STD Management in the HIV Care Setting -- The New CDC Guidelines

Although the new guidelines on the management of sexually transmitted diseases (STDs) in the setting of human immunodeficiency virus (HIV) are not yet published, Kimberly Workowski, MD, FIDSA, Professor of Medicine, Emory University, and Team Lead, Guidelines Unit, Division of STD Prevention, Centers for Disease Control, provided a thorough overview of their contents during the 48th annual meeting of the Infectious Diseases Society of America, emphasizing that they represent the authoritative source for STD evaluation and management.

"New to these guidelines is the inclusion of special populations," Workowski said."We have included a section on corrections, with a background paper to accompany that in Clinical Infectious Diseases, because we felt it to be of critical importance, given the prevalence of STDs in correctional facilities."

The guidelines also contain new information on clinical prevention, with a key focus on high-intensity behavioral counselling. "We believe that STDs in an HIV-infected person is a sentinel event, and these patients should receive intense counselling and behavioral intervention." The revised guidelines will also include content regarding pre-exposure vaccinations for Hepatitis A and B infection, as well as human papillomavirus (HPV) vaccine studies currently in progress. "And given the high-rate of re-infection with chlamydia (CT) and gonorrhoea (GC), we have also included the need for retesting in HIV- and non-HIV-infected individuals," Workowski said.

A section on male circumcision has been added based on data which show an associated reduced risk of HIV acquisition, as well as a number of studies that show reduced acquisition of HPV and genital herpes simplex virus (HSV) acquisition in circumcised males.

With respect to prevention, pre-exposure prophylaxis has been included, specifically content on the potential of antiretroviral therapy to impact HIV transmission. "But we still have no good data on pre-exposure prophylaxis for STI prevention," Workowski said. Of note, prevention strategies regarding condom usage remain similar to earlier guidelines. The data show that correct consistent latex condom use is highly effective in preventing sexual transmission of HIV, and in reducing the risk for CT, GC and trichomoniasis. Further, their use may reduce of HSV-2, as well as genital warts and cervical cancer.

Post-exposure prophylaxis for HIV/STIs is addressed in the guidelines as well. "We wanted to highlight the fact that genital hygiene methods such as douching and washing after sexual exposure, particularly in developing countries, are ineffective and may actually increase the risk of disease acquisition," Workowski said.

Screening recommendations for STIs at the initial clinical encounter for all HIV-infected men and women now include syphilis serology and nucleic acid amplification tests (NAAT) for GC and CT at anatomic sites of exposure, whether or not condoms were used. Serology for hepatitis A, B, and C should also be done. Women should be tested for trichomonas, and undergo a cervical Pap test. For people engaging in receptive anal intercourse, NAAT should be done for CT and CG, and laboratory validated. "These tests are not FDA-cleared at pharyngeal and rectal sites, so it's very important to talk to your lab about validating the assays so you're able to use these tests, because they are much more sensitive than culture," Workowski said. And GC culture or NAAT should be done in persons engaging in receptive oral intercourse.

Workowski said the CDC anticipates November publication for the complete guidelines. When they do become available, it will be possible to order companion wall charts, pocket guides, and an educational slide deck that can be downloaded. Hard copies can be ordered here.