In an effort to make health science information accessible, Carbon Health has partnered with Rob Swanda, PhD to answer questions about sexual infections and transmission, from actual people (via Dr. Swanda’s Twitter and newsletter followers). Dr. Swanda is joined by Dr. Justin Young, a southern California regional clinical director at Carbon Health, to tackle sexual health questions below, and many more in the full-length video discussion found near the bottom of this post.
Dr. Swanda: “I'm going to turn it over to Justin to just give a brief description about a very common question that we've received, what are the differences between an STI and an STD?”
Dr. Young: “I think one of the reasons to answer a question about the difference between what is an STI versus an STD is that there's been a lot of stigma that was associated with a sexually transmitted disease. One of the ways that we approach it is that sexually transmitted infection or STI is probably 1. more accurate, 2. is the more appropriate, and I don't want to say modern way but it kind of is, the more modern progressive way of approaching these types of infections that befall many adults across the globe. So, the STD connotation carries a little bit more of a negative stigma, but in the clinical sense the STD, or sexually transmitted disease, is when an infection persists long enough to actually cause a disease state that disrupts the normal function of the body so on a more chronic or ongoing basis. The likelihood of someone contracting a disease just doesn't really fit for what these types of infections are. Even the types of infections that are incurable that a person would contract from one partner to another during a sexual episode, the term disease in that moment is just not accurate. So historically the negative connotation that was associated with it is just not helpful, not accurate, and the stigma associated with limiting our patients ability to really open up and communicate about what their needs are just doesn't really have a place in the healthcare setting. When a patient walks into the room or when I have a conversation with them whether it's virtually or in person it really is important for them to be able to feel comfortable talking about what their medical needs are. The medical history I don't know about can really harm a patient and limit my ability to provide them with the best quality care. So, I want to make sure that the space is welcoming and honest and open.”
Dr. Swanda: “If somebody is coming in to get checked out for a sexually transmitted infection, potentially, what could they expect to see in terms of the type of tests that would be done and samples that might be collected?”
Dr. Young: “Typically what you would end up doing is giving a blood sample, giving a urine sample, and a little throat swab. Or, to be fair and to be clear the swabs could also be a rectal swab to check for gonorrhea and chlamydia. It can be a throat swab for gonorrhea and chlamydia. And in certain instances if there is discharge that's noticeable it can be a specific urethral swab at the opening of their urethral meatus, at the tip of the penis, or if there's vaginal discharge that's noticeable a swab there as well would be collected. So, in that way you can check for gonorrhea and chlamydia in the urine sample. You can check for things like trichomoniasis, gonorrhea, and chlamydia with a vaginal swab. And then when it comes to blood tests, typically the blood tests that you're going to encounter are for HIV and then also for syphilis. But, in some instances, say for instance a patient comes in and they've already noticed that they have a lesion or a rash or a spot that is concerning, for them we can also do a little direct swab as well to determine whether or not what type of lesion it might be. Particularly, recently, a lot of people in this most recent outbreak of monkeypox that we've noticed in a lot of parts of the country, swabs for that were taken as well, so it's just dependent on what symptoms a patient presents with, so it can be very specific or if it's just a screening test then all of those types of samples would be collected.”
Dr. Swanda: “I'm going to transition the conversation a bit to a big bulk of questions that we got related to HIV, and we know that HIV has historically been very difficult to treat due to it infecting the immune system specifically which our bodies need in order to fight off other pathogens, so I'd love for you to just give a bit of preventative measures that individuals could take to prevent HIV before we jump into some of the details related to medications.”
Dr. Young: “One of the first key pieces is communication, being open, having honest conversations with your sexual partners and it isn't just about HIV. This is about all STIs and just general sexual health. It's important to be tested, ideally before engaging in sexual activity with a new partner. There are instances where if there is concern about HIV exposure, post-exposure prophylaxis (PEP) helps to prevent the seroconversion to being HIV positive. Advances in pre-exposure prophylaxis (PrEP), access to the medications that can be taken daily or under certain circumstances there are injectable medications as well, that help with that and has been shown to significantly reduce the risk of contracting HIV during sexual activity. So, that's another part of how we've been preventing HIV really across the globe. And there are definitely certain communities, in certain parts of the world, where we can do a better job of making sure there is more access to PrEP, so those medications are really important. But, beyond that, even if a patient does contract HIV I think one of the big things to think about is that with the advancements with regular medications that are taken on a regular basis in management with your primary care doc or other specialists, there are ways to make sure that you are undetectable and make sure that that viral load and the viral burden of HIV is undetectable, which basically means that it will not be able to be transmitted.”
Dr. Swanda: “What is PrEP as a daily pill?”
Dr. Young: “So, PrEP is, as I mentioned, pre-exposure prophylaxis. It's a medication that helps one prevent the contraction of HIV. So, the two medications that are commonly out there are Truvada and Descovy, both use a combination of medications emtricitabine and tenofovir alafenamide. Descovy, because of the formulation of one of those medications, it basically is a little bit more protective as it's a little bit easier on your kidneys. You can have a conversation with your primary doctor or even pop into an urgent care; most urgent cares these days are equipped to be able to take care of the screening process to get you started on PrEP, but it is one of those medications that you have to take regularly for it to be protective and effective. With daily dosing, it is roughly 99% effective at preventing the infection of HIV if you are exposed in a sexual context. So, it's really important to make sure that you do take it and you do take it regularly and you are regularly testing. The way that it works for Truvada and Descvey in particular, there are baseline testing based upon whether or not you're HIV positive or negative. Ideally in this context you should be HIV negative to start PrEP, otherwise you would be on another series of antiretrovirals or anti-HIV medications. In that context, baseline testing makes sure that your kidney function is doing okay, and makes sure that you're HIV negative. We also test for additional STIs as well. And then based on that, if all is negative, we would go ahead and start you off with a prescription. In most cases it's a daily dosing and you take the pill once daily and after basically seven days you should have enough of the medication circulating to be protective, and that's protective for receptive anal intercourse. When it comes to vaginal intercourse, it's at a protective circulating level in the body at 21 days: it's just due to a series of different absorption and mucous membranes that are associated with each area. So, that's the difference there but ultimately after that baseline startup of seven days or 21 days, and continue to take it daily thereafter, then you're all set.”
Dr. Swanda: “Can you give a description of PEP to the audience?”
Dr. Young: “PEP basically is kind of, I don't want to say a modified form of PrEP, but it's essentially a way for us to prevent someone who may have been exposed to HIV and prevent them from contracting the virus. What that means is similar to PrEP; it's a medication that will help prevent the virus from being able to replicate. So, how it works is you start off with a similar medication like Truvada plus another anti-HIV or antiretroviral medication that you would take daily for 28 days or essentially a month after that exposure. But, the importance of PEP is that you have to be very time sensitive about it. It's been studied and shown to be effective within three days of potential exposure. Whatever the reason within three days of exposure is, if you take PEP it is effective in preventing conversion of HIV or contracting the virus.”
Dr. Swanda: “If someone is feeling uncomfortable bringing up this topic to their Primary Care Providers what advice do you have that they can do?”
Dr. Young: “I hope that this is a relationship and a communication that is open, that is comfortable and even the uncomfortable topics and the uncomfortable decisions and discussions that you have to have with your doctor hopefully you feel supported enough and welcomed enough to be able to have these conversations because that's what is the most effective and most protective. I think very common in medicine what we're trying to do is to share decision making and really trying to get you to a place to provide you with information that helps you decide what is going to be best for you and your care so I can't do my job if I'm not creating a space where you can talk to me about what you like to do sexually, how many partners you have, how many partners you don't have, what type of sex you might be having in any given time context. I want to know about your kinks, I want to know about who your preferences are, I want to know when was the last time that you had sex, what kind of sex, who you have sex with. It should be in the most non-judgmental context. That's what we do, that's who we are, that's what I am as a healthcare provider. And quite frankly I really think this is critical and really important because medicine is about advocacy for your patients and really showing up for them in a way that is protective and not in a way that I'm protecting a patient but I'm providing information so that the patient can do what they feel is the most important and most protective for what their needs are and what their lifestyle might be and how it pertains to the medications we need to prescribe or the treatment we recommend and that can't happen if it's not in a space that is non-judgmental.”
Watch the full conversation posted on January 25th, 2023.
Rob Swanda, PhD is an mRNA biochemist and science communicator who obtained his PhD from Cornell University in 2021. Follow Rob Swanda, PhD on Twitter: @ScientistSwanda
Dr. Justin Young is a regional clinical director at Carbon Health. Follow Dr. Justin Young on Twitter: @YoungDocJustin