Clinical Features

STIs, HIV and Effective Screening

An interview with Theresa Lowry Lehnen (PhD), Clinical Nurse Practitioner and Associate Lecturer South East Technological University

Sexually transmitted infections (STIs) are a major public health concern, and an increasing cause of ill health globally. STIs are spread through intimate sexual contact, including unprotected vaginal, anal and oral sex with an infected partner. Even protected sex can be a risk of contracting some sexually transmitted infections. We spoke with Theresa Lowry Lehnen, RGN, RNP, BSc, MSc, PG. Dip. Ed, M. Ed, PhD Clinical Nurse Practitioner and Associate Lecturer South East Technological University to find out more about sexually transmitted infections and their associated screening. STIs usually affect the genitals, anus, or mouth, but can also affect other areas of the body.

Many STIs have no signs and symptoms and if left untreated have the potential to cause significant morbidity in women and men, including infertility, ectopic pregnancy and other medical conditions, which is why STI screening is so important. “Some activities pose higher risk than others including unprotected sex with casual partners, multiple partners, with a partner who has taken risks – had unprotected sex with casual partners or with a partner who has injected drugs. Men who have unprotected anal sex with other men (MSM) are also at higher risk,” says Theresa.

Chlamydia trachomatis (CT, chlamydia) is the most commonly diagnosed bacterial sexually transmitted infection (STI) in Ireland, and most cases occur in young people under the age of 25. Theresa explains, “Often asymptomatic in both males and females, symptoms in males can include dysuria and a urethral discharge, and in women, vaginal discharge, intermenstrual bleeding and post coital bleeding. Infection can lead to epididymitis in males and Pelvic Inflammatory Disease (PID) in females. PID is associated with an increased risk of tubal factor infertility, ectopic pregnancy and chronic pelvic pain. Diagnosis can be made on first void urine in males and vulvovaginal or endocervical swab (less sensitive) in females. Vulvovaginal swabs can be provider or self-taken. In MSM, as well as first void urine, pharyngeal and rectal sites should also be tested.”

Gonorrhoea (Neisseria gonorrhoeae) is the second most common bacterial sexually transmitted infection in Ireland, and is found most frequently in young people under the age of 25 and in men who have sex with men (MSM). Infection may involve the genitals, mouth, or rectum. Infected men may experience pain or burning with urination, discharge from the penis, testicular pain and epididymitis. Symptoms in women can include vaginal discharge, intermenstrual bleeding, post coital bleeding and PID. Rectal infection can lead to proctitis. Diagnosis can be made on first void urine in males and vulvovaginal or endocervical swab in females. Vulvovaginal swabs can be provider or self-taken. In MSM, pharyngeal and rectal sites should also be tested. Gonorrhoea is a notifiable disease. Theresa continues, “The Nucleic Acid Amplification Test (NAATs)/ PCR is the gold standard for chlamydia and gonorrhoea testing. The type of test may vary at different laboratories.”

Genital herpes is a viral infection caused by the herpes simplex virus (HSV). There are two types: HSV-1 and HSV-2. “Type 2 is most commonly associated with genital infection. Type 1 has also been found to cause genital infection but is more commonly associated with oral herpes (cold sores). Genital herpes is common in Ireland, and is mostly diagnosed in young women. “The diagnosis can be made clinically but should be confirmed with a HSV NAAT swab of the lesions to determine if HSV-1 or HSV-2.”

Turning to Hepatitis B, a viral infection that infects the liver and is a major cause of serious liver disease, Theresa notes, “Hepatitis B affects millions of people worldwide. It is vaccine preventable. Hepatitis C is a viral infection that can cause long-term liver disease, such as liver cirrhosis and liver cancer. There is currently no vaccination against hepatitis C. Most cases of hepatitis C are found in people who inject drugs, however, the number of cases of sexually transmitted hepatitis C diagnosed in men who have sex with men (MSM) in Ireland, has increased. “Many cases have been in MSM who are also infected with HIV. “Hepatitis C testing (HCV) should be considered part of routine sexual health screening for MSM; people living with HIV; commercial sex workers and people who inject drugs (PWID). Partners should also be considered for HCV testing.

Trichomoniasis (TV) is a sexually transmitted infection (STI) caused by a protozoan-Trichomonas vaginalis. Most cases are found in women, and although it can affect both men and women, infection in men is uncommon. TV can infect the vagina and cervix in women, and the urethra and underneath the foreskin in men. “In women it usually presents with a vaginal discharge which may be offensive with an associated vulvitis /vaginitis. Men usually present as sexual contacts of women with infection, and may present with symptoms of urethritis including dysuria and urethral discharge. Trichomoniasis is a notifiable disease.”

Syphilis is a sexually transmitted infection caused by a bacterium called Treponema pallidum. There were 611 cases reported in Ireland in 2020. The highest rate in males and females was in the 30-34- year age group, 75.6 per 100,000 population and 6.9 per 100,000 population, respectively. Most new cases of syphilis are among men who have sex with men. While the number of STI notifications decreased in Ireland in 2020, most likely due to the impact of the COVID-19 pandemic, early infectious syphilis (EIS) is on the increase, with a 43% increase (498 cases) reported by HPSC in 2021 between 01/01/2021 and 21/08/2021, compared to the same time- period in 2020 (349 cases).

She adds, “Human Immunodeficiency Virus (HIV) is a virus that attacks the human immune system and weakens its ability to fight infection and disease. Over 6,000 people are estimated to be living with HIV in Ireland and approximately 15% of people with HIV in Ireland are unaware they have the condition, because they have either not been tested, or developed HIV since their last test. “Approximately half of new cases of HIV in Ireland are among men who have sex with men (MSM), the other half being mostly heterosexual men and women, and people who inject drug. HIV is diagnosed with a blood test. HIV testing is available in many health care settings including STI clinics, GPs and student health clinics.

Many NGOs offer HIV testing in Ireland, including rapid HIV testing in community venues. HIV is a notifiable disease.” HIV Prevention: PrEP and PEP/PEPSE Pre-exposure prophylaxis (PrEP) is the use of oral antiretroviral therapy in HIV negative people to reduce the risk of HIV infection. Theresa told us, “PrEP is taken by HIV negative people prophylactically before having sex (pre-exposure) and after sex, to prevent HIV. The window period for HIV is 45 days. PrEP is available free of charge through the HSE to people who meet the clinical eligibility criteria and who are deemed to be at substantial risk of acquiring HIV.

“Post-exposure prophylaxis (PEP) is short-term antiretroviral treatment to reduce the likelihood of HIV infection after potential exposure, either occupationally or through sexual intercourse. PEP may prevent infection with HIV developing. A full course of PEP (two or three antiretroviral HIV drugs) is for 28 days (4 weeks). The medication must be started within 72 hours of possible exposure to HIV infection to be effective. The term PEPSE is sometimes used, and stands for PEP after Sexual Exposure.”

Who is eligible for free PrEP? HIV negative individuals who are aged 17 years or older, have a PPSN and fall into one of the categories set out below.

1. Men who have sex with men or transgender women who have sex with men who are:

  • Sexually active with likelihood of remaining sexually active in the next 3 months AND one of the following:
  • Reported condomless anal sex with at least two partners over the last 6 months
  • Episode of documented or reported acute STI over the last 12 months
  • Documented or reported use of HIV post-exposure prophylaxis following sexual exposure (PEPSE) over the last 12 months
  • Reported engagement in chemsex over the last 6 months

2. Individuals having condomless sex with a HIV positive person who is not suitably suppressed on antiretroviral therapy specifically:

  • Where the person living with HIV is not on antiretroviral therapy
  • Where the person living with HIV has initiated antiretroviral therapy but has not yet achieved virological suppression
  • Where the person living with HIV has loss of virological control on antiretroviral therapy and the risk of HIV transmission has been deemed by a consultant physician specialising in HIV Medicine to be substantial and warrant PrEP for the HIV-negative partner

3. Other heterosexual men, heterosexual women considered by a senior clinician specialising in HIV Medicine to be at substantial risk for sexual acquisition of HIV

HIV can be treated effectively with antiretroviral medications which stops HIV reproducing in the body. When taken properly, HIV treatment reduces the chance of a person living with HIV passing it on to someone else. When a person living with HIV is on treatment and the viral load in the body is ‘undetectable’, HIV cannot be transmitted to sexual partners. This is known as ‘undetectable’ equals ‘un-transmittable’ (U=U).

Current Situation and Outlook

Theresa concludes, “The timeliness of treatment for STIs can have consequences for the individual and increase the likelihood of infecting others. Given the high burden of STIs, and the risk of medical complications associated with these infections, screening, accurate diagnosis, and timely and appropriate treatment are critical. The testing and treatment of sexual partners is important in preventing the spread of STIs, decreasing the rate of reinfection, and preventing medical complications of asymptomatic infections.

“The continuing rise in STIs annually in Ireland is a worrying trend. The key message from the HSE HPSC is for people to get tested regularly, use condoms for vaginal, oral and anal sex and reduce the number of partners and overlapping partners. People should get tested for STIs if they have symptoms of an STI, change their sexual partner, have multiple or overlapping partners or their partner has an STI.

“Stigma causes many people to avoid seeking STIrelated services because of negative experiences such as discrimination, indifference, and overt hostility in health care settings. In addition to effective public health infrastructures and the technologies needed for diagnosis and treatment, global STI prevention and control efforts require renewed commitment to systematic programmatic approaches to prevent or reduce STI-related stigma.”

The HSE, SHCPP’s Sexual Health Promotion Training Strategy 2019-2029, directs the activities and funding of the SHCPP, and aims to address the training of professionals enabling them to respond to the sexual health education and information needs of their service users. The strategy enables the integration of sexual health promotion into core support services within health, social care, education, community and youth work so that service users can be supported to make good sexual health choices.

She adds, “Sexual health is an essential component of overall health. Effective STI prevention and control emerges from a holistic, sexual health perspective involving many levels of society and a variety of approaches. An integrated approach is required that involves taking action throughout the entire population and at all levels of the prevention and care continua. Further advancement in technology, specifically the development of rapid, sensitive and specific point-of-care testing, will provide additional tools for STI diagnosis and control. These actions can lead to better prevention, screening, and treatment.”

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