Chapter 117: Sexually transmitted infections

Sexually transmitted infections (STIs) are a group of communicable infections, usually transmitted by sexual contact. STIs that have developed a high profile include chlamydia, the most common notifiable disease in Australia and a major cause of pelvic inflammatory disease (PID), HIV infection, syphilis and multi-drug resistant gonorrhoea. Presentations of STIs are summarised in TABLE 117.1, however most STIs are asymptomatic.

• Young people aged 15–29 years

• Men who have sex with men (MSM), especially:

  • – unprotected anal sex

  • – >10 partners in past 6 months

  • – participate in group sex

  • – use recreational drugs during sex

  • – are HIV-positive

• Aboriginal and Torres Strait Islander people

• Sex workers

• People who inject drugs

• People with a past history of STIs

• People who have unprotected sex with casual partners

• People who have unprotected sex overseas

• Sexual partners of a person with an STI

• Pregnant women (more detail in CHAPTER 108)

• Neonates born to infected mothers

Since most STIs are asymptomatic, it is important to offer appropriate opportunistic testing to people at risk. A discrete history is also important—a detailed history and examination may serve as a barrier to proceeding to testing. Consider the following questions:

• Before we do a cervical screening test/prescribe your pill, would you also like a chlamydia test?

• It is recommended that anyone under 30 years of age who is sexually active should have an annual chlamydia test. Would you like a test today?

• I would like to ask you some questions about your sexual activity so we can decide what tests to do, is that okay?

Patients often request to be ‘tested for everything’ and it is important to explain that certain STIs, in particular genital warts and genital herpes, are not tested for in asymptomatic people. Genital warts is a clinical diagnosis and herpes are diagnosed on a swab of a specific lesion.

Guidelines on STI testing in asymptomatic patients are summarised in TABLE 117.2. Nucleic acid amplification tests (NAATs), such as polymerase chain reaction (PCR), should be employed on swabs in asymptomatic patients. TABLE 117.3 outlines how to test for each infection.

Testing after exposure¹

Patients may present requesting STI testing following condom breakage or suspected STI exposure/contact. Post-exposure prophylaxis (PEP) for HIV or hepatitis B immunoglobulin and immunisation may be appropriate within 72 hours if moderate to high risk (more detail in CHAPTER 118). Testing should be performed, depending on risk, at the following intervals:

• HIV, syphilis and hepatitis B (if not immune)

  • – baseline testing, repeat at 6 and 12 weeks

• chlamydia, gonorrhoea and trichomonas

  • – initial screening with swab of any involved orifice, repeat at 2 weeks

A detailed sexual history may be important if a patient presents requesting STI testing or if they present with symptoms. Doctors and patients alike usually find discussing sexual matters uncomfortable, even when STI testing is requested. A skilful approach will help overcome barriers or discomfort. A non-judgmental approach and appropriate body language will facilitate patient disclosures on sensitive sexual issues.

• Are you currently in a relationship?

• How many sexual partners have you had in the past 3–12 months?

• Were these casual or regular partners?

• Were your sexual partners male, female or both?

• When you had sex, was it vaginal, oral or anal sex?

• Did you use condoms?

• Have you ever been diagnosed with or thought you had an STI?

  For a detailed STI risk assessment:

• I’d like to ask you about some other activities that could increase someone’s risk of some sexually transmitted infections and blood-borne viruses, is that okay?

• Have any of your male partners ever had sex with men?

• Have you ever been paid to have sex?

• Have you ever paid to have sex?

• Have you received any tattoos overseas?

• Have you ever injected drugs and, if so, have you ever shared needles?

• Have you ever been in jail?

• Are you a recent migrant or refugee?

Urethritis in men³

Urethritis can be classified as gonococcal or nongonococcal urethritis (NGU). NGU is caused most commonly by Chlamydia trachomatis and Mycoplasma genitalium, however it is common to not find any cause. Herpes simplex virus (HSV), adenovirus and Trichomonas vaginalis are less common causes. Ureaplasma urealyticum is another cause which exists as normal urethral flora.

Symptoms

The main symptoms (if present) are:

• a burning sensation when passing urine (dysuria)

• a penile discharge or leakage (clear, white or yellow)

Sometimes there is no discharge, just pain. Most often the symptoms are trivial with chlamydia. Although a creamy pus-like discharge is typical of gonorrhoea (see FIG. 117.1), and a less obvious milkywhite or clear discharge typical of chlamydia (see FIG. 117.2), it is often difficult to differentiate the causes from the discharge. In some males the only complaint is spots on the underpants or dampness under the foreskin.

Diagnosis

• First-pass urine (FPU) for Chlamydia and Gonorrohoea NAAT

• Urethral swab for microscopy (for NGU)

Management principles

• Given the prevalence of chlamydia in the community, it is recommended to treat with azithromycin 1 g (o) stat while waiting for other test results.

• If tests are negative and symptoms persist, consider referral for first-pass urine NAAT testing for Mycoplasma genitalium, HSV and adenovirus (if not available through general practice).

• Consider seeking specialist advice before treating infection other than chlamydia/gonorrhoea.

• Regardless of results, female partners are at greater risk of PID and require assessment.

Chlamydia

Incubation period

Symptoms appear 1–2 weeks after intercourse, although the incubation period can be as long as 12 weeks or as short as 5 days (compared with incubation period of gonorrhoea—about 2–3 days).

Presentation

50% of men and 75% of women are asymptomatic. Genital and anorectal infections are most common, with rare infections of the eye and oropharynx.

Infection in men can cause urethritis and lead to epididymo-orchitis. In women, infection can cause cervicitis with vaginal discharge and postcoital bleeding.

Male symptoms:

• urethritis (dysuria, penile discharge)

• testicular pain

• anorectal symptoms

Female symptoms:

• dysuria

• vaginal discharge

• dyspareunia

• increased dysmenorrhoea

• pelvic pain

• anorectal symptoms

Complications

• epididymo-orchitis and secondary reduced male fertility

• chronic prostatitis

• pelvic inflammatory disease (PID)

• tubal factor infertility and ectopic pregnancy

• chronic pelvic pain

• perinatal conjunctivitis or pneumonia

• reactive arthritis +/- conjunctivitis (rare)

Treatment

For uncomplicated genital or pharyngeal infection:

• doxycycline 100 mg (o) 12 hourly for 7 days

  or

  azithromycin 1 g (o) single dose

For anorectal infection:

• doxycycline 100 mg (o) 12 hourly for 7 days if

  asymptomatic, 21 days if symptomatic

Sexual intercourse must be avoided until 7 days after both partners have received treatment. Reinfection rates are high so retest after 3 months.

Gonorrhoea

Gonorrhoea is most common in MSM, Aboriginal and Torres Strait Islander people living in rural and remote areas, and travellers from endemic areas.

Incubation period

Gonorrhoea has a short incubation period of 2–3 days and symptoms usually appear 2–7 days after vaginal, anal or oral sex. The incubation period can be as long as 3 weeks.

Presentation

Up to 80% of women and 10–15% of men have no genital symptoms and most people are asymptomatic in other sites, especially the pharynx, rectum and endocervix. Upper genital infection can lead to pelvic inflammatory disease in women. Gonococcal urethritis in men is characterised by a purulent urethral discharge.

Other manifestations of gonorrhoea

• epididymo-orchitis and prostatitis (males)

• urethral stricture is not uncommon in males

• perinatal conjunctivitis or pneumonia

• reactive arthritis +/- conjunctivitis (rare)

Investigations

NAATs for gonorrhoea are highly sensitive, however false positives can occur at non-genital sites. Gonococcal culture is not as sensitive but has high specificity and allows for antibiotic susceptibility testing. If an NAAT is positive, a swab should be obtained (if not already collected) for culture to determine antibiotic susceptibility prior to commencing treatment.

Treatment

Alternative treatments are not recommended because of high levels of resistance.

For uncomplicated genital, anorectal or pharyngeal infection:

• ceftriaxone 500 mg IM (dissolved in lignocaine 2 mL 1%) as a single dose

  plus

  azithromycin 1 g (o) as a single dose

Sexual intercourse must be avoided until 7 days after both partners have received treatment. Test of cure 2 weeks after treatment is advisable.

Mycoplasma genitalium³

Mycoplasma genitalium should be considered in patients with persistent genital tract symptoms when chlamydia and gonorrhoea have been excluded. It has been recently identified as a cause of urethritis in men, proctitis, cervicitis and PID.

Testing has not been widely available, although access to commercial assays is increasing. NAAT can be performed on vaginal, cervical and rectal swabs or first-pass urine. Testing is only offered to asymptomatic patients if a symptomatic partner has tested positive.

Optimal treatment is still unclear with increasing macrolide resistance. Most people diagnosed will have been treated empirically with azithromycin 1 g (o) stat. This is likely to be effective in up to 60% of cases, however specialist advice is required if symptoms persist. Guidelines may soon change to recommend doxycyline as first-line treatment.

Anorectal syndromes (proctitis)

Proctitis is characterised by anal discharge, pain and bowel symptoms including tenesmus and constipation. The most common causes are HSV, N. gonorrhoea and C. trachomatis (particularly lymphogranuloma venerum, LGV, strains). Other causes include M. genitalium and non-STI causes such as inflammatory bowel disease.

It is important to perform an examination and collect swabs at the time. Request NAAT for HSV and C. trachomatis and culture and NAAT for N. gonorrhoea. LGV should be tested in the event of a positive chlamydia test, which requires the same treatment as symptomatic anorectal chlamydia infection.

Treatment should be empirical, taking into account the clinical picture and likelihood of particular STIs in the patient. Consider a combination of ceftriaxone 500 mg (IM) stat and doxycyline 100 mg (o) BD for 14–21 days, +/- antiviral therapy.⁷

Epididymo-orchitis

Epididymo-orchitis is covered in more detail in CHAPTER 111. Consider chlamydia and gonorrhoea in all sexually active men, especially men aged <35 years.

Vaginal discharge

Vaginal discharge is presented in more detail in CHAPTER 106. The most common cause of vaginal discharge in women of reproductive age is normal physiological discharge. It should be noted that vaginal thrush and bacterial vaginosis are not considered STIs, but can be associated with sex. The pathogens to consider are:

• Candida albicans → vaginal thrush

• Gardnerella vaginalis → bacterial vaginosis

• Chlamydia trachomatis

• Neisseria gonorrhoeae

• Mycoplasma genitalum

• Trichomonas vaginalis (more common in Aboriginal and Torres Strait Islander women, older women and women living in rural and remote areas)

Herpes simplex virus may cause vaginal discharge if HSV cervicitis is present.

Cervicitis

Cervicitis is often a forerunner to PID. The likely organisms are C. trachomatis or N. gonorrhoeae. Others causes include M. genitalium, T. vaginalis and HSV. If there is cervicitis only (mucopus at the cervix without uterine pain or tenderness) treat with azithromycin (o) 1 g stat.

Pelvic inflammatory disease

PID is covered in more detail in CHAPTER 103. It is not always an STI. The intra-uterine device is a possible cause. Often multiple pathogens are involved in the infection and 70% of cases have an unidentified cause.

Common pathogens are N. gonorrhoeae, C. trachomatis and M. genitalium. Swabs from the cervical os frequently underestimate the organisms involved and thus treatment needs to be directed to all possible pathogens.

Specimen collection

• endocervical swabs for NAAT and culture for N. gonorrhoeae

• NAAT for C. trachomatis and M. genitalium

Treatment

Therapy for PID is deliberately vigorous because the major aim is to prevent infertility and the consequent need for assisted reproductive treatment (ART) in the long term. The detailed treatment is outlined in CHAPTER 102.

Summary

Mild to moderate infection:

• ceftriaxone 500 mg IM (in 2 mL of 1% lignocaine) or IV (as single dose)

  plus

  azithromycin 1 g as single dose

  plus

  metronidazole 400 mg BD for 14 days

  plus

  doxycycline 100 mg BD for 14 days

Severe PID: hospitalise for IV therapy

Anogenital ulcers

Most genital ulcers are herpes—any small genital ulcer that is superficially ulcerated, scabbed, red-edged, multiple and painful is invariably herpes. Consider herpes zoster if unilateral genital ulcers are present.

STI causes of anogenital ulcers include:

• Herpes simplex virus (HSV 1, HSV 2)

• Treponema pallidum (primary chancre)

• Haemophilus ducreyi (chancroid)

• Klebsiella granulomatis (donovanosis)

Genital ulcers due to primary syphilis and donovanosis are usually painless. Chancroid and donovanosis are rare, almost always imported infections and require specialist input if suspected. Collect a swab of the base of the ulcer or deroofed vesicle and send for NAAT testing, which is available for most causative organisms.

Genital herpes¹

The incubation period varies from 2–12 days. A microbiological diagnosis is recommended as clinical diagnosis can be unreliable.

HSV 2 is associated with genital lesions and HSV 1 with oral lesions. HSV 1 is an increasingly common cause of a first episode of genital herpes, although recurrent genital herpes is usually caused by HSV 2.⁷ Studies suggest that about 12% of Australian adults are infected with HSV 2 and 76% with HSV 1.⁸ The majority of patients remain undiagnosed, with mild or asymptomatic recurrences. Once infected with HSV, the virus achieves latency in the nerve roots and is usually a lifelong infection.

Symptoms

With the first attack there is a tingling or burning feeling in the genital area. A crop of small vesicles then appears; these burst after 24 hours to leave small, red, painful ulcers. The ulcers form scabs and heal after a few days. The glands in the groin can become swollen and tender, and the patient might feel unwell and have a fever.

The first attack lasts about 2 weeks if untreated.

Males

The virus usually affects the shaft of the penis, but can involve the glans and coronal sulcus, and the anus (see FIG. 117.3). Other presenting symptoms include painful splitting of the skin, erythema with tingling/itch, urethritis and proctitis.

Females

Vesicles develop around the opening of and just inside the vagina, and can involve the cervix and anus (see FIG. 117.4). Passing urine might be difficult. The cervix may be the only site of lesions and these cases may be asymptomatic or present with symptoms of cervicitis including vaginal discharge. The problem could be a simple tingling around the saddle area or a scratch-like lesion on epithelium.

In both sexes, it can affect the buttocks and thighs. A serious but uncommon complication, especially in females, is the inability to pass urine.

Specimen collection

Take a swab from a deroofed vesicle for NAAT testing. Serological tests for HSV are not recommended.

Transmission⁴

HSV can be caught by direct contact through vaginal, anal or oral sex. Transmission of HSV 1 is usually by contact with saliva and HSV 2 is usually by sexual contact. It can appear spontaneously in people in stable relationships or years after cessation of sexual relationships. 50% of first presentations are not true primary infections.

Most HSV transmissions occur within the first few months of a relationship with asymptomatic viral shredding as the main mechanism. Combined condom use and antiviral therapy reduces the risk of transmission.

Recurrence

It is unlikely for HSV 1 to recur in the genital area. Recurrences of HSV 2 may produce prodromal symptoms prior to an outbreak, including burning, tingling or neuralgia. Fortunately, episodes become milder and less frequent over time and many will stop eventually. Emotional stress is a common trigger.

Treatment (antimicrobial therapy)

Topical treatment³

Pain relief can be provided in some patients with topical lignocaine 2% gel but caution is needed since it may cause sensitisation with prolonged use.

Oral treatment—first episode

For the first episode of primary genital herpes:

• valaciclovir 500 mg (o) bd for 5–10 days

  or

  aciclovir 200 mg 8 hourly for 5–10 days

Episodic genital herpes (within 24 hours)

• valaciclovir 500 mg (o) bd for 3 days

  or

  famciclovir 250 mg (o) 4 tablets statim, repeat in

  12 hours

Suppressive treatment

Very frequent recurrences (six or more attacks annually) benefit from continuous low-dose therapy for 6 months (e.g. valaciclovir 500 mg (o) once daily). Interrupt at 6 months to evaluate.

Supportive treatment (advice to the patient)

• Rest and relax as much as possible. Warm salt baths can be soothing.

• Icepacks or hot compresses can help.

• Painkillers such as paracetamol or ibuprofen may give relief.

• If urination is painful, pass urine under water in a warm bath.

• Wear loose clothing and cotton underwear.

Counselling

‘A chat beats medicine for herpes’. Since genital herpes is distressing and recurrent, patients are prone to feel stressed and depressed, and can be assisted by appropriate counselling and support. Sexual abstinence should be practised while lesions are active.

Syphilis

In Australia, syphilis, which has re-emerged, usually presents either as a primary lesion or through chance finding on positive serology testing (latent syphilis).

It is important to be alert to the various manifestations of secondary syphilis (refer to CHAPTER 122). The classification and clinical features of syphilis are presented in TABLE 117.4 (see also CHAPTER 29).

Transmission

• sexual intercourse (usual common mode)

• transplacental to fetus

• direct contact with open lesions (e.g. oral)

Management

The management of syphilis has become quite complex and referral of the patient to a specialist facility for diagnosis, treatment and follow-up is recommended.

Recommended antimicrobial therapy

Early syphilis (primary, secondary or latent) of not more than two years duration:⁷

• benzathine penicillin 1.8 g IM as single dose

  or

  procaine penicillin 1 g IM daily for 10 days

  For patients hypersensitive to penicillin:

  doxycycline 100 mg (o) 12 hourly for 14 days

Note:

• sex should be avoided until ulcers are healed

• sexual contacts in the past 3 months should have treatment

• repeat serology at 3 months and then 3 monthly

Late latent syphilis: more than 2 years or indeterminate duration:

• benzathine penicillin 1.8 g IM once weekly for 3 doses

  or

  procaine penicillin daily for 15 days

Sexual contacts in the past 6 months should have treatment. Neurosyphilis and cardiovascular and congenital syphilis are also treated with penicillin but require special regimens.

Anogenital lumps

Common pathogens:

• Human papillomavirus (HPV 6 and 11 account for 90%)

• Molluscum contagiosum (pox) virus

Uncommon:

• Treponema pallidum—condylomata lata

Physiological:

• Fordyce cysts, which are enlarged ectopic sebaceous glands in the mucosa, are a differential diagnosis of a genital lump

Others:

• fixed drug eruptions, aphthous ulcers, trauma, carcinoma, Crohn disease

• be aware of increased risk of HPV-related anorectal cancers in MSM.

Diagnosis

Warts and Molluscum contagiosum have a distinctive appearance and are readily diagnosed by inspection (see FIG. 117.5). Removal for diagnosis is usually not required. Condylomata lata are multiple lesions that resemble warts superficially but are covered by abundant exudate. They occur in secondary syphilis and leutic screen is positive.

Treatment of warts

Warts may be removed by chemical or physical means, or by surgery. Treatment is cosmetic rather than curative and needs to be individualised. For small numbers of readily accessible warts the simplest treatment is:⁷

• cryotherapy weekly until resolved

  or

  podophyllotoxin 0.5% paint or 0.15% cream:

  • – apply bd with plastic applicator for 3 days

  • – repeat in 4 days and then weekly for 4–6 cycles if necessary

  Note: Paint is more suited for use on external keratinised skin. Cream is best used in perianal area, introital area and under the foreskin.

  or

  topical imiquimod 5% cream applied to each wart by the patient 3 times a week at bedtime (wash off after 6–10 hours) until the warts disappear (usually 8–16 weeks)

If warts are in the pubic region avoid shaving or waxing as this may facilitate local spread by autoinoculation of HPV into areas of microtrauma.

Treatment of Molluscum contagiosum³

These lesions often resolve spontaneously in immunocompetent patients. There are many treatment choices to provoke resolution. These include:

• cryotherapy with liquid nitrogen (for a few seconds)—can be repeated after several weeks

• podophyllotoxin 0.5% cream or paint twice daily 3 days per week for 4 weeks

Cryotherapy is usually the treatment of choice. If lesions are widespread or severe, refer for expert advice. Other destructive methods such as piercing with a needle, application of phenol or diathermy are seldom performed due to issues of pain and potential scarring.

Itch

Common pathogens:

• Sarcoptes scabei (scabies)

• Phthirus pubis (pubic lice)

• C. albicans:

  • – vulvovaginitis—females

  • – balanitis—males

C. albicans is not considered an STI but can be associated with sex. Other non-STI itchy rashes on genitals include dermatitis and psoriasis.

Diagnosis

Scabies: inspection on scraping and microscopy. Scabies is diagnosed by a very itchy, lumpy rash. It is rare to find the tiny mites, but it may be possible to find them in the burrows, which look like small wavy lines.

Pubic lice: inspection for moving lice and nits (eggs) on hair shaft.

C. albicans: swab for Candida culture.

Treatment

Scabies⁹

• permethrin 5% cream if >6 months of age. Apply to whole body from jawline down (include every flexure and area), leave overnight, then wash off.

  or

  benzyl benzoate 25% emulsion left for 24 hours before washing off. Repeat after 7 days.

Wash clothing and linen after treatment and hang in sun. Repeat treatment in 7 days.The whole family and close contacts must be treated, regardless of symptoms, which can take weeks to develop. Treatment of children younger than 6 months is covered in CHAPTER 120.

Note: Persistence of the itch after treatment is common, which can take 3 weeks or more to resolve. Also prescribe a moderately potent topical corticosteroid +/- an oral antihistamine for the itch.

Pubic lice

• permethrin 1% lotion: apply to pubic hair and surrounding area, leave for 20 minutes and then wash off

  or

  pyrethrins 0.165% with piperonyl butoxide 2% in foam base; apply as above

Shaving pubic hair is also effective. Bed clothes and underwear should be washed normally in hot water after treatment and hung in the sun to dry. Repeat the treatment after 7 days. Sometimes a third treatment is necessary. Sexual contacts and the family must be treated (young children can be infested from heavily infested parents). Where the lice or nits are attached to eyelashes, insecticides should not be used: apply white soft paraffin (e.g. Vaseline) liberally to the lashes bd for 8 days. Then remove the nits with forceps.

Viral hepatitis

Sexual activity is a factor in the transmission of hepatitis B (in particular), hepatitis A (where faecal–oral contact is involved), hepatitis C (rare and mostly in MSM, particularly with HIV) and hepatitis D (rare, in people with hepatitis B only).

Hepatitis A vaccination is recommended to men who have sex with men and people who inject drugs.⁶

Hepatitis B

In Western societies, sexual transmission of HBV is a common mode of spread and there is a higher prevalence in men who have sex with men (MSM), inmates in correctional facilities and injecting drug users. It is also prevalent among Aboriginal and Torres Strait Islander people living in remote areas and among people from culturally and linguistically diverse populations.

Transmission can be via:

• parenteral contact including intravenous needle sharing and non-sterile tattoo equipment

• horizontal spread via exposure to blood and bodily fluids, including semen and vaginal secretions

• vertical from mother to child (usually intrapartum or perinatal)

Even though studies have shown minute quantities of the virus can be present in saliva, tears and breast milk, they are not considered to be in high enough levels to transmit the virus.

There is no specific therapy for hepatitis B, so prevention through vaccination is important. Antiviral and immunomodulatory drugs, including entecavir, tenofovir or peginterferon alfa-2a, can be used to prevent progression to liver failure and hepatocellular carcinoma.¹⁰

Immunisation

Hepatitis B immunisation is provided to all Australian children and most people born from the 1990s should have received immunisation. It should be encouraged in hepatitis B marker-free people at risk of acquiring this infection. At-risk groups include Aboriginal and Torres Strait Islander people, MSM, people who inject drugs, sex workers and close contacts of persons with hepatitis B.

Hepatitis C

Sexual transmission of hepatitis C is considered rare but can occur in men who have sex with men, especially men with HIV. Over 90% of newly acquired hepatitis C infections in Australia are attributable to injecting drug use.¹²

HIV infection

Infection with HIV causes chronic immune deficiency which, if untreated, leads to acquired immunodeficiency syndrome (AIDS) after an average period of 10 years after infection.

Male-to-male sex continues to be the major HIV risk exposure in Australia, reported for 68% of HIV diagnoses in 2015, with heterosexual sex reported for 20%, both male-to-male sex and injecting drug use for 5%, and injecting drug use for 3%.¹²

HIV infection is considered in more detail in CHAPTER 27.

Pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP)

Daily use of coformulated tenofovir and emtricitabine for HIV pre-exposure prophylaxis (PrEP) by populations at high risk of HIV infection is now recommended through the 2015 WHO guidelines.¹³

Post-exposure prophylaxis may be indicated when there is exposure to a known or potential HIV source. Antiretroviral treatment can be taken within 72 hours of exposure to reduce the chance of infection. Consider specialist advice, as every presentation for PEP should be assessed on a case-by-case basis.

• Non-gonococcal urethritis:

  • – if symptoms do not resolve with treatment

• Gonorrhoea:

  • – if complications or symptoms do not resolve with treatment

• Syphilis:

  • – early referral or discussion with a sexual health specialist/service is strongly recommended

• HIV:

  • – experience in prescribing antiretroviral treatment required

• Genital warts:

  • – urethral, cervical warts

  • – refractory warts

Contact tracing is the responsibility of the infected individual but the healthcare provider also has a responsibility to initiate the process. The person infected with an STI should be advised to inform partners that they may have been exposed and should seek testing and treatment. All current partners should be treated simultaneously.

Government guidelines on contact tracing can be found at <www.contacttracing.ashm.org.au>, and include how far back to trace, which varies between conditions. In the case of a positive Chlamydia test, it is recommended to notify partners from the previous 6 months. Assistance from the local sexual health service is recommended for HIV and syphilis because it leads to more contacts being tested and treated.

There are several helpful websites including <www.letthemknow.org.au>, which assist with sending anonymous emails or text messages to contacts.

Patient-delivered partner therapy, which is when the treating clinician provides another prescription for the current partner without a consultation, remains controversial. It should be restricted to times when other means of contact tracing are likely to fail. Clinicians are advised to check with their local health department for advice on the current legislation.

Note: Tests for STIs, including the HIV antibody test, should only be performed with the patient’s knowledge and consent, and after adequate counselling. An appointment should be made to give results in person, irrespective of the results.

Hand-out sheets from Murtagh’s Patient Education 7th edition:

• Chlamydial urethritis

• Gonorrhoea

• Hepatitis B

• Herpes: genital herpes

• HIV infection and AIDS

• HIV post-exposure prophylaxis

• Lice: pubic lice

• Pelvic inflammatory disease

• Warts: genital warts

Australian STI Management Guidelines for use in primary care.

Australian Sexual Health Alliance 2017. <www.sti.guidelines.org.au>