Sexually Transmitted Infections

Last updated: 9/15/23

Key resources

Santa Clara County is experiencing record-high rates of syphilis, a sexually transmitted Infection (STI) caused by the bacterium Treponema pallidum. Syphilis can cause serious health effects without adequate treatment, especially when transmitted from a pregnant person to their fetus.

Local Syphilis Recommendations and Resources

Local rates are especially high among females of childbearing age, making Santa Clara Count a high-risk jurisdiction. The County STD Controller recommends all providers follow guidelines for syphilis screening in high-risk jurisdictions, in accordance with the recently updated California Guidelines for Syphilis Screening to Prevent Congenital Syphilis and the 2021 CDC STI Screening Recommendations. Providers must also comply with state law that requires syphilis testing during pregnancy.

The local STD Controller also strongly recommends that emergency departments and urgent care settings offer routine opt-out screening for syphilis and HIV in accordance with recommendations from CDPH . The STD/HIV Prevention & Control Branch is available to provide technical assistance to providers wishing to implement or automate the above screening guidelines , please contact [email protected] for more information.

For questions about complicated syphilis cases or to access a patient’s syphilis history, providers can call our syphilis investigators at (408) 792-3739.

CDPH Dear Colleague Letter Opt-Out ED Screening 3/28/22

Disseminated Gonococcal Infections (DGI)

Disseminated Gonococcal Infection (DGI) is an uncommon, but severe, complication of untreated gonorrhea that has been increasing across California in recent years. DGI occurs when the sexually transmitted pathogen Neisseria gonorrhoeae invades the bloodstream and spreads to distant sites in the body, leading to clinical manifestations such as septic arthritis, polyarthralgia, tenosynovitis, petechial/pustular skin lesions, bacteremia, or, on rare occasions, endocarditis, or meningitis.

If you identify a case of DGI in a Santa Clara County resident:

Complete DGI form
Fax DGI form (408) 797-3722
Follow up with a phone call to (408) 792-3739 to ensure report was received
For more information for providers on DGI:

Gonorrhea

Gonorrhea is a sexually transmitted infection (STI) caused by infection with the Neisseria gonorrhoeae bacterium. N. gonorrhoeae infects the mucous membranes of the reproductive tract, including the cervix, uterus, fallopian tubes and or urethra. N. gonorrhoeae can also infect the mucous membranes of the mouth, throat, eyes, and rectum. To combat rising rates an emerging drug resistance, CDC recently updated the treatment recommendations for uncomplicated gonorrhea infections (STI Treatment Guidelines, 2021).

Gonorrhea resources

Chlamydia

Chlamydia is an STI caused by infection with Chlamydia trachomatis and is the most common reportable disease in Santa Clara County (Santa Clara County Health Data and Statistics). It can cause cervicitis, urethritis, and proctitis. In people with a vagina and uterus, these infections can lead to, pelvic inflammatory disease, tubal factor infertility, ectopic pregnancy, and chronic pelvic pain.

Chlamydia Resources

Vaginitis: Candida, Bacterial Vaginosis, and Trichomonas

Vulvovaginal itching, burning, irritation, odor and/or discharge can be caused by a variety of infections. Clinical evaluation and laboratory testing are required to distinguish among them and determine the appropriate treatment.

Bacterial Vaginosis vs. Trichomonas Provider Toolkit

Bacterial vaginosis (BV) is a condition that happens when there is too much of certain bacteria in the vagina. This changes the normal balance of bacteria in the vagina. Recurrences are common even after appropriate treatment, and the STD Controller is available for case consultation in cases of treatment failure and recurrences.

Trichomoniasis (or “trich”) is a very common STI caused by infection with the protozoan Trichomonas vaginalis. The CDC recently updated the recommendation for treatment of vaginal trichomoniasis infections. Although symptoms of the disease vary, most people who have the parasite cannot tell they are infected. Recurrence and reinfection are common, and antimicrobial resistance may be increasing. The STD Controller is available for case consultation in instances of repeated reinfection or treatment failure.

Vulvovaginal Candidiasis is a common cause of vaginal itching and discharge, usually caused by Candida albicans and occasionally by other Candida species or yeasts. Patients with recurrent VVC without known cause should be tested for HIV. Recurrence and reinfection are common, and antimicrobial resistance may be increasing. The STD Controller is available for case consultation in instances of repeated reinfection or treatment failure, and the Public Health Department can assist with advanced antimicrobial susceptibility testing as needed.

Human Papilloma Virus (HPV)

Human Papilloma Virus (HPV) is the most common STI, with about 43 million HPV infections in 2018, many among people in their late teens and early 20s. Most individuals will clear HPV infections without intervention, but some types can cause genital warts or progress to cause cervical, vaginal, penile, anorectal, or head and neck cancers. Vaccination is the most important method of preventing HPV-related cancers. Some populations are recommended to receive routine screening for HPV-related cervical changes and infections.

HPV resources

Pelvic Inflammatory Disease (PID)

Pelvic inflammatory disease (PID) is an infection of the female reproductive organs. It most often occurs when sexually transmitted bacteria spread from your vagina to your uterus, fallopian tubes or ovaries.

The signs and symptoms of pelvic inflammatory disease can be subtle or mild. Some people may not experience any signs or symptoms. As a result, some people might not realize they have it until they have trouble getting pregnant or you develop chronic pelvic pain.

PID Resources

Meet the STI/HIV Controller

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STDs are increasing in California

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HCV

What is Hep C?

Hep C (HCV) is an infection caused by a virus that attacks the liver which leads to inflammation. HCV is usually spread when someone comes into contact with blood from an infected person. When the liver is inflamed or damaged, its function can be affected. When someone is infected with Hep C they can have a very mild illness with few or no symptoms or a serious condition requiring hospitalization. Most individuals who get infected will develop a chronic or lifelong infection. If left untreated Hep C can cause serious health problems including liver disease, liver failure, liver cancer, and even death.

Key Steps for Providers

Screen Using a rapid or lab-based HCV antibody assay: All persons born between 1945-1965 (baby boomers) once in their lifetime without attaining past risk; People who inject drugs who are currently injecting or who have ever injected Persons living with HIV (PLWH) at their first medical visit, plus annually for all men who have sex with men living with HIV.
Confirm With an HCV RNA test using reflex-to-RNA to streamline diagnosis and reduce loss-to-follow-up (or refer and link for confirmatory testing).
Refer and Link to RNA confirmatory testing for antibody-positive patients or, to be assessed for treatment for RNA-confirmed patients.
Counsel HCV-positive persons on adherence for those receiving treatment, transmission prevention, and liver health HCV-negative persons on harm reduction information.

Hep C Transmission

Birth
Sharing drug injection equipment (sharing needles/ syringes)
Sex with an infected person and men who have sex with men are at greater risk.
Unregulated tattoos or body piercings
Sharing personal items such as glucose monitors, razors, nail clippers, toothbrushes, and other items that may have come into contact with infected blood.
Blood transfusions and organ transplants.
Before widespread screening of blood supply in 1992, Hep C was also spread through blood transfusions and organ transplants.

Symptoms

Many People with Hep C do not have symptoms and do not know they are infected. Individuals with chronic Hep C can live for years without symptoms or feeling sick. When symptoms appear with chronic Hep C they often are a sign of advanced liver disease. Getting tested is the only way to know if you have Hep C.

If symptoms occur, they can include:

Yellow eyes
Yellow skin
Loss of appetite
Upset stomach

Vomiting
Stomach pain
Fever
Dark urine
Light color stool

Joint pain
Fatigue

CDC Prevention Guidelines for Hepatitis C Screening Among Adults - 2020
Rapid increases in acute infections among young adults, including reproductive-aged persons, have put multiple generations at risk for chronic hepatitis C. CDC now recommends one-time hepatitis C testing of all adults (18 years and older) and all pregnant women during every pregnancy. CDC continues to recommend people with risk factors, including people who inject drugs, be tested regularly.

HCV Guidance: Recommendations for Testing, Managing and Treating Hepatitis C
Resource is an updated web experience to facilitate easier and faster access to recommendations for testing, managing and treating HCV by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America. Includes access to a Simplified HCV Treatment Algorithm for Treatment-Naïve Adults Without Cirrhosis.

HCV FDA Approved Medications
Learn more about approved FDA treatments for hepatitis C, prescribing information, clinical studies and obtain access to slide decks.

HCV Toolkit & Resources – Southeast AIDS Education & Training Center

The purpose of this training and resources are to improve providers’ capacity to screen, medically manage, and provide advanced care for patients with Hepatitis C virus.

Hepatitis C Linkage Program

The Public Health Department is now offering support and linkage to treatment for individuals who have a known Hepatitis C diagnosis. The program aims to promote better health outcomes to HCV treatment, education and supportive services. Services are free and confidential and include:

Connecting to HCV care and treatment
Assessing barriers to care including health insurance
Navigating through the HCV care plan to promote successful completion of treatment
Reducing risk for reinfection

To refer clients, please complete the HCV Linkage Referral Form and email to [email protected]. For more information, call (408) 792-5128.

PrEP and PEP

HIV prevention PrEP and PEP

About PrEP

PrEP 2021 Clinical Guidelines

PrEP and PEP for Providers

PrEP and PEP For Your Patients

PrEP Program Brochure

TRUVADA for PrEP is a once-daily prescription medicine that can help reduce the risk of getting HIV-1 through sex, when taken every day. Also available as generic Emtricitabine/Tenofovir Disoproxil Fumarate.
DESCOVY for PrEP (pre-exposure prophylaxis) is a once-daily prescription medicine for adults and adolescents at risk of HIV. It helps lower the chances of getting HIV through sex.
APRETUDE is given every other month by a healthcare provider after initiation injections have been given 1 month apart for 2 consecutive months.
- Apretude is the first injectable form of PrEP for HIV prevention for adults and adolescents weighing at least 77 pounds. Individuals must have a negative HIV test prior to initiating Apretude. Anyone who wants PrEP can ask their health care provider for it
- Any licensed medical provider can prescribe Apretude, such as a primary care doctor, nurse practitioner, obstetrics, specialty pharmacist, and gynecologist.
- Two major clinical trials, HPTN 083 and HPTN 084, showed that injectable cabotegravir as an HIV pre-exposure prophylaxis reduced HIV transmission by 70% in men who have sex with men and transgender women. In cisgender women, the risk of infection was reduced by 90%.
- Injectable PrEP is for people of all genders and identities at risk of HIV infection due to sex. Currently, the injectable method of PrEP is recommended for people who have a negative reaction to oral medications or have trouble adhering to the daily pill schedule. Apretude should not be prescribed to anyone already with HIV. This can lead to drug resistance.
- Appointment reminders and other tools to keep PrEP care appointments. Plan for STI prevention and contraception or safer conception. Encourage patient to report if they want to stop or have stopped PrEP. Support additional prevention methods when needed.
- Cabotegravir injection: one 600mg IM gluteal injection (ventrogluteal preferred) at baseline, 1 injection 4 weeks later, 1 injection every 8 weeks thereafter (+/- 7 days). Optional oral cabotegravir start: 30mg pill once daily for 28 days* before 1st injection, 1st injection on last day of oral lead-in (or <3 days after), continue injection protocol; OR prescribe up to 8 weeks around missed injection. Missed injections: Administer injection 4 weeks later if >7 days late for 2nd dose or >1 month late for 3rd or later dose.
- ICD-10 Z20.6: HIV exposure

What is PEP?

Post-Exposure Prophylaxis (PEP) is an HIV prevention option that should be used only in emergency situations. PEP must be initiated within 72 hours after a recent possible exposure to HIV.

PrEP and PEP navigation services for clients

To prevent the spread of COVID-19, all Pre-Exposure Prophylaxis (PrEP) Navigation Services are conducted remotely via telephone. If you are interested in PrEP please complete our online referral form or call us at (408) 792-3250. We will get in touch with you to assist you with your PrEP needs.

Santa Clara County HIV testing services

HIV testing is recommended for all persons seeking STI evaluation who are not already known to have HIV infection. Testing should be routine at the time of the STI evaluation, regardless of whether the patient reports any specific behavioral risks for HIV.

STI and HIV Testing Services in Santa Clara

HIV Treatment

Health care providers play an important role in helping patients initiate ART, including describing the benefits of early initiation of ART, offering and prescribing ART, helping to manage long-term ART use, and providing information on other interventions that can reduce HIV transmission risk. Contact us at [email protected] for assistance setting up a Rapid ART Initiation Program in your clinic.

Undetectable = Untransmittable

Antiretroviral therapy keeps HIV from making copies of itself. When a person living with HIV begins an antiretroviral treatment regimen, their viral load drops. For almost everyone who starts taking their HIV medication daily as prescribed, viral load will drop to an undetectable level in six months or less. Continuing to take HIV medications as directed is imperative to stay undetectable.

Notification and Partner Services

STI exposure notification and partner services

The Public Health Department offers Partner Services, a program designed to help inform the partners of your patients of potential exposure to HIV or an STI. We can then assist Notified partners in receiving appropriate testing and/or empiric treatment or post-exposure prophylaxis.

Patients with infections have the option to:

Obtain materials on how to notify their partners
Schedule a dual notification with a trained Public Health HIV/STI counselor to help you notify your partner
Request a trained Public Health HIV/STI counselor to notify your partner anonymously

Partner Services is a free, voluntary, and confidential service and offered with all testing done at the Crane Center.

For more information, please call the Crane Center at: (408) 792-3720

Expedited Partner Therapy

Expedited Partner Therapy (EPT) is the clinical practice of prescribing medications to the sex partners of patients diagnosed with STIs such as chlamydia, gonorrhea, and trichomonas. Special legal protections in California allow clinicians to prescribe such medications to their patients’ partners without the health care provider first examining the partner.

Provider procedure for EPT

A prescriber can legally prescribe treatment for the partner(s) in any of the following ways:

If the patient provides the partners’ names, the prescriber may write a separate prescription for the partners without having clinically evaluated the partners.
The prescriber may write a single prescription for both the patient and the partners by adding the partners’ name to the prescription and increasing the quantity appropriately.
The prescriber may simply add “and partner(s)” to the name on the prescription and increase the quantity appropriately.
A clinic may dispense medication directly to the patient for delivery to partners (patient-delivered partner therapy or PDPT), if dispensed with information about its use.

A separate prescription for each partner is preferred. However, all options are valid, and all prescription types can be filled by a pharmacist. Options 2 and 3 can be billed to the patient’s insurance in most instances inclusive of the treatment for the partner(s).

Patient-Delivered Partner Therapy (PDPT): The Most Common Type of EPT

Essential Access Health's Chlamydia/Gonorrhea (CT/GC) Patient-Delivered Partner Therapy (PDPT) Distribution Program offers certain clinics the ability to receive free packages of STI treatment medications to be dispensed to patients with an STI diagnosis, for delivery to their partners. This is a great option for uninsured or privately insured patients.

Providers can refer to the Essential Access Health PDPT Distribution Program to learn more about eligibility, participation, registration, and the order process.

Client resources

To enroll in the PrEP-AP, uninsured applicants must also enroll in the drug manufacturer’s Patient Assistance Program. Currently Gilead Sciences, Inc. (Gilead) is the sole manufacturer of Truvada® for PrEP Clients enrolled in Gilead’s Patient Assistance Program will receive Truvada® free of charge from Gilead. Clients are required to maintain eligibility in both programs to receive PrEP-AP benefits. This includes re-enrolling every twelve months in both PrEP-AP and Gilead’s Patient Assistance Program.

PrEP Assistance Program

Medicare clients without drug coverage must enroll in the Gilead Patient Assistance Program, which provides Truvada® free of charge, before enrolling into PrEP-AP. Medicare clients with drug coverage are not eligible for the Gilead Patient Assistance Program, but are eligible for PrEP-AP.

Getting to Zero Program

The Getting to Zero program offers opportunities for community providers and organizations to request academic detailing, clinical trainings or other technical assistance related to STD/HIV screening, testing, treatment and clinical care practices. Please email [email protected] to request detailing, training or technical assistance.

STI and HIV financial resources for clients

Patient Access Program:

Office: 770 S. Bascom Ave., San Jose, CA 95128 (Monday to Friday, 8:30 a.m. to 4:30 p.m.)
Phone number: (866) 967-4677

CDPH HIV Care Branch
FAQ: For Insured Clients (PDF)
FAQ: For Uninsured Clients (PDF)

DoxyPEP

What is DoxyPEP?

DoxyPEP is like the morning after pill that helps prevent sexually transmitted infections (STIs)! Instead of preventing pregnancy within hours of unprotected sex, DoxyPEP can prevent STIs such as chlamydia, gonorrhea, and syphilis.

When should patients take DoxyPEP?

Patients are advised to take 200mg of doxycycline within 24hrs but no later than 72hrs after condomless oral, anal or vaginal sex.

Doxycycline can be taken every day depending on frequency of sexual activity.

However, patients should not take more than 200mg within a 24hr period.

What should providers monitor?

LFTs, renal function and CBC should be checked periodically in patients taking doxycycline for a prolong period. Consider checking these laboratory parameters annually.

Screen every three months for gonorrhea, and chlamydia at all anatomic sites of exposure, syphilis, and HIV.

Patients should be counseled about the following:

1. Risks and serious side effects

2. After taking doxycycline, remain upright for 30 minutes after taking it to reduce pill esophagitis.

3.Doxycycline should be avoided during pregnancy. Patients who could get pregnant should be counseled to stop doxycycline if they become pregnant.

4. Although doxycycline is generally well-tolerated, there is a risk of sun sensitivity. Patients should be counseled to wear sunscreen and/ or avoid prolonged sun exposure while taking doxycycline.

Reference

Doxycycline Post-Exposure Prophylaxis Reduces Incidence of Sexually Transmitted Infections