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Sexually transmitted diseases (STDs) constitute an important source of morbidity in incarcerated patients. In addition, the presence of an STD is a clear sign of HIV risk behavior. The presence of an STD in an inmate should (1) stimulate a discussion of HIV risk behaviors; (2) prompt a discussion of the need for follow-up HIV testing; and (3) provide an opportunity to teach inmates about the facilitating role some STDs play in HIV transmission. This article reviews the diagnosis and treatment of common STDs and highlights differences in the clinical presentation or management of STDs in the HIV infected patient.
Numerous studies have documented high rates of incident STDs in people with HIV (1,2). Though STD rates in people with HIV declined in the early years of the HIV epidemic (3,4), recent reports of rising numbers of cases of gonorrhea, chlamydial infection and syphilis mandate a state of vigilance, particularly among inmates who have participated in unsafe sexual practices (5). These rising STD rates are concerning not only because they suggest increased levels of unsafe sexual behavior, but also because gonorrhea, syphilis, HSV, and other STDs are associated with increased HIV shedding in genital secretions and, consequently, increased HIV transmission (6).
Limited information on the prevalence of STDs among prison and jails inmates is available. One study, however, estimated that approximately 210,000-345,000 (2.6-4.3%) of inmates released from prisons and jails in 1997 had syphilis at the time of release, 184,000 (2.3%) had chlamydia, and 70,000 (1%) had gonorrhea (7). Studies of women in New York City jails found a much higher prevalence of STDs; 35% of jailed women had syphilis at the time of arrest, 27% had chlamydia and 8% had gonorrhea (8, 9). In a separate study, the rate of syphilis infection was determined to be 1000 times higher among women admitted to New York City jails in 1997 (6.5 infections per 100 woman-years) than the rate of syphilis among women in the surrounding community (New York City) (8).
Case reports and case series early in the course of the AIDS epidemic suggested that patients with HIV may be prone to more rapid progression of syphilitic disease and atypical clinical presentations. (See figure 1) In particular, patients with HIV were reported to have early occular or neurological involvement, gummatous lesions, ulcerative skin lesions and persistent chancres. More recently, a large prospective study of 101 HIV-infected and 440 HIV-uninfected patients with syphilis found that patients with HIV were more likely to have multiple chancres and a slow serologic response to therapy, but were not more likely to have early ophthalmic or neurosyphilis (10).
The laboratory evaluation of syphilis can be altered by HIV. Typically, this evaluation consists of non-treponemal screening tests (RPR) and confirmatory testing with specific treponemal tests (MHA-TP, TPHA, or FTA) when the RPR is positive. Patients with HIV may have atypical results from all of these tests. Among injection drug users with or without HIV, biological false positive results on non-treponemal serological tests (RPR or VDRL) are more common (thus a positive RPR or VDRL is always followed by a more specific test). In addition, people with HIV are more likely to revert to a negative treponemal test following treatment (11).
In cases where syphilis infection is present (a positive RPR and confirmatory test such as an FTA), clinicians should carefully evaluate the patient and stage the infection. Which patients require lumbar puncture (LP) for presumed tertiary syphilis is controversial. CDC recommends that LP be performed on HIV- and syphilis-infected patients with neurological or ocular symptoms, those with late latent syphilis (>1 years duration), and those who experience a rise in titer following treatment or fail to have at least a 2-dilution decline in serum titer within 6-12 months following therapy. Clinicians should consider performing treponemal tests on cerbrospinal fluid (CSF) for patients with HIV, as other signs of tertiary syphilis (elevated CSF protein and pleocytosis) may be associated with HIV infection and may obscure results. (12)
Case reports of treatment failure, the delayed serological response to therapy, and the recognition of the role typically played by the cellular immune response in controlling syphilis have raised concerns about the adequacy of standard syphilis treatment regimens in HIV patients. To date, prospective studies have not demonstrated that conventional treatment is associated with an elevated risk of treatment failure and CDC treatment recommendations for syphilis do not differ for patients with HIV (see HIV 101, Page 7)(13). However, even the largest published study was not adequately powered to exclude the possibility that HIV patients are at significantly elevated risk of treatment failure. Consequently, extra vigilance is required in monitoring HIV patient's response to therapy and repeat serological testing should be performed 3, 6, 9, 12 and 24 months after treatment.
Genital herpes simplex virus (HSV) infections are extremely common in incarcerated HIV-infected patients. Typical manifestations of genital herpes include pustules, vesicles, ulcers and crusted genital lesions. However, viral shedding in the absence of symptoms or with only mild symptoms such genital tingling, itching or numbness is common. HSV can also cause urethritis, cervicitis, atypical appearing perianal ulcers and fissures, and proctitis. Diagnosis is usually made clinically but can be confirmed by direct fluorescent antibody testing or viral culture of specimens taken from lesions using a Dacron swab.
In people with HIV, herpes can cause extremely painful and severe lesions that are slow to respond to therapy. Clinical occurrences of HSV reactivation, both symptomatic and asymptomatic, increase in frequency and duration at lower CD4 counts. CDC recommendations for the treatment of genital herpes in patients with HIV do not differ from those without HIV. However, because response to therapy can be delayed, treatment should be continued beyond the standard 10 days if ulcers have not healed or if new lesions continue to appear. Chronic suppressive therapy with anti HSV agents such as Acyclovir (or derivatives such as Famcyclovir or Valacyclovir) have been shown to decrease the frequency and duration of symptomatic outbreaks of genital HSV as well as asymptomatic HSV shedding in patients with HIV. Suppressive treatment should be considered in patients with frequent or severe recurrences (14). While acyclovir resistance has very seldom been a problem in immunocompetent patients, resistance does occur in the context of HIV associated immunosuppression and, resistance testing should be performed in HIV-infected patients who fail to respond to therapy. Foscarnet is the drug of choice to treat resistant virus.
More than 100 different human papillomaviruses (HPV) have been detected and, combined, these viruses are the most common STD. Current studies suggest that over 50% of sexually active adults have been infected with one or more HPV types (15). Most often, HPV infection causes genital warts, however some types of HPV infection are linked to cancer. While overlap in clinical manifestations exists, HPV types 16, 18, 31 and 35 are responsible for most cases of cervical and anal cancer, while types 6 and 11 are the most common causes of genital warts.
Anogenital warts most commonly present as verrucous (cauliflower appearing) or papular lesions (condyloma acumiminata). Less frequently, warts can be keratotic (like palmar warts), smooth (dome-shaped), or flat. Flat warts are more common within the vagina. Warts can occur anywhere in the anogenital area and usually are asymptomatic, though some patients complain of rectal discomfort, itching, burning or discharge, symptoms that they frequently attribute to hemorrhoids. HIV patients with CD4 counts below 50 are more likely to have diffuse condylomatosis. At higher CD4 counts, extensive warts and the prevalence of HPV of low oncogenic potential do not appear to be increased (16).
Therapy for genital warts can be divided into patient applied-treatments and provider applied or administered treatments (see HIV 101, page 7). An excellent review of these treatments was recently published (17). CDC recommendations for wart treatment do not differ for people with HIV. No consensus exists regarding a single best approach, therefore decisions regarding care need to factor in patient preference, patient ability to follow application instructions, wart location and accessibility, and cost. Referral to a specialist is indicated if no improvement is seen after 3 treatments, complete clearance has not occurred after 6 treatments, or continued treatment would extend beyond the duration recommended by manufactures of patient applied therapy. Over treatment should be avoided. Unfortunately, recurrence of warts following treatment is extremely common. Patients with more extensive initial disease are more prone to recurrence. Treatment with HAART has been associated with a significant decline in wart recurrence (18).
HIV-related immunosuppression is associated with an elevated risk of genital shedding of oncogenic HPV types, cervical and anal dysplasia, invasive cervical cancer and possibly anal cancer. Incarcerated women with HIV infection should have regular Pap screening. Many correctional institutions have set guidelines for performing Pap smears every 6 months for incarcerated women as they belong to a very high risk group with limited access to healthcare outside correctional facilities. Care is then based on Pap smear results as detailed in published guidelines (19). While some authorities have advocated anal Pap smears be done on men with HIV, the natural history of anal dysplasia remains ill-defined and the utility of Pap smears in preventing cancer is controversial. Current guidelines do not recommend anal Pap smears for men (20). However, clinicians should have a low threshold for performing biopsies on suspicious lesions.
Neisseria gonorrhoeae and Chlamydia trachomatis are common causes of STD in people with HIV. Gonococcal urethritis is symptomatic in over 80% of cases, however, chlamydial urethritis is asymptomatic in as many as 50% of cases, and most cervical, pelvic and anorectal infections with both pathogens are asymptomatic. Urethral Gram stain is 95% sensitive in detecting gonorrhea, but rectal and cervical testing are much less sensitive, and culture or DNA amplification testing are generally required to make a diagnosis. Laboratory tests for detecting Chlamydia trachomatis vary in sensitivity from 30-98% (21). DNA amplification testing is most sensitive and is recommended when available. HIV is not known to affect the natural history of these infections in men, however, pelvic inflammatory disease in women with HIV may be more protracted and the risk of tubo-ovarian abscess may be increased (22). Recommended treatment of these infections is the same as for non-HIV infected persons.
Trichomonas vaginalis, a protozoan STD, is a common cause of vaginal discharge, may increase the risk of transmission of HIV, and may also predispose pregnant HIV-infected women to premature rupture of membranes and early labor. Diagnosis is difficult, since the symptoms of trichomoniasis mimic those of other STDs and detection methods lack precision. Although current treatment protocols involving nitroimidazoles are curative, reinfection is common among incarcerated women. Yeast (Candida albicans) infections are also extremely common among HIV-infected women and recurrent vaginal yeast infections may be the first presentation of HIV infection. Topical treatment is usually effective, however chronic suppression with oral fluconazole is necessary in some cases of frequent recurrence. Resistance may occur. Bacterial vaginosis, the most common cause of vaginal discharge or malodor, is caused by mixed flora including anaerobic bacteria, Garderella vaginalis, and Mycoplasma hominis. Metronidazole is effective.
A major challenge for STD treatment is related to the high population turnover rate - more than 50% of arrestees are released within a 48 hour period (8, 22). This high turnover rate makes STD screening an even more important public health intervention. However, despite widespread knowledge about the high STD prevalence among newly incarcerated women and men, less than half of city and county jails surveyed in a CDC study had implemented "routine STD screening" policies. Most facilities polled for the study said that STD testing was performed only if a patient requested the test or if the patient presented with STD symptoms (see Table 1) (23).
In light of these challenges, correctional facilities should develop routine STD screening programs, especially for persons with HIV (24). STD screening should be performed fairly regularly after incarceration (in conjunction with Pap smears) as both HSV and Trichomonas have been noted to be increased in HIV-infected incarcerated women.
The CDC recommends chlamydial screening for all sexually active women under age 20, women 20-24 with either more than one partner in the preceding 60 days or a history of inconsistent use of barrier contraception, and women 25 and over with both of these risk factors. Many recently incarcerated women would qualify for gonorrhea, syphilis, and chlamydia screening by these criteria.
Over the last decade, chlamydial screening programs have been established in some correctional facilities in the U.S, though most US city and county jails test for STDs only if inmates present for symptoms (25). The prevalence of chlamydia infection detected by jail based screening programs has generally vastly exceeded that seen in non-incarcerated populations (26).
HPV-associated cervical cancer can be prevented by routine Pap screening. Among HIV -infected incarcerated women, 6-monthly or annual pelvic exams for Pap smears are already part of routine HIV care.
Screening for syphilis in jail populations has been shown to be cost-saving, however, screening is still not routine in many facilities (Table 1) (23). Screening should be routine for all incarcerated HIV-infected patients at the time they initiate care for HIV (if not already performed at intake). The RPR test should be repeated annually, regardless of whether or not patients are released to the community and return to prison (27). Clinicians should maintain a low threshold for repeating the RPR test in the assessment of patients with genital ulcers, new rashes of uncertain etiology and changes in mental status.
A study at the Cook County Jail in Chicago (CCJ) demonstrates the public health importance of syphilis screening in corrections. CCJ used the "stat RPR" test to screen for syphilis. As a result, the number of cases identified at the CCJ increased from 10% of Chicago's total to 22%. After implementation of the Stat RPR protocol in the CCJ, cases of early syphilis rates for women in the Chicago actually decreased by 24%. This certainly suggests that declining syphilis morbidity in the city might be related to increased screening and improved treatment (24).
Another approach, implemented in NYC, involved developing an algorithm for triaging patients based on RPR tests and city records. Use of this algorithm led to an increase in the number of patients treated for syphilis from 7% to 84% of women and 88% of pregnant women. Seven out of eight babies who might otherwise have required treatment for congenital syphilis did not need to be treated because their mothers were adequately treated while incarcerated (8).
Very little data on screening for STDs in HIV infected incarcerated men currently exists. Given the important role that asymptomatic, prevalent STDs may play in HIV transmission, it seems reasonable to err on the side of extra screening as data accumulates. One approach is to screen at least annually for rectal gonorrhea and chlamydial infection by culturing all men who may have engaged in receptive anal intercourse, screen all recently incarcerated men for urethral chlamydial infection, and culture the pharynx for gonorrhea in patients who may have engaged in receptive oral sex (28).
Counseling about safer sexual habits should be a routine part of the screening process. Providers should emphasize that adopting safer behaviors is important not only to prevent HIV transmission, but also to safeguard the patient's individual health. It is important to use every STD clinic visit as an opportunity to educate the patients about well recognized and common STDs (gonorrhea, chlamydial infection, syphilis, herpes, warts) as well as diseases that many patients may not generally associate with sexual transmission, such as cervical and anal cancer, Kaposi's sarcoma, and, possibly, drug-resistant HIV. In cases of bacterial STDs and HIV, providers should emphasize the importance of notifying sex partners and, when needed and possible, should request the assistance of public health authorities to do so.
*Nothing to disclose.
1. Zenilman JM, Erickson B, Fox R, et al. JAMA 1992 Feb 12;267(6):843-5.
2. Otten MW, Jr., Zaidi AA, Wroten JE, et al. Am J Public Health 1993 Apr;83(4):529-33.
3. Golden MR, Rompalo AM, Fantry L, et al. Sex Transm Dis 1996 Sep-Oct;23(5):370-7.
4. Osewe PL, Peterman TA, Ransom RL, et al. Sex Transm Dis 1996 May-Jun;23(3):230-3.
5. CDC. "Gonorrhea Among Men Who Have Sex with Men -- Selected Sexually Transmitted Diseases Clinics, 1993-1996" MMWR September 26, 1997/Vol. 46/No. 38:889-892.
6. Fleming DT, Wasserheit JN. Sex Transm Infect 1999 Feb;75(1):3-17.
7. This information was derived from limited reports from five jurisdictions to the CDC Prevalence Monitoring program, and extrapolated to represent the greater prison and jail population based on comparison of gender-specific screening in the local free populations. Overall prevalence was estimated based on the gender distribution of jail inmates reported by the Bureau of Justice Statistics in 1997. Hammett TM, Harmon P, Rhodes W. The Burden of Infectious Disease Among Inmates and Releasees from Correctional Facilities. Prepared for: National Commission on Correctional Health Care-National Institute of Justice "Health of Soon-to-be-Released Inmates" Project, Chicago IL, June 14-15 1999. Updated via personal communication, Ted Hammett, Abt Associates, December 8, 2000.
8. Blank S. J Infect Dis 1999 Oct;180(4):1159-63.
9. Holmes MD, Safyer SM, Bicknell NA et al. Am J Public Health 1993 Apr;83(4):551-5.
10. Rolfs RT, Joesoef MR, Hendershot EF, et al. N Engl J Med 1997 Jul 31;337(5):307-14.
11. Janier M, Chastang C, Spindler E et al. Dermatology 1999;198(4):362-9.
12. Marra C. Neurosyphilis. In: Davis L, PGE K, eds. Oxford: Butterworth Neinemann; 2000:373-400.
13. CDC. MMWR Recommendations and Reports, January 23, 1998 / 47(RR-1);1-118.
14. Schacker T, Hu HL, Koelle DM, et al. Ann Intern Med 1998 Jan 1;128(1):21-8.
15. Koutsky L, NB K. In: Holmes K, ed. Sexually Transmitted Diseases. third ed. New York: McGraw-Hill; 1999:347-359.
16. Palefsky JM, Holly EA, Ralston ML, et al. J Infect Dis 1998 Feb;177(2):361-7.
17. Beutner KR, Wiley DJ, Douglas JM, et al. Clin Infect Dis 1999 Jan;28 Suppl 1:S37-56/ (See also see MMWR 1998 Guidelines for Treatment of STDs, available at http://ww2.aegis.org/pubs/mmwr/1998/RR4701.html).
18. Orlando G, Fasolo MM, Schiavini M, et al. Aids 1999;13(3):424-5.
19. Kurman RJ, Henson DE, Herbst AL, et al. Jama. 1994;271(23):1866-9.
20. Kaplan JE, Masur H, Holmes KK, et al. Clin Infect Dis. 2000;30 Suppl 1:S15-28.
21. Marrazzo JM, Stamm WE. Curr Clin Top Infect Dis. 1998;18:37-59.
22. Irwin KL, Moorman AC, O'Sullivan MJ, et al. Obstet Gynecol. 2000;95(4):525-34.
23. CDC. MMWR 1998 Jun 5;47(21):429-31.
24. CDC MMWR. 1998;47(RR-12):1-24.
25. CDC. Assessment of Sexually Transmitted Disease Services in City and County Jails-United States, 1997. MMWR 1998 Jun 5;47(21):429-31
26. Parece MS, Herrera GA, Voigt RF, et al. Sex Transm Dis. 1999;26(8):431-7.
27. Marrazzo JM, White CL, Krekeler B, et al. Ann Intern Med. 1997;127(9):796-803.
28. Van Hoeven KH, Rooney WC, Joseph SC. Am J Public Health. Dec 1990; 80(12):1505-6.
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©1997,1998,1999,2000. The recently formed HIV Education Prison Project (HEPP) is a medical education program that targets a growing population, inmates in correctional facilities, that has been underserved in HIV care. It is part of the Brown University AIDS Program. Permission to use and reproduce portions of this newsletter is hereby granted provided that author and publication are fully credited and both copyright and permission notice appear with reprinted material. Inquiries may be directed to heppnews@brown.edu. Website: HIV Education Prison Project.
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