Guidance for STD Clinical Preventive Services for Persons Infected With HIV

A considerable amount of epidemiologic data has accumulated over the last decade showing that sexually transmitted diseases (STDs) such as syphilis, chancroid, herpes, gonorrhea, chlamydia, and trichomoniasis and abnormalities of the vaginal ecosystem (i.e., bacterial vaginosis) facilitate HIV transmission (two- to fivefold with ulcerative STDs increasing the risk the most). Clinical research has shown that symptomatic STDs increase HIV shedding among persons infected with HIV and it is likely that asymptomatic infections also produce some inflammation with resultant increased HIV shedding. One randomized trial in an African community showed that improving community level STD control decreased HIV incidence by 40%. After reviewing available data, the CDC Advisory Committee for HIV/STD Prevention released recommendations (MMWR Morb Mortal Wkly Rpt July 1998; 47:RR-12) concluding that STDs facilitate HIV transmission and that controlling STDs should be added to behavioral change as a primary HIV prevention intervention. In the United States the attributable fraction of HIV transmission facilitated by STDs has not been determined. Studies to quantitate the contribution of STDs, both symptomatic and asymptomatic, in HIV transmission are difficult to conduct and it will be many years before such data will be available. However, the committee commented that the effect of STD control on HIV prevention should be most apparent in populations with a high STD prevalence. Given all the evidence, the committee recommended that STD prevention and control be incorporated as an explicit component in HIV prevention plans. Even though the role of asymptomatic STDs and genital tract inflammation from non-STD organisms in increasing HIV shedding has not yet been clearly quantified, the committee recommended that persons infected with HIV (potential transmitters) be screened for STDs as part of clinical preventive services. It follows that these services could be most easily delivered (from the client’s point of view) during their initial HIV medical evaluation and during periodic medical care visits. If unsafe sexual behavior is occurring, and is likely to continue, risk reduction counseling should be provided and STD screening should be repeated as necessary (see Appendix B). Ryan White resources (HIV Care) are available to cover STD screening (such as urine-based chlamydia and gonorrhea nucleic acid amplification tests, and a pelvic examination to identify trichomoniasis and bacterial vaginosis). The cost for these STD tests compared with the cost of failure to prevent HIV transmission warrants STD screening as a means of HIV prevention. Since symptomatic STDs have been clearly shown to increase HIV shedding, counseling patients infected with HIV about STD symptom recognition and the importance of refraining from sexual activity until effective treatment is completed is important. Patients should know where they can receive prompt diagnosis and treatment of STDs. STD clinics can provide a backup service for diagnosis and treatment when necessary. Clinicians are urged to conduct a sexual risk assessment that includes an STD history and to discuss strategies with the patient that will facilitate adoption of risk-reducing behavior that the patient believes he/she can perform. These data should be recorded in the medical record. Preprinted forms with standardized questions can help to assure that all the basic risk behavior issues and STD history are covered, and can serve as a record to monitor behavior and intervisit STD symptoms and STDs. Specific Recommendations Risk Assessment and Health Education Obtain a sexual and injection drug use risk assessment and record in the medical chart (e.g., number of sex partners in last 3 months, location of partner meeting, known versus anonymous partners, condom use, drug/alcohol use around sexual activity). Obtain an STD history (disease/infection, number of times, approximate dates) and record in medical chart. Provide educational material about STD symptoms and advise about the importance of refraining from sexual activity until a diagnosis is made and treatment is completed. Provide advice on how to obtain STD diagnostic and treatment services (if not readily available from HIV care provider, use a local STD clinic). Assess the patient’s perception of their risk for STDs. Identify risk-reduction activities that the patient believes can be accomplished. Develop and record a risk reduction plan. Provide referral to risk-reduction programs as needed. Discuss the need for partner HIV counseling and testing and, if patient is infected with an STD, discuss the need for partner STD treatment and testing. Local HIV/STD prevention programs may be able to provide assistance in delivering partner management services. Clinical Preventive Services and Screening Tests Specific STD clinical preventive services for persons infected with HIV are listed in Table 1. We recommend that clinicians caring for persons infected with HIV provide these services at the initial medical evaluation and at least once for patients in on-going care, especially for persons who report ever having had an STD or have a lifestyle indicating unsafe sexual behavior; repeat periodically based on the client’s sexual behavior. For persons who have been practicing unsafe sex and are likely to continue these practices, providing risk-reduction client-centered counseling (refer to risk reduction counseling program–Appendix C) and periodic STD screening should be strongly considered (e.g., prevention case management). Likewise, clients infected with HIV who have an STD diagnosed at the initial exam should have a repeat STD screening every 3 to 6 months, since data show that the risk of having another STD in the near future is increased. Table 1: STD Clinical Preventive Services and Screening Recommendations for HIV-Infected Persons on Initial Visit and Whenever Sexual Exposure Indicates Repeat ScreeningRepeat tests can be obtained during follow-up medical evaluations. Some testing, such as urine-based chlamydia and gonorrhea tests, could also be obtained at counseling sessions. In some instances, medical care providers could share the delivery of prevention services with early HIV intervention programs and STD clinics.