Study Points

Viral Sexually Transmitted Infections

Course #94181 - $25 • 5 Hours/Credits

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    • Review the course material online or in print.
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    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.
  1. Which of the following is NOT one of the Five Ps of sexual history taking?

    GENERAL STI ASSESSMENT AND PREVENTION COUNSELING

    The "Five Ps" approach elicits sexual history information related to five key areas of interest: partners, practices, prevention of pregnancy, protection against STIs, and past history [1].

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  2. Increased STI prevalence rates are found in

    GENERAL STI ASSESSMENT AND PREVENTION COUNSELING

    All sexually active adolescents are considered at increased risk for STIs and should be counseled. Other at-risk groups include adults with current or past-year STIs, with multiple sex partners, or who use condoms inconsistently. African Americans have the highest STI prevalence of any racial/ethnic group, and STI prevalence is higher in American Indians, Alaska Natives, and Latino/as than in white populations. Increased STI prevalence rates are also found in men who have sex with men (MSM), persons with low incomes living in urban settings, current or former inmates, military recruits, persons who exchange sex for money or drugs, persons with mental illness or a disability, current or former injecting drug users (IDUs), persons with sexual abuse history, and patients of public STI clinics [3].

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  3. Which of the following statements regarding external condoms is TRUE?

    BARRIER AND NONBARRIER APPROACHES TO PREVENT OR REDUCE VIRAL STI TRANSMISSION AND INFECTION

    As U.S. Food and Drug Administration (FDA)-regulated medical devices, condoms are subject to quality-control testing. Each latex condom manufactured in the United States is tested electronically for holes before packaging. The rate of condom breakage during sexual intercourse and withdrawal is approximately 2 per 100 condoms used, with slightly higher rates during anal intercourse [7,8]. Condom failure to protect against STI or unintended pregnancy is usually caused by inconsistent or incorrect use, instead of condom breakage [9]. Latex condoms should not be used beyond their expiration date or more than five years after the manufacturing date, and users should check the expiration or manufacture date on the packaging before use [1]. In 2022,the FDA cleared the first natural rubber latex condom designed specifically to be used in anal intercourse [150].

    External condoms made of materials other than latex fall in two general categories: synthetic and natural membrane condoms. Polyurethane and other synthetic condoms provide protection against STIs/HIV and pregnancy comparable to latex condoms and are used mainly as latex condom substitutes by persons with latex allergy. These condoms are more resistant to deterioration and are compatible with oil-based or water-based lubricants. The preventive efficacy of other synthetic external condoms is not well studied, and the FDA restricts their use to persons with latex sensitivity or allergy [6,10].

    Natural membrane condoms (termed "natural skin" or "lambskin") are made from lamb cecum. The pores, no greater than 1,500 nm in diameter, block passage of sperm but are more than 10 times the diameter of HIV and more than 25 times that of HBV. Therefore, sexual transmission of hepatitis B, herpes simplex, and HIV organisms can occur with natural membrane condoms. These condoms are recommended for preventing pregnancy but not STIs/HIV [10,11,12].

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  4. Which of the following methods has shown some efficacy in reducing the risk of STI transmission?

    BARRIER AND NONBARRIER APPROACHES TO PREVENT OR REDUCE VIRAL STI TRANSMISSION AND INFECTION

    Male circumcision has been found to reduce the risk for HIV and some STIs in heterosexual men. By various means, penile foreskin is the primary biologic weak point and conduit for HIV infection during heterosexual intercourse [15]. Several controlled studies of heterosexual HIV transmission in sub-Saharan Africa found circumcision reduced the risk for HIV acquisition in men by 50% to 60% and protected against high-risk genital HPV infection and genital herpes [16,17,18]. These benefits of circumcision were sustained over time, and the effects were not solely related to reductions in herpes simplex virus type 2 (HSV-2) infection or genital ulcer disease [19,20].

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  5. Genital herpes screening should be conducted

    SCREENING RECOMMENDATIONS

    VIRAL STI SCREENING RECOMMENDATIONS

    InfectionPopulation Screened
    WomenPregnant WomenMenMSMTransgender and Gender Diverse PeoplePersons with HIV
    Genital herpesConsider testing during STI evaluationNot supported without symptomsConsider testing during STI evaluationConsider testing if status unknown or if previous undiagnosed genital tract infectionConsider testing during STI evaluation, especially if high risk
    HPV/cervical cancer
    Age 21 to 29 years: Every three years with cytology
    Age 30 to 65 years: Every three years with cytology or every five years with cytology plus HPV testing
    Same as nonpregnant cis-gender womenDigital anorectal rectal exam (anal cytology not recommended)Follow recommendations for persons with a cervixWithin one year of sexual activity or first HIV diagnosis, using standard or liquid-based cytology. Repeat testing in six months.
    Hepatitis BWith increased risk
    At first prenatal visit for each pregnancya
    Retest at delivery if high risk
    With increased riskTest for HBsAg, anti-HBc, and anti-HBsTest for HBsAg, anti-HBc, and anti-HBs
    HIVAll aged 13 to 64 years (opt-out) and all seeking STI testing and treatment
    All during first prenatal visit (opt-out)
    Retest in third trimester if high risk
    Rapid testing should be performed at delivery if not previous screened during pregnancy
    All aged 13 to 64 years (opt-out) and all seeking STI testing and treatment
    At least yearly if: sexually active, HIV status negative or unknown, patient or sex partner(s) had more than one partner since last HIV test
    Consider more frequent screening (every 3–6 months) with increased risk
    Test all transgender patients
    Frequency of repeat screenings should be based on level of risk
    aRegardless of whether prior testing was performed.
    Anti-HBc = antibodies to hepatitis B core antigen, anti-HBs = antibodies to hepatitis B surface antigen, HBsAg = hepatitis B surface antigen, HIV = human immunodeficiency virus, HPV = human papillomavirus, MSM = men who have sex with men.
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  6. Most genital herpes infections are transmitted

    HERPES SIMPLEX VIRUS

    In the United States, approximately one in eight persons 14 to 49 years of age is infected with HSV-2. The virus remains for life once infection has occurred, and prevalence rates generally increase with age due to cumulative sexual exposure [37]. Most people infected with genital herpes have not been diagnosed, and many with undiagnosed HSV-2 have minimal or no signs and symptoms, but shed virus intermittently in the anogenital area [38]. As a result, most genital herpes infections are transmitted by people who are unaware they are infected or are asymptomatic when transmitting. The risk of transmission is highest when outbreaks develop with new blisters in the anogenital area [3,36].

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  7. What is the preferred herpes simplex virus (HSV) test for persons presenting for general STI evaluation (especially with multiple sex partners)?

    HERPES SIMPLEX VIRUS

    HSV serologic testing is used for persons presenting for general STI evaluation (especially with multiple sex partners), those with HIV infection, and MSM at increased risk for HIV. Serologic HSV antibody testing detects the specific immune protein response to herpes infection. Several days after the primary (initial) HSV infection, immunoglobulin M (IgM) antibody is produced, remaining detectable in serum for several weeks. After HSV IgM, the body begins producing HSV IgG antibody. IgG serum levels rise for several weeks, then slowly decline, stabilize, and remain detectable forever in those with HSV exposure [42,45]. With type-common antibody testing, positive HSV IgM antibody indicates active or recent infection, while positive HSV IgG antibody indicates previous infection. A significant recent increase in HSV IgG antibodies is a sign of active or recent infection. Negative HSV antibody testing implies HSV exposure is unlikely or the body has had insufficient time to produce HSV antibodies [42,45].

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  8. Which of the following is a recommended treatment regimen for the first clinical episode of genital herpes?

    HERPES SIMPLEX VIRUS

    TREATMENT OF GENITAL HERPES INFECTIONS

    Infection Stage or Patient GroupRecommended Treatment Regimen
    First clinical episode
    Any of the followinga:
    Acyclovir 400 mg oral three times per day for 7 to 10 days
    Valacyclovir 1 g oral twice per day for 7 to 10 days
    Famciclovir 250 mg oral three times per day for 7 to 10 days
    Recurrent: suppressive therapy
    Any of the following:
    Acyclovir 400 mg oral twice per day
    Valacyclovir 500 mg oral once per dayb
    Valacyclovir 1 g oral once per day
    Famciclovir 250 mg oral twice per day
    Recurrent: episodic therapy
    Any of the following:
    Acyclovir 800 mg oral twice per day for 5 days
    Acyclovir 800 mg oral three times per day for 2 days
    Valacyclovir 500 mg oral twice per day for 3 days
    Valacyclovir 1 g oral once per day for 5 days
    Famciclovir 125 mg oral twice per day for 5 days
    Famciclovir 1 g oral twice per day for 1 day
    Famciclovir 500 mg once, followed by 250 mg twice per day for 2 days
    Severe diseasecAcyclovir 5–10 mg/kg IV every 8 hours until clinical improvement, followed by oral antiviral therapy to complete ≥10 days total therapy
    During pregnancyd
    Either of the following:
    Acyclovir 400 mg oral three times per day
    Valacyclovir 500 mg oral twice per day
    Comorbid HIV Infection
    Daily suppressive therapy
    Any of the following:
    Acyclovir 400–800 mg oral twice to three times per day
    Valacyclovir 500 mg oral twice per day
    Famciclovir 500 mg oral twice per day
    Episodic infection
    Any of the following:
    Acyclovir 400 mg oral three times per day for 5 to 10 days
    Valacyclovir 1 g oral twice per day for 5 to 10 days
    Famciclovir 500 mg oral twice per day for 5 to 10 days
    Severe HSV diseaseInitiate with acyclovir 5–10 mg/kg IV every 8 hours
    aTreatment can be extended if healing is incomplete after 10 days of therapy.
    bValacyclovir 500 mg once per day might be less effective than other valacyclovir or acyclovir dosing regimens in persons who have very frequent recurrences (i.e., ≥10 episodes per year).
    cHSV encephalitis requires 21 days of intravenous therapy. Impaired renal function warrants an adjustment in acyclovir dosage.
    dTreatment recommended starting at 36 weeks' gestation.
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  9. What is the most common STI in the United States?

    HUMAN PAPILLOMAVIRUS

    HPV is the most common STI in the United States. During 2013–2014, the prevalence of genital HPV in adults 18 to 59 years of age was 45.2% in men and 39.9% in women [75]. Around 100 HPV types have been identified, and at least 40 can infect the anogenital area in men and women. HPV types vary by propensity to cause genital warts and recurrent respiratory papillomatosis (HPV types 6 and 11), or cervical, penile, vulvar, vaginal, anal, and oropharyngeal cancers and precancers (HPV types 16 and 18) [36]. Most HPV infections are self-limited, asymptomatic, or unrecognized, and many sexually active persons will be infected with HPV at least once in their lifetime [76].

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  10. Prevention of high-risk HPV is most effectively achieved through

    HUMAN PAPILLOMAVIRUS

    Prevention of high-risk HPV is most effectively achieved through vaccination. The FDA has approved three vaccines that protect against HPV and the diseases and cancers caused by HPV. A bivalent vaccine (Cervarix) and Gardasil were previously available, but are no longer used in the United States. The currently recommended vaccine is nine-valent Gardasil 9, which protects against HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58 [80,81].

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  11. Which of the following statements regarding HPV vaccination is TRUE?

    HUMAN PAPILLOMAVIRUS

    All boys and girls 11 to 12 years of age are now recommended to receive HPV vaccines, as they are most effective when given at younger ages, before the onset of sexual activity and initial exposure to the virus. The earliest approved age is 9 years. The vaccine in clinical use is recommended for girls/women and boys/men. Young sexually active people should still receive the vaccination, because those already infected with one type of HPV may benefit from the protection against other types included in the vaccine. In those who have not received any or all vaccine doses, vaccination is recommended through 26 years of age for all girls/women and boys/men [80]. HPV vaccine is also recommended for those 27 to 45 years of age if desired or if a risk factor is present.

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  12. Genital warts (condyloma acuminatum) are

    HUMAN PAPILLOMAVIRUS

    Genital warts (condyloma acuminatum) are benign and mainly caused by HPV types 6 and 11. The types affecting the anogenital region are usually transmitted sexually by penetrative vaginal or anal intercourse, but digital, oral, and nonpenetrative genital contact may be involved. The development of genital warts is more common in patients who are immunocompromised. Growth rates vary, but pregnancy, immunosuppression, or maceration of the skin may accelerate the growth and spread of warts [89].

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  13. Trichloroacetic acid (TCA) or bichloroacetic acid (BCA) is recommended for the treatment of genital warts occurring on all of the following locations, EXCEPT:

    HUMAN PAPILLOMAVIRUS

    RECOMMENDED TREATMENT OF GENITAL WARTS

    Wart LocationRecommended Treatment
    External anogenital warts (penis, groin, scrotum, vulva, perineum, external anus, perianus)a
    Patient-applied therapy:
    Imiquimod 3.75% or 5% creamb
    Podofilox 0.5% solution or gel
    Sinecatechins 15% ointmentb
    Provider-administered therapy:
    Cryotherapy with liquid nitrogen or CryoProbe
    Surgical removal by tangential scissor or shave excision curettage, laser, or electrosurgery
    TCA or BCA 80% to 90% solution
    Urethral meatus warts
    Cryotherapy with liquid nitrogen
    Surgical removal
    Vaginal warts
    Cryotherapy with liquid nitrogenc
    Surgical removal
    TCA or BCA 80% to 90% solution
    Cervical wartsd
    Cryotherapy with liquid nitrogen
    Surgical removal
    TCA or BCA 80% to 90% solution
    Intra-anal wartse
    Cryotherapy with liquid nitrogen
    Surgical removal
    TCA or BCA 80% to 90% solution
    a Many patients with external anal warts have intra-anal warts; consider anal canal inspection by digital examination, standard anoscopy, or high-resolution anoscopy.
    b May weaken condoms and vaginal diaphragms.
    c Do not use a CryoProbe in the vagina because of risk for vaginal perforation and fistula formation.
    d Consult with a specialist. In women with exophytic cervical warts, a biopsy should be performed before treatment to exclude high-grade squamous intraepithelial lesion.
    e Consult with a specialist.
    BCA = bichloroacetic acid, TCA = trichloroacetic acid.
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  14. Most cases of hepatitis are caused by

    VIRAL HEPATITIS

    Hepatitis is an inflammatory state of the liver. Most cases of hepatitis are caused by viral infection; other causes include exposure to chemicals, over-the-counter or prescription drugs, heavy alcohol use, inherited diseases, autoimmune disease, and fatty buildup in the liver [104]. In all patients with symptoms that suggest acute viral hepatitis, clinicians should assess the patient and, if necessary, refer for hospital admission. Tests should be performed to assess hepatitis severity, including liver function tests, coagulation tests, and hepatitis serology (i.e., anti-HAV IgM, HBsAg, hepatitis C virus [HCV] antibodies/RNA, and hepatitis E serology/PCR) [105].

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  15. Which of the following is a common sign of hepatitis A virus (HAV) infection?

    VIRAL HEPATITIS

    The icteric phase is characterized by jaundice (mixed hepatic and cholestatic) and is associated with anorexia, nausea, and fatigue that usually lasts one to three weeks. This phase can persist 12 or more weeks in a minority of patients who have cholestatic symptoms (e.g., itching, deep jaundice). Fever is rare. Up to 10% of patients experience symptomatic relapse in the six months following acute illness.

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  16. After an incubation period of 40 to 160 days, hepatitis B virus (HBV) concentrations are highest in

    VIRAL HEPATITIS

    After an incubation period of 40 to 160 days, HBV concentrations are highest in the blood and present (but in lower concentrations) in wound exudates, semen, vaginal secretions, and saliva. HBV is efficiently transmitted by percutaneous or mucous membrane exposure to infected blood or body fluids. HBV is more infectious and more stable in the environment than other bloodborne pathogens, including HCV and HIV [1].

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  17. HBV vaccination is recommended for the following unvaccinated persons, EXCEPT:

    VIRAL HEPATITIS

    HBV vaccination is recommended for the following unvaccinated persons [120]:

    • Children and adolescents

    • All adults who are IDUs, MSM, or with multiple sex partners

    • All adults wanting protection from HBV

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  18. Approximately what percentage of persons living with HIV are unaware of their infection?

    HIV/AIDS

    As of 2016, an estimated 1.1 million individuals 13 years of age or older were living with HIV or acquired immune deficiency syndrome (AIDS) in the United States [129]. The CDC estimates that approximately 14% of these individuals are unaware of their infection [129].

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  19. Which of the following types of sexual contact poses the highest risk of HIV infection?

    HIV/AIDS

    Posing the highest risk of infection is unprotected receptive anal intercourse, followed by unprotected receptive vaginal intercourse and unprotected insertive anal intercourse (particularly for uncircumcised men) [134,135]. Risk is reduced through the use of latex condoms. For the wearer, latex condoms provide a mechanical barrier limiting penile exposure to infectious cervical, vaginal, vulvar, or rectal secretions or lesions. Likewise, the partner is protected from infectious pre-ejaculate, semen, and penile lesions. As discussed, natural membrane condoms (made from lamb cecum) contain small pores and do not block HIV passage. It is estimated that latex condom use reduces the risk of HIV transmission by approximately 70% to 80% [136,137,138]. Although abstinence from sexual contact is the sole way to absolutely prevent sexual transmission, sexual activity in a mutually monogamous relationship in which neither partner is HIV-infected and no other risk factors are present is considered safe [139]. However, men who identify publicly as heterosexual and generally have committed relationships with women, but who also engage in sexual activity with other men, may be a transmission bridge to heterosexual women [140]. To better understand the actual extent of this behavior and its impact on HIV transmission, more research is necessary.

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  20. Which of the following patients would be considered a candidate for pre-exposure prophylaxis for HIV?

    HIV/AIDS

    In 2017, the CDC and the U.S. Department of Health and Human Services updated its clinical practice guidelines for pre-exposure prophylaxis for the prevention of HIV infection [145]. This guideline outlines indications for prophylaxis as one prevention option for HIV transmission. The most important first step in determining if an individual is a candidate for pre-exposure prophylaxis is a thorough history, including sexual and injection drug activities. All candidates will be adults without an acute or established HIV diagnosis. Pre-exposure prophylaxis is indicated for high-risk MSM, meaning those who have had any male sex partners in the past six months, are not in a monogamous partnership with a recently tested, HIV-negative man, and have one of the following [145]:

    • Anal sex without condoms (receptive or insertive) in the past six months

    • Any STI diagnosed or reported in the past six months

    • An ongoing sexual relationship with an HIV-positive man

    • High number of sex partners

    • Commercial sex work

    Prophylaxis is also recommended for high-risk heterosexual adults who have had sex with an opposite sex partner(s) in the past six months, are not in a monogamous partnership with a recently tested, HIV-negative partner, and one of the following [145]:

    • Is a man who has sex with both women and men (behaviorally bisexual)

    • Infrequently uses condoms during sex with one or more partners of unknown HIV status who are known to be at substantial risk of HIV infection (IDU or bisexual male partner)

    • Is in an ongoing sexual relationship with an HIV-positive partner

    • Any STI diagnosed or reported in the past six months

    • Commercial sex work

    • In high HIV prevalence area or network

    IDUs are also considered candidates for pre-exposure prophylaxis if they meet certain criteria. The guideline states that persons who have injected drugs not prescribed by a clinician in the past six months may be candidates for prophylaxis if they also are positive for one of the following factors [145]:

    • Any sharing of injection or drug preparation equipment in the past six months

    • Been in a methadone, buprenorphine, or buprenorphine/naloxone treatment program in the past six months

    • Increased risk of sexual acquisition (based on the previously outlined criteria)

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  • Back to Course Home
  • Participation Instructions
    • Review the course material online or in print.
    • Complete the course evaluation.
    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.