Low HIV Risk Does Not Mean NO HIV Risk

3rd January 2019/in HIV & AIDS, STD & HIV /by Miri Yeo

As we approach the year-end festivities and parties, I am reminded of an article published more than 5 years ago on HIV (Human Immunodeficiency Virus) scares amidst getting a needle stick injury from infected blood.
http://news.asiaone.com/News/AsiaOne+News/Singapore/Story/A1Story20110801-292087.html
The story above went that a partygoer had been going to famous clubs and jabbing people with an HIV tainted syringe, presumably of her own blood, to take revenge on them.
The following excerpt reproduced from the AsiaOne article, explains this risk further
Quoting Professor Roy Chan, president of voluntary organization Action for Aids, said it is possible for HIV to be contracted in the way described. But for that to happen, the blood has to be injected within a few hours of it being drawn from the infected person.

“The needle must also penetrate the skin of the victim and reach some blood deposits.
“And it is possible for people who have been exposed to tainted blood to seek post-exposure treatment within the first day or two at a hospital to reduce the risk of contracting the infection,”

Prof Chan told TNP.

What are the odds?

So realistically what are the exact numbers and risk for such exposure? There haven’t been any studies of HIV infected needle transmissions studied outside the healthcare setting but the numbers in a comprehensive study are:

Blood Transfusion – 9250/10000 or 93% risk
Needlestick – 23/10000 or 0.23% risk
Needle sharing – 63/10000 or 0.63% risk

So far there hasn’t been any case reported or recorded, in the world of a successful HIV transmission from a needlestick attack or a needlestick injury outside the healthcare setting

So What about Tattoos or Piercings?

Again through numerous studies, the risk of HIV transmission through tattoos and piercings depend on a number of factors. Mainly the sterilization techniques of the equipment used.
Transmission occurs if the equipment (needles/tattoo gun) were contaminated with blood from a previously tattooed individual who carried HIV. Or even the use of dyes, wiping material (sponges/clothes) contaminated with blood. These are liquid solutions where at room temperature HIV virus may remain for up to 2 weeks
This percentage again is closely associated with the needlestick injury risk of 0.23%. However, repeated use of the needle/tattoo gun for the process does increase the overall risk percentage

What is the take-home message?

Around the world, HIV is a disease that has a stigma in society. And surrounding this stigma is a lot of unknowns and ultimately fear.
Only recently again in 2018 the media picks up on such another case in India where HIV transmission occurred during a blood transfusion.
https://www.channelnewsasia.com/news/asia/pregnant-woman-in-india-contracts-hiv-after-blood-transfusion-in-11063528
The good news is that in Singapore, all blood products are tested and screened by the authorities
If you suspect an episode which could lead to a possible HIV risk – tainted needle, needle attack, transfusion error, do speak to your doctors early to discuss this risk with us. If within 72 hours, there are options such as HIV Post Exposure Prophylaxis (PEP) which can significantly decrease the risk of HIV transmission by more than 90%

Low HIV Risk Doesn’t Mean NO Risk

From all of us at Dr Tan and Partners, stay safe and enjoy your festive season.
Take Care!

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References

Padian N Transmission of HIV Possibly Associated with Exposure of Mucous Membrane to Contaminated Blood.MMWR Morb Mortal Wkly Rep11;46(27): 620-3, July, 1997
Bernard EJ Texas jury concludes saliva of HIV-positive man a “deadly weapon”, sentenced to 35 yrs jail.com, available online at: www.aidsmap.com/page/1430404/, 16 May 2008
Pretty IA et al. Human bites and the risk of human immunodeficiency virus transmission.Am J Forensic Med Pathol. 20(3):232-9, 1999
Gilbart VL Unusual HIV transmissions through blood contact: analysis of cases reported in the United Kingdom to December 1997.Communicable Disease and Public Health 1: 108-13, 1998
Baggaley RF Risk of HIV-1 transmission for parenteral exposure and blood transfusion: a systematic review and meta-analysis.AIDS 20(6): 805-812, 2006
Nishioka SA, Gyorkos TW. Tattoos as risk factors for transfusion- transmitted diseases. International Journal of Infectious Diseases 2001;5(1):27-34.
Messahel A, Musgrove B. Infective complications of tattooing and skin piercing. Journal of Infection and Public Health 2009;2(1):7-13.
Garland SM, Ung L, Vujovic OV, Said JM. Cosmetic tattooing: A potential transmission route for HIV? Australian & New Zealand Journal of Obstetrics & Gynaecolo- gy 2006;46(5):458-9.

Genital Blisters, Genital Warts and Genital Ulcers – Causes & Treatments

24th December 2018/in Herpes, HPV (Human Papilloma Virus), Skin, STD & HIV /by Miri Yeo

Genital blisters, genital warts, genital ulcers – more common than you think but invariably exceedingly distressing for the person suffering from them. Today we talk a little about the various causes for the above genital skin conditions.
Genital lumps, bumps and sores can be an alarming phenomenon for anyone. One day you notice a tiny little bump, or perhaps several bumps.
Now you’re not sure when they appeared – was your skin normal last week, or did you just never notice the bumps for a good duration? Or perhaps you notice what you thought was a little pimple or an ingrown hair follicle which happens from time to time because you shave. But now it’s burst, leaving a painful raw ulcer.

What are the Causes of Genital Blisters, Genital Warts and Genital Ulcers?

1) What are the Causes of Genital Blisters?

Genital blisters are small, fluid-filled bumps and can occur anywhere over the genital region.

a) Genital Herpes

One of the classic causes of genital blisters is genital Herpes, caused by the Herpes Simplex Virus.
Here’s a video about Herpes

Genital herpes has Several Stages:
Stage 1: Prodrome – the skin appears normal but you may feel an unusual sensation like a tingling or itching. This indicates that the virus is active and heralds an impending outbreak
Stage 2: Redness – you may notice some nonspecific red spots which may be uncomfortable or slightly painful.
Stage 3: Blisters – this is usually when people realise something is not right, Initially, these may resemble tiny pimples. They then grow in size and become fluid-filled and painful.
Stage 4: Ulcers – the blisters burst, leaving shallow, painful ulcers
Stage 5: Scabbing or crusting – a scab or crust forms over the ulcer, which eventually heals
Also, check out What is Oral Herpes & Cold Sore

b) Balanitis

In males, balanitis may sometimes present with tiny blisters. The term “balanitis” is a descriptive term which means inflammation of the head of the penis and foreskin. This usually manifests as skin redness, with some tiny blisters or whitish bumps, as well as possible itching/pain or discomfort.
There can be multiple causes of balanitis. The skin on the penis is no different from skin elsewhere on your body and redness, discomfort and irritation can be caused by many factors:

Infections such as fungal skin infections
Skin irritation caused by external factors like soaps (irritant or contact dermatitis)
Mechanical trauma in the form of excessive friction e.g. masturbation or sexual intercourse with insufficient lubrication
Poor hygiene
Sensitive skin e.g. in people prone to eczema or dry skin

Depending on the possible underlying trigger or cause, various topical creams may be useful. In some cases, skin swab tests or urine tests may be useful in checking for underlying infections.
Read more about What is a Penile Infection?

2) What are the Causes of Genital Warts?

a) Human Papilloma Virus

This is THE cause of genital warts. Genital warts are skin coloured, fleshy bumps which may occur singly or in clusters around the genital and anal region. They can range from tiny firm bumps to larger, irregular shaped bumps which are classically described as “cauliflower-like” in appearance.
The Human Papilloma Virus (HPV) is a sexually transmitted viral infection. There are many strains of HPV and they are transmitted through sexual contact. Some strains are responsible for genital warts, while other “high risk” strains can lead to an increased risk of cancers such as cervical, oral and anal cancers.
If you have warts, it effectively means you have been infected by at least one strain of HPV. If you are female and you are not already doing your regular PAP smear for cervical cancer, you should do a PAP smear with high risk HPV testing because an individual may have not just one but several strains of HPV. You can read more about PAP smears and cervical cancer screening.
There are various methods available for the treatment of genital warts, ranging from topical medications to freezing or cryosurgery electrosurgery. But one must be prepared that warts can unfortunately recur as the treatment for warts addresses the effects of a HPV infection but does not clear the virus from your body.
The best defence we have against genital warts is the HPV vaccine – Gardasil 9, which provides immunity against certain wart causing strains of HPV.

3) What are the Causes of Genital Ulcers?

When people think of genital ulcers, often the first few causes that spring to mind may be herpes or syphilis. However, genital ulcers can be due to other infections as well as rarer, non-infective causes such as autoimmune diseases.
This is why various tests are useful in differentiating the causes of genital ulcers. The treatment of choice varies drastically depending on what the underlying cause is.
Caused by Sexually transmitted infections (STIs)

Herpes Simplex Virus (Common)
Syphilis (Common)
Chancroid (Rare)
LGV (Rare)
Donovanosis (Rare)

Non-infective causes

Behcet’s (Autoimmune)
Crohn’s disease (Autoimmune)
Fixed drug eruption (rare causes)
Skin Cancer (rare causes)

a) Herpes Simplex Virus

(Painful shallow ulcers and blisters)

As mentioned earlier, both genital blisters and ulcers are different stages of a herpetic flare. A genital skin swab test for the presence of HSV DNA is helpful in confirming HSV as the cause of genital ulcers.

b) Syphilis

(Painless ulcers)

Syphilis can cause ulcers both during its primary and secondary stages. A chancre, a painless round ulcer, occurs in primary syphilis, while in secondary syphilis, multiple painless ulcers may occur as well. One of the defining traits of a syphilitic ulcer is its painlessness.
These ulcers may be accompanied by other symptoms such as a rash elsewhere on the body.

C) Chancroid

(Multiple painful deep ulcers and swollen groin lymph nodes)
Chancroid is a painful ulcer which is frequently associated with enlarged and painful inguinal (groin) lymph nodes. These are located along your underwear line and may be felt as tender swollen lumps. There are usually several or multiple deep and painful ulcers.
This is caused by a bacterium called Hemophilus ducreyi, which is transmitted through sexual contact. Painful lymph nodes and negative test results for both Herpes and syphilis support this diagnosis. The good news is that antibiotic treatment can clear this up.

Lymphogranuloma venereum (LGV)

Small ulcer, swollen groin lymph nodes, possible rectal pain

Lymphogranuloma venereum (LGV) is an uncommon cause of genital ulcers. It is caused by the bacterium called Chlamydia trachomatis (serovars L1-3). This Chlamydia is different from the “subtype” of Chlamydia trachomat is that causes the common STD you are thinking about. A Rapid Chlamydia & Gonorrhoea PCR test will be about to detect the infection.
The ulcer it causes tends to be small and often goes unnoticed. The lymph node swelling is dramatic and painful and may even discharge pus.
If this was acquired through anal intercourse, inflammation of the anal and rectal canal (known as “proctitis”) can occur, causing rectal pain, bleeding and discharge and diarrhoea.

Donovanosis

Shallow beefy looking ulcers

This is again a rare cause of genital ulcers in the developed world. It is caused by a bacterium called Klebsiella granulomatis and causes shallow ulcers which may bleed easily. This is usually diagnosed with a punch biopsy, which is when a sample of skin tissue is removed for evaluation in the lab.

Other rare causes:

Autoimmune or inflammatory causes, skin cancers, drug reactions

“Autoimmune” diseases occur when your body’s immune system has a tendency to attack itself and one of the many manifestations can be genital ulcers. These are rare and treatment is by a specialist doctor. These ulcers will go away only with good control of the underlying disease.
Sometimes, a bad reaction to a certain medication may cause a persistent, painful ulcer.
Very rarely, genital ulcers may be due to cancer.

All in All

The good news is that most of the above mentioned causes for genital blisters, warts and ulcers can be treated. But an even better step would be to protect yourself from even developing these – safe sexual practices (using barrier protection, doing your regular sexual health screening, and getting the HPV vaccine) are your best bet against these.
Take Care!

10 Common HIV-related Opportunistic Infections

24th December 2018/in HIV & AIDS, People Living with HIV, STD & HIV /by Miri Yeo

In late-stage HIV infection, the virus would have spread through the body and attacked the immune system for many years without treatment. On blood tests, the number of viral copies, or viral load (VL), will be very high, while the CD4 cells of the immune system would be very low.
When the immune system is in this weakened state, it is much easier for certain pathogens (bacterial, viral, fungal etc.) to invade and cause an infection – these types of infections are called Opportunistic Infections (OI’s). Sometimes, these infections can cause certain types of cells to become cancerous, and these are also classified as Opportunistic Infections.

What is an Opportunistic Infection?

In a healthy and normal functioning immune system, these pathogens do not usually cause infection, or they may cause very mild disease. Apart from advanced HIV infection, Opportunistic Infections may affect people who are on chemotherapy for cancer, immunosuppression for autoimmune diseases or post-organ transplant, among other conditions.
In HIV, many of these Opportunistic Infections are what we also term as “AIDS-defining illnesses” – that is, if these infections are found in someone who has HIV, we would classify them as having AIDS (Acquired Immunodeficiency Syndrome). Many of the symptoms and signs of late-stage HIV infection are due to these Opportunistic Infections rather than directly from the virus itself.

What is HIV Treatment?

HIV treatment and management consists of taking a set of correct HIV medicines to delay the control HIV, monitoring for and treating any opportunistic infections, and taking care of the patient’s general health and well being.

What are the most common Opportunistic Infections?

This is a list of some of the most common HIV-related opportunistic infections:

1) Candidiasis (Esophageal, Tracheal, Bronchial)

Also known as thrush, candida is a very common fungal organism that is found almost everywhere in the environment and can be isolated from around 30-50% of healthy people. Most of the time, it does not cause any symptoms of infection; however, in people with HIV, there can be invasive candida overgrowth in the esophagus and airways. It is often the first sign of a weakened immune system in previously undiagnosed individuals.

2) Cryptococcosis

Caused by the fungus cryptococcus neoformans, this can infect any part of the body, but most commonly will invade the lungs (pneumonia) or the brain (abscesses).

3) Cytomegalovirus (CMV)

Caused by an intracellular virus, this infection can cause inflammation of the brain, lungs, intestines, and eyes. CMV retinitis of the eye is sight-threatening and should be treated as a medical emergency.

4) Herpes Simplex Virus (HSV)

Another common virus, Herpes Simplex Virus (HSV) can cause symptoms in people with a normal immune system as well – usually cold sores or blisters around the mouth, genital region or anus.
However, in people with a weak immune system, outbreaks tend to be more frequent, severe, and prolonged in duration, and can also invade the lungs and esophagus.

5) Mycobacterium Tuberculosis (TB) & other Mycobacterial infection

Tuberculosis (TB) would most commonly affect the lungs, but may also spread to lymph nodes, brain, kidneys, or bones. Symptoms of TB include recurrent fever, night sweats, chronic cough, and weight loss. Other mycobacteria are very commonly found in soil and around the environment, and very rarely would cause problems in healthy individuals; as Opportunistic Infections, they will usually affect the lungs but can spread throughout the body.

6) Pneumocystis Carinii Pneumonia (PCP)

Caused by a fungus pneumocystis carinii, now renamed as pneumocystis jirovecii, this infection is commonly one of the first signs of a late-stage HIV infection. Symptoms would include shortness of breath on exertion, dry cough, and high fever, and if left untreated can be deadly.

7) Salmonella septicemia

Salmonella is a common bacteria that is usually found in contaminated food or water. In healthy individuals, this may cause an acute ‘food poisoning’ with vomiting, diarrhoea, and sometimes fever. However, salmonella as an Opportunistic Infection can spread throughout the body and cause septicemia, or blood poisoning, leading to multi-organ failure and death.

8) Toxoplasmosis

This is caused by a parasite called toxoplasma gondii, which is found in the faeces of certain animals (normally cats, rodents, and birds), and can be found in undercooked red meat such as pork. It can cause infection of the lungs, eyes, liver, and brain.

9) Kaposi’s Sarcoma (KS)

This is a type of abnormal growth/tumor of connective tissue – more specifically, of the capillaries (small blood vessels). It can occur anywhere in the body, but if it arises on the skin or mucous membranes, KS will usually appear as firm reddish or purplish lumps. The cancerous changes in the cells are a result of infection by human herpesvirus 8 (HHV8),

10) Invasive cervical cancer

This is a cancer of the cervix, which is the neck of the womb, or uterus. Malignant changes can occur after infection with certain types of human papillomavirus (HPV), and all women (HIV or not) should be screened regularly with pap smears and HPV testing. It is also recommended to get the HPV vaccine (Gardasil 9), to prevent HPV infection, cervical cancer, and genital warts.

How can Opportunistic Infections be prevented?

As these infections only occur in people with a weakened immune system, the most important way to prevent them would be to treat the underlying HIV infection. Highly Active Antiretroviral Treatment (HAART) is very effective at treating HIV and ensuring the virus is adequately suppressed. With a low or undetectable viral load, the body’s immune system has time to recover – and when the CD4 cells have returned to sufficient numbers, the risk of Opportunistic Infections is lowered drastically. The earlier an HIV infection is diagnosed, the earlier treatment can be started and the better the chances of avoiding Opportunistic Infections.
For patients who are diagnosed with HIV later and have low CD4 counts at diagnosis (<500), it is important to consider Opportunistic Infections prophylaxis while we are waiting for HAART to work. This means starting patients on certain medications (e.g. antibiotics, antifungals, and/or antivirals) to prevent some of these specific infections. It may take 6-12 months for the CD4 counts to recover once HAART has been initiated; once the CD4 counts are improved, these prophylactic medications may be stopped.
Other general advice for people living with HIV would include:

Reducing or preventing exposure to other sexually transmitted infections
Getting vaccinated (e.g. HPV vaccine, annual flu vaccine, pneumococcal vaccine, etc.)
Avoiding undercooked or raw foods (including eggs, meat, unpasteurized milks and cheeses, etc.)
Avoid drinking untreated water
Speak to your doctor about any other changes that may need to be made at home, work, or when on vacation to reduce exposure to OI’s

Take Care!

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What are the Signs & Symptoms of HIV / AIDS

19th December 2018/in HIV & AIDS, STD & HIV /by Miri Yeo

Human Immunodeficiency Virus (HIV) is a virus that can be spread through sexual contact, contaminated needles, blood transfusions, and other infected body fluids. It targets the immune system, specifically CD4 cells, and if left undiagnosed and untreated, can overwhelm the immune system and cause life-threatening complications.
HIV symptoms can appear at different times for different people, and some may not recall having any symptoms at all until diagnosis (which can be many years after the initial infection).

What are the Different Stages of HIV Infection?

HIV infection occurs in three main stages:

Acute HIV Infection,
Chronic HIV Infection (Clinical Latency Stage),
and Late-Stage HIV or AIDS (Acquired Immunodeficiency Syndrome).

HIV symptoms may vary depending on the individual and the stage of infection, and some people may not have any HIV symptoms at all.

1) Acute HIV Infection

Within the first 2-4 weeks after initial infection, the virus replicates very quickly and HIV viral load will reach a high level. People may experience flu-like symptoms, which they may describe as ‘the worst flu ever’.
This is known as Acute Retroviral Syndrome or ARS. These acute HIV symptoms may occur in about 70-80% of people.
Acute Retroviral Syndrome ARS / HIV Symptoms may include:

Fever
Night sweats
Swollen glands
Sore throat
Body rash
Fatigue
Body aches
Headache
Nausea and vomiting
Diarrhea

Acute HIV symptoms can last between several days to several weeks, until the body can develop HIV antibodies to fight the virus. This is also the stage of the greatest infectious risk to others as the HIV viral load is very high. However, do remember that these symptoms are seen in other common conditions as well, and you shouldn’t assume you have HIV just because you experienced them.
If you are concerned about any symptoms or potential exposure, it is best to see a doctor to have them evaluated and consider HIV testing.

Different HIV tests are able to detect the infection at different times

The earliest you may be able to detect the virus is with HIV DNA/RNA PCR testing, which can be accurate from 10-12 days post-exposure. Other more common tests would be the 4th Generation HIV p24 Antigen/Antibody test, which is considered conclusive from 28 days post-exposure.
If you have had a potentially risky exposure within the last 72 hours, you can consider a course of medication called HIV Post-Exposure Prophylaxis (HIV PEP). This works to prevent the virus from replicating and taking hold in the body, and can reduce risk of transmission by more than 90%. It is only effective if started within 72 hours.

2) Chronic HIV Infection

After the early stage of acute HIV infection, the disease enters into a clinical latency stage, where the virus is developing in the body, but no symptoms are seen. During this time, the virus is still active but will replicate slowly inside the cells – it can still be transmitted to others, but the risks of transmission are lower than during the acute phase.
If you have been diagnosed with HIV and are on HIV antiretroviral treatment (HAART), the virus is often kept under control and you may experience a symptom-free period that can last decades. If the virus can be suppressed to undetectable viral load levels, we would deem the risk of transmission extremely low. This stage of HIV infection can last for 5-10 years.
If you have HIV but are not on treatment, then it will eventually progress to late stage infection, known as AIDS.

3) AIDS (Acquired Immunodeficiency Syndrome)

Late Stage HIV / AIDS (Acquired Immunodeficiency Syndrome)
If you have HIV but are not on antiretroviral treatment, it will eventually weaken your immune system and progress to AIDS, or Acquired Immunodeficiency Syndrome.
Symptoms or signs of late stage HIV / AIDS may include:

Rapid weight loss
Recurring fever
Profuse night sweats
Extreme tiredness
Swollen glands
Persistent diarrhea
Mouth or genital sores and ulcers
Fungal infections, especially oral thrush
Shortness of breath, lung infections (e.g. PCP)
Memory loss, limb weakness and other neurological disorders
Mucous membrane and skin rashes and lesions (patches of reddish-purplish lesions may be characteristic of Kaposi sarcoma)

Many of these signs and symptoms in AIDS are due to Opportunistic Infections (OI’s), which are organisms that usually only cause infections in people with a weak immune system. People with normal functioning immune systems will typically be able to fight these types of infections off, or suppress them so they do not manifest with significant symptoms.
Common types of OI’s include candidiasis (thrush), pneumocystis carinii pneumonia (PCP), tuberculosis (TB), and salmonella colitis infection, among many others.
In someone who is diagnosed with late-stage HIV and whose CD4 cell count is found to be very low, doctors will usually start on certain medications such as antifungals or antibiotics to prevent these OI’s; they will be kept on these medications as prophylaxis, while they are taking their regular HIV medications, until their CD4 count is high enough (indicating their immune system is strong enough to fight off these infections by itself).
Even if you experience the previously mentioned symptoms, it is impossible to confirm HIV infection unless you get tested. If you are concerned about a possible exposure, please visit our clinics for a consultation and evaluation.
Take Care!

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Syphilis Symptoms & Treatment (Painless STD Sores and Rashes)

17th December 2018/in STD & HIV, Syphilis /by Miri Yeo

What is syphilis?

Syphilis is a sexually transmitted infection (STD) with many different manifestations and potentially serious complications. It is caused by a bacteria called “Treponema pallidum”.
In the past, before the advent of antibiotics, syphilis was considered a dangerous illness with long-term, devastating consequences which could even affect the brain and nerves.
Thankfully, with the development of penicillin antibiotics and lab tests to detect syphilis infection early, modern medicine is now well equipped to diagnose, treat and cure syphilis well before complications can set in.

Syphilis – Still a Real and Relevant Infection Today

As of recent years though, there has been a rise in syphilis cases amongst both heterosexuals as well as homosexual couples, as reported by the Centers for Diseases Control (CDC), a reminder that syphilis remains a very real infection concern that any sexually active individual should be aware of.
Syphilis is transmitted by direct contact with a syphilis sore, which is a painless ulcer known as a “chancre”. These chancres can occur both in the mouth/oral cavity or in the genital region and the rectum. Sexual contact in the form or oral, vaginal or anal intercourse can all spread syphilis. If a pregnant mother has syphilis, she can also transmit it to her unborn child.

What are the symptoms and different stages of syphilis?

Reading about syphilis can be confusing because it is an infection with different stages and a multitude of varied symptoms.
But to simplify things, there are three stages of syphilis: primary, secondary and tertiary.

Primary Syphilis Symptoms

(usually begins a few weeks up to 3 months from infection)

a.) Syphilis Symptoms: Chancres

Painless, round ulcer
usually single – occurring at the site where the infection enters the body which is usually in the genital, anal or oral region
lasts between 3 – 8 weeks

Note that chancres will heal by themselves and disappearance of the chancre does not mean the infection is gone!

Secondary syphilis

(months or more after initial infection)

b.) Syphilis Symptoms: Rashes

Syphilis is known in the medical world as “the Great Mimicker” – so keep in mind that the rash it causes may look very different from what you see in photos!
The classic rash is a brownish rash over the palms and soles but syphilis can also cause a rash anywhere over the body
May range from very faint rashes to obvious reddish patches
Generally not itchy
Can occur anytime from when the initial chancre is healing to weeks after
May come and go

c.) Snail track ulcers

Raw reddish ulcers in the mouth and genital region

d.) Condylomata Lata

Raised, greyish patches that occur in moist regions of the body like the groin, armpits

e.) Nonspecific symptoms

Fever
Enlarged lymph nodes
A sore throat

Tertiary syphilis

(occurs decades after initial infection)

Tertiary syphilis is now fairly rare as most cases are detected and treated before they progress to this. Symptoms depend on the organs affected by syphilis

NOTES:
Someone with syphilis can also feel entirely well and not have any symptoms- this is known as latent syphilis. If the infection was acquired within the last year, it is considered early latent syphilis, but if it occurred more than a year ago, then it is considered late latent syphilis.
Syphilis can affect the eyes and nerves during any stage of infection. This can result in a variety of symptoms including vision problems, abnormal body movements and even early dementia or memory problems.

What Does a Syphilis Test Do

Who should test for syphilis and what tests are done to diagnose syphilis?

You should test for syphilis…

If you have had sexual contact with someone with known syphilis
If you have symptoms suspicious for syphilis
As part of your regular STD screening if you have an active sex life and have had partners whose infection status you are unsure of

Diagnosis of a syphilis infection is done through a blood test which looks for antibodies to syphilis. Syphilis blood tests can be a little complex and your doctor will be able to explain more to you about the interpretation of results and what to look out for.

What Treatment is Available for Syphilis?

Syphilis infections are treated with penicillin which is administered as an injection. The dosage or number of injections required depends on the stage of the infection.
In unfortunate cases where the infection fails to clear up with initial treatment (which is known as treatment failure), then additional antibiotics may be required for a longer duration of time.
In order to determine if treatment is successful, as well as to monitor for recurrence of the syphilis infection, regular blood tests at intervals of a few months may be required. Until one is clear of syphilis, it is best to abstain from the sexual activity so as to minimise the risk of transmitting the infection to others.
Syphilis remains a problem in the present day, but while it is a potentially serious infection, the good news is that with early diagnosis, the frightening complications that occur with untreated syphilis can very easily be prevented.

Take Care!

What is the Treatment for Cold Sores? What Causes Cold Sores?

16th December 2018/in General Health, STD & HIV /by Miri Yeo

What exactly is a cold sore?
You have probably heard of cold sores or even have had one at some point in your life. But perhaps you’re not entirely sure of what it is caused by and what else you may need to be concerned about.
A cold sore is a small, painful, fluid-filled blister that most commonly occurs near the mouth or on the face, although it may infrequently appear elsewhere on the body. Cold sores tend to occur in clusters. The appearance of a cold sore is sometimes preceded by an unusual tingling or itching sensation over the same area.
The blisters then form and eventually burst, leaving shallow ulcers/open sores which scab over, forming a crusty lesion. They may come and go, with each flare lasting up to a few weeks.

What Causes Cold Sores?

Cold sores are caused by the Herpes Simplex Virus
There are two types of Herpes Simplex Viruses (HSV) – Type 1 and Type 2.
Cold sores are caused by the Herpes Simplex Virus (Type 1), and genital sores are caused by the Herpes Simplex Virus (Type 2).

Herpes Simplex Viruses (Type 1)

HSV-1 usually causes cold sores, while HSV-2 tends to be responsible for genital sores. HSV-1 is extremely common in the general population, with the World Health Organisation (WHO) estimating 3.7 billion people under the age of 50 have HSV-1 globally.
Herpes Simplex Viruses (HSV) is transmitted through body secretions.
HSV-1 can be transmitted through saliva via kissing, or sharing of utensils (oral-to-oral transmission), but oral-to-genital secretion can also occur through oral intercourse. This means that someone with cold sores can transmit HSV-1 to their partner’s genitals, resulting in genital sores. An STD Screening can screen for both herpes simplex viruses.
Individuals with HSV are most contagious when they have cold sores, but can still be infectious even when they have no sores or blisters.
Here’s a video about Herpes

Unfortunately, HSV infections are lifelong – meaning there is no cure for HSV and once infected a person carries the virus for life.
This is the reason why cold sores can flare up from time to time. There are certain triggers that can set off an outbreak of cold sores- for instance, environmental factors such as sunlight and cold temperatures, or anything which weakens your immune system, such as an illness, or medications which suppress your immunity.

What is the Treatment for Cold Sores?

Antivirals can help clear up and keep cold sores away.
While there is no cure for HSV, the good news is that anti-viral medications (treatment for cold sores) are extremely effective in suppressing the virus and can be used to treat an outbreak of cold sores, and even prevent or minimise future outbreaks.
Some people may not be significantly bothered by their cold sores, which flare up only occasionally and go away by themselves. However, if you are troubled by your symptoms and worried about transmission of the virus to people around you during a flare, anti-virals such as acyclovir or valacyclovir are available as both oral tablets and topical creams.
Sometimes, just the topical cream (treatment for cold sores) may be enough to address your cold sores but if they fail to respond or if your flare is particularly bad, your doctor may prescribe a short course of tablets on top of the cream.
If you are someone who experiences frequent and painful outbreaks of cold sores, or if you are concerned about transmitting the virus to your loved ones, then suppressive anti-viral therapy may be a good option for you. This is when you take the anti-viral medication on a daily basis in order to achieve continued suppression of the virus just like HIV treatment. This not only stops flares from occurring but also reduces your infectivity and the risk of transmitting HSV to others.
Now that you know a little more about, the cause of and, the treatment for cold sores, hopefully, this has helped you realise that you do not need to live with intermittent painful outbreaks. There are treatment options available in our clinics, so if this is an issue which has been troubling you, then it’s time to make that a thing of the past.
Take Care!

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Cervical Cancer, Pap Smear & HPV Vaccination – What You Need To Know

30th November 2018/in Cancer, Genital Warts, STD & HIV, Women's Health /by Miri Yeo

What is Pap Smear?

Pap smear is a cervical cancer screening recommended every 3 years for all sexually active females starting from age 25 years old.

This is a quick, simple and painless procedure that can be done in the clinic and it only takes a few minutes. A brush will be used to collect some cells from the neck of the womb (cervix) and it will be sent to the lab to identify any precancerous and cancerous cells.

Cervical Cancer

In Singapore, cervical cancer is the 3rd leading cause of cancer deaths in women age 15-44 years old.
Cervical cancer risk is increased with :

Multiple sexual partners
Human papillomavirus (HPV) infection
Smoking
Unprotected sex

What is Human papillomavirus (HPV)?

Human papillomavirus (HPV) is one of the commonest sexually transmitted infection. It can affect both men and women.
There are 2 types of HPV – the low risk and high-risk types.

Low-risk HPV can cause genital warts in both female and males. These are flesh coloured growths on the genitals, and they are infectious.
High-risk HPV plays a significant role in the increased risk of cancer, such as cancer of the cervix, vulva, and vagina in women as well as anal cancer in men who have sex with men (MSM)..

The American College Obstetrician and Gynaecologist (ACOG) strongly recommends co-testing using Pap smear and HPV DNA testing (high-risk HPV types) especially for women ages 30-65 years old.
Patients are advised to repeat these tests in 5 years if pap smear and HPV results are negative.
This allows patients to extend their screening interval.

However, for women who test positive for high-risk HPV types, this means their risk is increased and hence, may need to have Pap smear screening at a closer interval, i.e once a year and depending on the results of the pap smear, some may need a referral to a gynaecologist for early intervention.

Remember, women can have no symptoms with an abnormal pap smear and HPV infection. Hence, early detection and screening are crucial as early intervention can be life-saving. Symptoms such as bleeding and pain during sex (postcoital bleeding), bleeding in between periods, heavy vaginal bleeding, and bleeding after menopause are usually late signs of cervical cancer.

The good news is cervical cancer can be prevented through vaccination.

GARDASIL 9 is a vaccine that helps protect against Human Papillomavirus (HPV). Most people infected with HPV show no signs or symptoms, this means they can transmit the HPV virus to others without knowing it in any kind of sexual activity or skin to skin contact.

Gardasil 9 provides protection against 9 major strains of HPV, which includes HPV types 6,11,16,18,31,33,45, 52 and 58 which are responsible up to 90% of genital warts and cervical cancers or precancer changes.

The vaccine, however, does not treat the infection.

It can be given to both females and males from the age of 9 up to 45 years old.
From the age of 9-14 years, 2 doses 6 months apart is recommended while those age 15 onwards, 3 doses will be recommended according to the schedule of 0, 2 and 6 months.
The side effects post vaccination is usually mild and temporary including pain, swelling, bruising over injections site and very rarely may cause fever and nausea.
HPV vaccine reduces your risk significantly but it does not mean your risk becomes zero.

After the completion of HPV vaccination, all women who are sexually active and above the age of 25 should still undergo routine screening via pap smear.

Take Care!

HIV PrEP for Travel – Things You Need to Know

26th November 2018/in STD & HIV, Travel Health /by Miri Yeo

What is HIV PrEP?

Use of oral anti-retroviral drugs by HIV-uninfected people to block the acquisition of HIV before exposure to HIV.

Why HIV PrEP?

Many trials have been conducted to determine the effectiveness of oral HIV PrEP across couples of all orientations. When patients follow the treatment and prevention strategies closely, significant prevention of HIV levels was achieved
In 2014, WHO (World Health Organisation) developed consolidated HIV guidelines for key populations, including men who have sex with men, sex workers, transgender people. In those guidelines, HIV PrEP was strongly recommended for men who have sex with men (MSM).⁶
During travel, the risk of acquiring HIV is the result of a change of HIV prevalence at the destination, and more importantly the change of sexual behaviour abroad and the increase of risk-taking behaviour. Studies have shown that amongst the MSM community, awareness of a special form of PrEP use, often described as “holiday PrEP” is becoming increasingly popular. This holds true even for MSM who do not consider themselves to be at high risk for HIV.⁷

How?

Prior to starting PrEP, your doctor will do blood tests to monitor your kidney and liver function, a full STI screen if you have not had one recently and also an HIV test.
Subsequently when on PrEP, your renal function will be monitored every quarter. Long-term PrEP use will also require monitoring of your bone density.

When?

How you take your PrEP depends on¹⁰:

how far in advance you plan on having sex
how regularly you have sex.

It does not necessarily depend on how much sex you have.

There are 4 Different Ways to Use HIV PrEP

There are 4 different ways to take PrEP, we discuss this further below:

1. Daily PrEP

Daily PrEP Regimen:

Lead in time 7 days.
Taken daily at the same time +/- a few hours ok

Type:

Anal, Vaginal/Frontal sex

Considerations:

Can be taken any time of the day with or without food
In the event a pill is missed, adequate protection is still conferred.

2. On-Demand PrEP (Event-Based Dosing)

On-Demand PrEP Regimen:
Planned condom-less sex 24 hours in advance:
Strictly:

take 2 pills 2 – 24 hours before sex
take 1 pill on the day of sex
take 1 pill 24 hours later

If having sex for an extended period of time, perhaps over a few days or a weekend, continue to take a pill every 24 hours until you have 2 sex-free days.

The regime requires the patient to take 2 tablets of the HIV PrEP medicine between 2 to 24 hours prior to the event followed by 1 tablet 24 hours after the initial dose and a final tablet 48 hours after the initial dose. Medical studies show that the protection provided against HIV for this regime is not as good as if the medicine is taken daily.
Furthermore, thus the regime is more complex and therefore increases the risk of the patient taking the wrong amount of medicine at the wrong time.

Type:

Only for Anal sex
More studies required to show effectiveness in Vaginal/Frontal sex

Considerations:

This option is not recommended if you have an active hepatitis B infection. The drugs in PrEP also suppress the hepatitis B virus and so starting and stopping PrEP can cause viral flare-ups and liver inflammation.

3. Ts and Ss (Tues, Thurs, Sat, Sun dosing)

Ts and Ss Regimen:

Daily dosing for 7 days,
then dropping down to 4 pills per week on Tues/Thurs/Sat/Sun

Type:

Only for Anal sex
More studies required to show effectiveness in Vaginal/Frontal sex

Considerations:

If you only have sex once or twice a month, you might not want to take a pill every day.
4 pills per week will maintain a good baseline of the drug in your system and you can choose to increase up to daily 7 pills per week when you know you’re in a more sexually active period.
Some people using PrEP On Demand find that they might be taking 4 pills per week most weeks of the month and so opt for structuring this into the Ts and Ss instead.

4. Holiday PrEP

Holiday PrEP Regimen:

PrEP before a pre-planned block of time when your risk of exposure to HIV will be higher due to:
- an increased number of partners of unknown HIV status
- situations where condoms are not easily or always used
- where alcohol or substances might be used
- having sex while travelling to a country with a high HIV prevalence
Based on a 7-day period we recommend 7-7-7:
- 7 days daily dosing before the period
- 7 days daily dosing during the period (or for as long as the specific period lasts)
- 7 days daily dosing after the period.

Type:

Anal, Vaginal/Frontal sex

Considerations:

7 days of PrEP before and after your last sexual encounter for several reasons:
- 7 days lead-in provides adequate levels for both anal and vaginal or frontal sex.
- 7 days lead in before the holiday or travel will allow the body to adjust to any possible side effects, most people do not experience any and these should have subsided within a week.

Worry Less, Worry Free!
PrEP is an ‘opt-in’ treatment – it is not meant to be taken forever.
Trying to stay HIV negative during the holiday or trip result in an anxious and stressful experience.
Your peace of mind and release from this stress and anxiety is important so that you can enjoy the moments that matter with your partner!
Safe Trip and Have Fun!
This article was written by Dr Tan & Partners, in collaboration with Oogachaga.

References

Vivancos R, Abubakar I, Hunter PR. Foreign travel, casual sex, and sexually transmitted infections: systematic review and meta-analysis. International Journal of Infectious Diseases. 2010;14(10):e842–51.
Svensson P.,et al. A meta-analysis and systematic literature review of factors associated with sexual risk-taking during international travel. Travel Medicine and Infectious Disease. 2018; Jul – Aug;24:65-88
https://wwwnc.cdc.gov/travel/page/std
https://www.fitfortravel.nhs.uk/advice/general-travel-health-advice/sexual-health-risks
Riddell Jt, Amico KR, Mayer KH. HIV Preexposure Prophylaxis: A Review. Jama. 2018;319(12):1261-8.
WHO Guidelines Approved by the Guidelines Review Committee. Guideline on When to Start Antiretroviral Therapy and on Pre-Exposure Prophylaxis for HIV. Geneva: World Health Organization Copyright (c) World Health Organization 2015.; 2015.
Elsesser SA, Oldenburg CE, Biello KB, Mimiaga MJ, Safren SA, Egan JE, et al. Seasons of Risk: Anticipated Behavior on Vacation and Interest in Episodic Antiretroviral Pre-exposure Prophylaxis (PrEP) Among a Large National Sample of U.S. Men Who have Sex with Men (MSM). AIDS and behavior. 2016;20(7):1400-7.
Brett-Major DM, Scott PT, Crowell TA, Polyak CS, Modjarrad K, Robb ML, et al. Are you PEPped and PrEPped for travel? Risk mitigation of HIV infection for travelers. Tropical diseases, travel medicine and vaccines. 2016;2:25
Hampel B, Reinacher M, Fehr JS, HIV pre-exposure prophylaxis (PrEP): Is it time to rethink HIV prevention in travelers?, Travel Medicine and Infectious Disease (2018), doi: 10.1016/j.tmaid.2018.06.008
https://www.iwantprepnow.co.uk/how-to-take-prep/

Top Travel Tips for Persons Living With HIV (PLHIV)

22nd November 2018/in STD & HIV, Travel Health /by Miri Yeo

Planning for a long Vacation or Preparing for a Business trip? The travel preparation can sometimes be challenging for People Living with HIV (PLHIV).
Making sure there is enough medication. Making sure you get the correct travel vaccine or visiting the doctor to get prescription (just in case you might be questioned during immigration check)

Travel Tips For Travelling with HIV (B.R.A.V.E)

B for Board, Bottle

Carry Your HIV Medication with You on Board
Carry your HIV medications with you on Board rather than checking them in and have a memo from the prescribing doctor’s memo with you.

Carry Your Doctor’s Memo with You
The contents of the memo should confirm that the medication is necessary during the trip. It does not need to discuss HIV and can state the medications are for a chronic medical condition and for personal use.

Use Medication’s Original Packet or Bottle
It is also advisable to have the medication’s original packet/ Bottle, showing the name of the person carrying the medication and medication details.

R for Reveal, Reiterate

You Don’t Need to Discuss Your HIV Status!
When crossing international borders, one might be questioned on the medication carried. Preparing for these questions can facilitate an easier border crossing experience. HIV need not be discussed or Revealed and that these medications are for a chronic health problem can be Reiterated.

A for Adjust, Avoid, Anonymous Testing, Advice

Adjusting Your Dose Timing
Discuss with your doctor dose timing adjustments when travelling across different time zones. Medication can usually be taken one or two hours later for a number of days until the timing fits with the destination country. The process should be reversed on return.

Avoid Missing Your Medication Dose
Missing medication doses should be avoided at all cost. Treatment breaks should be avoided unless discussed with your doctor.

Advice, Anonymous testing
If you are travelling in and out of Singapore and need advice on HIV treatment or testing, At DTAP, we provide a safe and discreet environment for testing. You can find out more about Anonymous HIV Testing.

V for Vaccinations

General principles for vaccination of PLHIV as follows:

Killed or inactivated vaccines do not represent a danger to immunocompromised people and generally should be administered as recommended for other people.
Live-virus or live-bacteria vaccines such as BCG, oral poliovirus, typhoid (Ty21a), varicella, Yellow fever should be avoided unless the benefits outweigh the cons

The main vaccinations we recommend for PLHIV besides the country-specific vaccinations are.

HPV Vaccination
Hepatitis A
Hepatitis B
Influenza
Pneumococcal
Meningococcal

E for Extra Medication

Bring Extra Medication
It is imperative to bring enough medication and slightly more for a few days as getting a prescription or purchasing your medications in a foreign country may not always be possible. Furthermore, there is no way to ascertain whether the purchased medication might be of the same quality, type and efficacy.

If you are travelling with a partner/s who are not HIV positive, you can find out more information on getting PrEP (Pre Exposure Prophylaxis) for their protection as well – Non-HIV partners for HIV PrEP.

Here are some further resources you can explore to find out more about the country you are travelling to and its restrictions if any:
1.) www.aidsmap.com – HIV-related services worldwide and access country-specific information and news
2.) www.hivtravel.org – International database on HIV related travel and occupation

Safe Trip and Have Fun!
This article was written by DTAP, in collaboration with Oogachaga.

What is Rapid Chlamydia & Gonorrhea PCR STD Testing?

30th October 2018/in Chlamydia, Gonorrhoea, STD & HIV /by Miri Yeo

Chlamydia and gonorrhoea are 2 common Sexually Transmitted Infections (STIs) which can infections in various parts of the body such as penis, vaginal, anus, throat and eyes.
Most commonly you will experience discharges from the penis/ vaginal or discomfort when passing urine.
However, the majority of men may not have any symptoms and for women, 50% may also not have symptoms.
The infection will stay in the body for a few weeks after the symptoms have been treated.
In rare instances, Gonorrhoea and Chlamydia can continue to cause damage to the body, specifically the urethra and testicles. Pain may also spread to the rectum. An overview of Gonorrhoea

At Dr Tan and Partners, we recognize that symptoms like abnormal vaginal discharges, penile discharge or discharge from the rectum can cause quite a bit of worry.
Thus, we have introduced a Rapid STD testing (next day results) that can detect these 2 infections within a day.
Which means that you can get the necessary treatment quickly as well.
All it requires is a urine sample or swab from the vaginal/ throat/ anal

This Rapid STD Testing detects for the presence of the DNA of the 2 organisms, making the test very sensitive

If you think you may have symptoms suggestive of chlamydia or gonorrhoea infection or if you think you may have been exposed and you are interested in an STD Screening, please visit a doctor for further evaluation.

Take Care!

Other Reads:

What are the odds?

So What about Tattoos or Piercings?

What is the take-home message?

Low HIV Risk Doesn’t Mean NO Risk

Other Interesting Reads:

An Overview of STD – From an STD Doctor

References

What are the Causes of Genital Blisters, Genital Warts and Genital Ulcers?

1) What are the Causes of Genital Blisters?

a) Genital Herpes

b) Balanitis

2) What are the Causes of Genital Warts?

a) Human Papilloma Virus

3) What are the Causes of Genital Ulcers?

a) Herpes Simplex Virus

(Painful shallow ulcers and blisters)

b) Syphilis

(Painless ulcers)

C) Chancroid

Lymphogranuloma venereum (LGV)

Small ulcer, swollen groin lymph nodes, possible rectal pain

Donovanosis

Shallow beefy looking ulcers

Other rare causes:

Autoimmune or inflammatory causes, skin cancers, drug reactions

All in All

An Overview on STD from an STD Doctor

What is an Opportunistic Infection?

What are the most common Opportunistic Infections?

1) Candidiasis (Esophageal, Tracheal, Bronchial)

2) Cryptococcosis

3) Cytomegalovirus (CMV)

4) Herpes Simplex Virus (HSV)

5) Mycobacterium Tuberculosis (TB) & other Mycobacterial infection

6) Pneumocystis Carinii Pneumonia (PCP)

7) Salmonella septicemia

8) Toxoplasmosis

9) Kaposi’s Sarcoma (KS)

10) Invasive cervical cancer

How can Opportunistic Infections be prevented?

Other Interesting Reads:

An Overview of STD – From an STD Doctor

What are the Different Stages of HIV Infection?

1) Acute HIV Infection

Different HIV tests are able to detect the infection at different times

2) Chronic HIV Infection

3) AIDS (Acquired Immunodeficiency Syndrome)

Other Interesting Reads:

An Overview of STD – From an STD Doctor

What is syphilis?

Syphilis – Still a Real and Relevant Infection Today

What are the symptoms and different stages of syphilis?

Primary Syphilis Symptoms

a.) Syphilis Symptoms: Chancres

Secondary syphilis

b.) Syphilis Symptoms: Rashes

c.) Snail track ulcers

d.) Condylomata Lata

e.) Nonspecific symptoms

Tertiary syphilis

What Does a Syphilis Test Do

Who should test for syphilis and what tests are done to diagnose syphilis?

What Treatment is Available for Syphilis?

Other Interesting Reads:

An Overview of STD – From an STD Doctor

What Causes Cold Sores?

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Herpes Simplex Viruses (Type 1)

What is the Treatment for Cold Sores?

Other Interesting Reads:

An Overview of STD – From an STD Doctor