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Sexually Transmitted Diseases and HIV

Complications of sexually transmitted diseases

Upper tract infections

Infertility, ectopic pregnancy and chronic pelvic pain

Congenital infections, clamidia

Genital cancers

HIV coinfection

Role of STDs in HIV Transmission
Syndrome	Risk Estimate Median (range)
Genital Ulcers	4.7 (3.3 - 18.2)
Syphilis	3.0 (2.0 - 9.9)
Genital Herpes	3.3 (1.9 - 8.5)
Chlamydia	4.5 (3.2 - 5.7)
Gonorrhea	4.7 (3.5 - 8.9)
Trichomoniasis	2.7

Increased transmission of HIV in the presence of other STDs

By increasing susceptibility

Mucosal breakdown due to genital ulcer may facilitate HIV entry.

Recruitment of white blood cells to the site of active infection may act as an area of increased HIV receptors.

By increasing infectiousness

Increase of HIV viral load in semen, genital secretions or genital ulcers (Malawi Study)

Epidemiologic Synergy Between HIV and Other STDs

Health districts with the highest HIV seroprevalence among women who bore children in 1994, counties reporting the highest primary and secondary syphilis rates in 1993, and states reporting the highest gonorrhea rates in 1993 - United States

Implications for HIV Prevention

Little evidence for efficacy of intermittent STD mass treatment in areas with late HIV epidemics and low STD rates (Rakai)

Evidence for efficacy of treatment of symptomatic STDs in areas with substantial STD rates and early HIV epidemics (Mwanza)

More research needed on impact of treating asymptomatic STDs in areas with substantial STD rates and early HIV epidemics

Current Recommendations for HIV Prevention Through Diagnosis and Treatment of Other STDs

STD screening recommendations

Screen for asymptomatic or unrecognized STD infections in medical-care settings according to current guidelines, and expand screening as needed based on prevalence of infections (>2%) CAPS detected in

Chlamydia and gonorrhea

<25 years annually

>25 years only if high risk (eg, those who abuse substances, persons with a

Syphilis

High-risk (eg, those with multiple sex partners, persons who have exchanged sex for money or

HIV Infected Populations

Screening frequency should depend on the person's risk behavior, the potential risk behavior of

New counseling messages for persons HIV infected and persons at risk for HIV and other STDs

Other STDs facilitate HIV transmission, and early STD detection and treatment is an important HIV

Guidelines for the Treatment of STDs

Guidelines Development

Evidenced-based on 4 principle outcomes of STD therapy

Changes since the 1993 Guidelines

Chlamydia

Screening adolescents annually and women 20-24 years if a new or multiple partners and no using barriers methods consistently, although

Screening programs: Are essential for reducing complications of chlamydia in an individual and reducing the reservoir of asymptomatic

1)Population's chlamydia prevalence (eg, >2-3%)
2)Sensitivity of the screening criteria
3)Cost and test performance characteristics of the diagnostic test

Nucleic acid amplification tests are more sensitive in some settings Comparative Sensitivity and Specificity of Chlamydia Tests

Nucleic acid amplification tests offer unK ue screening opportunities using urine or self collected vaginal swab specimen

Recommended regimens include both Azithromycin and Doxycycline

The importance of partner management counseling regarding risk of further transmission and re-infection stressed

To reduce risk of further transmission abstain from sex for 7 days after single dose and until completion of 7 day regimen and to reduce risk of re-infection abstain from sex until all partners are cured

Time interval for managing sex partners is 60 days and importance of partner management counseling to prevent reinfection is stressed

Amoxicillin added as a recommended regimen in pregnancy

Azithromycin added as an alternative regimen in pregnancy but included in the Region IX Infertility Treatment Guidelines as a recommended regimen

Test of Cure only recommended if using amoxicillin or erythromycin

Co-treatment in patients with gonorrhea may no longer be indicated if co-infection rate is low (<15-20%), sensitive tests are used, and follow-up is likely

GONORRHEA

Quinolone resistance is still relatively low in the U.S. (<.03%), but may ultimately limit the ability of quinolones to treat GC (of > 1%)

Monitored through the GISP

Culture and susceptibility testing is recommended in patients with persistent symptoms after

3. Urethritis

Diagnostic criteria have been changed to include only evidence of discharge or microbiologic evidence by gram stain or by evaluation of first void urine
Azithromycin has been added to the recommended regimen for treatment of NGU

Treatment of recurrent or persistent urethritis includes erythromycin plus metronidazole

4. MUCOPURULENT CERVICITIS

Management of MPC is no longer clear cut

9. Syphilis

Criteria for lumbar puncture has been simplified: neurologic symptoms or signs, evidence of tertiary syphilis, treatment failure, and syphilis of greater than one year's duration or unknown duration in HIV infected individuals

Treatment of early latent syphilis in HIV infected individuals is now the same as HIV uninfected individuals, based on