STBBI prevention guide: Treatment and follow-up

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• Management based on etiology or syndrome
• Treatment
  • Suppressive therapy and prophylaxis
  • Antimicrobial resistance
  • Co-infections
  • Expedited partner treatment
• Follow-up
• Reporting and partner notification
• References

Management based on etiology or syndrome

A syndromic approach refers to the management of an individual based on signs and symptoms, prior to laboratory confirmation of the etiologic agent(s). Some syndromes are commonly associated with STIs and the determination of the most likely etiologic agent(s) should be based on the evaluation of the likelihood that the individual acquired an STI. Laboratory testing should be done to confirm infection when there are signs and symptoms that are consistent with a STBBI or the individual has a sexual partner who has been diagnosed with a STBBI. Refer to the STI-associated Syndromes guide for an overview of the management of the following STI-associated syndromes: anogenital ulcers, cervicitis, epididymitis, pelvic inflammatory disease (PID), proctitis, urethritis and vaginitis.

When an STBBI has been identified, refer to the etiology-specific guide(s) for guidance on:

• Management and treatment
• Test of cure (TOC) and follow-up
• Reporting requirements
• Notification and treatment of partners

Individuals who require advanced diagnostics or hospitalization should be cared for in consultation with an experienced colleague or referred to a specialist.

Treatment

Treatment objectives depend on the specific pathogen and whether the infection is curable (e.g. bacterial, HCV) or chronic and manageable (e.g. HSV, HBV, HIV).

Empiric treatment is useful to manage symptoms, to control transmission and to prevent complications. At the same time, different STBBIs may have similar presentations or conversely, the same STBBI may present in different ways. Waiting for test results before treatment allows for the appropriate use of antibiotics which can enhance health outcomes, reduce antimicrobial resistance (AMR) and decrease the likelihood of unnecessary or inadequate treatment. Delaying treatment until laboratory test results are available may be preferable when the clinical condition is not severe, risk factors suggest that it’s unlikely that an STI is the cause of symptoms and the person is willing to abstain from sex and to return for test results or follow-up.

Consider providing empiric treatment as a public health preventive measure, to prevent the development of infection in a sexual contact of a person with a confirmed STI. If empiric treatment is provided for a suspected STI, advise the person to abstain from sex until therapy is completed, symptoms have resolved, and sex partners have been adequately treated. If abstinence is in doubt, recommend the use of barrier protection for oral, genital and anal sex.

For confirmed cases of a STBBI, consult etiology specific guides for treatment recommendations of sexual partners.

Suppressive therapy and prophylaxis

Suppressive and prophylactic therapies are available for some viral STBBIs. Encourage individuals taking suppressive and prophylactic therapies to adhere to these therapies as prescribed and to use condoms and dental dams consistently and correctly to prevent the acquisition or transmission of other STBBIs.

HAV

Refer to the Canadian Immunization Guide regarding post-exposure prophylaxis for susceptible close contacts of people with HAV^{Footnote 1}.

HBV

Refer to the Canadian Immunization Guide regarding the use of HBV vaccination and immunoglobulin as prophylaxis following a potential sexual exposure to HBV.

HIV

Early diagnosis and treatment can lead to reduced morbidity and mortality associated with HIV infection and disease progression. The goal of antiretroviral treatment (ART) is to achieve and maintain an undetectable viral load to improve the overall health of people living with HIV. Another advantage of effective ART is the prevention of HIV transmission. Pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) are also effective strategies to reduce acquisition of HIV.

HIV treatment and prophylaxis are rapidly evolving and complex areas, with changes in recommended regimens occurring as new research and evidence becomes available. Consider consulting a colleague experienced in HIV/AIDS care or an infectious diseases specialist for guidance on treatment or prophylaxis. Consult Canadian, provincial or territorial guidelines for prescribing information and indications for HIV treatment and prophylaxis. Consult your provincial or territorial drug formulary regarding coverage.

ART

Undetectable = Untransmittable (U = U)^{Footnote 2Footnote 3} reflects the scientific evidence that people living with HIV who take ART and who achieve and maintain an undetectable viral load have effectively no risk of transmitting HIV sexually. Effective ART can also help to prevent the vertical transmission of HIV.

Adherence to ART is essential to achieve and maintain an undetectable viral load. It can take up to six months to achieve an undetectable viral load; regular viral load testing is the only way to know whether viral levels are undetectable. At least two consecutive undetectable results over a six month period are required before U = U can be used as strategy to prevent the sexual transmission of HIV.

Discuss the benefits of ART as part of routine HIV care.

PrEP

PrEP is the use of antiretroviral medication by people who are HIV negative - but at high risk of exposure to HIV – to prevent HIV infection^{Footnote 4}. Taking antiretroviral medication before exposure interrupts HIV's ability to copy itself in the body and prevents it from establishing an infection. The consistent and correct use of PrEP is a highly effective strategy to help prevent the sexual acquisition of HIV.

Offer PrEP to individuals at high risk for HIV infection as part of a combination prevention strategy which includes regular STBBI screening as well as ongoing counselling on adherence and risk-reduction.

PEP

PEP is the use of antiretroviral medication by people who are HIV negative to lower the risk of HIV acquisition following a high-risk exposure. PEP should be initiated as soon as possible, within 72 hours after an exposure^{Footnote 4}. Adherence is essential for maximizing effectiveness^{Footnote 4}.

Baseline HIV status should be determined when PEP is being considered.

PEP is not intended for people with ongoing exposures to HIV and should not replace the use of other highly effective prevention strategies such as condoms and PrEP^{Footnote 4}.

HSV

Refer to the Genital herpes guide for indications and recommendations for treatment and suppressive therapy.

Daily suppressive antiviral therapy reduces the length, frequency and severity of genital herpes recurrences^{Footnote 5Footnote 6Footnote 7Footnote 8} and decreases asymptomatic viral shedding and transmission, but does not eradicate the virus.

Antimicrobial resistance (AMR)

AMR is a global public health challenge. Practice antimicrobial stewardship when treating STBBIs. The following practices can limit the development and spread of AMR infections:

• Promote safer practices
• Normalize and increase screening
• Increase detection by testing all affected sites (genital and extra-genital)
• Treat individuals and their sex partner(s) according to current guidelines
• Consider testing and waiting for test results, in order to provide etiology-guided treatment, when the person’s clinical condition allows, they are willing to abstain from sex, they are likely to return for follow up and/or test turnaround time is rapid
• Follow up with a TOC, as appropriate (Refer to etiology-specific guides)
• Conduct pre-travel counselling and take a travel history

Neisseria gonorrhoeae and Mycoplasma genitalium have demonstrated resistance to multiple antibiotics. In Canada, an accurate picture of drug resistance is difficult because of a shift towards testing using nucleic acid amplification tests (NAAT) rather than culture; as a result, fewer samples are tested for susceptibility^{Footnote 9}. Refer to the Neisseria gonorrhoeae and Mycoplasma genitalium guides for recommendations on diagnostic testing and treatment.

Co-infections

Transmission routes are similar for many STBBIs; co-infection is common and can have treatment and follow-up implications.

In people living with HIV, co-infection with HBV, HCV or syphilis may impact the course of disease. As well, there may be special considerations for treatment and monitoring to ensure treatment effectiveness and to prevent long-term complications^{Footnote 10}.

Expedited partner treatment

Some jurisdictions offer expedited partner treatment (EPT). Check with provincial or territorial health authority and professional association(s) regarding policies and guidelines for EPT. EPT could involve providing:

• A prescription or medications for partner(s) without requiring assessment by a healthcare provider
• Test kits for sexual partner(s) to mail back
• Information sheets, referral instructions
• Telemedicine consultations

Potential advantages of EPT include:

• Increased proportion of treated partners, particularly those populations that are hard-to-reach or disproportionately affected by STBBIs
• Timely treatment of partners
• Reduced transmission
• Reduced reinfections
• Treatment of undiagnosed STBBI
• Prevention of morbidity and complications

Challenges related to EPT include:

• A therapeutic relationship is not established
• Difficulty verifying treatment completion
• Potential for negative partner reaction
• Partners not seeking testing and care
• Loss of counselling opportunity
• Possible allergic or adverse drug reactions^{Footnote 11Footnote 12}

Follow-up

Ideally, follow-up should be conducted by the healthcare provider who diagnosed and treated the person, to ensure:

• Resolution of symptoms
• Follow-up testing
• Follow-through on partner notification and treatment

If the same healthcare provider is not available, individuals should be directed to appropriate resources, counselled on when to follow up and on symptoms that may indicate treatment failure.

Follow-up testing is needed if baseline testing might have occurred during the window period.

A TOC may be recommended depending on the pathogen and treatment regimen. For some pathogens a TOC is always recommended and for others, a TOC is recommended only in specific situations. In syphilis cases, post-treatment serologic testing is needed to assess treatment response and should be performed at the recommended intervals for stage of infection.

Offer repeat screening for STBBIs based on ongoing risk factors and continued potential for exposure. Repeat screening is generally recommended 3 to 6 months after treatment for a bacterial STBBI, due to the potential for reinfection.

Refer to etiology-specific guides for information on follow-up.

Reporting and partner notification

STI reporting requirements and confidentiality

STBBI reporting requirements vary by province and territory. Inform individuals that provincial or territorial public health acts and the Child Protection Act supersede healthcare provider-client confidentiality and require the release of personal information without consent of the individual for all reportable STBBIs and in suspected child abuse.

Assure the person that the information will be reported to authorities only as required by law and will otherwise remain confidential. Advise the person that those who receive and process this personal information are bound by ethical, legal and professional obligations to protect confidentiality.

Partner notification

Healthcare providers are required to maintain confidentiality related to the person: no information related to the person can be released to the partner(s) without consent.

Partner notification is a secondary prevention process through which sexual partners and other contacts potentially exposed to a STBBI are identified, located, assessed, counselled, screened and treated. Partner notification has public health benefits (e.g. disease surveillance and control) and for many STBBIs it reduces the potential of reinfection. Partner notification can be an effective means of finding persons with a STBBI or at risk of acquiring a STBBI^{Footnote 13Footnote 14}.

While partner notification is sometimes seen as a conflict between societal and individual rights, its aim is to assist in honouring the rights of the sex partners to know whether they have been exposed to a STBBI and to make informed decisions about their health.

Partner notification practices vary by province and territory. More than one strategy can be used to notify different partners. Partner notification strategies include:

• Self-referral: The person accepts full responsibility for informing their partners of the possibility of exposure to a STBBI and for referring them to appropriate services.
• Healthcare provider or public health referral: With the consent of the person, the healthcare provider or public health professional takes responsibility for confidentially notifying partners of the possibility of their exposure to an STBBI. In general, healthcare provider referral ensures more partners are notified, counselled and assessed^{Footnote 13Footnote 14}.
• Contract referral: The healthcare provider negotiates a time frame with the person (usually 24–48 hours) to inform their partner(s) of their exposure and to refer them to appropriate services, after which time, if not done, the healthcare provider or public health professional will notify the partner(s)^{Footnote 14}.

Barriers to partner notification

If the person does not wish to notify partners or if partners have not come forward, consider the following partner notification barriers. If needed, report to public health authorities.

Potential partner notification barriers

Potential barrier	Barrier reduction strategies
Actual or fear of physical or emotional abuse	Healthcare provider or public health referral may be the best option in these cases to protect the person If there is a safety threat, public health officials should be notified of this so that proper safety precautions are taken to protect the person Prioritize safety over the notification process
Fear of losing a partner due to a STBBI diagnosis (blame or guilt)	Discuss the asymptomatic nature of STBBI and the benefits of asymptomatic partner(s) knowing they can have an infection
Fear of legal procedures	Assure the person the information will be reported to authorities only as required by law but will otherwise remain confidential Provide counselling on risk reduction and prevention measures, refer person to appropriate and relevant support services The consistent and correct use of condoms and the use of ART to achieve and maintain an undetectable viral load are highly effective strategies to help prevent the sexual transmission of HIV Health professionals should not provide legal advice; provide appropriate referrals for additional information, such as the HIV Legal Network In Canada, criminal law imposes a duty to disclose HV positive status before sexual activities that pose a “realistic possibility of transmission”Footnote 15 People living with HIV who take ART, who achieve and maintain a suppressed viral load (less than 200 copies per ml) have a negligible risk of sexually transmitting HIVFootnote 2Footnote 15
Fear of re-victimization (sex crime victims)	Healthcare provider or public health referral may be the best option for notification of partners
Anonymous partnering	Wherever possible, encourage notification of partners (e.g., self-referral strategy)

References