ASHM Report Back

Clinical posts from members and guests of the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) from various international medical and scientific conferences on HIV, AIDS, viral hepatitis, and sexual health.

New WHO STI Treatment Guidelines

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The new WHO STI Treatment Guidelines were released August 2016 after 3 years of a very complex process, this was the first update since 2003. The recommendations were mostly based on very low - low quality levels of evidence but resulted in 'Strong Recommendations' or 'Conditional Recommendations'. 

Target populations were based on the same as Australian target groups but I was surprised to see the adolescent group include 10 - 19 year olds compared to Australia's young people aged 15 - 24 year olds. 

N. Gonorrhoea 

Recommended treatment 

* 250mg ceftriaxone IMI + 1gm azithromycin oral stat

When asked why 250mg ceftriaxone IMI as opposed to 500mg ceftriaxone IMI as recommended in may developed countries including Australia, Prof Magnus Unemo explained that there were no adequate RCT to support the larger dose worked any better than the recommended. 

Also they advised a 'Strong Recommendation' for all neonate to receive prophylactic treatment for prevention of gonococcal and chlamydial ophthalmia neonatorum, a practice abandoned in Australia with no subsequent increase in occurrence of infection or childhood blindness.

C. Trachomatis

* Azithromycin or doxycycline remain the treatment of choice for CT

* Anogenital CT - treatment changed to 7/7 of doxycycline 100mg BD.                                                                       Australian STI Guidelines recommend 7/7 of doxycycline 100mg BD if asymptomatic and 21/7 if symptomatic

Prof. Nicola Low advocated that the doxycycline regime of 7/7 of treatment still cures CT as well as if not better than azithromycin even if the course is not completed in non compliant people. 

* There is no evidence that repeating or lengthening the course of treatment is any more effective. 

Syphilis

* Nothing has changed in Rx recommendations for syphilis

* There is very low quality evidence to support the recommended treatment

* Treatment is based on 70 years of successful treatment.

I enjoyed Dr Francis Ndowa's analogy that there were no RCT proving the use of parachutes when jumping out of a plane greatly improved survival over not using one, so proving benzathine penicillin successfully treated syphilis didnt require RCT. 

* There is a pending global shortage of benzathine penicillin so alternatives include

        * doxycycline, ceftriaxone and in special circumstances azithromycin 

Genital Herpes

The only change recommendation for treatment is to increase treatment of the first outbreak of genital herpes to 10 days as most first outbreaks are prolonged. 

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