• Insertive and receptive oral sex
• Insertive and receptive anal sex

• Urethra
• Pharynx
• Rectum

• Urethritis: dysuria, clear to purulent urethral discharge
• Rectum: usually asymptomatic ( May cause anal discomfort, tenesmus, mucopurulent discharge )
• Pharynx: asymptomatic

• Gonorrhea
  • PHAC Guideline – Ceftriaxone 250 mg IM PLUS Azithromycin 1g PO
  • CDC Guideline – Ceftriaxone 500 mg IM alone
  • Alternate – Cefixime 800mg PO
• Chlamydia
  • Urethra and pharyngeal – Azithromycin 1g PO
  • Proctitis – Doxycycline 100 mg BID for 7 days

Transmission

• Oral and anal sex, kissing, close intimate contact

Symptoms

• Primary: Chancre. A painless red papule or shallow ulcer on penis, around anus, and/or in mouth.
• Secondary: Systemic symptoms. May include a generalized or localized rash, headache, myalgias, etc.
• Early latent: asymptomatic and infected within the last 12 months
• Late latent: asymptomatic and infected more than 12 months ago
• Organ involvement: Uveitis and/or retinitis; hepatitis; meningitis; nephritis, etc

Testing

• Blood test. Request “syphilis serology” on an Ontario Public Health Laboratory requisition.
• Negative: A nonreactive syphilis screening test.
• Positive: This will include (1) a reactive syphilis screening test, (2) a reactive confirmatory Treponema pallidum particle agglutination (TP-PA) if not done previously, and (3) an RPR titer.

Treatment

• Primary, secondary and early latent:
  • Benzathine Penicillin (Bicillin) 2.4 million units IM as a single dose.
  • Alternate: Doxycycline 100 mg BID for 14 days
• Late latent:
  • Benzathine penicillin (Bicillin) 2.4 million units IM weekly for 3 weeks.
  • Alternate: Doxycycline 100 mg BID for 28 days
• Neurosyphilis, ocular syphilis and/or other organ involvement should be managed by, or in consultation with, an infectious diseases specialist.

• Physical contact. Active lesions increase risk of transmission.

• Painful vesicular rash and ulcers on penis, scrotum, and/or around the anus.

• Swab active lesions and send in viral transport media for either culture or nucleic acid amplification (NAAT).

• First outbreak:
  • Acyclovir 200mg PO 5 times a day for 5-10 days
  • Famciclovir 250mg PO TID for 5 days
• Valacyclovir 1000mg PO BID for 10 days

• Recurrent outbreak:
  • Acyclovir 800 mg TID for 2 days
  • Famciclovir 125 mg BID for 5 days
  • Valacyclovir 1000 mg daily for 3 days
• Suppressive therapy:
  • Acyclovir 400 mg BID
  • Famciclovir 250 mg BID
  • Valacyclovir 500 mg daily if <9 recurrences per year / 1000 mg daily if >9 recurrences per year

• Physical contact

• Warts on penis and/or around anus

• None. Diagnosis is by visual inspection.

• Patient applied:

1. Podofilox 0.5% solution or gel apply to wart BID for 3 days, followed by 4 days of no treatment. Repeat up to 4 times.
2. Imiquimod 5% cream apply once daily at bedtime, 3 times a week for 16 weeks. Wash area 6-10 hours after application.
3. Sinecatechins 15% ointment apply to warts TID for no more than 16 weeks

• Provider applied:

1. Cryotherapy with liquid nitrogen. Repeat every 1-2 weeks.
2. Podophyllin resin 10-25% apply to warts, use <0.5mL per session, wash area 1-4 hours after application. Repeat weekly.
3. Trichloroacetic acid 80-90% apply to warts, repeat weekly.

• GARDASIL®9 (Human Papillomavirus 9-valent Vaccine, Recombinant)
  • 0.5 mL IM administered at 0, 1-2 and 6 months.
• Gardasil-9 is recommended for all gay men regardless of age.
  • Free through Public Health for gay men <26 years of age
  • Covered by some insurance plans for men >26 years of age. Cost: ~$600

• Hep A: Oral-Anal contact, poor sanitation, contaminated food or water
• Hep B: exchange of bodily fluids through sexual intercourse or needle sharing
• Hep C: exchange of blood through needle sharing. Low transmission by exchange of bodily fluids through sexual intercourse.

• Ranges from asymptomatic with increased transaminases on blood work to fulminant liver failure with nausea, fatigue and jaundice.

• Blood test using an Ontario Public Health Laboratory requisition.
• Hep A:
  • positive HAV IgM antibodies indicate acute infection
  • positive HAV IgG antibodies indicate immunity
• Hep B:
  • Positive surface antigen indicates chronic active Hep B infection
  • Positive surface antibody and core antibody indicate resolved Hep B infection
  • Positive surface antibody and negative core antibody indicate immunized with Hep B vaccine.
• Hep C: positive HCV antibodies, then Hep C nucleic acid amplification to confirm active infection.

• Hep A: self-limited. No treatment
• Hep B: suppressive therapy with entecavir, tenofovir or lamivudine
• Hep C: curative treatment with direct acting antivirals. Choice depends on genotype.

• Hepatitis A:  HAVRIX, 1 mL (1440 ELU) at 0 and 6 months
• Hepatitis B:
  • Engerix-B, 1 mL (20 mcg HBsAg) at 0, 1 and 6 months
  • Recombivax HB, 1 mL (10 mcg HBsAg) at 0, 1 and 6 months
• Hepatitis A and B: Twinrix, 1 mL at 0, 1 and 6 months
• Hepatitis C: no vaccine

• Insertive and receptive oral and anal sex

• Small ulcers on penis or inside anus
• Inguinal lymphadenopathy or anal inflammation causing pain, constipation, anal discharge and/or bleeding.

• LGV is caused by a more virulent strain of Chlamydia known as the L serovar. Detection is as for typical forms of Chlamydia with nucleic acid amplification (NAAT).
• Urethra: collect first voided urine (20-60mL), not midstream
• Rectum: swab. First moisten the swab with tap water. Then insert 4 cm into the rectum.

• Doxycycline 100mg BID for 3 weeks

• Oral-anal contact (known as “rimming”)

• Watery diarrhea, abdominal cramping/bloating, and flatulence

• Collect 3 separate stool samples and send stool for detection of Giardia lamblia trophozoite or cyst. Use an Ontario Public Health Lab requisition.

• Metronidazole 500 mg twice daily for 5-10 days