NUR 7074 Module 4 Sexual Health Paper: STI Screening, Treatment and Starting HIV PrEP for a Young Adult Example

Three Sites, One Pill: Screening and HIV Prevention for a Young Man in Primary Care

Student Name

M.S. in Nursing, Family Nurse Practitioner, Thomas Edison State University

NUR-7074: Adolescent and Early Adult Primary Care

Mentor Name

Month Day, Year

Three Sites, One Pill: Screening and HIV Prevention for a Young Man in Primary Care

The Patient

Jordan Ellis, an invented 22-year-old college junior, came in asking about preexposure prophylaxis after a friend started it. He has sex with men, reports three male partners over the last six months and inconsistent condom use, and he has receptive and insertive anal sex and oral sex. He has no symptoms. He has never had an HIV test. He drinks socially, does not use other drugs and takes no medicines. His examination was normal, with no rash, lesions or lymph node swelling.

Who Should Be Screened

Chlamydia and gonorrhea screening is advised for every sexually active woman up to age 24 and for older women at higher risk, while the evidence on screening men in general was judged insufficient (US Preventive Services Task Force, 2021). Workowski et al. (2021), writing the CDC's treatment guidelines, go further for specific groups. For men who have sex with men, including gay and bisexual men, they advise testing at least once a year for chlamydia and gonorrhea at each site of contact, urethra, rectum and pharynx, regardless of condom use, along with syphilis and HIV testing, and testing every three to six months for those at increased risk. Rectal and pharyngeal infections are often without symptoms and are missed when only urine is tested.

Screening Jordan

Jordan was tested with nucleic acid amplification tests from urine, a rectal swab and a throat swab, which he chose to collect himself after instruction. Blood tests included HIV antigen-antibody testing, syphilis serology, hepatitis B surface antigen, surface antibody and core antibody, hepatitis C antibody and serum creatinine. His rectal swab was positive for chlamydia; all other results were negative, and he was immune to hepatitis B from childhood vaccination.

Treatment

Workowski and colleagues changed the preferred chlamydia treatment in 2021 to a seven-day course of doxycycline, 100 mg twice a day, replacing single-dose azithromycin, partly because doxycycline works better for rectal infection. For uncomplicated gonorrhea, the guidelines recommend ceftriaxone 500 mg given once as an injection. Jordan was prescribed doxycycline and told to avoid sex for seven days after starting treatment and until his partners were treated. Partners from the past 60 days should be notified and treated; the guidelines support expedited partner therapy where state law permits. He will be retested in three months, because reinfection is common.

Preventing HIV

Grant et al. (2010) randomly assigned 2,499 HIV-negative gay and bisexual men and transgender women across six countries to daily emtricitabine-tenofovir disoproxil fumarate or placebo. The drug reduced new HIV infections by 44 percent overall. The benefit was closely tied to adherence: among participants with detectable drug in their blood, the risk of infection was dramatically lower, while most infections in the treatment group occurred in people with no detectable drug. Side effects were mild, mainly early nausea, and small rises in creatinine reversed after stopping.

Starting PrEP

Jordan's negative HIV test, normal creatinine and hepatitis B status allowed PrEP to start the same day. He chose daily emtricitabine-tenofovir disoproxil fumarate. We discussed taking it at the same time each day, linked to brushing his teeth, and that protection for receptive anal sex builds after about a week of daily doses. Other options, including an on-demand schedule for some men who have sex with men and long-acting injectable cabotegravir every two months, were described for future consideration.

Ongoing Care

PrEP care includes a visit every three months with HIV testing, STI testing at exposed sites and a prescription for no more than 90 days, with creatinine checked periodically. Condoms remain the only method that protects against other STIs, and we discussed them without judgment. Missed doses and side effects will be reviewed at every visit. He was also offered doxycycline postexposure prophylaxis counseling as a newer option some clinics use for men with recent bacterial STIs, with a plan to discuss it at his next visit.

Window Periods

HIV antigen-antibody tests detect most infections within several weeks of exposure, so a very recent exposure can be missed. Jordan reported condomless sex ten days earlier, so I explained the window period and planned a repeat HIV test at his first follow-up visit, about a month after starting PrEP, to confirm he was not already infected when he began.

Alcohol and Mental Health

Young sexual minority men face higher rates of depression and substance use, often linked to stigma. Jordan's PHQ-2 and AUDIT-C screens were negative, and he was told the clinic's behavioral health team is available if that changes.

Respect and Confidentiality

Jordan said he had avoided clinics because of a past provider's reaction to his sexuality. I asked about partners and practices in neutral language, explained why each test was needed and assured him that his information is confidential. He is on his parents' insurance, so we discussed how explanations of benefits might reach them and how the clinic can help.

Vaccines

His HPV and hepatitis B vaccines were complete. He was offered hepatitis A vaccine, which is advised for gay and bisexual men, and the mpox vaccine according to current recommendations for his risk.

Limits

The iPrEx trial included few participants in the United States, and adherence in the trial differed from real-world use. The patient is invented.

Conclusion

The task force set the routine floor for screening, Workowski and colleagues supplied the site-specific testing and treatment that found and treated Jordan's rectal chlamydia and Grant and colleagues showed that daily PrEP prevents HIV when taken consistently. Testing where exposure happens, treating him and his partners and starting PrEP the same day give Jordan care built on evidence and respect.

References

Grant, R. M., Lama, J. R., Anderson, P. L., McMahan, V., Liu, A. Y., Vargas, L., Goicochea, P., Casapía, M., Guanira-Carranza, J. V., Ramirez-Cardich, M. E., Montoya-Herrera, O., Fernández, T., Veloso, V. G., Buchbinder, S. P., Chariyalertsak, S., Schechter, M., Bekker, L.-G., Mayer, K. H., Kallás, E. G., . . . Glidden, D. V. (2010). Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. New England Journal of Medicine, 363(27), 2587-2599. https://doi.org/10.1056/NEJMoa1011205

US Preventive Services Task Force. (2021). Screening for chlamydia and gonorrhea: US Preventive Services Task Force recommendation statement. JAMA, 326(10), 949-956. https://doi.org/10.1001/jama.2021.14081

Workowski, K. A., Bachmann, L. H., Chan, P. A., Johnston, C. M., Muzny, C. A., Park, I., Reno, H., Zenilman, J. M., & Bolan, G. A. (2021). Sexually transmitted infections treatment guidelines, 2021. MMWR. Recommendations and Reports, 70(4), 1-187. https://doi.org/10.15585/mmwr.rr7004a1