FYI on STDs

Educational Objectives

The goal of this program is to improve screening for and treatment of HIV and other sexually transmitted diseases (STDs) in primary care settings. After hearing and assimilating this program, the clinician will be better able to:

1.   Implement screening recommendations for HIV, Chlamydia trachomatis (CT), and gonorrhea.

2.   Incorporate HIV testing into routine screening procedures.

3.   Interpret HIV test results and select appropriate treatments.

4.   Describe new and established concepts in screening for CT and gonorrheal infections.

5.   Select appropriate treatment for CT and gonorrheal infections in pregnant women.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning com­mittee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose.

Acknowledgments

Dr. Hersh spoke in Ocean City, MD, at Family Physicians Gathering Strength: 2009 Annual CME Assembly and Trade Show, presented June 20, 2009, by the Maryland Academy of Family Physicians. Dr. Hering spoke in Minneapolis, MN, at 23rd Annual Family Medicine Today, Building Blocks of Knowledge for Primary Care, presented March 12-13, 2009, by the HealthPartners Medical Group & Clinics, Department of Family Medicine, and HealthPartners Institute for Medical Education, Center for Continuing Professional Development. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

HIV: Family Physician's Role in Diagnosis and Treatment

Eva S. Hersh, MD, Chief Medical Officer, Chase Brexton Health Services, Baltimore, MD

Terminology: HIV both name of virus and name of disease; HIV attacks CD4 cells; CD4 count  —  number of cells/mL; measures degree of disease and effectiveness of treatment; viral load (VL)  —  number of copies of HIV per milliliter of blood; genotype  —  virus’ genetic sequence and, by extrapolation, sensitivity to anti-HIV drugs; phenotype  —  which medications effective for that genotype; determined empirically; opportunistic infection prophylaxis (OIP)  —  given at specific CD4 counts to prevent specific opportunistic infections; antiretroviral (ARV) medications  —  formerly known as highly active antiretroviral therapy (HAART); opt-out testing  —  automatic testing for HIV unless patient declines; opt-in testing  —  consent form signed to allow testing

HIV in United States: in 2008, 56,000 people newly infected with HIV; 1.3 million people in United States living with HIV; »25% of HIV-infected individuals unaware of infection; twice as many infections transmitted before di­agnosis (>50% of new HIV infections transmitted by those with undiagnosed disease)

Centers for Disease Control and Prevention (CDC) HIV screening recommendations (2006): test all persons 13 to 64 yr of age in all health care settings, especially where other tests routinely done; patients notified of HIV test­ing on general consent form (opt-out screening); test patients with high-risk behaviors (eg, multiple sex partners, intravenous drug users [IVDU]) ³1 time/yr; no testing interval for individuals without known risk factors, but test all patients ³1 time

HIV in the United States: geography  —  mainly in metropolitan areas; rates in rural areas increasing; infection rates highest in Miami, followed by Baltimore and Washington DC; ethnicity and sex  —  although blacks 13% of US pop­ulation, in 2006, blacks comprised »50% of new US AIDS cases and 90% of new AIDS cases in Maryland; HIV predominantly in black men, but rates of HIV- positive Hispanic men and black women increasing; data from Africa indicate that infection in women will equal and perhaps exceed those in men over time

HIV transmission patterns: heterosexual contact  —  fastest increasing route of transmission; more efficient in women than men (transmission to receptive sexual partner more efficient than to insertive partner); accounts for 80% of new cases in women; receptive anal intercourse  —  most common route of transmission in men

Diagnosis of AIDS often missed: claims data from 8 US health maintenance organizations reviewed; identified >7500 cases with potentially AIDS-defining diagnoses (eg, Pneumocystis pneumonia [PCP], cryptococcal menin­gitis, lymphoma, invasive cervical cancer) with no diagnosis of HIV; »4% tested for HIV during period from 5 mo before to 2 mo after AIDS-defining diagnosis made; conclusion  —primary care physicians not testing for HIV in inpatient and outpatient care; several major organizations of internists and obstetricians/gynecologists recommend universal HIV screening; American Academy of Family Physicians (AAFP) has not yet taken position; goal to make HIV testing as routine as cholesterol screening; CDC recommends that specific written consent no longer be required; federal government denies Ryan White HIV funding to states requiring specific written consent

HIV in Maryland: many heterosexual women unaware of risk; IV drug users assumed to have contracted HIV through drug use (most direct route of transmission); bisexual men assumed to have contracted HIV from men; age  —people 50 to 59 yr of age comprise 25% of cases; no longer at risk, but had risk factors in past; may be at ad­vanced stage of infection; resurgence of HIV in young (20 to 29 yr of age) gay men, particularly among minorities

Criteria for screening: HIV meets all criteria; 1) serious health problem; 2) can be diagnosed before symptoms develop; 3) diagnosis inexpensive and noninvasive; 4) major health gains when treated before symptoms de­velop; 5) screening cost-effective (dollars saved by avoiding acute care exceed testing costs)

Reasons for reluctance to screen: my patients do not want HIV tests  —  patients assume HIV testing done when blood drawn for other tests; routine testing eliminates stigma associated with testing and decreases need to screen for risk factors (determining risk factors still important for prevention); there is little HIV in my practice  —  recommended in areas where prevalence >0.1% (most areas in United States); patients routinely screened for low-prevalence diagnoses, eg, invasive cervical cancer; discussing HIV testing takes too much time  —  pretest counseling not required; inform patients about opt-out consent on general consent form (opting-out indication for further dis­cussion); retesting at provider's discretion (previous recommendation to retest after 3 mo, but not necessary if no risky behaviors); negative results may be given by phone or letter; we do too many screening tests  —  simple test (eg, serum, saliva, or fingerstick blood test); can order when blood drawn for common laboratory tests; in-office tests cost $8 to $16; what do I do if it is positive?  —discuss with patient; have supportive other present, if possible; explain health status and benefits of immediate treatment; notify partner anonymously or in office; educate about preventing transmission (eg, condoms, safer sex); recommend limited disclosure of status (potential sex partners and supportive others); offer social work and mental health support; obtain laboratory tests and schedule 2- to 3-wk follow-up visit

Initial work-up of HIV: CD4 (absolute number and percent); viral load; baseline genotype; complete blood count (CBC; anemia common in HIV patients); metabolic profile (look for hepatitis and kidney disease); fasting lipid profile (for cholesterol baseline, because ARVs affect cholesterol); test for other sexually transmitted diseases (STDs); screen for hepatitis A, B, and C and immunize against hepatitis A and B if patient not immune); skin test for tuberculosis; annual Papanicolaou test

Interpretation of results: CD4 count  —  determines stage of disease and whether OIP and/or ARVs needed; CD4 count <200/mL  —  AIDS defined; OIP and ARVs needed; CD4 count 200/mL to 350/mL  —  ARVs needed; OIP not needed; CD4 count 350/mL to 500/mL  —  consider ARVs; CD4 >500/mL  —may defer ARVs; possible indicators to start ARV when CD4 count >350/mL  —  any stage of pregnancy (to prevent transmission to fetus); HIV-associated nephropathy (refer patient with any renal impairment to nephrologist for biopsy); VL >100,000 indicates rapid HIV progression; CD4 count falling >100 points/yr; active chronic hepatitis B or C; ³50 yr of age, due to age-acceler­ated effect (however, no evidence of benefits in treating older HIV patients at earlier stages); percent CD4  —  indicates proportion of WBCs that are CD4 cells; less variable than absolute CD4 count; CD4 percent <14 defines AIDS; VL  —  maps disease over time; useful in monitoring therapy; monitor VL progression; goal is undetectable VL by ultrasensitive tests; women have lower VLs than men at same stage of disease (eg, women at risk for rapid progression with VL ³50,000; baseline HIV genotype  —  checks for resistance before choosing treatment; 10% of patients initially infected with resistant virus transmitted from patient taking ARVs (in HIV patient not on ARVs, virus mutates back to wild type); in some cases, multiple HIV strains present due to virus mutation; in viral subpop­ulations, genotype may not show resistance, as one strain dominant (usually wild type; resistance will likely occur when treatment implemented); hepatitis panel  —  if hepatitis B virus (HBV) surface antigen (HbsAg) present (ie, active HBV infection), check HBV DNA, which indicates stage of HBV infection and quantity present; if hepatitis C virus (HCV) antibody present, check HCV RNA; »10% of patients with HCV infections recover; VL indicates active HCV infection or past infection; VL helps physician choose medications and timing of initiation; coinfection (HIV with HBV or HCV) speeds progression of both diseases

Prophylaxis of opportunistic infections: start if indicated; no resistance, even if patient partially compliant; CD4 <200/μL  —  co-trimoxazole (Bactrim) single or double strength once daily for PCP prophylaxis; if allergic to Bac­trim, substitute dapsone 100 mg/day; CD4 <50/mL  —  PCP and mycobacterium avium intracellulare complex (MAC) prophylaxis; treat MAC with azithromycin 1200 mg once weekly or 600 mg twice weekly (if patient has nausea); do not give prophylaxis if patient already has MAC (risk for resistance); if signs of MAC infection present (eg, unexplained fever or anemia), take culture for MAC; if culture negative, start prophylaxis

Where to refer: HIV specialist (physician who cares for >50 HIV patients); American Academy of HIV Medicine (AAHIVM)  —gives certification as HIV expert; www.aahivm.org

Starting ARVs: do not start until patient ready; increased risk for resistance with missed doses; MAC prophylaxis one way for patient to practice taking medications daily; increases probability of compliance with treatment; ad­dress barriers (eg, depression, substance abuse); 85% to 90% compliance required for ARV effectiveness

Resources: San Francisco Warm Line (800-933-3413)  —http://www.nccc.ucsf.edu/; open 24 hr; questions answered by phone or email

Case study: 55-yr-old black woman; HIV-positive on routine screen; no risk factors; not IVDU; not sexually active; CD4 count 220/mL; hepatitis screen negative; past medical history  —depression; high blood pressure; osteoporo­sis; seizures; alcohol use; conclusion  —  OIP not needed (CD4 count >200/mL); ARVs needed, but must ensure compliance before treatment; efavirenz  —  key element of 1-pill-once-daily treatment; optimal for compliance; low­ers seizure threshold, so contraindicated in patients with seizure disorder; patient acceptance  —  has difficulty ac­cepting diagnosis; refuses treatment; 4 mo later  —  CD4 count 190/mL (CD4 percentage 12); unprepared for ARVs; refuses specialist referral; starts co-trimoxazole; 6 mo later  —  oral thrush; 10-lb weight loss; feels ill; considers ARVs; starts atazanavir (Reyataz), ritonavir (Norvir), and tenofovir/emtricitabine (Truvada); starts fluconazole for oral thrush (200 mg on day 1, 100 mg/day for 9 days); 4 mo after  —  CD4 count 230/mL; VL undetectable; creati­nine concentration increased from 1.1 mg/mL to 1.5 mg/mL (likely due to effect of tenofovir on kidneys); substi­tute abacavir/lamivudine (Epzicom) for Truvada; 2 mo after  —creatinine at baseline; CD4 count 245/mL; VL undetectable; do not stop co-trimoxazole until CD4 count >200 for 6 mo

STDs: Are you Asking the Right Questions?

John W. Hering, MD, Clinical Associate Professor of Obstetrics and Gynecology, University of Minnesota Medical School, and Department of Obstetrics and Gynecology, HealthPartners Medical Group and Clinics, Minneapolis, MN

Virgins and sex: virgins can be sexually active; 55% of teenage boys have had vaginal sex; two-thirds of teenage boys have engaged in oral sex, anal sex, and masturbation by partner; >1 in 10 boys engaged in anal sex; 50% of boys received oral sex from girls; more than one-third had performed oral sex on girls; teen magazine online survey revealed that teenagers 13 to 18 yr of age do not perceive oral sex as “sex”

Study of pharyngeal gonorrhea in Tel Aviv: 301 women sex workers; pharyngeal cultures positive for Neisseria gonorrhoeae (GC) in 27 (9%); urine polymerase chain reaction (PCR) positive for gonorrhea in 3% of women; 88% of participants use condoms regularly during vaginal sex; 60% of participants use condoms regularly during oral sex

Adolescents’ perception of sex: oral sex precedes or substitutes for intercourse; black and Hispanic boys almost twice as likely as whites to engage in anal intercourse; anal and oral sex perceived as abstinence by some

Study of adult sexual practices: 12,571 men and women 15 to 44 yr of age surveyed (79% response rate); results  —one-third of men and women have had anal sex; three-quarters of men and women have had oral sex; condom use during last oral or anal sex uncommon

Effect of values on behavior: condoms worn only for vaginal sex to prevent pregnancy and HIV; oral sex not consid­ered adultery; prostitutes require condoms for vaginal sex, but not oral sex; friends require condoms for vaginal sex, but not oral sex; female can engage in oral and anal sex and still be considered virgin

Questions to ask when patients say, “I always use a condom”: for all sexual activity? for vaginal and/or anal, but not oral sex? for vaginal sex only? importance of sexual history  —  how and what questions asked and responses de­termine nature of screening for STDs

Chlamydia trachomatis (CT): symptoms in throat  —  in 17 of 65 cases (26.2%) of tonsillitis, CT recovered from ton­sillar crypts; 10 of 17 CT-positive patients presented for recurrent sore throat and 5 of 17 for lingering tonsillitis; 11 of 17 CT-positive patients had pertinent histories of orogenital sexual activity; prevalence of CT infections  —  found in uterine cervix in 33.3% of sex workers and 7.9% of women in general; found in pharynx in 22.5% of sex workers and 5.2% of women in general

Testing for CT in throat and rectum: no clear CDC recommendations for testing; CT cultures or Gen-Probe acceptable

Treatment of CT: CDC does not mention pharynx, but recommended treatments for CT of cervix or urethra probably suitable; standard care  —  azithromycin (1 g single oral dose) or doxycycline; alternative regimens  —  erythromycin base; erythromycin ethylsuccinate; ofloxacin; levofloxacin; pregnant women  —  all regimens acceptable except ofloxacin and levofloxacin

Testing for GC in pharynx and rectum: CDC recommends Thayer-Marten plates; Gram stain does not work in women

Treatment of GC in cervix, urethra, and rectum: ceftriaxone recommended for all adults and adolescents, (1 dose, 125-mg intramuscular injection); cefixime and ciprofloxacin also used; ofloxacin and levofloxacin permissible ex­cept in pregnant women; treat for CT in all patients with GC; CDC does not recommend quinolones for men who have sex with men and recent immigrants; test and treat patients whose partners have GC or CT

Skin as barrier: herpes, HIV, and GC do not penetrate intact skin; herpes, human papillomavirus (HPV), GC, and syphilis enter via mucous membranes of rectum, urethra, and cervix

Hepatitis B: transmission  —  through vaginal and anal intercourse; percutaneous contact with bodily fluids (eg, se­men)

Suggested Reading

Bachmann LH et al: Nucleic acid amplification tests for diagnosis of Neisseria gonorrhoeae oropharyngeal infections. J Clin Micro­biol 4:47, 2009; Butler AM et al: Impact of disclosure of HIV infection on health-related quality of life among children and adoles­cents with HIV infection. Pediatrics 3:123, 2009; DeJesus E et al: Impact of switching virologically suppressed, HIV-1-infected patients from twice-daily fixed-dose zidovudine/lamivudine to once-daily fixed-dose tenofovir disoproxil fumarate/emtricitabine. HIV Clin Trials 2:9, 2008; Mascolini M et al: XVII International AIDS Conference: From Evidence to Action  —  Clinical and bio­medical prevention science. J Int AIDS Soc 6:12, 2009; Mimiaga MJ et al: Gonococcal, chlamydia, and syphilis infection positivity among MSM attending a large primary care clinic, Boston, 2003 to 2004. Sex Transm Dis 8:36, 2009; Mofenson LM et al: Guide­lines for the Prevention and Treatment of Opportunistic Infections among HIV-exposed and HIV-infected children: recommendations from CDC, the National Institutes of Health, the HIV Medicine Association of the Infectious Diseases Society of America, the Pedi­atric Infectious Diseases Society, and the American Academy of Pediatrics. MMWR Recomm Rep 4:58, 2009; Ota KV et al: Detec­tion of Neisseria gonorrhoeae and Chlamydia trachomatis in pharyngeal and rectal specimens using the BD Probetec ET system, the Gen-Probe Aptima Combo 2 assay and culture. Sex Transm Infect 3:85, 2009; Paul KJ et al: Generation C: prevalence of and risk factors for chlamydia trachomatis among adolescents and young women in Lima, Peru. J Womens Health 9:18, 2009; Rahim S et al: Geographic and temporal trends of transmitted HIV-1 drug resistance among antiretroviral-naïve subjects screening for two clinical trials in North America and Western Europe. HIV Clin Trials 2:10, 2009; Rhee SY et al: Predictive value of HIV-1 genotypic resis­tance test interpretation algorithms. J Infect Dis 3:200, 2009; Smith KY et al: Randomized, double-blind, placebo-matched, multi­center trial of abacavir/lamivudine or tenofovir/emtricitabine with lopinavir/ritonavir for initial HIV treatment. AIDS 12:23, 2009; Strauss SM et al: HIV care providers' implementation of routine alcohol reduction support for their patients. AIDS Patient Care STDs 3:23, 2009.