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This document is being maintained for historical purposes, but is now out of date.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

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1993 Sexually Transmitted Diseases Treatment Guidelines

09/24/1993

SUGGESTED CITATION
Centers for Disease Control and Prevention. 1993 Sexually
transmitted diseases treatment guidelines. MMWR 1993;42(No. RR-14):
{inclusive page numbers}.

CIO Responsible for this publication:
National Center for Prevention Services,
Division of Sexually Transmitted Diseases and HIV Prevention

Initial Evaluation and Planning for Care
     
     Practice settings for offering early HIV care are variable,
depending upon 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; it is preferable for persons with HIV infection to receive
care from a single source that is able to provide comprehensive
care for all stages of HIV infection. But the limited availability
of such resources often results in the need to coordinate care
among outpatient, inpatient, and specialist providers in different
locations. Because of the progressive nature of HIV and the
increased risk for bacterial infections, including TB -- even
before HIV infection becomes advanced -- it is essential to
establish specific provisions for handling the medical,
psychological, and social problems likely to arise at any stage of
infection. An important component of early intervention is
effective linkage with referral settings where off-hours care and
specialty services are available. Development of an appropriate
plan for care involves the following:

--   Identification of patients in need of immediate medical care
     (e.g., patients with symptomatic HIV infection or emotional crisis)
     and of those in need of antiretroviral therapy or prophylaxis for
     opportunistic infections (e.g., PCP).

--   Evaluation for the presence of diseases associated with HIV,
     such as TB and STDs.

--   Administration of recommended vaccinations.

--   Case management or referral for case management.

--   Counseling (see Counseling for Patients with HIV Infection).

     The CD4+ T-lymphocyte count is the best laboratory indicator
of clinical progression, and comprehensive management strategies
for HIV infection are typically stratified by CD4 count. Either the
absolute number or the percentage of CD4+ T cells may be
determined. CD4+ percentage is more consistent than absolute CD4+
count with successive measurements for the same person and less
variable with delays in specimen processing. However, most clinical
trials have used absolute CD4+ count to evaluate the need for and
timing of therapeutic interventions. Patients with CD4+ counts
greater than 500/uL usually do not demonstrate evidence of clinical
immunosuppression. Patients with 200-500 CD4+ cells/uL are more
likely to develop HIV-related symptoms and to require medical
intervention. Patients with CD4+ counts less than 200 cells/uL, and
those with higher CD4+ counts who develop thrush or unexplained
fever (temperature greater than 37.8 C for greater than or equal to
2 weeks) are at increased risk for developing complicated HIV
disease. Such patients should be managed in a comprehensive
treatment setting with access to specialty resources and
hospitalization.

     Providers unable to offer therapeutic management of HIV may
use the initial evaluation to identify the need for prompt referral
to appropriate resources. The initial evaluation of HIV-positive
patients should include the following essential components:

--   A detailed history, including sexual history, substance abuse
     history, and a review of systems for specific HIV-related symptoms.

--   A physical examination; for females, this examination should
     include a gynecologic examination.

--   For females, testing for N. gonorrhoeae, C. trachomatis, a
     Papanicolaou (Pap) smear, and wet mount examination of vaginal
     secretions.

--   A syphilis serology.

--   A CD4+ T-lymphocyte analysis.

--   Complete blood and platelet counts.

--   A purified protein derivative (PPD) tuberculin skin test by
     the Mantoux method and anergy testing with two delayed-type
     hypersensitivity (DTH) antigens (Candida, mumps, or tetanus toxoid)
     administered by the Mantoux method or a multipuncture device.

--   A thorough psychosocial evaluation, including ascertainment of
     behavioral factors indicating risk for transmitting HIV and
     elucidation of information about any partners who should be
     notified about possible exposure to HIV.

Preventive Therapy for TB
     Studies conducted among persons with and without HIV infection
have suggested that HIV infection can depress tuberculin reactions
before signs and symptoms of HIV infection develop. Cutaneous
anergy (defined as skin test response of less than or equal to 3 mm
to all DTH antigens) may be present among greater than or equal to
10% of asymptomatic persons with CD4+ counts greater than 500
cells/uL, and among greater than 60% of persons with CD4+ counts
less than 200.

     HIV-positive persons with a PPD reaction greater than or equal
to 5 mm induration are considered to be infected with M.
tuberculosis and should be evaluated for preventive treatment with
isoniazid after active TB has been excluded. Anergic persons whose
risk for tuberculous infection is estimated to be greater than or
equal to 10%, based on available prevalence data, also should be
considered for preventive therapy. For further details regarding
evaluation of patients for TB, refer to Purified Protein Derivative
(PPD-tuberculin anergy) and HIV Infection: Guidelines for Anergy
Testing and Management of Anergic Persons at Risk of Tuberculosis
(7).

     The preliminary results from a randomized clinical trial
suggest that treatment with isoniazid is effective for preventing
active TB among HIV-infected persons. The usual regimen is
isoniazid 10 mg/kg daily, up to a maximum adult dose of 300 mg
daily. Twelve months of isoniazid preventive treatment is
recommended for persons with HIV infection. For further details
regarding preventive therapy for TB, refer to The Use of Preventive
Therapy for Tuberculous Infection in the United States (8) and
Management of Persons Exposed to Multidrug-Resistant Tuberculosis
(9).

Recommended Immunizations for Adults and Adolescents
     Specific recommendations for immunization of persons infected
with HIV are listed below:

--   Pneumococcal vaccination and an annual influenza vaccination
     should be administered.

--   Persons at increased risk for acquiring HBV and who lack
     evidence of immunity may receive a three-dose schedule of hepatitis
     B vaccine, with postvaccination serologic testing between 1 and 6
     months after the vaccination series.

     Recommendations for vaccinating HIV-infected persons are based
on expert opinions and consensus of the Advisory Committee on
Immunization Practices (ACIP). No clinical data exist to document
the efficacy of inactivated vaccines among HIV-infected persons,
and pneumococcal vaccine failures have been reported. However, the
use of inactivated vaccines may be beneficial for persons with HIV
infection and there is no evidence that they are harmful.
Immunogenicity studies have suggested a generally poorer response
among HIV-infected persons, with higher response rates among
asymptomatic persons than among those with advanced HIV disease.

     Current evidence indicates that HIV infection does not
increase susceptibility to HBV, nor does it increase the severity
of clinical disease. The presence of HIV infection is not an
indication for hepatitis B vaccine, but HIV-infected persons are at
increased risk for becoming chronic carriers after hepatitis B
infection. Because the routes of transmission of HBV parallel those
of HIV, efforts to modify risky behaviors must be the primary focus
of prevention efforts. However, vaccine should be administered to
HIV-infected patients who continue to have a high likelihood for
HBV exposure.

     Persons with HIV infection also are at increased risk for
invasive Haemophilus influenzae type B (Hib) disease and for
complications from measles. Immunization against Hib and measles
should be considered for asymptomatic HIV-infected persons who may
have an increased risk for exposure to these infections. For
further details on immunization 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 (10).

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