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 (twoto 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 This document was developed by infectious disease experts of the California STD Controllers Association (CSTDCA), the California Conference of Local AIDS Directors (CCLAD), the STD Control Branch and the Office of AIDS, California Department of Health Services. Evidence reviewed in this process included local STD prevalence data among persons with HIV or in at-risk groups. The Guidance was written by Robert A. Gunn, MD, MPH, Past Chair, CSDTCA, and STD Control Officer, Office of Public Health, Health and Human Services Agency, San Diego, CA; Jeffrey D. Klausner, MD, MPH STD Control Officer, Department of Public Health, San Francisco, CA; and Alice Gandelman, MPH, Director, California STD/HIV Prevention Training Center, Berkeley, CA. The membership of both the CSTDCA and CCLAD approved the final document. Correspondence: Robert A. Gunn, MD, MPH, STD Control Officer, 3851 Rosecrans Street, San Diego, CA 92110. E-mail: [email protected] Received for publication November 20, 2000, and accepted February 21, 2001.