesion. They’ve never had an outbreak. And so it becomes a very sticky situation to talk about what it means to actually have herpes.

Tony: You know, talking about this sort of stigma surrounding herpes reminds me a lot about the stigma surrounding HIV. Up until recently, being infected with HIV was thought to be a, quote unquote, death sentence. But that’s not necessarily the case thanks to advancements in treatments for the virus. You mentioned antivirals as a treatment for herpes, but could you talk about antiretrovirals for HIV positive patients and its preventative uses today?

Ken: Yeah. So for {Stutters] for herpes. We would treat that with an antiviral. HIV is [Stutters] is a retrovirus. So you know, through time, you know, HIV came along. We didn’t have treatments and it was you know, that’s where this whole concept of HIV being a death sentence kind of came from. And then medications evolved and we call them antiretrovirals, which kind of make sense, anti HIV medications and came up with the whole combination antiretroviral therapy that was really highly successful and changed the whole trajectory of how we look at and treat HIV. And then I think along that line, somebody came up with a bright idea, Well, maybe we can use these medications to prevent HIV. The problem was a lot of the older medications really toxic, but along came FTC,, TDF or Truvada and by it’s brand name um and to one pill once a day with fairly few side effects and they tested that as a preventative for HIV. And lo and behold, it worked very well in lots of people. And I think there’s a whole body of literature that basically supports that to the point where today, you know, we can offer people who want to prevent HIV in themselves a daily pill to take, and that works really quite well.

Tony: So while we’re on the topic, Ken, I know you’re deeply involved in PrEP services and resources. What are all the current options for PrEP? What makes each treatment different and why do you think we need more than one option?

Ken: Right. So lots of stuff to unpack there. [Laughs] So I’ll start out with the different types of PrEP. So I talked about FTC, TDF as a one pill once a day regimen. There is now another option called Descovy or FTC. TAF. Actually, it’s very it’s very similar medication with a slightly different, I guess, side effect profile, but taken the same way, one pill once a day. It’s a smaller pill too currently that’s only FDA approved for people whose risk factor is not receptive vaginal sex. And that’s [Stutters] that’s simply due to the fact that the big trials have been done in certain populations and not in, for example, cisgender women. Hopefully that will change over the next couple of years So so two different pill options. The advantage of the Descovy is, you know, you can actually use it in people who may have kidney function that’s not as good or uh. maybe have issues with their bone health. And then finally, new as of probably last year is that long acting injectable. So a uh, an injection that you can receive it’s in the buttocks uh every two months roughly and [and actually is very effective at preventing PrEP as well sorry [Stutters] as preventing HIV as well and has been compared to PrEP the standard PrEPlike Truvada and just as good if not better.

Linda: Uh so, can [Stutters] if someone comes in to see you per say and they um want to explore those options, how would you guide them in terms of doing the injectable versus the, the oral prevention?

Ken: Yeah, I think a lot of different factors kind of play into that. You know, a lot of, you know, when I see someone new, it’s sort of getting into the reasons they want to go on, PrEP their experience with taking medications, trying to remember to take things side effects, all of those kind of come into play. With oral PrEP. It’s you have to remember to take it once a day. And for some people, that’s a really easy thing to do. Common side effects are usually stomach side effects, which tend to go away with time and uh, and for most people and I probably say like 90% of people, they actually have no problem with the side effects. But some people do have some mild stomach issues. For the injectable you’re going to get a shot in the buttocks. That’s going to hurt a little bit. Then some people may have an aversion to needles, which might make them not want to do that. But the idea that you could sort of leave the clinic every two weeks and not have to worry about a single thing is really powerful, really important, because when it comes to prevention, adherence is kind of the Achilles heel. That’s kind of the thing that makes or breaks the success of prep. And so if somebody really has struggles with [Stutters] with remembering to take preventative medication, maybe the injectable works better.

Tony: Linda, do you have any tips on how to effectively take PrEP and are there options for people who may have missed a dose and are exposed to HIV?

Linda: Yeah, so that’s a case by case basis. So I think if somebody has been taking prep and they’ve been adherent, they’ve missed a day or two of it, we can safely say that they’re probably they’ve been taking it for some time and we can probably safely say that it’s still effective and they have not caught HIV per se. However, I don’t want to put that out there that every person is safe when they miss their medication. So attention adherence is a huge issue, especially in our younger population, who are not taking other medications. Um, those who are a little bit older may be on anti-hypertensive and maybe have diabetic medications. So adding a pill to that regimen may not be as difficult as someone who’s not taking medicine at all. Or, for example, they leave for a long weekend or a vacation. They forgot their PrEP pills. And we’ve heard that story a lot. I’m sure Ken can attest to that

So the most important thing is the adherence. And um uh, if there’s an adherence issue, certainly the injectable may be the option for these particular patients. If there is no, um [Stutters] no, no potential side effects to that. So in terms of adherence, I would take that in terms of exposure, I would take that on a case by case basis. Certainly the longer that they’ve been off PrEP pills, the more likely they are to be at risk for HIV. And so if someone has been off of PrEP for some period of time being speaking to your clinician right after exposure, certainly that that particular case could warrant being a PEP, which is post-exposure prophylaxis. So you’re basically putting somebody on HIV medications for about 30 days. But again, you know, it’s hard to say and it’s certainly a case by case basis.

Tony: As someone who has tried the weekly pill organizer, sticky notes and even alarm clocks, I still find that a missed dose here and there can still happen. So it’s good to know that there are different daily pills and less frequently dose injectables to choose from, depending on which is right for you and your lifestyle. That brings me to my next question. Ken, in your opinion, who should be taking PrEP and how do they know if PrEP is right for them?

Ken: There are, for example, guidelines which, you know, have risk factors that that makes sense. You know, more than one partner if they’ve had a recent STI in the past six months, if they’re having transactional sex, which means like sex for money or drugs, if they’re condom use, it’s inconsistent, which is super, super common. So these all make sense. Um, but what I found that when people like take these guidelines, they like try to make like algo- complicated algorithms to figure out who gets and who doesn’t get PrEP. And I feel like it doesn’t necessarily need that much brainpower. Where we are right now is that people are not prescribing PrEP enough that the people who need it are not getting it.

And so I think in response to that, actually the guidelines have changed a little bit in that the classic risk factors which include all those people who are using injection drugs, but also anybody who asks for PrEP should get PrEP, so they don’t need to justify why they want PrEP, they just need to ask for it. And we should be aware of the fact that there’s a lot of stigma and sometimes people don’t want to share that information and that’s okay.

Linda: To add onto Ken I do want to bring up a very important point here. He’s absolutely right prescribing PrEP is not hard to do. It really is not a difficult thing to do. And I’ve had certainly patients ask for prep and by other clinicians and they were denied and then somehow have found me and in the meantime have caught HIV. And I think that as an absolute missed opportunity and it is our responsibility to if we cannot prescribe PrEP to be able to help these patients find a place that would be able to evaluate them.

Ken: Thanks so much for that. I feel so strongly about that. And I’ve had patients who kind of fell into the same situation where they went to their PCP. Their PCP said you need to be using condoms, not prep, and they ended up getting HIV. And here they are seeing me for HIV treatment. And I said, Oh my goodness, we could have made a difference there.

Tony: Recently, there has been an increase in some bacterial sexually transmitted infections, notably ones that have developed antibiotic resistance to treatments. Is super gonorrhea something that people should think about and be mindful of nowadays?

Ken: Yeah, I think that’s oh, yes, I think that’s something that we do need to think about. I mean, at least locally here, we haven’t seen a lot of drug resistant gonorrhea. I think the last reported case was in Massachusetts, I think back in January. And I think ultimately it was treated with our available antibiotics. But the concern is that this could worsen. And, you know, could we envision a scenario where we have gonorrhea that we simply can’t treat? That is a possibility. And I think it speaks to the importance of testing for gonorrhea, because a lot of gonorrhea is, you know, you have no symptoms. And then so people are going about their lives getting antibiotics for other things in that gonorrhea that they have and spreading around other people could potentially become resistant through that mechanism.

So that speaks to the importance of diagnosing it, treating it and kind of going out. And, you know, when you diagnose that, you do partner notification to get their partners treated as well. So it’s sort of everybody is involved from the public health standpoint to just the treatment standpoint to talking to other partners as well.

Linda: Yeah, we’ve certainly seen gonorrhea has progressively developed resistance to antibiotics and we’ve seen that initially we were treating it with fluoroquinolones, certain antibiotics and now it’s changed down now to cephalosporins. So we are seeing this trend. Um, it is certainly a public health concern and with, you know, I think in terms of the clinician side of things, certainly testing those who are not necessarily symptomatic but may be at risk for catching gonorrhea. And it really goes back to the kind of sexual history talking to your patient, testing and treating. Can. I wanted to ask you, what are your thoughts on tests of cure and when would you do it? So if someone comes in and they’re want to do their standard STI testing at what point do you think of a test, the cure, as it relates to chlamydia and gonorrhea?

Ken: Right. I actually think a large part of when you look at guidelines, again, they largely recommend screening in three months, which I guess could be kind of like a test of cure, but it’s not really in the spirit of test of cure. I think the idea being that, you know, people who have in this test might get reinfected, and that’s not uncommon. Where I think test of cure really does come into play is especially pharyngeal gonorrhea and the reason for that is a lot of the antibiotics we use to treat gonorrhea don’t penetrate into the pharynx as well. And so there’s the higher risk of failure. And for that reason there is the provision to do a test of cure. I think it’s two weeks after treatment for pharyngeal gonorrhea. I think, you know, I think this can be case by case basis too. You may have somebody who has symptoms.

You treat them to get a little bit better. They get worse then and then granted there, you know, that would they be symptomatic. So it’s a reason to to test again. But I think when the flag goes up, like could this person have resistance, that that does kind of complicate matters and, and the problem is our testing is largely it’s it’s not based on nucleic acid amplification, amplification which tells you whether you have it or not. It doesn’t tell you about resistance. And so if you are concerned for resistance, you actually do need to get a gonorrhea culture. And that may involve, you know, for example, the local health department or what have you to do, testing for resistant gonorrhea.

Linda: Right, It’s not as simple. Let’s just test you for resistant gonorrhea right here, right now. I mean, it could include a consultation form of the CDC or your local health department. So certainly, you know, it’s not easy. And also it’s not easy to get your patient to come back in a few weeks as we know, to repeat their tests. You know, many times they say, hey, I feel great, don’t call me. So, you know, it’s you know, there are challenges on multiple levels here in terms of testing, treatment and then testing for a cure.

Tony: Recently, the CDC has raised concern over another bacteria that is resistant to all the antimicrobial treatments that are typically used to treat it. What is drug resistant shigella and how would either of you treat it?

Linda: So shigella in general, and I’ll defer to Ken for treatment of drug resistance figure is a bacteria that can be either it’s a foodborne um illness or or infection through sexual transmission. So when we think about shigella, it doesn’t necessarily mean you have an STD. Again, also the flip side doesn’t mean you have foodborne illness, right? And so when we put that word out there, I don’t want people to say, hey, I have shigella, I have an STI. When we think about diagnosis of Astragalus as per say, you know, diagnosis or transmission can be sexual, it could be through foodborne. Um there could be what we call intercontinental transmission. So one has traveled overseas and caught shigellosis and so kind of bringing it down to treatment of shigellosis, certainly we are seeing is a thromycin resistant shigellosis out there.

Ken: Yeah. One of the challenges with shigella is only a tiny, tiny little bit can cause an infection. And a lot of times that happens because, you know, someone may have had, you know, a little bit on their fingers and they eat a sandwich or something like that, and then they get it right. And so it can spread very fast in the right situation. So hand-washing actually becomes a big part of the prevention of shigella as well as, you know, potentially, especially in outbreak situations, avoiding certain activities that might predispose one. And if we if we think about like sexual activity, that might be something like, for example, rimming where it’s like kind of oral anal contact. [Laughs] I said it. Um, getting to treatment you know, actually most of the times shigella, it’s, you know, causes diarrheal illness. It usually gets better on its own most of the time in healthy people it’s not going to require treatment.

It’s just in people who may have compromised immune systems or a complication where we might bring out the antibiotics. I guess for starters, most of the time shigella, we are not even going to treat with antibiotics. The concern for drug resistant shigella is in those people who have complications, prolonged illness or immunocompromised that you may want to treat it. And if they have the resistant form and the most resistant form is called XDR, which is extensively drug resistant, then we have very few, if any, options. And then we’re stuck with treating kind of using combinations of antibiotics such as carbapenems or what have you, that, you know, we don’t have a lot of evidence for, but it’s based on kind of experience elsewhere.

Tony: So one of the reasons we are seeing such a dramatic rise in superbug infections in general is because of the overuse and misuse of antibiotics. You both mentioned PrEP and PEP for HIV, but is there something similar for these other bacterial infections out there on the market?

Ken: So yeah, so it’s not so much, so when we think of PrEP, that’s pre-exposure prophylaxis. So taking a medication before your exposure, whereas post-exposure prophylaxis is after the exposure. More recently there’s been data on the use of an antibiotic called doxycycline. It’s used a lot for acne, for treatment of Lyme disease as a post-exposure prophylaxis for sexually transmitted infections. And so the idea here is after a sexual exposure can be any kind of sexual exposure, you would take 200 milligrams. So that’s two tablet, two standard tablets of doxycycline within about 24 hours after your exposure. Generally, it’s a very well tolerated medication. It lasts a long time. And then now we are actually seeing data largely in gay and bisexual men that it is that can really reduce the risk of developing gonorrhea, chlamydia and syphilis um after those kinds of exposures, reducing it really by like 70 to 80%. That hasn’t been shown in in women or people who are side female at birth yet but we’re trying to figure out why and if that’s the case or not. So right now, it’s not FDA approved, but it has become kind of the local community standard of care, especially in sexual wellness clinics, to use doxycycline as a post-exposure prophylaxis in certain groups of people.

Linda: And I think can, you know, hit the nail on the head. This is a post-exposure prophylaxis. And so it’s not you’re going to be almost like you’re taking your prep, you’re not taking it daily, but you’re taking it after a sexual experience to reduce your rates.

Tony: What do you think, if any, are the implications surrounding drug resistance and using this method for bacterial infections?

Ken: Yeah, that’s a big question, right? Uh, we tend to go back and forth. There was some recent data at our big retroviral conference which suggested that there might be a slight increase in certain types of resistant staph or, or things like that. But overall there was actually less staph, period. So that kind of counters that I think the moral of the story in this particular presentation was they didn’t see a huge uptick in resistant organisms after use, maybe just a tiny bit. How that plays out over time, I think we still need to to figure that out. And also keep in mind that we have been using doxycycline for acne and for prevention and treatment of Lyme disease for decades and you know, it seems like we haven’t seen emergence of super doxy resistant organisms such as, for example, Lyme disease.

Linda: Yeah, I was just going to add on to what kind of thing. I think the answer there is, we don’t know. We don’t have the studies and we that the data that Ken is talking about is very compelling to reduce rates of STIs, chlamydia, gonorrhea and syphilis, and at risk populations are at [Stutters] at risk individuals. So it’s compelling data and terms.

Linda: And those are very thoughtful questions to ask. You know, are we are we setting, setting ourselves up for resistance in the future? And the reality is we don’t know. We know that Dr. Cyclin does a carry heavy burden in terms of treatment of other organisms. And so I think it’s a question that has to be continued certainly.

Tony: We’ve talked a lot about the topic of superbugs on the show so far, and we would be remiss not to mention the role they can play concerning sexual health as well as overall health.

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Tony: Today we’ve learned about some of the drug resistance that can be seen in sexually transmitted infections, and that is why it is so important for patients to have access to education testing and treatment options and settings which are free of stigma. Thank you again, Linda, for your insight. You are an absolute delight to have on the show.

Linda: Thanks for having me.

Tony; And Ken, thank you for also sharing your clinical experiences with us today.

Ken: It’s been great. Thank you.

Tony: Please join us next time as we dive deeper into microscopic topics on microbe matters.

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Tony: Thanks for listening. If you enjoyed this episode, make sure to subscribe to the show wherever you listen to podcasts and be sure to check us out on social media at ID Pitstop.

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