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This document is being maintained for historical purposes, but is now out of date.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

Continuing Management of Patients with Early HIV Infection
     
     Providing comprehensive, continuing management of patients
with early HIV infection can include additional diagnostic studies
(e.g., chest x-ray, serum chemistry, antibody testing for
toxoplasmosis and hepatitis B), antiretroviral therapy and
monitoring, and PCP prophylaxis. Treatment of HIV infection and
prophylaxis against opportunistic infections continue to evolve
rapidly. This treatment should be undertaken in consultation with
physicians who are familiar with the care of persons with HIV
infection. The complete therapeutic management of HIV infection is
beyond the scope of this document.

Antiretroviral Therapy
     The optimal time for initiating antiretroviral therapy has not
yet been established. Zidovudine (ZDV) at a dose of 500 mg/day (100
mg orally every 4 hours while the patient is awake) has been
recommended for symptomatic persons with less than 500 CD4+
T-cells/uL, and for asymptomatic persons with less than 300 CD4+
T-cells/uL. This recommendation is based on results of short-term
follow-up in three randomized clinical trials demonstrating that
the initiation of ZDV therapy delays progression to advanced
disease. Evidence for improved long-term survival after early
treatment is less conclusive. The effects of ZDV may be transient,
possibly because of the development of viral resistance or other
factors. Sequential or combination therapy with other
antiretroviral agents could be more efficacious.

     Whether other daily dosages, dose schedules, or dosages based
on body weight would result in greater therapeutic benefit or few
side effects is not known. Providers should work with patients to
design a treatment strategy that is both clinically sound and
appropriate for each individual patient's needs, priorities, and
circumstances. An initial dose of 600 mg in divided doses has been
recommended by a panel of experts convened by the National
Institute of Allergy and Infectious Diseases (NIAID). Preliminary
data suggest ZDV can yield therapeutic results when the dosing
interval is increased to 8 hours, and at doses of 200 mg three
times daily. Antiretroviral efficacy is diminished at doses less
than 300 mg/day, and it has been suggested that higher oral doses
may be required to achieve effective levels in the central nervous
system.

     There are no data to support the use of antiretroviral drugs
other than ZDV as initial therapy. Didanosine (DDI) is recommended
for persons who are intolerant of ZDV or who experience progression
of symptoms despite ZDV. Two 100 mg tablets of DDI are recommended
every 12 hours for persons who weigh greater than or equal to 60
kg; the recommended dose for adults less than 60 kg is one 100 mg
tablet and one 25 mg tablet every 12 hours. Two tablets are
recommended at each dose so that adequate buffering is provided to
prevent gastric acid degradation of the drug.

     Benefits have been reported from other antiretroviral
regimens, including treatment with combinations of ZDV, DDC
(dideoxycytidine {zalcitabine}), and DDI, or switching therapy to
DDI after long-term therapy with ZDV. Experience with these
alternatives is insufficient to serve as a basis for
recommendations. Providers managing patients who are taking
antiretroviral therapy should be familiar with evidence being
developed in several clinical trials. Current information is
available from the NIAID AIDS Clinical Trials Information Service,
1-800-TRIALS-A.

     Side effects that are serious (e.g., anemia, cytopenia,
pancreatitis, and peripheral neuropathy) and uncomfortable (e.g.,
nausea, vomiting, headaches, and insomnia) are common during
antiretroviral therapy. Although hematologic toxicity from ZDV is
less common with the lower doses recommended, approximately 2% of
patients who receive 500 mg/day manifest severe anemia by the 18th
month of treatment -- most within the 3rd through 8th month of
treatment. Careful hematologic monitoring of patients receiving ZDV
is recommended.

PCP Prophylaxis
     Adults and adolescents with less than 200 CD4+ T-cells/uL or
with constitutional symptoms, such as thrush or unexplained fever
greater than 100 F for greater than or equal to 2 weeks, and any
patient with a previous episode of PCP should receive PCP
prophylaxis. Prophylaxis should be continued for the lifetime of
the patient.

     Based upon evidence from randomized controlled clinical
trials, the Public Health Service Task Force on Antipneumocystis
Prophylaxis has recommended the following regimens for PCP
prophylaxis among adults and adolescents:

--   Oral trimethoprim-sulfamethoxazole (TMP-SMX) at a dose of one
     double-strength tablet (800 mg SMX and 160 mg TMP) orally once a
     day.

--   For patients unable to tolerate TMP-SMX: aerosol pentamidine
     administered by either the Respirgard II nebulizer regimen (300 mg
     once a month) or the Fisoneb nebulizer (initial loading regimen of
     five 60 mg doses during a 2-week period, followed by a 60 mg dose
     every 2 weeks).

     The efficacy of alternatives for patients unable to tolerate
TMP-SMX, including dapsone 100 mg orally once a day and sulfa
desensitization, has not been studied extensively. For further
details on PCP prophylaxis, refer to Recommendations for
Prophylaxis Against Pneumocystis carinii pneumonia for adults and
adolescents infected with human immunodeficiency virus (11).

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