CDC emphasizing role of STDs in HIV care
With recent surveillance data showing increases in the rates of some sexually transmitted diseases (STDs), health care professionals need to remember to screen patients for curable STDs and counsel both HIV-negative and HIV-positive patients about how STDs increase the risk of transmitting the virus.
The Centers for Disease Control and Prevention (CDC) of Atlanta, along with the Advisory Committee for HIV and STD Prevention (ACHSP), which provides oversight and guidance to the CDC, have said that early detection and treatment of STDs is an effective strategy for preventing sexually transmitted HIV infection. A CDC report on STDs and HIV notes that ACHSP makes these recommendations:
- Early detection and treatment of curable STDs should become a major, explicit component of comprehensive HIV-prevention programs at national, state, and local levels.
- In areas where STDs that facilitate HIV transmission are prevalent, screening and treatment programs should be expanded.
- HIV- and STD-prevention programs in the United States, together with private and public sector partners, should take joint responsibility for implementing this strategy.
The CDC also has published sample case examples and guidance for providing prevention messages to HIV-infected patients. These sample case situations are as follows:
Examples of Case Situations for Prevention Counseling
Example 1. A patient with newly diagnosed HIV infection comes to your office for initial evaluation. Of the many things that must be addressed during this initial visit (e.g., any emergent medical or psychiatric problems, education about HIV, history, physical, initial laboratory work — if not already done), how do you address prevention? What is the minimum that should be done, and how can it be incorporated into this visit?
CDC: Assuming no emergent issues preclude a complete history and physical examination during this visit, the following should be done:
• During the history, question how the patient might have acquired HIV, current risk behaviors, current partners and whether they have been notified and tested for HIV, and current or past STDs.
• During the physical examination, include genital and rectal examinations, evaluation and treatment of any current STD, or if asymptomatic, appropriate screening for STDs.
• Discuss current risk behavior, at least briefly. Emphasize the importance of using condoms; address active injection-drug use.
• Discuss the need for disclosure of HIV serostatus to sex and needle-sharing partners, and discuss potential barriers to disclosure.
• Note issues that will require follow-up; e.g., risk behavior that will require continuing counseling and referral and partners who will need to be notified by either the patient or a health department.
Example 2. A patient with chronic, stable HIV comes to you with a new STD. What prevention considerations should be covered in this visit?
CDC: For the patient who has had a stable course of disease, a new STD can be a sign of emerging social, emotional, or substance abuse problems. These potential problems should be addressed in addition to the STD.
• During the history, cover topics related to acquisition of the new STD — number of new partners, number of episodes of unsafe sex, and types of unsafe sex.
• Address the personal risks associated with high-risk behavior, e.g., viral superinfection and HIV/STD interactions.
• Address personal or social problems (including substance abuse and domestic violence) that might have led to a change in behavior resulting in the acquisition of the new STD; refer to social services, if necessary.
• Address other issues (e.g., adherence to HAART) that may be affected by personal or social problems. Check viral load if nonadherence is evident or is suspected.
• During the physical examination, include a careful genital and rectal examination and screen for additional STDs, such as syphilis, trichomoniasis, (for women), chlamydia infection (for sexually active women ages < 25 and selected populations of men and women), and gonorrhea (for selected populations of men and women).
• Discuss the need for partner notification and referral for counseling and testing.
• Note in the chart that risk behavior should be addressed in future visits and that tailored counseling may be needed for the patient.
Example 3. A patient with chronic, stable HIV has been seen regularly in a health care setting. What should be included in this patient’s routine clinical care?
CDC: Discussion of sexual and needle-sharing practices should be integrated into a routine part of clinical care.
• Periodically (e.g., annually) screen for STDs. STDs to be included in screening should be determined by patient’s sex, history of high-risk behavior, and local epidemiology of selected STDs.
• Reiterate general prevention messages and patient education regarding partner notification, high-risk behaviors associated with transmission, prevention of transmission, or condom use, as deemed appropriate by the clinician.
Example 4. A patient who has been treated with HAART for two years comes to you. At the time of treatment initiation, CD4+ count was 200 cells/µL and the viral load was 50,000 copies/ml. The response to therapy was prompt; CD4+ count increased to 500 cells/µL, and the viral load has been undetectable since soon after treatment began. The patient now has mildly elevated cholesterol, some mild lipodystrophy, and facial wasting. He states that he would like to stop HAART because of the side effects. What should you tell this patient?
CDC: Take the following steps:
• Inform the patient that upon stopping HAART, CD4+ count and viral load will likely return to pretreatment levels with risk for opportun-istic infections and progression of immune deficiency.
• Inform the patient that an increase in viral load to pretreatment levels likely will result in increased infectiousness and risk for transmission of HIV to sex or needle-sharing partners.
• Counsel the patient regarding the option of changing the HAART regimen to limit progression of metabolic side effects.
For patients who are not infected with HIV, diagnoses of STDs could be an important factor to consider. According to the CDC, the United States has the highest rates of STDs in the industrialized world, and the potential impact of STDs in facilitating HIV transmission depends on these factors:
• magnitude of the STD cofactor effects;
• overall STD prevalence rates;
• extent to which STDs are concentrated disproportionately among persons and subpopulations likely to be exposed to HIV.
HIV coinfection with other STDs is more likely among people with ulcerative STDs, such as early syphilis, genital ulcer disease, which suggests that it’s very important to diagnose STDs early and offer HIV prevention messages at the time of STD diagnosis.
One of the challenges faced by health care workers is getting the message across that anyone who is sexually active is at risk for an STD and that other STDs facilitate HIV transmission, according to the CDC.
Finding STD services also presents a challenge to many Americans, as only half of the local health departments offer STD prevention services, according to the CDC.
In the CDC’s Recommendations for Public Health Surveillance of Syphilis in the United States, published March 2003, this guidance is offered:
• Assure proper diagnosis, treatment, and partner management for all cases of early syphilis.
• People infected with primary syphilis have an increased risk of acquiring HIV infection, and people coinfected with syphilis and HIV are at increased risk of transmitting HIV, so patients who are infected with syphilis are good candidates for HIV prevention messages.
• Assess the effectiveness of syphilis prevention and control programs through monitoring trends of reported cases.
• Monitor syphilis outbreaks and trends within certain populations.
• Identify characteristics of infected persons and generate hypotheses regarding risk factors.
• Identify gaps in health care and missed opportunities for intervention.
• Target interventions at populations at increased risk for STDs and HIV.
(Editor’s note: For more information about HIV and syphilis and prevention, go to the CDC’s web site at www.cdc.gov.)