In June, the U.S. Centers for Disease Control and Prevention (CDC) released its updated Sexually Transmitted Diseases Treatment Guidelines, 2015. There are several key changes in the document, but I would like to reinforce important STD clinical management issues and highlight what is new for physicians and clinicians who regularly work with patients living with HIV.
I'd like to reiterate the continued need for providers to take a sexual history, conduct a risk assessment, and perform STD screening for persons living with HIV. STD screening not only identifies curable infections but STDs are also biologic markers of risk particularly for HIV transmission among some men who have sex with men (MSM).
- At the initial HIV care visit, providers should test all sexually active persons with HIV infection for curable STDs (e.g., syphilis, gonorrhea, and chlamydia) and perform testing at least annually during the course of HIV care. Specific testing includes syphilis serology and NAAT for gonorrhea and chlamydia at the anatomic site of exposure, as the preferred approach.
- Extra genital screening for gonorrhea and chlamydia is especially important for MSM with HIV as most infections will be missed if only urethral testing is done. A test for rectal gonorrhea and chlamydia is recommended if receptive anal intercourse is reported during the preceding year and a test for pharyngeal gonorrhea if receptive oral intercourse during the preceding year.
- All persons with HIV should be screened for HBV, and all MSM regardless of HIV status.
- New recommendations for MSM living with HIV include HCV screening at the initial visit and at least annually thereafter and for all males living with HIV, the quadrivalent or 9-valent HPV vaccination is recommended through age 26.
- More frequent screening for curable STDs and hepatitis C might be appropriate depending on individual risk behaviors and the local epidemiology of STDs. Many STDs are asymptomatic, and a diagnosis of an STD in a person living with HIV should prompt referral for partner services and STD prevention counseling.
Additionally, CDC now recommends that women living with HIV be screened for trichomonas at the initial visit and annually thereafter. Women should also receive the bivalent, quadrivalent or 9-valent HPV vaccine through age 26 and be screened for cervical cancer precursor lesions by cervical Pap tests per existing guidelines.
Other noteworthy clinical management topics that have been updated include the recommended dual treatment regimen for gonorrhea. CDC recommends Ceftriaxone 250 mg IM plus Azithromycin 1 g orally, as the threat of untreatable gonorrhea remains high. Doxycycline is no longer a preferred option for dual therapy because of higher prevalence of tetracycline resistance in isolates with reduced susceptibility to cephalosporins; and monotherapy with Azithromycin 2 gm is no longer recommended as an alternative regimen because of documented treatment failures.
While treatment recommendations for syphilis have not changed (e.g., single dose of Benzathine penicillin) for primary, secondary and early latent syphilis for persons living with HIV, a careful ocular and neurologic exam remains an essential part of any syphilis evaluation. However, when to perform a CSF examination has been updated and is now recommended only if clinical neurological findings are present. No evidence supports variation from the recommended treatment regimens with Benzathine penicillin for any stage of syphilis in persons with HIV and no neurologic signs or symptoms.
The full Guidelines and resources such as a pocket guide, wall chart, Apple STD Tx Guide App and summary are available at www.cdc.gov/std/tg2015/default. The summary provides an overview of important updates to the previous iteration with new diagnostic, treatment and prevention recommendations.
The National Network of STD Clinical Prevention Training Centers (NNPTC) can also provide physicians with guidance for the prevention and clinical management of STDs. To view the national training calendar, register for courses, find resources and access STD consultation, visit the NNPTC at www.nnptc.org.
Gail Bolan, M.D., is director of the Division of STD Prevention at the U.S. Centers for Disease Control and Prevention.