Important note: Information in this article was accurate in July 2002. The state of the art may have changed since the publication date.
In May, the Centers for Disease Control and Prevention (CDC) released a new version of their guidelines for the diagnosis and management of STDs [MMWR May 3, 2002 / 51(RR06);1-80]. The previous version was released in 1998. These guidelines are reviewed and updated by expert consensus panels every 4-5 years, and they represent the standards for the clinical management of STDs in the U.S. This article will highlight and explain some important new changes in the CDC treatment guidelines that may have particular relevance to clinicians treating HIV-infected patients.
Chlamydia is a prevalent infection among adolescents and young adults and is the most common bacterial STD in the U.S. The sequelae of untreated chlamydia infection include pelvic inflammatory disease as well as tubal infertility and ectopic pregnancy related to tubal scarring. As such, it poses a particular health burden on women. Untreated chlamydial infection also biologically enhances HIV transmission. Asymptomatic chlamydia infections are common, both for men and for women, making aggressive screening programs among populations at risk the major public health strategy for reducing the adverse health outcomes associated with chlamydia infection. Recent reports describe a very high rate of reinfection among young persons treated for chlamydia [Burstein, et al. JAMA 1998 Aug 12;280(6):521-6; Rietmeijer, et al. Sex Transm Dis 2002 Feb;29(2):65-72]. This reinfection rate is unlikely to be due to antibiotic failure, but rather is related to reinfection from contact with untreated sex partners or to new infection due to repeated exposure within a high prevalence sexual network. In this version of the treatment guidelines, the CDC recommends re-screening at 4-6 months following treatment of chlamydia in women.
Fluoroquinolone Resistance Among Neisseria gonorrhoeae Isolates
There were over 350,000 cases of gonorrhea reported in the U.S. in 2000, the last year for which complete surveillance data have been released, making this the second most common reported infectious disease. Gonorrhea rates are highest among adolescents and young adults, particularly among racial and ethnic minorities living in poverty. Untreated gonorrhea causes reproductive sequelae similar to that of chlamydia, and it also biologically facilitates the transmission of HIV. Evolving antibiotic resistance represents a major obstacle to successful worldwide control of gonorrhea. Ciprofloxacin has been used to treat gonorrhea since 1993, with only sporadic reports of resistance in the U.S. through the 1990s. However, in 2000, ciprofloxacin resistance among N. gonorrhoeae isolates was reported to be endemic in Hawaii. Resistance was known to be endemic in Southeast Asia and countries of the Pacific Rim since the mid-1990s and appeared to be marching eastward. With this version of the STD Treatment Guidelines, the CDC warns that fluoroquinolone resistance has become so common on the west coast of the continental U.S. that ciprofloxacin, ofloxacin, and levofloxacin should no longer be used as first line therapy to treat gonorrhea infections. Cefixime and ceftriaxone are recommended as first-line antibiotics in Hawaii and California. Health care providers throughout the U.S. are encouraged to remain vigilant for the possibility of treatment failure when fluoroquinolones are used to treat gonorrhea, and to report identified cases of fluoroquinolone resistant gonorrhea to the CDC.
Ongoing STD Prevention Needs of HIV-infected Persons
Current national HIV prevention strategies emphasize the need to provide more aggressive STD prevention services to those already infected with HIV in the settings where they receive clinical services. This version of the CDC STD Treatment Guidelines makes a strong statement about the need for HIV clinical providers to regularly discuss sexual risk behaviors during clinic visits, provide risk reduction counseling to those whose behavior may continue to expose others to HIV, and screen for new, curable sexually transmitted infections (syphilis, gonorrhea, chlamydia) on an annual basis. A newly identified sexually transmitted infection in a person known to be HIV-infected signals the need for more intensive or more
specialized counseling. More extensive guidelines for STD screening and counseling for use in the HIV treatment setting have been developed jointly by the CDC/IDSA and should be released shortly.
Emphasis on STD Prevention Services for Men Who Have Sex With Men (MSM)
Rising rates of rectal gonorrhea and outbreaks of syphilis among men who have sex with men have been reported from many U.S. cities and indicate an urgent need for all health care providers to enhance STD screening, treatment, and prevention services in this population. Specific practice standards for MSM appear for the first time in the 2002 edition of the CDC STD Treatment Guidelines. Healthcare providers are urged to routinely discuss sexual risk behavior with all male patients, including specifically assessing the gender of partners. For MSM who are sexually active, the CDC guidelines recommend annual screening for HIV, syphilis, gonorrhea (oral, urethral and rectal sites) and for chlamydia (urethral and rectal sites).
Though urine-based screening of asymptomatic men for gonorrhea and chlamydia through nucleic acid amplification tests is convenient and widely accepted, these tests have not yet been commercially licensed for specimens collected from oral or rectal sites. Detecting infection in these sites may require culture (and chlamydia culture may not be widely available). Hepatitis A and B vaccination for non-immune MSM patients is also recommended.
Using Type-specific HSV-2 Serologic Tests
The majority of persons with recurrent outbreaks of genital herpes are infected with HSV-2. Antiviral therapy, either used episodically to treat outbreaks, or used chronically for suppression, can either shorten the course of symptoms or prevent outbreaks. It is estimated that 50 million Americans are infected with HSV-2, and the vast majority of these are individuals who are either asymptomatic or who have not had symptoms that led a health care provider to diagnose genital herpes. These infected individuals still shed HSV-2 at nearly the same rates as those who have had symptomatic outbreaks and have been diagnosed with genital herpes. Viral detection methods (viral culture or tests based upon HSV antigen detection) are
insensitive for the diagnosis, particularly if obtained from patients with atypical or healing herpes lesions. Type-specific herpes serologic tests based upon detection of antibodies to the glycoprotein G2 have been licensed in the U.S. since 1999, and when applied to a population with a relatively high risk for HSV-2 may be very useful in identifying cases. False positive tests can occur, and they are not useful tests for population-based screening. Because current tests on the market are IgG based, the current tests may be insensitive for detecting HSV infection in those who have new infection and have not yet seroconverted at the time of clinical evaluation. Serologic testing may be particularly useful in diagnosing infection in a
person with lesions that are atypical but suggestive of herpes and in counseling the partner of a person with known genital herpes. Some experts recommend consideration of HSV-2 type specific testing for all persons presenting for HIV care [Sex Transm Dis 2001 Aug;28(8):460-3].
Providing effective clinical services for STDs in the clinical setting relieves symptomatic illness, prevents adverse sequelae of STDs, and prevents STD transmission in the wider community. Aggressive STD screening, appropriate clinical management, and effective risk reduction counseling in those already diagnosed with HIV infection and in those at high risk for HIV is a critical component of the national HIV prevention agenda. Copies of the Sexually Transmitted Disease Treatment Guidelines—2002 can be obtained from http://www.cdc.gov/std.
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