CONSEQUENCES OF RISKY BEHAVIOR
From the 33rd Annual Family Practice Refresher Course, sponsored by the David Geffen School of Medicine at the
University of California, Los Angeles
| SEXUALLY TRANSMITTED DISEASE (STD) UPDATE —Richard A. Johnson, MD, Clinical Professor of Family Medicine
and Radiology, David Geffen School of Medicine at the University of California, Los Angeles and Staff Physician,
Palisades Medical Group, Pacific Palisades, CA
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| 2002 Centers for Disease Control and Prevention (CDC) guidelines: few changes from 1998 guidelines;
chlamydia—rescreen patients 3 to 4 mo after treatment (to look for reinfection, not test of cure); levofloxacin added as
effective quinolone; gonorrhea—becoming quinolone-resistant; dual therapy recommended
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Chlamydia Infections
| Prevalence: ≤20% in high-risk populations; 4 million cases annually; if untreated, can cause pelvic inflammatory disease
(PID), resulting in infertility; complications in newborn delivered through infected birth canal; majority of cases asymptomatic;
more common and more easily acquired in women than men; predominantly disease of young adults and teenagers
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| Diagnostic tests: historical gold standard—grown on mammalian cell lines in tissue culture (similar to virus); today’s
standard—nucleic acid amplification methods (NAAMs), eg, polymerase chain reaction (PCR), ligase chain reaction
(LCR), transcription-mediated amplification (TMA), strand displacement amplification (SDA); more accurate
than culture; performed on first-void urine specimens or on cervical or vaginal discharge; live organisms not required;
positive ≤3 wk after treatment because of residual DNA; enzyme immunoassay (EIA)—in-office testing; specific (no
false positives) but only 60% to 90% sensitive (10%-40% of cases missed); possibly good for noncompliant patient populations
(do not return for results on more sensitive testing); not big role in current diagnosis; Papanicolaou (Pap)
test—cannot diagnose chlamydia; leukocyte esterase test (LET)—used on urine samples from men; sensitive but not
specific; needs confirmation by DNA testing, unless high suspicion for chlamydia
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| Treatment: uncomplicated chlamydia—azithromycin 1 g po single dose; doxycycline 100 mg po bid for 7 days; alternative
regimens—erythromycin regimens not tolerated well; ofloxacin and levofloxacin (also used for gonorrhea); retest
only if symptoms persist or if patient pregnant; female patients retested in 3 to 4 mo for reinfection; partner
screening—if patient symptomatic, treat all partners within last 30 days; if patient asymptomatic, treat all partners
within last 60 days or last sex partner; azithromycin—good tissue penetration, long intracellular half-life, category B in
pregnancy, and well tolerated; 2-g dose approved by Food and Drug Administration (FDA) for treatment of gonorrhea, so
simultaneous treatment of chlamydia and gonorrhea possible, but not recommended because of poor tolerability
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Gonorrhea
| Diagnostic tests: historical gold standard—culture on chocolate agar; today’s standard—NAAM; PCR and LCR
15% to 20% more sensitive than culture; remain positive for ≤3 wk after treatment; same advantages and types of specimens
as for chlamydia; NAAM can also be used on liquid-based Pap tests
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| Treatment: cefixime 400 mg po single dose or ceftriaxone 125 mg intramuscular (IM) single dose; almost all quinolones
(ciprofloxacin, ofloxacin, and levofloxacin) effective in single doses as long as no quinolone resistance present; spectinomycin
useful in special circumstances and pregnancy; other single-dose cephalosporins (ceftizoxime, cefoxitin, cefotaxime)
can be used; azithromycin 2 g po single dose FDA-approved, but can cause significant side effects; test of
cure—not needed, unless quinolone used; quinolone resistance ≈25% in Hawaii and 5% to 15% in California; sex
partners—same principles as chlamydia; disadvantages of quinolones—resis--tance; not used if patient <17 yr of age
or pregnant; cefixime—effective, category B in pregnancy, and relatively inexpensive; at present, difficult to find 400-
mg tablets; use 20 mL of pediatric 100 mg/5 mL suspension; other oral cephalosporins—cefuroxime (Ceftin), cefpodoxime
(Vantin) and ceftibuten (Cedax); not CDC-approved because only 85% to 95% effective (CDC requires >95%
cure rate)
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| Screening issues: same for chlamydia and gonorrhea; since screening and treatment easy and disease often asymptomatic,
physician should screen all patients in target age group; serious morbidity and mortality—chance of infertility
≈100% after 3 episodes of chlamydia; chance of infertility 20% with 1 episode of PID
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Viral STDs
| Genital ulcers and inguinal lymphandenopathy: herpes common; remember chancroid, syphilis, and lymphogranuloma
venereum (LGV) in patients with nontraditional sexual practices (eg, men who have sex with men
[MSM]); people from overseas, eg, Africa has higher rates of chancroid and LGV
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| Herpes simplex virus-II (HSV-II): one fifth of US population infected (ie, have IgG antibodies to HSV-II), but of
these, only ≈5% have symptoms; misunderstood by public; can be psychologically disabling; serious problems occur in
immunocompromised patients and if initial infection in third trimester of pregnancy (risk for congenital herpes)
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| Viral shedding: patients without history of infection shed virus ≈5% of year (17-18 days/yr); patients with positive history
but no current lesions also shed ≈5% of year; patients with symptomatic disease and current lesions shed ≈60% of
days with lesions; risk for transmission to uninfected partner 5% to 10% per year (abstaining during outbreaks); study
found 4-fold reduction in transmission with daily oral valcyclovir
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| Herpes simplex virus-I (HSV-I): most people infected with HSV-I by 25 to 30 yr of age (manifested by oral lesions);
patients positive for HSV-I have lower rate of recurrence and reduced severity of HSV-II infection
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| Diagnosis of HSV-II: primarily by clinical presentation; NAAM and antibody tests not helpful; cultures only 60% to
70% sensitive (must perform on early lesions); classic symptoms— itching, tingling, or burning of skin for 12 to 72 hr;
vesicles that scab over; tender inguinal lymphadenopthy; painful urination, vaginal or urethral discharge; viral prodrome
(fever, arthralgia, myalgia) more common with primary infection; can be subtle, eg, simple fissures or abrasion; screening
not recommended by CDC; possibly use antibody testing during pregnancy if partner positive and pregnant woman
negative
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| Treatment: primary episodes—treatment with acyclovir, famciclovir, or valcyclovir reduces duration of pain (1 to 3
days) and reduces healing time (2 to 5 days); recurrent episodes—use of medications reduces symptoms by few hours
to 1 day if patient-initiated
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| HIV and AIDS —Mark H. Katz, MD, Regional HIV/AIDS Physician Coordinator, Kaiser Permanente, Southern California
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| Twelve things to know: no changes in transmission; health care worker risk <0.5% from high-risk exposure; primary
HIV infection presentation similar to flu or mononucleosis; during “window period,” patient infected and can infect others,
but antibody test not yet positive; use T cell count and viral load (VL) together for tracking; screen HIV-positive patient
for other infectious conditions (eg, tuberculosis [TB], syphilis, hepatitis B and C, neoplasms); commonest cause of diagnosis
of AIDS in HIV-positive patient T cell count <200/mm3 , Pneumonocystis jirovecii (formerly carinii) pneumonia
(PCP) second most common; usually use 3 drugs (never monotherapy); always treat pregnant HIV-positive patient (goal to
have VL low as possible); must treat pregnant patients with AIDS; use prednisone with PCP treatment; major opportunistic
infec--tions—purplish skin lesions, think Kaposi’s sarcoma (KS); dyspnea, think PCP; dysphagia, think esophageal
candidiasis; visual disturbances, think cytomegalovirus (CMV) retinitis; fever, chills, sweats, and anemia, think Mycobac-terium
avium complex (MAC); headaches, think toxoplasmosis, cryptococcosis, or lymphoma; diarrhea, think
cryptosporidiosis
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| Epidemiology and transmission: 40 million people worldwide with HIV, majority in sub-Saharan Africa; fastest rate
of new infections in Eastern Europe; India has largest number of HIV infections; ≈1 million in North America; death
toll >30 million; introduction of protease inhibitors in 1996 caused death rate to plummet by >80%; percentage of infected
non-Hispanic whites decreasing, but epidemic soaring in blacks and slightly increasing in Hispanics; young
adults still targeted (≈25% females); 25% to 30% of HIV-positive women in United States have AIDS; more people
living with HIV; co-epidemics—in Los Angeles county starting in 2001, increase in syphilis cases in MSM, majority
of whom known HIV-positives; soaring methamphetamine use associated with HIV-positive status
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 | Transmission: risk highest after initial infection (when VL high and before immune system can contain infection); unable
to detect HIV by blood test during initial infection; risk behaviors—unprotected sexual contact; injection drug use;
lack of circumcision (in Africa, circumcision shown to reduce transmission; associated with histologic changes in
glans); substance abuse (altered judgment); transmission occurs when blood, semen, or vaginal secretions of infected
person come into immediate contact with break in skin or mucous membrane of recipient; rates of infection—blood
transfusion 90%; risk with other exposures <1%; pregnan--cy—zidovudine (AZT) alone, given in second and third
trimesters, lowers rate of transmission to infant by two thirds (25% to 30% without treatment); at present, transmission
8% with single drug and with 3-drug therapy in mother, <100 infants with HIV born in United States over past year
(600000 in Africa); postexposure prophylaxis (PEP)—indicated for high-risk exposure; 2 to 3 drugs for 30 days,
starting as soon as possible (within 3 days) after exposure; should have educational component; virtually zero seroconversion
on such regimens; prophylaxis initiated immediately; prophylaxis not recommended if HIV status unknown
(use judgment); in study, 5 counseling sessions during PEP reduced high-risk behaviors 6 mo to 1 yr after PEP
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| Diagnosis: HIV testing—blood enzyme-linked immunosorbent assay (ELISA) standard test in United States; buccal
mucosal ELISA (Epitope) and urine ELISA also used; home blood collection kit available without prescription; rapid
HIV test performed in 15 to 30 min but must be confirmed by Western Blot; diagnosis—confirm positive ELISA by repeating
ELISA (2% false positive); second positive ELISA confirmed by Western Blot; negative Western Blot, even with
positive ELISA, means HIV infection not present to extent of diagnostic capabilities at present time; false negatives due
to window period (counsel patient and retest later); false positives caused by HIV vaccine studies and factitious infection;
interdeterminate results—ELISA positive, Western Blot indeterminate; possible HIV infection; seroconversion
may be occurring (repeat in 1-3 wk); pregnancy may cause indeterminate Western Blot and false-positive ELISA;
recommendations—counsel---ing and possibly testing for sexually active college student with viral illness; know sentinel
symptoms (recurrent sinusitis, oral or vaginal candidiasis, unremitting herpes zoster); if HIV infection suspected, take
thorough risk history, suggest HIV antibody test (not VL; can be undetectable in HIV-positive patiet), and arrange follow-up
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| CDC definition of AIDS: positive HIV plus ≥1 of 25 CDC-defined conditions; most common T cell count <200/mm3 ;
less common PCP, KS, wasting syndrome, TB, and other opportunistic infections
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| Work-up of new HIV-positive patient: complete blood count (CBC), T cells, VL, chemistries, hepatitis panel, STD
screening, toxoplasmosis titer, hepatitis A and B vaccines, pneumonia vaccine, purified protein derivative (PPD), Pap test
(cervical, possibly anal), behavioral and psychosocial counseling, assessment of cardiac and osteoporosis risk, and legal
issues; VL—quantitative viral HIV RNA in copies/mL; quali--tative used for diagnosis; quantitative measured serially in
HIV-positive patients; negative VL (<50-75 copies/mL) does not mean virus not present, means virus undetectable
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| Assisted reproductive techniques for HIV-positive patient: sperm washing for men, in vitro fertilization or intracytoplasmic
sperm injection for women; refer to specialty centers
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| Treatment: goal to achieve and maintain undetectable VL and to prevent T cell destruction and opportunistic infections;
initiate treatment in—patients with AIDS, pregnant patients, and patients with symptoms (gray zone); asymptomatic
patients with T cell counts <350/mm3 or VL >100000 copies/mL; higher the T-cell count at time treatment started, more
likely patient will do well (balance with side effects of treatment); highly active antiretroviral therapy (HAART)—3-
drug therapy standard; most commonly used regimen 2 nucleoside analog reverse transcriptase inhibitors (NARTIs or
“nukes”); usually AZT or tenofovir plus lamivudine (Epivir) or emtricitabine (Emtriva); third drug non-NARTI efavirenz
(Sustiva) or protease inhibitor lopinavir/ritonavir (Kaletra); switch regimen if patient cannot tolerate it or virus not suppressed;
maximize adherence; resistance testing as indicated; treatment not usually interrupted, unless patient needs
break; care usually left to HIV specialist due to complexity; treatment monitoring goals and expectations—VL undetectable;
if VL decreases but not enough, add another drug and determine whether patient taking drug; reasons for HAART
failure—patient nonadherent, pharmacokinetics, drug not potent enough, or HIV/AIDS too advanced; frequently adjust
medication due to side effects; future—one pill, once daily
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| HIV-related metabolic changes: hyperlipidemia, diabetes or impaired insulin tolerance, body fat redistribution, osteopenia,
avascular necrosis, and lactic acidosis; 50% report change in body (central fat accumulation); HIV and HAART
treatment associated with increase in acute cardiovascular syndromes and myocardial infarction; more cancer in HIV patients
as they live longer (head and neck, liver, testicular, melanoma, Hodgkin’s disease, and lung); no increase in colorectal
or renal cancer
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Educational Objectives
| The goal of this activity is to discuss the infections and diseases that can occur as consequences of high-risk behaviors. After
hearing and assimilating this program, the clinician will be better able to:
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| 1. List the differences in the 1998 and 2002 Centers for Disease Control and Prevention (CDC) guidelines for the treatment
of sexually-transmitted diseases (STDs).
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| 2. Describe appropriate counseling and screening procedures for chlamydia, gonorrhea, herpes simplex, and HIV.
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| 3. Review the diagnosis and treatment of chlamydia and gonorrhea.
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| 4. Explain viral shedding and suppressive therapy for herpes simplex virus-II (HSV-II).
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| 5. Discuss the diagnosis, treatment, and possible long-term health care sequelae of HIV infection.
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Discussed on this Program
Acyclovir (acycloguanosine) [Zovirax]
Azithromycin [Zithromax, Zmax]
Cefixime [Suprax] (discontinued)
Cefoxitin sodium [Mefoxin]
Cefpodoxime proxetil [Vantin]
Ceftibuten [Cedax]
Ceftizoxime sodium [Cefizox]
Ceftriaxone sodium [Rocephin]
Cefuroxime [Ceftin, Kefurox, Zinacef]
Ciprofloxacin [Ciloxan, Cipro, Cipro I.V., Cipro XR, Proquin XR]
Doxycycline [Adoxa, Atridox Injection, Bio-Tab, Doryx, Doxy 100, Doxy 200, Periostat, Vibramycin, Vibra-Tabs]
Efavirenz [Sustiva]
Emtricitabine [Emtriva]
Erythromycin base [Eryc, Ery-Tab, Erythromycin Filmtabs, PCE Dispertab]
Erythromycin ethylsuccinate [E.E.S. 200, E.E.S. 400, E.E.S. Granules, EryPed, EryPed 200, EryPed 400, EryPed Drops]
Famciclovir [Famvir]
Lamivudine (3TC) [Epivir, Epivir-HBV]
Levofloxacin [Levaquin, Quixin]
Lopinavir/ritonavir [Kaletra]
Ofloxacin [Floxin, Floxin Otic, Ocuflox Ophthalmic Solution]
Penciclovir [Denavir]
Ritonavir [Norvir]
Spectinomycin [Trobicin]
Tenofovir disoproxil fumarate (PMPA) [Viread]
Valacyclovir HCl [Valtrex]
Zidovudine (azidothymidine; AZT; compound S; ZDV) [Retrovir]
Suggested Reading
CDC STD Guidelines and Recommendations. http://www.cdcnpin.org/scripts/std/cdc.asp; CDC HIV/AIDS Guidelines
and Recommendations. http://www.cdcnpin.org/scripts/hiv/cdc.asp; Corey L et al: Once-daily valacyclovir to reduce
the risk of transmission of genital herpes. N Engl J Med 350:11, 2004; The Data Collection on Adverse Events of
Anti-HIV Drugs (DAD Study Group): Combination antiretroviral therapy and the risk of myocardial infarction. N
Engl J Med 349:1993, 2003; Grinspoon SK: Metabolic syndrome and cardiovascular disease in patients with human immunodeficiency
virus. Am J Med 118 Suppl 2: 23S, 2005; Law MG et al: The use of the Framingham equation to predict
myocardial infarctions in HIV-infected patients: comparison with observed events in the D:A:D Study. HIV Med 4:218, 2006;
Lifson AR el al: Reporting and evaluation of HIV-related clinical endpoints in two multicenter international clinical trials.
HIV Clin Trials 7:125, 2006; Morse CG, Kovacs JA: Metabolic and skeletal complications of HIV infection: the price of
success. JAMA 296:844, 2006; NHANES III data. http://www.cdc.gov/nchs/about/major/nhanes/nh3data.htm; Pantanowitz
L, Schlecht HP, Dezube BJ: The growing problem of non-AIDS-defining malignancies in HIV. Curr Opin Oncol
18:469 2006.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue the following
has been disclosed: Dr Katz is on the Speakers’ Bureau for Boehringer-Ingelheim and Abbott Pharmaceuticals.
Drs. Johnson and Katz were recorded in Beverly Hills, CA, at the 33rd Annual UCLA Family Practice Refresher Course,
sponsored by the David Geffen School of Medicine at the University of California, Los Angeles, and held June 5-9, 2006.
The Audio-Digest Foundation thanks the speakers and sponsor for their cooperation in production of this program.
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