LECTURE-4

WHO CLASSIFICATION OF INFECTIOUS DISEASES,

ESPECIALLY SEXUALLY TRANSMITTED DISEASES. THE
GENERAL SCHEME OF THE FLOW OF SYPHILIS AND
ITS LABORATORY DIAGNOSTICS. SECONDARY PERIOD
OF SYPHILIS. FEATURES OF THE MODERN FLOW OF
TERTIARY AND CONGENITAL SYPHILIS. PRINCIPLES
OF THERAPY AND PREVENTION.
 DISCLAIMERS
 I have no conflicts of interest to disclose.

 I will discuss off-label use of diagnostic tests.

PRESENTATION OUTLINE
 Clinical overview of reportable STDs

 Local and state epidemiology

 Current state of STD control

 Role of public health department

 Role of healthcare providers

 SYPHILIS NATURAL HISTORY

Exposure 30-50% Primary Secondary Latent 30% Tertiary

25%

Incubation 2-6 weeks 2-20 years

Period Possible
3-4 weeks relapse

After 3-8 weeks

lesions disappear
spontaneously

Neurosyphilis can occur at any stage

 PRIMARY SYPHILIS
 Characterized by one or more painless ulcers
(chancres) at the site of inoculation

 Appears 10-90 days after infection

 Modest, rubbery and non-tender inguinal LAD

may be present.

 Serologies are negative in 10-25% of patients

with early primary syphilis.
PRIMARY SYPHILIS

Raguse et al, Ann Int Med 2012

STD Atlas, 1997

T. PALLIDUM ON DARKFIELD
MICROSCOPY
 SECONDARY SYPHILIS
 Usually occurs 3-6 weeks after primary chancre

 Rash (75-90%), involving palms/soles (60%)

 Generalized lymphadenopathy (70-90%)

 Constitutional symptoms (50-80%)

 Mucous patches (5-30%)

 Condylomata lata (5-25%)

 Patchy alopecia (10-15%)

 Symptoms of neurosyphilis (1-2%)

 Less common: meningitis, hepatitis, arthritis, nephritis

SECONDARY SYPHILIS

Courtesy: Gregory Melcher, UC Davis, Susan Philip,

SF DPH & UCSF

Photo: CDC
SECONDARY SYPHILIS

Courtesy: Gregory Melcher, UC Davis, Susan Philip,

SF DPH & UCSF
 LATENT SYPHILIS
 No signs or symptoms of active disease

 Categorized into early and late disease:

 Early: < 1 year duration

 Late: ≥ 1 year or unknown duration

 Most relapses to secondary syphilis occur during first

year of infection.

 Patients are considered non-infectious after first year

of infection (not true for mother-to-child transmission).
 NEUROSYPHILIS
CAN OCCUR AT ANY STAGE OF SYPHILIS
 All patients with syphilis should be evaluated for neurologic symptoms and
signs.

 Asymptomatic CNS invasion is common in early syphilis.

 Early symptomatic forms (months to a few years):

 Acute syphilitic meningitis (CN VI, VII, VIII)

 Hearing loss

 Ocular syphilis

 Meningovascular (stuttering stroke)

 Altered mental status

 Late symptomatic forms (>2 years):

 General paresis and tabes dorsalis

CRITERIA FOR CSF EXAMINATION*
 Neurologic or opthalmic symptoms/signs:

 Auditory disease, cranial nerve dysfunction, meningitis,

stroke, altered mental status, loss of vibration sense,
iritis, uveitis

 Evidence of tertiary disease:

 Aortitis, gumma

 Serologic treatment failure

In HIV infection, unless neurologic symptoms, there is no evidenc
that CSF exam is associated with improved outcomes, so not
recommended. *CDC 2015 STD Treatment Guidelines
Guidelines for Prevention and Treatment of OI in HIV+ 201
 Ocular Syphilis
Manifestations:
• Conjunctivitis, scleritis, and episcleritis
• Uveitis: anterior and/or posterior
• Elevated intraocular pressure
• Chorioretinitis, retinitis
• Vasculitis

Symptoms:
• Redness
• Eye pain
• Floaters
• Flashing lights
• Visual acuity loss
• Blindness

Diagnosis:
• Ophthalmologic exam
• Serologies: RPR, VDRL, treponemal tests
• Lumbar puncture
Slide courtesy of Sarah Lewis, MD
Wender, JD et al. How to Recognize Ocular Syphilis. Review of Ophthalmology. 2008
 OCULAR SYPHILIS
WHAT DO CLINICIANS NEED TO KNOW?
 Test for syphilis in patients with visual or ocular symptoms/signs.

 Ask patients with syphilis about changes in their vision.

 Patients with positive syphilis serology and visual complaints

should receive immediate ophthalmologic evaluation.

 Patients with suspected ocular syphilis should receive LP and

treatment for neurosyphilis.

 Test for HIV.

 Report cases of syphilis to the health department within 1 day.

*Moradi Am J Ophthal 2015

CONGENITAL SYPHILIS

Photos courtesy of Public Health

Image Library, CDC and Drs.
Norman Cole, Susan Lindsley,
Robert Sumpter, and J. Pledger
 CONGENITAL SYPHILIS…..
IS COMPLETELY PREVENTABLE THROUGH:
 Timely diagnosis of maternal syphilis:
 Syphilis screening during first prenatal visit (required by law)

 Repeat screening during third trimester (28 weeks) and at delivery for high-risk
women

 No newborn should be discharged from the hospital if the mother’s syphilis status
has not been determined.

 Appropriate and timely treatment of maternal syphilis:

 CDC-recommended penicillin-based therapy

 Initiation of treatment at least 30 days prior to delivery

 Ensuring that partner(s) are managed appropriately to prevent repeat

infection during pregnancy
 SYPHILIS DIAGNOSIS
BOTH NON-TREPONEMAL AND TREPONEMAL
TESTS ARE NEEDED TO ESTABLISH A NEW
DIAGNOSIS!
 Non-treponemal testing (RPR, VDRL, TRUST):
 Non-specific but correlates with disease activity

 May be negative in ~25% of patients with early primary syphilis

 Semiquantitative (reactive results expressed as titer)

 Treponemal testing (EIA, CIA, TPPA, MHA-TP, FTA-ABS,

MBIAs):
 Specific for T. pallidum; usually positive for life after initial infection

 Usually positive in primary syphilis (90%), invariably positive in secondary

syphilis
 SYPHILIS STAGING
SIGNS OR SYMPTOMS?

YES NO

Chancre Rash, etc. LATENT

PRIMARY SECONDARY ANY IN PAST YEAR?
• Negative syphilis serology
• Known contact to an early case
• Good history of typical signs/symptoms
• 4-fold increase in titer
• Only possible exposure was this year

YES NO
EARLY LATENT LATE LATENT or UNKNOWN
(< 1 year) DURATION
 SYPHILIS TREATMENT
Primary, Secondary & Early Latent:

Benzathine penicillin G 2.4 million units IM in a single

dose

Benzathine Penicillin
Late Latent and Unknown G 7.2 million units total, given as 3 doses
Duration:
of 2.4 million units each at 1 week intervals
Neurosyphilis:

Aqueous Crystalline Penicillin G 18-24 million units IV daily

administered as 3-4 million IV q 4 hr for 10 -14 d

Only one dose of PCN Is recommended for early syphilis in HIV

infected persons, extra doses not needed
 SYPHILIS TREATMENT
PRIMARY, SECONDARY & EARLY LATENT
Alternatives (non-pregnant penicillin-allergic adults):
Doxycycline 100 mg po bid x 2 weeks
Tetracycline 500 mg po qid x 2 weeks
Ceftriaxone 1 g IV (or IM) qd x 10-14 d
Azithromycin 2 g po in a single dose*

* Do NOT use azithromycin in MSM or pregnant women

In pregnancy, benzathine penicillin is the only

recommended therapy. No alternatives
SYPHILIS CLINICAL PEARLS
 For suspected primary syphilis, order both
treponemal and non-treponemal testing (unless pt
has a previous history of syphilis).

 Always obtain an RPR titer on the day of

treatment initiation.

 Beware of the prozone effect.

 Counsel patients regarding the Jarisch-

Herxheimer reaction.
 SYPHILIS GREY AREAS
 When to perform lumbar puncture in HIV-infected
individuals

 Current recommendation: only if neuro or

ocular symptoms/signs are present.

 Management of patients who do not have the

expected four-fold decline in RPR titer

 Maximal acceptable interval between BPG doses

in non-pregnant patients
Primary & Secondary Syphilis, California ver
United States Incidence Rates, 1941-2016

Rev. 6/2017
24
STD Control Branch
genital Syphilis Cases versus Female Early Sy
Incidence Rates, California, 2007-2016

* Includes primary, secondary, and early latent syphilis.

Rev. 6/2017
25
STD Control Branch
 Primary & Secondary Syphilis Cases by Year
San Diego County, 1988 - 2016

Men who have sex with men Other

600

523
490
500

424

400 369
346 346 347
333
323
310
284 289
300 277
263
234

193
200
137
112106 109
98
100
52
35 38
23 23 25 27 27
47 25 33 12 20 10 16 5 11 5 1 10 13 14 26 94 111144 201290269227253 236282288282 428432
0
88 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Year
Note: The green area represents the proportion of cases who are not men who have sex with
The number above the columns represents the total number of primary and secondary syphilis cases p
 Primary & Secondary Syphilis Cases and
Rates by Year
San Diego County, 1988 - 2016
Cases Rate per 100,000 population
600 25.0

523
490
500
20.0
424

400 17.8
369
346 346 15.9 15.0
333 347 15.2
310 323
300 284 277 289
12.5 12.9 263
234 11.6
11.1 11.2 11.0
10.6
11.0 10.0
193
200 9.3
8.6 8.9
137 7.6
112106 109 6.3
98 5.0
100 4.6
4.3 4.1
3.8 52 3.7
35 38
23 23 25 27 27
2.0
1.3 1.3
0 0.9 0.9 0.9 1.0 0.9 0.0
8 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Year
 Primary & Secondary Syphilis Rates by
Gender and Year
San Diego County, 1997 - 2016

Females Males
35.0

30.5
30.0

25.0

20.0

15.0

10.0

5.0
1.2*

0.0
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Year
* Between 2015 and 2016, the female primary and secondary syphili
increased by 33%, and the number of cases increased by 27
 Primary & Secondary Syphilis Rates by
Gender and Age
San Diego County, 2016

Female Male
80

70 67.1

60 57.7 57.2

50 45.1

40

30

20.3
20 17.3

10
5.1 4.5
2.0 1.6 0.9
0.0 0.0 0.0 0.0 0.2
0
<10 10-14 15-19 20-24 25-29 30-34 35-44 45+
Age Group
 Primary & Secondary Syphilis Rates by
Gender and Race/Ethnicity
San Diego County, 2016
Female Male
60
56.3

50

40
35.3

30 27.5
25.5

20 18.7

14.2

10 8.4

1.9
0.9 0.8
0.0 0.0
0
Native American/ Asian/Pacific Islander Black Hispanic White Other/Mixed Race
Alaskan Native
Race/Ethnicity
Note: Rates exclude 28 cases missing race/ethnicity inform
 MSM* Primary & Secondary Syphilis Cases
Co-Infected with HIV by Year
San Diego County, 2007 - 2016
100

90

80

70

60

50

44%
40

30

20

10

0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Year *MSM: Men Who Have Sex With Me

Slide courtesy of Heidi Bauer, MD, MS, MPH
Slide courtesy of Heidi Bauer, MD, MS, MPH
 PUBLIC HEALTH RESPONSE

SYPHILIS
 Surveillance

 Disease investigation/partner Services

 Females of childbearing age

 1°/2° Syphilis, some EL

cases

 HIV prevention
Safety net clinical services

 Community engagement
 Support for community providers (syphilis histories, consultations)
 PUBLIC HEALTH CHALLENGES OF
SYPHILIS PREVENTION & CONTROL

PRE-AIDS POST-AIDS
 Occult/asymptomatic infection  Occult/asymptomatic infection

 Multiple partners  Multiple partners

 Anonymous partners  Anonymous partners

“Poppers”  Methamphetamine, ED medications

 Mistrust of medical community  Mistrust of the medical community

 Stigma  Stigma

 Prejudice  Prejudice

 Health inequity  Health inequity

Adapted from slide produced by Anne Rompalo, MD

 PUBLIC HEALTH CHALLENGES OF
STD PREVENTION & CONTROL

WHAT’S NEW?
 Changes in sexual practices:
 Less condoms?

 More oral sex? CDC

 Biomedical HIV prevention tools:

 ART, TasP

 PrEP

 Internet: geosocial networking apps

 Closure of STD clinics in many areas

 Not enough disease investigators

Adapted from slide produced by Anne Rompalo, MD

The Lancet HIV
 GONORRHEA
 Urethritis:

 Incubation period: 2-5 days in most (1-14 days)

 Frequently symptomatic (dysuria, discharge, meatal

swelling/erythema)

 Cervicitis:
 More variable incubation period, symptoms usually within 10 days

50-70% asymptomatic

 PID

 Epididymitis

 Conjunctivitis

 Pharyngitis

 Proctitis

STD Atlas, 1997

DISSEMINATED GONOCOCCAL
INFECTION (DGI)

 0.5-2% of mucosal infections

 Triad of polyarthralgia, tenosynovitis,

dermatitis

 Frank arthritis in 30-40%:

 Wrist, MCP, ankle, and knee joints

most commonly affected

 Meningitis, endocarditis (rare)

Photo Credit: CDC

 CHLAMYDIA
 Urethritis

 Cervicitis

 PID
 Epididymitis

 Pharyngitis (?)

 Proctitis
 Often asymptomatic Holmes K, et al. STD, 4th ed.

 Compared to gonorrhea, symptoms tend to be less abrupt in

onset and milder.
Who Should be Screened for CT/G
• < 25 annually, 25+ if at risk
Females • Pregnant <25, if at risk
• At least annually
MSM • Exposed sites: genital, rectal, thro

Hetero males • High prevalence settings

• At least annually
HIV + • All exposed sites

Patients on PrEP • Every 3 months

Post-Tx• All patients, 3 months after treatm

CDC 2015 STD Tx Guidelines www.cdc.gov/std/treatment

Plus: Guidelines for HIV care and PrEP
 Major conclusions
NAATs recommended for detection of genital tract infections in men
and
women - with and without- highly sensitive and specific compared to culture
symptoms
- less dependent on specimen collection and handling

Optimal specimen types are:

First catch urine for men
Self collected vaginal swabs from women

NAATs recommended for detection of rectal and oropharyngeal infections

 • HIV
• Syphilis
• Urethral GC and CT
• Rectal GC and CT (if anal sex) *
• Pharyngeal GC (if oral sex)

• HSV-2 serology (consider)

• Hepatitis B (HBsAg, frequency not specified)
• Hepatitis C (HIV+ MSM at least annually)
Anal Cancer in HIV+ MSM: Data insufficient to recommend
routine screening, some centers perform anal Pap and HRA

* At least annually, more frequent (3-6 months) if at high risk

(multiple/anonymous partners, drug use, high risk partners)
CDC 2015 STD Treatment Guidelines
MAJORITY OF RECTAL INFECTIONS IN
MSM ARE ASYMPTOMATIC

Rectal Infections

86% 84%

Chlamydia Gonorrhea
n=316 n=264 Asymptomatic
Symptomatic
Urethral 10%
Infections
42%

Chlamydia Gonorrhea
n=315 n=364
Kent, CK et al, Clin Infect Dis July 2005
High Proportion of Extragenital CT/GC
Associated with Negative Urine Test,
STD Surveillance Network (n=21994)

Patton et al CID 2014

PROPORTION OF CT/GC MISSED IF SCREENING
ONLY PERFORMED AT URETHRAL SITE (URINE),
SAN FRANCISCO, 2008-2009
N=3398 PATIENT VISITS

Chlamydia Gonorrhea
Among asymptomatic MSM
CT or GC was found in at least one anatomical site
at 16% of these patient visits

Marcus et al, STD Oct 2011; 38: 922-4

 Gonorrhea Dual Therapy
Uncomplicated Genital, Rectal,
or Pharyngeal Infections

Ceftriaxone 250 mg IM PLUS* Azithromycin

in a single dose 1 g orally

• Regardless of CT test result

CDC 2015 STD Treatment Guidelines

www.cdc.gov/std/treatment
Gonorrhea Treatment Alternatives
Anogenital Infections

ALTERNATIVE CEPHALOSPORINS:
 Cefixime 400 mg orally once
PLUS
 Azithromycin 1 g, regardless of CT co-infection

IN CASE OF SEVERE ALLERGY:

Gentamicin 240 mg IM + azithromycin 2 g PO
OR
Gemifloxacin 320 mg orally + azithromycin 2 g PO

CDC 2015 STD Treatment Guidelines www.cdc.gov/std/treatment

Alternative Urogenital GC Regimens:
AVOID MONOTHERAPY
 NIH-sponsored non-comparative randomized trial in
adults with urethral or cervical gonorrhea
1. gentamicin 240 mg IM + azithromycin 2 g PO, or
2. gemifloxacin 320 mg PO + azithromycin 2 g PO

 Per-protocol efficacy:
 gentamicin + azithromycin = 100% (202/202)
 gemifloxacin + azithromycin = 99.5% (198/199)

Kirkcaldy, CID 2014;59:1083-91.

 Any downside to the alternative
regimens?
Gentamicin Gemifloxacin
Regimen Regimen
Route IM or IV Oral
Nausea 27% 37%
Vomiting (<1 hour) 3% 7%

Availability OK FDA reported

shortage in May
2015
Volume Need 6 cc
(40mg/cc)
Who needs a test of cure for GC
• Patients with pharyngeal GC treated with an
alternative regimen
- Obtain test of cure 14 days after treatment, using
either culture or NAAT
• Cases of suspected treatment failure (culture
and simultaneous NAAT)
• Consider if using non-recommended or
monotherapy

CDC 2015 STD Treatment Guidelines www.cdc.gov/std/treatment

Suspected GC Treatment Failure
TEST WITH CULTURE AND NAAT:
• If GC culture not available, call your local health department

REPEAT TREATMENT:
• Gemifloxacin 320 mg + AZ 2g OR Gentamicin 240 mg IM + AZ 2g
• If reinfection suspected, repeat treatment with CTX 250 + AZ 1g

REPORT:
• To your local health department within 24 hours

TEST AND TREAT PARTNERS:

• Treat all partners in last 60 days with same regimen

TEST OF CURE (TOC):

• TOC 7-14 days with culture (preferred) and NAAT
 Chlamydia Treatment
Adolescents and Adults
Recommended regimens (non-pregnant):
 Azithromycin 1 g orally in a single dose
 Doxycycline 100 mg orally twice daily for 7 days

Recommended regimens (pregnant*):

Azithromycin 1 g orally in a single dose

* Test of cure at 3-4 weeks only in pregnancy

CDC 2015 STD Treatment Guidelines www.cdc.gov/std/treatment

 Chlamydia Treatment
Changes in 2015 CDC Tx Guidelines
New Alternative Regimen (non-pregnant):
Doxycycline (delayed release) 200 mg QD x 7 d
• Equally efficacious to doxycycline BID, ↓ GI side effects
• More $$$

Moved to Alternative Regimen (pregnant*):

Amoxicillin 500 mg po TID x 7 days
• CT persistence documented in vitro after treatment
prompted removal from recommended to alternate
The Effectiveness of Expedited Partne
Treatment on Re-Infection Rates

GONORRHEA CHLAMYDIA
20% P=.02 P=.17
15%
10%
13%
5% 11% 11%
3%
0%
Usual Care EPT Usual Care EPT

Golden M, et al. N Engl J Med 2005 Feb 17;352(7):676-85.

LEGAL STATUS OF EPT IN U.S.

http://www.cdc.gov/std/ept
 Gonorrhea Cases and Rates by Year
San Diego County, 1997 - 2016

Cases Rate per 100,000 population

4992
5000 200

4500 180

4000 160
3695

3391 151.8
3500 140

3000 2767
2865 120
2606 2597
114.5
2500 2376 2385 100
106.2
2128 2166
1972 2016 2019
1875 90.3 1843 90.9
2000 1797 85.7 80
83.0
15871560 78.9 77.0
1505 72.9
1500 65.5 66.4
69.5 60
63.9 64.2 65.2
60.1
56.7 58.7 56.7
1000 40

500 20

0 0
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 201

Year
 Gonorrhea Rates by Gender and Age
San Diego County, 2016

Female Male
600
548.0

489.2
500

427.8

400 386.1

300 288.8

240.6
208.7
200
163.1
147.0

98.1 98.2
100

14.8 12.3
1.5 0.5 4.1
0
<10 10-14 15-19 20-24 25-29 30-34 35-44 45+
Age Note:
GroupRates exclude 21 cases missing gender or age inform
 Gonorrhea Rates by Gender and
Race/Ethnicity
San Diego County, 2016
Female Male
600

500 482.2

437.8

400

300

200.8
200

123.7 115.1 119.7

106.4
100

45.4 52.2
34.7
0.0 9.1
0
Native American/ Asian/Pacific Islander Black Hispanic White Other/Mixed Race
Alaskan Native
Race/Ethnicity

Note: 40.9% of cases are missing race/ethnicity and are not included in the rate
Slide courtesy of Heidi Bauer, MD, MS, MPH
Slide courtesy of Heidi Bauer, MD, MS, MPH
PUBLIC HEALTH RESPONSE

GONORRHEA
 Surveillance

 Disease intervention

 HIV-negative rectal GC cases

 HIV prevention

 Monitoring of antimicrobial susceptibility (GISP):

 Male urethral isolates

 Coming soon: endocervical, pharyngeal, rectal

isolates

 Safety net clinical services: dual treatment

 Community
 Home engagement
testing program for young women

 Clinical consultation services

 Chlamydia Cases and Rates by Year
San Diego County, 1997 - 2016

Cases Rate per 100,000 Population

20000 800
18904

18000 17418
700
16538
16042
16000 15626
15336 15349
600
14073 14266
14000
12692 574.8
11980 528.6 539.7 500
12000 509.2
10822 11001 495.5 489.2
10225 10249 492.6
447.9465.5
10000 9168 400
8637 409.9
390.8
8000 7576 350.1 359.5361.9
7006 344.9 300
6360 306.9
6000 320.1
259.2
239.7 275.4 200
4000

100
2000

0 0
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year
 Chlamydia Rates by Gender and Year
San Diego County, 1997 - 2016

Females Males

800

700 713.6

600

500

434.7
400

300

200

100

0
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year
 Chlamydia Rates by Gender and Age
San Diego County, 2016

Female Male
4400
4130.3

4000

3600

3200

2800
2352.2
2400

2000 1814.8

1520.1
1600
1159.8
1200
816.3776.2
800
509.2
416.9
330.4
400
6.4 3.8 48.5 5.1 34.3114.9
0
<10 10-14 15-19 20-24 25-29 30-34 35-44 45+

Age Group
Note: Rates exclude 79 cases missing gender or age informa
Slide courtesy of Heidi Bauer, MD, MS, MPH
 PUBLIC HEALTH RESPONSE

CHLAMYDIA
 Surveillance

 Screening in juvenile detention facility

 Safety net clinical services

 Home testing program for young women

 TA for STD prevention education in local schools

 Clinical consultation services

 WHAT PROVIDERS CAN DO

 Test test test!

 3-site testing for GC/CT in MSM

 At least annually, more frequent if high-risk or on PrEP

 Normalize STD testing

 Offer options for expedited or “express” testing.

 Verify pregnancy status of all female syphilis cases, and ensure prompt
treatment of pregnant cases.

 Provide dual treatment to all gonorrhea cases.

 Report STD cases to local health department.

 Treat partners; consider EPT when feasible.

 FUTURE DIRECTIONS

 Research: drivers of increasing STD morbidity in MSM, vaccines,

new treatment options for GC
 POC testing

 Express visits, opt-out testing, validate GC/CT tests for self-collected

specimens

 Utilize STD prevention opportunities provided by increased PrEP

interest/uptake

 Better utilize existing resources:

 Disease investigators
 Community agencies/clinics

 Dedicated STD clinics

 ACKNOWLEDGEMENTS

 California STD/HIV Prevention Training Center

 Heidi Bauer, MD, MS, MPH (CA Dept of Public Health)

 Anne Rompalo, MD (Johns Hopkins University SOM)

 Juliet Stoltey, MD (CA Department of Public Health)

 THANK YOU!

 Myres Winston Tilghman, MD

 Winston.Tilghman@sdcounty.ca.gov

 Office Phone: (619) 692-8394

 Consultation Pager: 877-217-1816

 STD Field Services (syphilis histories): (619) 692-8501

 www.stdsandiego.org

On May 17, 2016, the County of San Diego Health and Human Services Agency Division
of Public Health Services received accreditation from the Public Health Accreditation Board.