Sexually transmitted infections (STIs), also called sexually transmitted diseases (STDs), are important topics for nursing students to understand because they are commonly tested on nursing exams and the NCLEX.

In this complete STI & STD NCLEX review, we will break down the most commonly tested sexually transmitted infections (see below).

Table of Contents (click which topic you want to learn):

• gonorrhea
• chlamydia
• trichomoniasis
• herpes simplex virus (HSV)
• human papillomavirus (HPV)
• HIV/AIDS
• hepatitis B
• syphilis
• video review lecture
• maternity study notes

For each infection, you will learn key nursing concepts such as pathophysiology, clinical manifestations, medications and treatments, nursing interventions, patient teaching, and important NCLEX tips.

Be sure to check out more maternity nursing reviews.

• COMPREHENSIVE STI/STD NCLEX Questions

Gonorrhea

What is Gonorrhea?

Gonorrhea is a sexually transmitted infection (STI) caused by the bacterium Neisseria gonorrhoeae. This bacterium is gram-negative, which can be remembered by noting the “G” and “N” in gonorrhea. Under a Gram stain, these bacteria appear as small, round, paired cells encased in a capsule, referred to as diplococci.

Transmission of Gonorrhea

Gonorrhea is primarily transmitted through unprotected sexual contact, including vaginal, oral, and anal intercourse with an infected person. Additionally, an infected pregnant person can transmit gonorrhea to their baby during childbirth, leading to complications such as premature birth and neonatal eye infections, which could result in blindness. It may also cause meningitis in newborns.

Signs and Symptoms of Gonorrhea

To remember the symptoms of gonorrhea, use the mnemonic “THE CLAP,” which is also a common nickname for the infection:

• Tender testicles: In males, gonorrhea can cause significant swelling and pain in the testicles, which may lead to infertility if untreated.
• Hurts to urinate: A burning sensation while urinating is common and may be mistaken for a urinary tract infection.
• Swelling: The affected area—genitals, throat, or anus—can become swollen and inflamed.
• Conjunctivitis: This eye infection primarily affects newborns who contract gonorrhea during delivery. Erythromycin is most commonly administered in the eyes of the newborn after birth to prevent this.
• Lack of symptoms: Many individuals, especially women, may experience mild or no symptoms, often mistaking them for a vaginal infection or urinary tract infection.
• Abnormal discharge: The infection causes thick, greenish-yellow discharge from the penis, vagina, or anus.
• Pelvic Inflammatory Disease (PID): If untreated, gonorrhea can spread to the fallopian tubes, ovaries, and uterus, leading to abdominal pain, infertility, and ectopic pregnancies.

The Nurse’s Role in Gonorrhea Screening and Treatment

Nurses play a crucial role in identifying gonorrhea in patients and ensuring they receive proper testing and treatment. The Centers for Disease Control and Prevention (CDC) recommends yearly screening for:

• Sexually active individuals under 25 years old
• Anyone with multiple sexual partners
• Individuals who engage in unprotected sex
• Incarcerated individuals
• Those who have tested positive for another STI, as gonorrhea often coexists with chlamydia.

For pregnant patients, testing is recommended during the first prenatal visit for those 25 and under, while older patients are tested only if they are considered high-risk. In addition, these patients should be retested in the third trimester (around 28 weeks). Testing involves urine samples or swabs from the affected area. There is currently NO blood test for gonorrhea.

Treatment Options

Gonorrhea is treated with antibiotics. The CDC currently recommends:

• A single intramuscular (IM) dose of ceftriaxone for uncomplicated gonorrhea.
• If Chlamydia trachomatis has not been excluded, doxycycline should be added.
• Pregnant patients follow the same ceftriaxone regimen, but an alternative to doxycycline is used due to its contraindications during pregnancy. Doxycycline can lead to bone and tooth development issues.

Past CDC guidelines recommended dual therapy with azithromycin, but this is no longer the standard treatment.

Patient Education and Prevention

Patients receiving treatment for gonorrhea should be advised to:

• Avoid all sexual activity until seven days after completing treatment and experiencing no symptoms.
• Use barrier protection (such as condoms) to prevent reinfection.
• Ensure their partner(s) are tested and treated.
• Follow up with testing three months after treatment to confirm the infection is cleared and has not recurred.

By understanding gonorrhea’s symptoms, risks, and treatments, nurses can play an essential role in controlling its spread and ensuring patients receive timely care. Proper education, screening, and treatment can help reduce complications and prevent reinfection.

COMPREHENSIVE STI NCLEX Review

Trichomoniasis

What Is Trichomoniasis?

Trichomoniasis (often called “Trich” which is pronounced as the word trick) is a sexually transmitted infection caused by a protozoan parasite called Trichomonas vaginalis. It primarily infects the urogenital tract and can affect both men and women, though women are more likely to show symptoms.

Transmission and Risk Factors for Trichomoniasis

A person can get trichomoniasis through:

• Unprotected vaginal intercourse with an infected partner
• Vertical transmission during childbirth when a baby passes through an infected birth canal
  • During delivery, the newborn may develop congenital conjunctivitis, or the infection can lead to low birth weight or preterm labor before birth.

High-Risk Populations

Screening is especially important for individuals who:

• Have multiple sexual partners
• Currently have or recently had another STI
• Are incarcerated
• Use drugs

Trichomoniasis Symptoms (Remember the Mnemonic: “TRICH”)

Use this nursing mnemonic to remember the signs and symptoms of Trichomoniasis:

• T: Thick, foamy discharge Foul-smelling, greenish-yellow discharge
• R: Redness Inflamed genital area; cervix appears “strawberry-like” on exam
• I: Itching Intense vaginal or urethral itching
• C: Cramping Lower abdominal or pelvic pain
• H: Hurts Pain during intercourse (dyspareunia) or urination (dysuria)

Screening Recommendations

According to the CDC guidelines, routine screening for trichomoniasis is not recommended for the general population. However, screen symptomatic patients or those at high risk based on the factors above. Early identification and treatment are key to preventing complications and reinfection.

Treatment and Nursing Considerations for Trichomoniasis

Medication: Metronidazole (Flagyl) is the first-line treatment for both pregnant and non-pregnant patients. It targets and kills Trichomonas vaginalis, curing the infection.

Patient Education: Nurses play a crucial role in patient teaching. Emphasize the following:

• Avoid alcohol while taking metronidazole and for 72 hours after the last dose.
  Combining alcohol with this medication can cause a disulfiram-like reaction (flushing, nausea, vomiting, and severe headache).
• Abstain from sexual activity until seven days after completing the full course of treatment.
• Inform all sexual partners so they can be tested and treated to prevent reinfection.
• Use condoms consistently to prevent future STI transmission.
• Retest in three months after treatment to confirm the infection is cleared.

Complications of Untreated Trichomoniasis

If left untreated, trichomoniasis can cause:

• Pelvic inflammatory disease (PID) in women
• Infertility
• Preterm labor or low birth weight in pregnancy
• Increased risk of acquiring or transmitting HIV

NCLEX Nursing Tip

• When you see frothy green discharge plus a strawberry cervix, think Trichomoniasis (Trichomonas vaginalis).
• When you see “no alcohol with metronidazole,” think Flagyl teaching.

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Herpes Simplex Virus (HSV)

What is Herpes?

Herpes Simplex Virus Infection is caused by two main virus types:

HSV Type 1 (HSV-1)

• Typically causes oral herpes
• Found around the mouth and lips (cold sores)
• Can spread to the genitals through oral sex

HSV Type 2 (HSV-2)

• Sexual contact (vaginal, anal, oral)
• Can spread even when no visible lesions are present

Remember: Both HSV-1 and HSV-2 can infect oral and genital areas

How HSV is Transmitted

HSV-1 Transmission

• Saliva (kissing)
• Shared contaminated objects (cups, utensils)
• Direct contact with oral lesions
• Oral sex → can spread to genitals

HSV-2 Transmission

• Sexual contact (vaginal, anal, oral)
• Can spread even when no visible lesions are present
• Typically causes genital herpes

Important Concept: Asymptomatic Viral Shedding

• Virus can be spread without symptoms or visible sores
• This is a major reason HSV spreads easily

HSV and Pregnancy Risks

HSV can affect pregnancy and newborns:

• Rarely crosses placenta (in utero transmission is uncommon)
• Most risk occurs:
  • During vaginal delivery
  • Postpartum close contact

Neonatal Herpes

• Can be transmitted from mother or caregiver
• Affects:
  • Nervous system
  • Organs
• Can cause severe infection or complications in newborns

Signs and Symptoms of Herpes: “HSV” Mnemonic

H – Herpetic Lesions

• Painful, red, fluid-filled sores
• Clustered blisters (mouth or genitals)
• Lesions eventually crust over and heal

S – Sensation

• Tingling, burning, or itching before outbreak
• Early warning sign of recurrence

V – Viral Symptoms

• Fever
• Fatigue
• Headache
• Swollen lymph nodes
• Body aches

Remember: Some patients may be asymptomatic.

Screening and Diagnosis (CDC Guidelines)

HSV is not routinely screened unless:

• Patient has symptoms
• High-risk patients:
  • Other STIs
  • Multiple sexual partners
  • Incarceration history

Pregnancy Screening:

• Not routinely screened unless:
  • Symptoms present
  • High-risk status

Treatment for HSV

No Cure Available

HSV is lifelong, but manageable.

Antiviral Medications

• Example: Acyclovir
• Ends in “-vir” → antiviral clue

How Antivirals Work

• Reduce severity and duration of outbreaks
• Decrease viral shedding
• Lower transmission risk

Timing Matters

• Most effective if taken within 1–2 days of symptom onset
• Especially when tingling/burning begins

Pregnancy Use

• Helps reduce risk of neonatal transmission
• Often given in late pregnancy (~36 weeks)

Patient Education

For Oral Herpes and Newborns

• Avoid kissing baby (especially face)
• Wash hands before/after touching baby
• Do not share items (cups, utensils, towels)
• Cover active lesions
• Avoid touching/picking lesions

For Genital Herpes

• Avoid sexual contact during outbreaks
• Use condoms consistently (reduces but does NOT eliminate risk)
• Inform sexual partners
• Avoid sharing items like razors or towels

General Prevention Tips

• Keep lesions clean and dry
• Do not pick or scratch lesions
• Practice frequent hand hygiene
• Notify partners for testing and treatment

Key Concepts

• HSV-1 = oral herpes, HSV-2 = genital herpes (but both can overlap)
• Transmission can occur even without symptoms
• No cure: only symptom control with antivirals
• Highest transmission risk occurs during active outbreaks
• Neonatal herpes is a serious complication
• Patient education is critical for prevention

Human Papillomavirus (HPV)

What is HPV?

HPV, or human papillomavirus, is a virus that infects the skin and mucous membranes. There are many types of HPV, but only specific strains cause genital warts and cancer. The most common strains causing genital warts are HPV 6 and 11, while HPV 16 and 18 are linked to cervical cancer.

How Is HPV Transmitted?

HPV can be transmitted through:

• Sexual contact – genital, anal, oral, or throat exposure
• Pregnancy – during delivery, rare cases can lead to respiratory papillomatosis in newborns, where papillomas develop in the airway

Signs and Symptoms of HPV

Many patients with HPV are asymptomatic. When symptoms do appear, genital warts are the most common sign. Use the mnemonic “WART” to remember:

W – Warty growths on genital or anal areas; this STI can still be spread even is warts are not present

A – Asymptomatic; Appearance varies in size, shape, and color

R – Rough texture, often clustered like cauliflower

T – Tender or bleeding with irritation or sexual activity

Even in the absence of visible warts, patients can still transmit HPV to others.

Screening Guidelines

HPV can cause cervical cancer, so screening is crucial. The CDC recommendations for cervical cancer screening include:

• Ages 21–29: Pap smear every 3 years; HPV testing is not routine due to high likelihood of immune clearance

• Ages 30–65: Options include:
  • Co-testing (Pap smear + HPV test) every 5 years
  • Pap smear every 3 years and HPV testing every 5 years

Abnormal Pap results prompt further HPV testing to identify high-risk strains.

Treatment and Prevention

Currently, there is no cure for HPV, but treatments can manage symptoms and reduce transmission:

1. Prevention via Vaccination:

• Gardasil 9 protects against 9 strains of HPV, including 6, 11, 16, and 18
• Recommended age: 11–12 years (2 doses, 6–12 months apart)
• Ages 15–26: 3 doses over 6 months
• Vaccination after 26 may be less beneficial, but some adults up to 45 may still be candidates
• Not recommended during pregnancy

2. Treatment of Genital Warts:

• Topical creams: Imiquimod (stimulates immune response), Podophyllotoxin, Trichloroacetic acid (destroy wart tissue); generally avoided during pregnancy
• Cryotherapy: Freezing wart tissue with liquid nitrogen; safe during pregnancy

Patient Education for Nurses

Nurses play a key role in patient education on HPV:

• Condom use reduces transmission risk but is not 100% effective
• Pregnancy considerations: Hormonal changes may enlarge warts; large warts may require a C-section
• Awareness: Patients may be unaware of warts due to asymptomatic infections
• Vaccination advocacy: Encourage age-appropriate vaccination to prevent infection and future complications

Key Takeaways for Nursing Students

• HPV is common, often asymptomatic, but can cause genital warts and cervical cancer
• HPV can still be spread even if warts are not present
• Transmission occurs primarily through sexual contact; perinatal transmission is rare
• Screening and vaccination are critical preventive measures
• Management includes topical treatments, cryotherapy, and patient education

Hepatitis B

What is Hep B?

Hepatitis B refers to inflammation of the liver caused by the hepatitis B virus.

Breaking down the term:

Hepat- = liver
-itis = inflammation

So hepatitis means liver inflammation, and in this case it is caused by a viral infection: the hepatitis B virus.

Transmission of Hepatitis B

Hepatitis B is spread through exposure to infected bodily fluids.

• Main transmission routes include:
  • Sexual contact involving exchange of:
    • Semen
    • Vaginal fluids
    • Blood
  • During pregnancy and delivery (major risk during birth due to fluid exposure)
    • Rare transmission through the placenta (in utero)
  • Contaminated equipment such as:
    • Shared needles
    • Needle sticks in healthcare settings
    • Unclean medical equipment
    • Razors

Complications in Newborns

If a baby contracts hepatitis B, possible complications include:

• Long-term liver damage
• Growth and development problems
• Jaundice

Signs and Symptoms (HEPAT B Mnemonic)

• H – Hepatomegaly
• E – Enlarged liver due to inflammation
• P – Pale stools
  • Occurs due to bilirubin not properly reaching the stool
• A – Abdominal pain and tenderness
  • Especially in the right upper quadrant (RUQ) where the liver is located
• T – Tiredness
  • Extreme fatigue
• B – Bilirubin buildup (see the patho below)
  • Causes:
    • Jaundice (yellow skin and eyes)
    • Dark urine
    • Pale stools in severe cases

Bilirubin Explained

Bilirubin is produced from the breakdown of old red blood cells (about 120-day lifespan).

Normal process:

• RBCs break down = bilirubin forms
• Liver processes bilirubin
• Bilirubin is excreted into bile
• Bile goes to intestines → stool becomes brown

In hepatitis B: Liver cannot properly process bilirubin

• Bilirubin leaks into:
  • Skin = jaundice
  • Eyes = yellowing of sclera
  • Urine = dark color
  • Stool may become pale due to reduced bilirubin in the GI tract

Nursing Role: Screening and Blood Work

Pregnant patients:

• All pregnant patients should be tested each pregnancy
  • Test: hepatitis B surface antigen (HBsAg)
  • Positive = current infection
• Additional pregnancy screening recommendations:
  • Hepatitis C screening
  • Hepatitis A vaccine if risk factors are present
  • Hepatitis B vaccine if not previously vaccinated

All Patients:

Hepatitis B Serology (Triple Panel)

1. Hepatitis B Surface Antigen (HBsAg)
   Positive = currently infected
2. Hepatitis B Surface Antibody (HBsAb)
   Positive = immune or vaccinated
3. Hepatitis B Core Antibody (HBcAb)
   Positive = past/recovered infection

Key exam concepts:
Vaccinated patient should have what results if they have NEVER had an actual hepatitis B infection?
-HBsAb = positive
-HBcAb = negative
Vaccination exposes body to surface antigen = creates surface antibodies
No exposure to core antigen = core antibody remains negative

Treatment and Nursing Management

Post-exposure (non-immune, no prior vaccine):

• Hepatitis B immunoglobulin (HBIG) within 24 hours
• Start hepatitis B vaccine series

Acute hepatitis B (non-pregnant):

Supportive care:

• IV fluids
• Rest (supports liver healing)
• Antiemetics for nausea

Severe cases:

• Antiviral medications
• Monitor liver labs, including PT/INR
• Rising values indicate worsening clotting ability and liver dysfunction

Chronic hepatitis B:

First-line antivirals such as:

• tenofovir
• entecavir
• Goal:
  • Decrease viral load
  • Reduce infectivity
  • Prevent liver damage

Pregnancy Treatment Considerations

• Antivirals typically started at 28–32 weeks
• Goal: reduce viral load and prevent transmission to baby

Newborn management:

• Hepatitis B vaccine at birth
• Hepatitis B immunoglobulin at ~12 hours after birth
• Continue full vaccine series
  • Hepatitis B Vaccine Schedule (Children)
    • Birth
    • 2 months
    • 6–18 months
    • Note: CDC update in 2025- if mother is hepatitis B negative, birth dose may be delayed.

Patient Education (Hepatitis Mnemonic)

• Prevention and safety:
  • Hepatitis B vaccine is preventative
• Use condoms to reduce transmission risk (not 100% protective)
• Breastfeeding:
  • Allowed if baby receives:
    • Immunoglobulin within 12 hours of birth
    • Vaccine at birth

• H – Hand hygiene
  • Strict handwashing to prevent spread
• E – Eat low-fat, high-carb diet
  • Supports liver regeneration and digestion
• P – Personal items not shared
  • No sharing:
    • toothbrushes
    • razors
    • cups
    • utensils
    • towels
• A – Activity conservation
  • Rest promotes healing
• T – Toxic substances avoided
  • Avoid:
    • alcohol
    • sedatives
    • aspirin
    • acetaminophen
    • other hepatotoxic medications
• I – Isolation precautions
  • Avoid sharing bathrooms during infectious period
• T – Test result understanding
  • HBsAg = infection
  • HBsAb = immunity/recovery
  • HBcAb = past infection
• I – Immunoglobulin timing
  • Within 24 hours after exposure
  • Within 12 hours after birth (newborn)
• S – Small frequent meals
  • Helps manage nausea

Additional Nursing Teaching Points

• Additional Nursing Teaching Points
• Encourage rest to allow liver healing
• Avoid cooking for others while infectious
• Emphasize vaccination importance
• Monitor for fatigue and jaundice
• Maintain infection control precautions

Syphilis

What is Syphilis?

Syphilis is a sexually transmitted infection caused by the bacterium Treponema pallidum. It is primarily transmitted in two ways: through sexual contact and from mother to baby during pregnancy or delivery.

1. Sexual Transmission: The infection is spread when a person comes into direct contact with painless ulcers, known as chancres, which can appear on the genitals, anus, mouth, or mucous membranes.
2. Mother-to-Baby Transmission: Syphilis can also be passed from a mother to her baby via the bloodstream. The bacterium enters the bloodstream and can be transmitted through the placenta or during delivery, when the baby may come into contact with the chancres.

Stages of Syphilis

Syphilis progresses in four distinct stages. These are not only important to remember for your nursing exams, but they are also important to know so that you can recognize the signs and symptoms of each stage to provide timely treatment.

1. Primary Stage

The primary stage of syphilis occurs about three weeks after exposure to the bacterium. During this stage, a painless ulcer, or chancre, appears at the site of infection, such as the genital area, anus, mouth, or mucous membranes. The chancre is highly contagious and can spread the infection to others. This stage typically lasts between three to six weeks and resolves on its own. However, if left untreated, the infection remains in the body, progressing to the next stage.

2. Secondary Stage

The secondary stage begins six to twelve weeks after the initial infection. In this stage, the patient typically develops a full-body rash, which is typically not itchy. The rash usually starts on the trunk but can spread to other areas, including the palms of the hands and soles of the feet. Flu-like symptoms may also occur, including low-grade fever, swollen lymph nodes, and muscle aches. The infection remains contagious at this stage, and the symptoms may go away on their own, but without treatment, the infection remains present and progresses to the next stage.

3. Latent Stage

The latent stage can last for years without symptoms. This stage is divided into two phases:

• Early Latent Stage: In this phase, the patient may relapse and experience signs and symptoms again, making them contagious.
• Late Latent Stage: In this phase, the patient typically has no symptoms and is no longer contagious. However, the syphilis bacterium can still be present in the bloodstream, which can pose a risk during pregnancy, as the infection can be transmitted to the baby.

4. Tertiary Stage

The tertiary stage occurs about 10 to 30 years after the initial infection if syphilis is left untreated. Not all individuals with syphilis will reach this stage. It can cause severe damage to the brain, nerves, heart, and other organs. The formation of gummas (growths) in organs like the liver, skin, eyes, and bones is a hallmark of this stage. At this point, the infection is generally not contagious.

Complications of Syphilis

If syphilis is transmitted to a baby, it can cause serious complications such as stillbirth, death at birth, or congenital syphilis. Congenital syphilis can manifest in the baby as deafness, blindness, birth deformities, or neurological damage.

Nurse’s Role in Syphilis Care

As a nurse, it is crucial to understand the screening and treatment protocols for syphilis, especially in pregnant patients.

Screening Recommendations:
The American College of Obstetricians and Gynecologists recommends that all pregnant patients be screened for syphilis, not just high-risk individuals. The screenings should occur at three points during pregnancy:

1. First prenatal visit
2. Third trimester (around 28 weeks)
3. At delivery

This is especially important due to the rise in cases of congenital syphilis. The tests typically involve blood tests such as the Rapid Plasma Reagin (RPR) test or the Venereal Disease Research Laboratory (VDRL) test.

Treatment of Syphilis:
The CDC recommends Penicillin G as the first-line treatment for all stages of syphilis. It is typically given intramuscularly but may also be administered intravenously if the patient has neurosyphilis (a form of syphilis affecting the central nervous system) or congenital syphilis. Penicillin G is the only recommended treatment for pregnant patients, as other antibiotics like doxycycline and tetracycline are unsafe during pregnancy.

If a patient is allergic to penicillin, a process called penicillin desensitization can be performed. This involves administering small doses of penicillin over time while closely monitoring the patient, gradually increasing the dose until the required therapeutic level is reached.

Patient Education and Follow-Up Care

After treatment, patients must be educated on the following points:

• No sexual activity until the treatment is complete and signs and symptoms have subsided.
• Use latex condoms during sexual activity to reduce the risk of transmission.
• Inform sexual partners about the infection and encourage them to get tested and treated to prevent reinfection.
• Follow-up testing is important to ensure the infection has been effectively treated and to monitor for reinfection. Typically, follow-up testing occurs at 3, 6, and 12 months after treatment.

By recognizing the symptoms of syphilis at each stage and ensuring timely treatment, healthcare providers can help prevent complications and stop the transmission of this infection.

Chlamydia

What is Chlamydia?

Chlamydia is caused by a gram-negative bacterium known as Chlamydia trachomatis.

How Is Chlamydia Transmitted?

Chlamydia is primarily spread in two ways:

• Sexual contact – Unprotected anal, oral, or vaginal sex with an infected person.
• During pregnancy and delivery – A baby exposed to chlamydia during delivery can develop:
  • Neonatal conjunctivitis (eye infection): can cause severe eye irritation or even blindness if untreated.
  • Respiratory infections such as pneumonia.

Signs and Symptoms of Chlamydia

Chlamydia is often called the “silent” infection because most patients don’t experience symptoms. However, even in the absence of symptoms, it can still spread and cause serious complications.

Remember SILENT:

• Symptoms absent: Many people show no signs but remain infectious.
• Increased painful urination: Discomfort or burning while urinating.
• Lower abdominal pain: Often in women; may indicate progression to pelvic inflammatory disease (PID), which can result in infertility or ectopic pregnancy.
• Excessive discharge: Abnormal vaginal, penile, or rectal discharge.
• Neonatal conjunctivitis: Eye infection in babies born to infected mothers.
• Testicles swollen: In men, swelling or pain in the testicles due to epididymitis.

Screening for Chlamydia

According to CDC guidelines, screening depends on whether the patient is pregnant or non-pregnant.

• Pregnant Patients
  • Screen if the patient is 25 or under or high risk (multiple partners, inconsistent condom use, history of STIs, incarceration, etc.).
  • Screen at the first prenatal visit and again in the third trimester.
• Non-Pregnant Patients
  • Screen annually if 25 or under or high risk (same risk factors as above).

How Is Chlamydia Tested?

• Urine sample
• Swab from the affected area (vagina, cervix, anal area, throat).
  • Also consider screening for co-infections such as gonorrhea, syphilis, or HIV.

Treatment for Chlamydia

Treatment depends on pregnancy status.

• Pregnant Patients
  • Azithromycin is the treatment of choice.
  • Test of cure at 4 weeks to ensure the infection is gone.
  • Retest at 3 months to confirm no reinfection.
• Non-Pregnant Patients
  • Doxycycline is typically prescribed.
  • Pregnant patients cannot take doxycycline due to risk of fetal bone and tooth abnormalities.
  • Retest at 3 months after treatment to confirm no reinfection.

Post-Treatment Education

• No sexual activity for at least 7 days after completing treatment and until symptoms resolve.
• Use condoms consistently when resuming sexual activity.
• Inform sexual partners so they can be tested and treated which helps prevent reinfection.

HIV / AIDS

What is HIV/AIDS?

HIV stands for “Human Immunodeficiency Virus” and AIDS stands for “Acquired Immunodeficiency Syndrome”.

HIV is a virus that attacks the human body’s immune system, specifically the CD4 positive cells. This mainly includes helper t cells. However, macrophages, dendritic cells, monocytes and other cells with CD4 receptors on their surface can also be attacked.

Helper t cells are white blood cells that help the immune system fight infection. These cells are strategically attacked and killed overtime by HIV. When the number of helper t cells fall too low, the body loses its ability to fight infection.

Therefore, if a person becomes infected with HIV and is not treated with medical therapy, HIV will turn into AIDS. HIV occurs in stages, and a person can have HIV for several years before it transitions into AIDS.

There is no cure for HIV, as of today, but medical therapy has advanced (and continues to advance) so that people with HIV can now live longer healthier lives.

Quick Statistics about HIV/AIDS

How many have died for this infection and how many people are currently infected?

According to the World Health Organization (WHO):

“Since the beginning of the epidemic, about 79.3 million people have been infected with the HIV virus and 36.3 million people have died from HIV.

Current number of people who have HIV? WHO estimates that: “globally at the end of 2020, 37.7 million  people were living with HIV.” (World Health Organization, 2021)

How is HIV Transmitted? What increases your risk of getting it?

Transmission from someone with HIV depends on:

• How much of the virus is present in the infected person’s blood…the viral load of the person
  • A high viral load can occur during the acute phase of HIV and if the person is not receiving medication therapy to help decrease the viral load.
• How much of the virus was actually transmitted (certain activities will transmit more of the virus)
• Type of contact with the person who has HIV
  • Example: a needle stick has a lower chance of transmitting the virus compared to unprotected sex or sharing of needles during IV drug use
    • An interesting statistic about this…CDC says that: “Healthcare workers who are exposed to HIV-infected blood via a needlestick have a 0.23% risk of becoming infected.” (Occupational HIV Transmission and Prevention among Health Care Works, 2015)
  • Immune system of the non-infected person
    • some people (a very small percentage) are actually resistant to HIV

In order to transmit the virus, the virus must be in a specific fluid like blood, semen, vaginal fluid, or breastmilk. This fluid must enter the blood stream directly or indirectly via injury or a mucous membrane (like the vagina, penis, rectum, or mouth).

Activities that could transmit HIV:

• Unprotected sexual contact
• Drug use (needle sharing)
• Blood product transfusion
• Needle stick injury or unclean needle from a piercing or tattoo
• During pregnancy (pregnancy itself, birthing process, or via breastmilk)

 HIV is NOT Transmitted

HIV is a weak virus without a host of fluid like blood, semen, vaginal fluid or breastmilk. It doesn’t survive without it. Therefore, activities that are not likely to transmit the virus include:

Hugging, closed mouth kissing, touching clothes or objects, tears, sweat, or saliva (without blood), insect bites mosquitoes, household items, coughing/sneezing

Pathophysiology of HIV

Key Players in the Patho:

• HIV (the virus) and its life cycle
• CD4+ receptors (mainly targeted is the helper t cells)

First, let’s look at the helper t cell:

Helper t cells are a type of white blood cell used to help us fight infection. They play a huge role in the adaptive immune system, which is what our body uses to help us respond and be protected from a foreign invader exposure.

Therefore, this system plays a vital role with us developing acquired immunity, which gives our body the ability to build a foreign invader memory bank against foreign invaders. If you don’t have this handy memory bank we are at risk for developing opportunistic diseases or infections.

OIs (opportunistic infections) don’t tend to cause an issue in a person with a healthy immune system. However, when HIV is present in the body it wipes out the immune system cells (hence helper t cells) that help protect us from them. OIs can be cancerous, viral, bacterial or protozoal.

When a patient with HIV develops an opportunistic infection or disease it could lead to death. In fact, the presence of an opportunistic disease in a patient with HIV is one of the criteria use to diagnose AIDS.

So, why do we call this type of t cell the “helper”?  Because it helps the immune system fight infection by activating other immune cells. They do this by releasing cytokines. When cytokines are released by the helper t cells, they act as a chemical agent that attaches a message to a receptor site on a targeted cell, which causes that cell to function in a certain way.

These cytokines help activate another type of t cell called cytotoxic t cells to kill invaders, macrophages who will eat invaders, and b cells who will make antibodies to fight invaders.

Now, let’s look at HIV:

HIV is a retrovirus that cannot grow or multiply by itself, but must find something that will allow it to do this…hence a host cell. Therefore, it finds the helper t cell and other cells that have a CD4 receptor on its surface as the perfect host cell. HIV uses this receptor to gain access to the cell, which allows the virus to reproduce and destroy its host cell.

This leads me to the “Life Cycle of HIV”. The Life Cycle of HIV is how HIV strategically takes over the host cells, replicates, matures, and eventually kills the host cell. As the nurse, it is important to have a basic understanding on this life cycle because this is what Antiretroviral Therapy (ART) targets in the treatment of HIV.

First, the basic anatomy of the HIV virus:

It’s an enveloped virus that is surrounded by proteins called glycoproteins. A particular glycoprotein I want you to pay close attention to is glycoprotein 120 (GP120).  These proteins look like a knob that projects from the virus. These protein projections are key for attaching to the CD4 receptor on the helper t-cell or CD4 positive receptor for entry into the cell.

Packaged on the inside of the virus is it’s “suitcase”. HIV doesn’t plan on staying as itself but plans to take a trip inside the host cell and set up a new temporary residence.

So, mainly on the inside of the virus is it’s RNA and three important enzymes that I want you to remember: Reverse transcriptase, Integrase, and Protease

Life Cycle of HIV

Step 1:

Attachment occurs when the GP120 protein projections make contact and bind with a CD4 receptor. In addition, there is also binding with certain co-receptors called CCR5 or CXCR4 to gain entry into the cell.

Step 2:

Fusion occurs when the virus becomes united with the cell and dumps its content into the cell, which is genetic material (RNA) and enzymes (unpacks it “suitcase”).

Step 3:

Reverse transcription: Now it’s time to set up shop with the goal of getting into the cell’s nucleus and becoming integrated with the cell! Therefore, the single strand of viral RNA needs to turn into viral DNA. The HIV virus brought along with it an enzyme called reverse transcriptase. This enzyme causes the viral RNA to turn into double stranded DNA. This viral DNA moves into the nucleus of the cell.

Step 4:

Integrate: Once inside the nucleus it needs to hijack the cell’s DNA (hence become part of it so it can take control, produce more HIV virus, and kill the cell). To do this, the HIV DNA strand releases another enzyme called integrase, which allows it to become part of the cell’s DNA. So, it’s now integrated into the cell’s DNA.

Step 5:

Replicate: Now that the HIV’s DNA is in control, it starts to use the parts of the hijacked cell to make long chains of the virus.

Step 6:

Assembly: These long chains and other viral material are being assembled and start to move toward the cell’s surface.

Step 7:

Budding: The assembled parts start to grow (hence bud) off the cell wall.

Step 8:

Maturity:

Once it has completely grown off the cell’s surface, it pops off.  Then protease (an enzyme that cuts the long chain of virus prepping it for maturity) completes its job of maturing the viral material and a new mature virus is born. The cell it hijacked dies and this new mature HIV virus has a mission of finding another cell victim with a CD4 receptor and start the whole process again.

HIV Stages, Sign/Symptoms & Testing

Acute Stage:

• Begins about a couple of weeks to a month after becoming infected
• Can spread to others
• Viral load very high in the blood (HIV rapidly killing CD4 cells and multiplying)
• Signs and symptoms are flu-like that last for a few weeks (many people don’t know they have HIV):
  • Aches, joint pain, headache, fever, fatigue, sore throat, swollen lymph nodes, GI upset, rash
• Tests to assess infection:
  • No test available that can show immediate infection because there is a window period. The window period is the time when infected to when a test can deliver a positive result (hence detect antibodies against the virus which is known as seroconversion).
  • Window periods vary on the test (some are earlier than others).
  • A person can have the virus in the body (get a negative test result) because not enough time has passed for the test to pick it up (still can transmit). If a person suspects they may have HIV they need to abstain for sex and drug usage until confirmation. There are tests available that can show infection a couple of weeks to months after infection, but not immediately.
  • Tests Types:
    • Combination test: tests for the antigen and antibodies of HIV
      • HIV antigen is p24 (shows HIV as early as 2 weeks)
    • Antibody HIV test: some types can give rapid results and you can self-test with these types but can’t detect as early as the combination test (2 ½ weeks) and test for the antibody (not antigen)
    • Nucleic acid test (NAT): assesses for the virus hence its RNA and measures the amount of virus in the blood (viral load)
      • used for high risk exposure patients
      • the test that can detect the earliest (around 10 days after exposure)
      • not commonly used unless high risk and showing symptoms due to costs of the test
    • CD4 count: not used to show if HIV positive but used to measure the helper t cells (when count falls too low the patient is at risk for opportunistic infections)
      • Normal range: 500 to 1500 cells/mm3 (cells per millimeter)…in this stage it should be greater than 500 cells per millimeter
      • <200 cells/mm3 AIDS and opportunistic infection
    • Antiretroviral therapy (ART) should be started as soon as possible (lowers viral load , lowers chance of transmission of virus, lowers risk of OIs)

Chronic Stage (Asymptomatic Stage):

• May not have signs and symptoms
• This stage can last up to a decade or more for people who are NOT taking medications to treat and some who are taking ART may stay in this stage and may never progress to the last stage…AIDS.
• Lower viral load but the virus is still replicating and destroying the cells
• Can still transmit HIV to others (ART can help lower this chance)
• CD4 count is more than 200 to about 500 cell/mm3
• No opportunistic infections present at time
• Stage ends: viral count increasing, CD4 drops less than 200, signs/symptoms start to appear along with opportunistic infections

Acquired Immunodeficiency Syndrome (AIDS)

• Last Stage
• Immune system will be completely destroyed by the virus (viral load very high and person can easily spread to others) and without medications survival time is only a few years
  • Diagnosed with AIDS if:
    • CD4 count drops to less than 200 cells per millimeter or
    • Opportunistic disease is present

Opportunistic Diseases or Infections:

This is a quick review over the main types of OIs a patient can experience with AIDS. The types of OIs include:

Cancerous, Viral, Bacterial, Fungal or Protozoal

Cancerous:

Kaposi’s Sarcoma: This is seen mainly in people who have a decreased immune system. It causes the small blood vessels to grow abnormally. This form of cancer can grow in various places like: the lymph nodes, organs, mucous membranes (mouth, throat etc.). It presents as dark purplish brown lesions. Below you can see Kaposi Sarcoma in the mouth. This patient has AIDS and CD4 count of less than 200. Also note the white film on the lesion this is another opportunistic infection called candidiasis.

Viral:

CMV (cytomegalovirus): It’s a virus that when assessed with magnification it has what is called an “owl eye” appearance like this picture here.

This virus can cause multiple problems in the body and affect the lungs, brain, GI system, and eyes. For example, CMV can cause retinitis in patients with AIDS and lead to blindness. Here is an illustration of a lesion caused by CMV on the eye that would be similar to what is seen with a funduscopic.

Epstein-Barr virus (EBV): A hallmark finding in a late stage of HIV that signals the immune system is being taken over by the virus is called oral hairy leukoplakia. These are white hair like spots on the side of the tongue that can’t be removed. The EBV can lead to this finding.

Herpes Simplex Virus (HSV): This virus causes cold sores and genital herpes depending on the type (I or II). It doesn’t tend to cause severe problems in people with healthy immune systems, but in AIDS it can lead to deadly infections and complications.

Bacterial:

Mycobacterium tuberculosis: It spreads easily in the air and affects the lungs and other parts of the body like the brain etc. Watch for s/s: night sweats, weight loss, trouble breathing, coughing

Salmonella septicemia: occurs from eating contaminated food or drinking contaminated water

MAC (Mycobacterium Avium Complex): These are various types of mycobacterium which is found in the environment that normally don’t harm people with healthy immune systems

Streptococcus Pneumoniae: causes pneumonia (educate about preventative vaccine Pneumovax)

Fungal:

Candidiasis: this happens in people without AIDS, but in a patient with AIDS it’s severe and doesn’t go away easily. It’s typically found in the mouth, vagina and lungs.

Coccidioidomycosis: infected from inhaling spores which are found in the soil

Crytococcosis: can cause  pneumonia and affect the neuro system

Histoplasmosis: found in soil that has a lot of animal feces in it like from birds. It causes a lung infection that can affect the neuro system

Pneumocystis pneumonia (PCP): causes a lung infection

Protozoal: parasitic type infections

Toxoplasmosis: parasitic infection that can be inhaled (found in cat and bird feces) or from ingestion of pork and red meat. It infects the lungs and other structure of the body.

Cryptosporidiosis (Cryto): GI problems

Cystoisosporiasis: infected from contaminated food and water that causes GI problems

Education on How to Prevent OIs

Patients develop OIs because of a WEAKEN immune system.

“Weaken”

• Water consumed should be treated (not from untreated sources and avoid water in foreign countries)
• Eat foods that are NOT raw or unpasteurized (avoid: raw meats, unpasteurized dairy products, or anything undercooked)…toxoplasmosis
• Avoid risky sexual activities (major risk for STIs) and drug activities
• Keep vaccines up-to-date (pneumonia major risk for death)
• Exposure to animal feces should be limited (birds, cats, rats).. toxoplasmosis
• Need to take ART (antiretroviral) therapy as prescribed to help maintain a healthy immune system

Nurse’s Role and Treatments for HIV/AIDS

Our Goal: Screening patients for possible HIV infection, Educating (testing, transmission, preventing OIs, antiretroviral therapy), Monitoring labs, patient’s signs/symptoms for opportunistic diseases (progression of the disease)

Who’s at risk? Anyone who has or is participating in an activity that allows their blood system or mucous membranes to come into contact with body fluids that transmit HIV.

As the nurse ask your patient questions about the following topics to help guide you in screening patients for HIV:

• Sexual behavior (assess if sexually active, how often, ever had an STI, barrier devices used, and number of partners)
• Drug usage (type or using devices to use drugs)
• Blood transfusions especially before 1985 (didn’t screen very well for HIV or AIDS virus)

If at risk, needs to be tested with HIV antibody testing. It’s very important HIV is detected early so ART can be initiated, prevent transmission, etc.

CDC recommends that high risk patients have yearly testing.

And that everyone ages 13 to 64 should be tested for HIV regardless of risk factors at least once during a routine health visit. This is because some people have HIV, don’t know it, and unknowingly spread it to others. If the patient is positive, they will need a lot of support and education. (“HIV Testing CDC”, 2020)

Educate High Risk Patients:

PrEP: Pre-Exposure Prophylaxis

• Prevents becoming infected with HIV BEFORE an encounter with HIV
• Must be HIV negative but engages in high risk activities that could transmit HIV
• Higher chance of prevention with sexual contact than with injecting drugs
• Truvada (emtricitabine/tenofovir disoproxil fumarate)
• Descovy (emtricitabine/tenofovir alafenamide)

PEP: (Post-Exposure Prophylaxis)

HIV medications taken AFTER an encounter with an HIV infected person to help prevent HIV.

• Has to be started within 72 hours of the exposure
• Not for routine use (if at high risk consider PrEP) but in emergencies (sexual assault, needle stick etc.)
• Taken for 28 days
• Example:
  • Truvada and Isentress (Raltegravir)
  • Truvada and Dolutegravir (Tivicay)
    • not for pregnant women or could become pregnant due to birth defects

Preventing Transmission, if Positive

Limit or eliminate activities that transmit HIV

• Nurse needs to assess patient’s understanding of how to prevent transmitting sexually and with drug use. Educate based on the patient’s needs, the importance of getting partners or others tested if they have participated in these activities with them.

Pregnancy: HIV can be spread to the baby during pregnancy, birth, and in breastmilk.

• Needs to start ART therapy during pregnancy to help decrease the transmission to baby. Breastfeeding should be avoided because breastmilk contains the virus.
• According to HIV.gov: “if HIV medications are taken as prescribed during pregnancy and childbirth and given to the baby for 4- 6 weeks after birth there is a 1% or less chance the baby will develop HIV.” (Preventing Mother-to-Child Transmission of HIV, 2021)

So, with that said, identifying and educating the pregnant woman about this is crucial in protecting a baby from HIV.

Antiretroviral Treatment (ART):

Goal of ART: limit the virus’ ability to replicate by interfering with parts of the HIV life cycle:

• Patient needs to take a combination of medications
  • typically the patient starts taking 3 medications from at least 2 drug classes
    • Result: decreases the amount of virus in the blood (viral load) within about 6 months (lower chances of transmission to others)
    • increases CD4 numbers (>500)
      • helps prevent opportunistic infections/diseases…will have these levels checked regularly to monitor treatment and make sure medication resistance isn’t developing

6 Classes of ARTs

Attachment Inhibitors:

Post-attachment Inhibitors: binds with the CD4 receptors and inhibits the HIV’s glycoprotein (gp120 knob) from being able to activate and engage the co-receptors CXCR4 and CCR5

• Trogarzo (ibalizumab)
• Given IV every two weeks (not a pill)

Attachment Inhibitors: binds to the glycoprotein on HIV (gp120) and inhibits it from engaging with the CD4 receptor

• Rukobia (Fostemsavir) (pill)

Entry Inhibitors:

Chemokine Receptor Antagonists (CCR5 Antagonist): blocks the co-receptor CCR5 on the cell so HIV can’t engage the receptor and enter the cell

• Maravirco (Selzentry) (pill)

Fusion Inhibitors: stops HIV from entering the cell (the virus must fuse with the CD4 cell in order to enter and inject its viral material into the cell)

• Enfuvirtide (Fuzeon)
• Injection in subq fat

Inhibits Reverse Transcriptase: prevents the enzyme reverse transcriptase from turning viral RNA into viral DNA

Non-nucleoside Reverse Transcriptase Inhibitors (NNRTIs): stops the enzyme reverse transcription from working by BINDING to it

• Doravirine, Efavirenz, Etravirine, Nevirapine, Rilpivirine

Nucleoside/Nucleotide Reverse Transcriptase Inhibitors (NRTIs): modifies reverse transcriptase’s role when it tries to convert viral RNA into viral DNA. This will alter the development of the HIV’s DNA so the virus can’t recreate itself.

• Abacavir, Emtricitabine, Lamivudine, Zidovudine, Tenofovir disoproxil fumarate

Integrase Inhibitors: prevents the enzyme integrase from allowing HIV to insert its DNA into the cell’s DNA

• easy to remember “tegra“…integrase
• Raltegravir (PEP), Dolutegravir, Cabotegravir

Protease Inhibitors: stops the enzyme protease from cutting the long chains of virus. This process is stopped so the immature virus can’t be assembled and mature.

• Atazanavir
• Darunavir
• Fosamprenavir

Education about ARTs:

• Even though viral load (the amount of the virus) that is in the blood is undetectable doesn’t mean the person is free from the virus (or cured)…they need to still take measures to prevent transmitting the virus others during risky activities (but risk of transmitting is low when medications are taken exactly as prescribed).
• These medications have to be taken exactly as prescribed (at the right time, frequency, dosage). The patient can’t skip dosage because the medication won’t work (viral load increases) and resistance can develop. Assess a patient’s ability to take the medications (financial, lifestyle etc.) The patient must be educated about this.
• Medications can interact with many over-the-counter medications (especially herbal)…know what other medications your patient is taking.

_References:

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_{Centers for Disease Control and Prevention. (2021). Sexually transmitted infections treatment guidelines (pp. 73–75). U.S. Department of Health & Human Services. Retrieved January 6, 2025, from https://www.cdc.gov/std/treatment-guidelines/STI-Guidelines-2021.pdf}

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