CDC's latest STD guidelines have changes for HIV clinicians to follow

Routine screening for STDs, HIV recommended

The latest sexually-transmitted diseases (STDs) treatment guidelines provide relevant new data about the increasing rates of risk behavior and STDs among HIV infected and uninfected men who have sex with men (MSM).

"One thing we highlight is the importance of STD screening, at least annually, for both HIV positive and negative men for gonorrhea, syphilis, and chlamydia," says Kimberly A. Workowski, MD, FACP, an associate professor of medicine in the division of infectious diseases at Emory University in Atlanta, GA.

Workowski is a co-author of the Sexually Transmitted Diseases Treatment Guidelines, 2006, which was updated for the first time in four years on Aug. 4, in the Morbidity and Mortality Weekly Report of the Centers for Disease Control and Prevention (CDC) in Atlanta. Workowski also will be discussing the guidelines at the 44th Annual Meeting of the Infectious Diseases Society of America, held Oct. 12-15, 2006, in Toronto, Ontario, Canada.

"We have to make sure if [at-risk people] have been vaccinated for hepatitis A and B that they're immune, and if they have not been vaccinated, then we recommend vaccination for all HIV-infected folks and men who have sex with men," Workowski says.

Another change in the recommendations involves screening for lymphogranuloma venereum (LGV), which is caused by C. trachomatis serovars L1, L2, or L3. While clinicians typically find manifestation of LGV among heterosexuals in tender inguinal and/or femoral lymphadenopathy, they should also look for proctocolitis, which is the result of rectal exposure, Workowski notes.

Clinical presentation of proctocolitis, especially among HIV-infected MSM, has become more common, she adds.

Proctocolitis includes symptoms of inflammation of the rectum, diarrhea, abdominal cramps, and inflammation of the colonic mucosa. If LGV is detected, then the treatment is 100 mg of Doxycycline therapy, administered twice daily for three weeks.1

"Most clinicians think of LGV disease in a different way," Workowski says. "But this presentation is a bloody discharge and pain in the rectum, so it's different from what providers commonly are seeing."

Also, acute, sexually-transmitted hepatitis C might be found in HIV-infected MSM, Workowski says.

About 15-20 percent of people with acute HCV infection have only sexual exposure as a risk factor for the disease, and case control studies show an association between acquiring HCV infection and exposure to a sex contact with HCV infection.1

Sexual transmission of HCV often is associated with syphilis infection and other STDs, and the CDC recommends antibody HCV testing for routine screening of asymptomatic persons based on their risk for infection, such as a history of injection drug use, but also including HIV infection.1

The new STD guidelines also recommend that clinicians do not use quinolones, such as ciprofloxacin, for the treatment of gonorrhea among MSM, for people who acquired infection while traveling abroad, and for all persons in Hawaii and California because of increasing resistance. Instead, cetraxal is preferred treatment, Workowski says.

Studies show that quinolone-resistant N. gonorrhoeae is more common among MSM than among heterosexual men (23.9% versus 2.9%).1

For MSM, international travelers, and people living in California and Hawaii, the CDC recommendations are to treat gonorrhea with either a single 125 mg dose intramuscular injection of ceftriaxone or with 400 mg orally in a single dose of cefixime.

Ceftriaxone 125 mg intramuscularly in a single dose.1

"There has been increasing quinolone resistance over the last four years," Workowski notes. "There's a surveillance project in effect since the mid-1980s, and it monitors trends in antimicrobial resistance, and it recently noted an increase in quinolone resistance."

Quinolone resistance is spreading through heterosexual society, as well, and it's likely to increase to the point where quinolones won't be useful for anyone, Workowski adds.

Providers have new tools with information about treating genital herpes (HSV), she says.

Most herpes cases involve HSV-2, although HSV-1 might become more common, the guidelines say.

"There is new information that daily treatment with 500 mg of Valacyclovir decreases the rate of HSV-2 transmission among HIV-discordant couples," Workowski says.

HIV-infected persons who have HSV infection commonly have severe and painful lesions, and HSV shedding is increased among people with HIV infection, and they're more likely to be contagious for HSV.1

The guidelines recommend a regimen of 400-800 mg Acyclovir taken orally two or three times a day for daily suppression therapy in HIV patients with HSV. Alternative therapies are 500 mg orally twice a day of Famciclovir or Valacyclovir.1

For HIV patients who have episodic infection of HSV, the recommendations are for 400 mg Acyclovir orally three times a day for five to 10 days, or 500 mg orally of Famiciclovir twice a day for five to 10 days, or 1.0 grams orally twice a day of Valacyclovir for five to 10 days.1

When HSV treatment resistance is suspected, a clinician is advised to consult with an HIV specialist before administering an alternative therapy.1

"Another important advance in STD prevention is the HPV [human papillomavirus] vaccine, which has just become available for females," Workowski says.

The vaccine, called Gardasil, was approved in June and it provides protection against for strains of genital human papillomavirus, including two of the strains that cause cervical cancer.

One of the key take-home messages in the updated STD guidelines is that health providers need to be aware that most cases of STDs are asymptomatic, Workowski says.

"So it's important to screen both MSM and HIV-positive individuals that continue to engage in high-risk activities, even if their sexual activities are protected by a condom," she says. "They're still at risk for STDs."

Condoms have proven effectiveness against gonorrhea, chlamydia, and HIV transmission, and there's limited data suggesting condoms are effective against herpes and HPV, Workowski notes.

"But it's important to provide regular screening and risk assessments each time the patient comes in," she says. "The other thing is there is a re-epidemic of syphilis, especially with the presentation of secondary syphilis because primary syphilis often is missed by patients and providers when it's in areas that are not as visible, such as the mouth and rectum."

So patients might come into a clinician's office with a highly contagious case of secondary syphilis, Workowski adds.

"Ryan White grants are mandating screening for syphilis at least annually, and there's a suggestion for screening for other STDs," Workowski says.

"The biggest message about syphilis is that it's out there, and patients are asymptomatic the majority of the time, so this emphasizes the importance of vigilance and screening," she adds.

The STD guidelines recommend that clinicians ask patients a series of questions as part of the screening effort. (See story about STD screening questions, p. 101.)

"These are some nice questions to go over with patients," Workowski says. "It helps providers facilitate discussions with their patients about their sexual practices."

The other changes in the latest guidelines include a change in wording about pregnant women and HIV screening: it's now recommended as part of a routine panel of prenatal testing, Workowski says.

"This is for all pregnant women in the United States," she adds.

Also, there soon will be guidance coming out of the CDC that HIV prevention counseling no longer has to be linked to HIV testing, meaning that clinicians can test for HIV on a more routine basis among at-risk groups, without having to provide concurrent HIV counseling, Workowski notes.

"The other thing that we'll highlight for clinicians is to increase their awareness of acute retroviral syndrome in which patients present with a fever, big lymph nodes, and a skin rash," Workowski explains. "Any suspicion should prompt testing for HIV, and the reason for this is because patients who are acutely infected are highly infectious."

Acutely-infected patients also might have another STD, which is what brought them to a clinician's attention, she adds.

"There are some programs, including one in North Carolina, which have been innovative in identifying these acutely-infected patients by testing patients for HIV viral load instead of HIV antibody when they come into the STD clinic," Workowski says.

"It's important to tie HIV screening into this because of studies showing that most acute HIV infections were among people who were identified as seeking care for STDs, when clinicians also discovered acute HIV infections," Workowski explains.

Reference:

  1. CDC. Sexually Transmitted Diseases Treatment Guidelines, 2006. MMWR Recomm Rep. 2006;55:1-94.