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Warning:
This document is being maintained for historical purposes, but is now out of date. To view current guidelines please visit:
- STD Treatment Guidelines at http://www.cdc.gov/STD/treatment
1998 Guidelines for Treatment of Sexually Transmitted Disease
Date: 01/23/98
Source: 47(RR-1);1-118
SUGGESTED CITATION: Centers for Disease Control and Prevention. 1998 Guidelines for Treatment of Sexually Transmitted Diseases. MMWR 1998;47(No. RR-1): {inclusive page numbers}.
The material in this report was prepared for publication by: National Center for HIV, STD and TB Prevention, Division of Sexually Transmitted Diseases Prevention
HIV INFECTION: DETECTION, INITIAL MANAGEMENT, AND REFERRAL
Infection with HIV produces a spectrum of disease that progresses from a clinically latent or asymptomatic state to AIDS as a late manifestation. The pace of disease progression is variable. The time between infection with HIV and the development of AIDS ranges from a few months to as long as 17 years (median: 10 years). Most adults and adolescents infected with HIV remain symptom-free for long periods, but viral replication is active during all stages of infection, increasing substantially as the immune system deteriorates. AIDS eventually develops in almost all HIV-infected persons; in one study of HIV-infected adults, AIDS developed in 87% (95% confidence interval {CI}=83%-90%) within 17 years after infection. Additional cases are expected to occur among those who have remained AIDS-free for longer periods.
Greater awareness among both patients and health-care providers of the risk factors associated with HIV transmission has led to increased testing for HIV and earlier diagnosis of the infection, often before symptoms develop. The early diagnosis of HIV infection is important for several reasons. Treatments are available to slow the decline of immune system function. HIV-infected persons who have altered immune function are at increased risk for infections for which preventive measures are available (e.g., Pneumocystis carinii pneumonia {PCP}, toxoplasmic encephalitis {TE}, disseminated Mycobacterium avium complex {MAC} disease, tuberculosis {TB}, and bacterial pneumonia). Because of its effect on the immune system, HIV affects the diagnosis, evaluation, treatment, and follow-up of many other diseases and may affect the efficacy of antimicrobial therapy for some STDs. Finally, the early diagnosis of HIV enables the health-care provider to counsel such patients and to assist in preventing HIV transmission to others.
Proper management of HIV infection involves a complex array of behavioral, psychosocial, and medical services. Although some of these services may be available in the STD treatment facility, other services, particularly medical services, are usually unavailable in this setting. Therefore, referral to a health-care provider or facility experienced in caring for HIV-infected patients is advised. Staff in STD treatment facilities should be knowledgeable about the options for referral available in their communities. While in the STD treatment facility, the HIV-infected patient should be educated about HIV infection and the various options for HIV care that are available.
Because of the complexity of services required for management of HIV infection, detailed information, particularly regarding medical care, is beyond the scope of this report and may be found elsewhere (3,5,10,11). Rather, this section provides information on diagnostic testing for HIV-1 and HIV-2, counseling patients who have HIV infection, and preparing the HIV-infected patient for what to expect when medical care is necessary. Information also is provided on management of sex partners, because such services can and should be provided in the STD treatment facility before referral. Finally, the topics of HIV infection during pregnancy and in infants and children are addressed.
Diagnostic Testing for HIV-1 and HIV-2
Testing for HIV should be offered to all persons whose behavior puts them at risk for infection, including persons who seek evaluation and treatment for STDs. Counseling before and after testing (i.e., pretest and posttest counseling) is an integral part of the testing procedure (see HIV Prevention Counseling). Informed consent must be obtained before an HIV test is performed. Some states require written consent.
HIV infection usually is diagnosed by using HIV-1 antibody tests. Antibody testing begins with a sensitive screening test such as the enzyme immunoassay (EIA). Reactive screening tests must be confirmed by a supplemental test, such as the Western blot (WB) or an immunofluorescence assay (IFA). If confirmed by a supplemental test, a positive antibody test result indicates that a person is infected with HIV and is capable of transmitting the virus to others. HIV antibody is detectable in at least 95% of patients within 6 months after infection. Although a negative antibody test result usually indicates that a person is not infected, antibody tests cannot exclude infection that occurred less than 6 months before the test.
The prevalence of HIV-2 in the United States is extremely low, and CDC does not recommend routine testing for HIV-2 in settings other than blood centers, unless demographic or behavioral information indicates that HIV-2 infection might be present. Those at risk for HIV-2 infection include persons from a country in which HIV-2 is endemic or the sex partners of such persons. HIV-2 is endemic in parts of West Africa, and an increased prevalence of HIV-2 has been reported in Angola, France, Mozambique, and Portugal. In addition, testing for HIV-2 should be conducted when there is clinical evidence or suspicion of HIV disease in the absence of a positive test for antibodies to HIV-1 (12).
Because HIV antibody crosses the placenta, its presence in a child aged less than 18 months is not diagnostic of HIV infection (see Special Considerations, HIV Infection in Infants and Children).
The following are specific recommendations for diagnostic testing for HIV infection:
Informed consent must be obtained before an HIV test is performed. Some states require written consent. (See HIV Prevention Counseling for a discussion of pretest and posttest counseling.)
Positive screening tests for HIV antibody must be confirmed by a more specific confirmatory test (either WB or IFA) before being considered diagnostic of HIV infection.
Patients who have positive HIV test results must either receive behavioral, psychosocial, and medical evaluation and monitoring services or be referred for these services.
Acute Retroviral Syndrome
Health-care providers should be alert for the symptoms and signs of acute retroviral syndrome, which is characterized by fever, malaise, lymphadenopathy, and skin rash. This syndrome frequently occurs in the first few weeks after HIV infection, before antibody test results become positive. Suspicion of acute retroviral syndrome should prompt nucleic acid testing to detect the presence of HIV. Recent data indicate that initiation of antiretroviral therapy during this period can delay the onset of HIV-related complications and might influence prognosis. If testing reveals acute HIV infection, health-care providers should either counsel the patient about immediate initiation of antiretroviral therapy or refer the patient for emergency expert consultation. The optimal antiretroviral regimen at this time is unknown. Treatment with zidovudine can delay the onset of HIV-related complications; however, most experts recommend treatment with two nucleoside reverse transcriptase inhibitors and a protease inhibitor.
Counseling for HIV-Infected Patients
Behavioral and psychosocial services are an integral part of health care for HIV-infected patients; such services should be available on-site or through referral when HIV infection is diagnosed. Patients often are distressed when first informed of a positive HIV test result. Such patients face several major adaptive challenges: a) accepting the possibility of a shortened life span, b) coping with others' reactions to a stigmatizing illness, c) developing and adopting strategies for maintaining physical and emotional health, and d) initiating changes in behavior to prevent HIV transmission to others. Many patients also require assistance with making reproductive choices, gaining access to health services, and confronting employment or housing discrimination.
Interrupting HIV transmission depends on behavioral changes made by those persons at risk for transmitting or acquiring infection. Infected persons, as potential sources of new infections, must receive additional counseling and assistance to support partner notification and counseling to prevent infection of others. Targeting behavior change programs toward HIV-infected persons and their sex partners, or those with whom they share injecting-drug equipment, is an important adjunct to AIDS prevention efforts.
The following are specific recommendations for counseling HIV-infected patients:
Persons who test positive for HIV antibody should be counseled by a person or persons, either on-site or through referral, who can discuss the behavioral, psychosocial, and medical implications of HIV infection.
Appropriate social support and psychological resources should be available, either on-site or through referral, to assist patients in coping with emotional distress.
Persons who continue to be at risk for transmitting HIV should receive assistance in changing or avoiding behaviors that can transmit infection to others.
Planning for Medical Care and for Continuation of Psychosocial Services
Practice settings for offering HIV care differ depending on local resources and needs. Primary-care providers and outpatient facilities must ensure that appropriate resources are available for each patient and must avoid fragmentation of care as much as possible. A single source that is able to provide comprehensive care for all stages of HIV infection is preferred; however, the limited availability of such resources often results in the need to coordinate care among outpatient, inpatient, and specialist providers in different locations. Providers should do everything possible to avoid fragmentation of care and long delays between diagnosis of HIV infection and access to medical and psychosocial services.
Recently identified HIV infection may not have been recently acquired. Persons newly diagnosed with HIV may be at any of the different stages of infection. Therefore, the health-care provider should be alert for symptoms or signs that suggest advanced HIV infection (e.g., fever, weight loss, diarrhea, cough, shortness of breath, and oral candidiasis). The presence of any of these symptoms should prompt urgent referral for medical care. Similarly, the provider should be alert for signs of severe psychologic distress and be prepared to refer the client accordingly.
HIV-infected patients in the STD treatment setting should be educated about what to expect when medical care is necessary (11). In the nonemergent situation, the initial evaluation of the HIV-positive patient usually includes the following components:
A detailed medical history, including sexual and substance-abuse history, previous STDs, and specific HIV-related symptoms or diagnoses.
A physical examination; for women, this should include a gynecologic examination.
For women, testing for N. gonorrhoeae and C. trachomatis, a Pap smear, and wet mount examination of vaginal secretions.
Complete blood and platelet counts and blood chemistry profile.
Toxoplasma antibody test, tests for hepatitis B viral markers, and syphilis serology.
A CD4+ T-lymphocyte analysis and determination of HIV plasma ribonucleic acid (i.e., HIV viral load).
A tuberculin skin test (TST) (sometimes referred to as a purified protein derivative {PPD} skin test) administered by the Mantoux method. The test result should be evaluated at 48-72 hours; in HIV-infected persons, a 5 mm induration is considered positive. The usefulness of anergy testing is controversial (13-15).
A chest radiograph.
A thorough psychosocial evaluation, including ascertainment of behavioral factors indicating risk for transmitting HIV and elucidation of information concerning any partners who should be notified about possible exposure to HIV.
In subsequent visits, once the results of laboratory and skin tests are available, the patient may be offered antiretroviral therapy (16), as well as specific medications to reduce the incidence of opportunistic infections (e.g., PCP, TE, disseminated MAC infection, and TB) (10,14,17-19). Hepatitis B vaccination should be offered to patients who do not have hepatitis B markers, influenza vaccination should be offered annually, and pneumococcal vaccination should be administered. For additional information concerning vaccination of HIV-infected patients, refer to "Recommendations of the Advisory Committee on Immunization Practices (ACIP): Use of Vaccines and Immune Globulins in Persons with Altered Immunocompetence" (20).
Specific recommendations for planning medical care and continuation of psychosocial services include the following:
HIV-infected persons should be referred for appropriate follow-up to facilities in which health-care personnel are experienced in providing care for HIV-infected patients.
Health-care providers should be alert for medical or psychosocial conditions that require immediate attention.
Patients should be educated about what to expect in follow-up medical care.
Management of Sex Partners and Injecting-Drug Partners
When referring to persons who are infected with HIV, the term "partner" includes not only sex partners but also injecting-drug users who share syringes or other injection equipment. The rationale for partner notification is that the early diagnosis and treatment of HIV infection possibly reduces morbidity and provides the opportunity to encourage risk-reducing behaviors. Partner notification for HIV infection must be confidential and will depend on voluntary cooperation of the patient.
Two complementary notification processes, patient referral and provider referral, can be used to identify partners. With patient referral, patients directly inform their partners of their exposure to HIV infection. With provider referral, trained health department personnel locate partners on the basis of the names, descriptions, and addresses provided by the patient. During the notification process, the anonymity of patients is protected; their names are not revealed to partners who are notified. Many state health departments provide assistance, if requested, with provider-referral partner notification.
The results of one randomized trial suggested that provider referral is more effective in notifying partners than patient referral. In that study, 50% of partners in the provider-referral group were notified, compared with 7% of partners notified by persons in the patient-referral group. However, whether behavioral change takes place as a result of partner notification has not been determined, and many patients are reluctant to disclose the names of partners because of concern about discrimination, disruption of relationships, loss of confidentiality for the partners, and possible violence.
The following are specific recommendations for implementing partner-notification procedures:
HIV-infected patients should be encouraged to notify their partners and to refer them for counseling and testing. If requested by the patient, health-care providers should assist in this process, either directly or by referral to health department partner-notification programs.
If patients are unwilling to notify their partners, or if they cannot ensure that their partners will seek counseling, physicians or health department personnel should use confidential procedures to notify the partners.
Special Considerations
Pregnancy
All pregnant women should be offered HIV testing as early in pregnancy as possible (21). This recommendation is particularly important because of the available treatments for reducing the likelihood of perinatal transmission and maintaining the health of the woman. HIV-infected women should be informed specifically about the risk for perinatal infection. Current evidence indicates that 15%-25% of infants born to untreated HIV-infected mothers are infected with HIV; the virus also can be transmitted from an infected mother by breastfeeding. Zidovudine (ZDV) reduces the risk for HIV transmission to the infant from approximately 25% to 8% if administered to women during the later stage of pregnancy and during labor and to infants for the first 6 weeks of life (22). Therefore, ZDV treatment should be offered to all HIV-infected pregnant women. In the United States, HIV-infected women should be advised not to breastfeed their infants.
Insufficient information is available regarding the safety of ZDV or other antiretroviral drugs during early pregnancy; however, on the basis of the ACTG-076 protocol, * ZDV is indicated for the prevention of maternal-fetal HIV transmission as part of a regimen that includes oral ZDV at 14-34 weeks of gestation, intravenous (IV) ZDV during labor, and ZDV Syrup to the neonate after birth (22). Glaxo Wellcome, Inc., Hoffmann-LaRoche, Inc., Bristol-Myers Squibb, Co., and Merck & Co., Inc., in cooperation with CDC, maintain a registry to assess the safety of ZDV, didanosine (ddI), lamivudine (3TC), saquinavir (SAQ), stavudine (d4t), and dideoxycytodine (ddC) during pregnancy. Women who receive any of these drugs during pregnancy should be reported to this registry; telephone (800) 722-9292, extension 38465. The number of cases reported through February 1997 represented a sample of insufficient size for reliably estimating the risk for birth defects after administration of ddI, 3TC, SAQ, d4t, ddC, or ZDV, or their combination, to pregnant women and their fetuses. However, the registry findings did not indicate an increase in the number of birth defects after receipt of only ZDV in comparison with the number expected in the U.S. population. Furthermore, no consistent pattern of birth defects has been observed that would suggest a common cause.
Women should be counseled about their options regarding pregnancy. The objective of counseling is to provide HIV-infected women with information for making reproductive decisions, analogous to the model used in genetic counseling. In addition, contraceptive counseling should be offered to HIV-infected women who do not desire pregnancy. Prenatal and abortion services should be available on-site or by referral. Pregnancy among HIV-infected women does not appear to increase maternal morbidity or mortality.
HIV Infection in Infants and Children
HIV-infected infants and young children differ from adults and adolescents with respect to the diagnosis, clinical presentation, and management of HIV disease. For example, because of transplacental passage of maternal HIV antibody, both infected and uninfected infants born to HIV-infected mothers are expected to have positive HIV-antibody test results. A definitive determination of HIV infection in a child less than 18 months of age should be based on laboratory evidence of HIV in blood or tissues by culture, nucleic acid, or antigen detection. In addition, CD4+ lymphocyte counts are higher in infants and children aged less than 5 years than in healthy adults and must be interpreted accordingly. All infants born to HIV-infected mothers should begin PCP prophylaxis at age 4-6 weeks; such prophylaxis should be continued until HIV infection has been excluded (18). Other modifications must be made in health services that are recommended for infants and children, such as avoiding vaccination with live oral polio vaccine when a child (or household contact) is infected with HIV. Management of infants, children, and adolescents who are known or suspected to be infected with HIV requires referral to physicians familiar with the manifestations and treatment of pediatric HIV infection.
* The Acquired Immunodeficiency Syndrome (AIDS) Clinical Trials Group Protocol 076, a clinical trial sponsored by the National Institutes of Health in collaboration with the National Institute of Health and Medical Research and the National Agency of Research on AIDS in France.
