HIV Prevention Through Early Detection and Treatment of Other Sexually Transmitted Diseases -- United States');
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Initial Steps to Enhance STD Detection and Treatment
Considering the data presented previously, ACHSP recommends that early detection
and treatment of curable STDs that facilitate HIV transmission should be a central
and explicit component of national, state, and local strategies to prevent HIV infection and AIDS. Although enhancing STD screening and treatment has always been desirable as a way to prevent the complications of STDs, current knowledge indicates it also is critical to preventing HIV infection. Any activity that decreases the incidence and prevalence of STDs in a population will decrease the prevalence of this key cofactor and should therefore decrease HIV transmission. Thus, health-care providers could prevent HIV transmission not just by treating STDs among persons with HIV infection, but also by treating and preventing STDs among any persons at risk for STDs. Other strategies to help achieve these goals are improving access to and quality of STD clinical services, expanding screening and treatment for STDs in medical settings, and establishing or expanding screening for STDs in nonmedical settings.
Initial steps for improving sexually transmitted disease (STD) detection and treatment to prevent human immunodeficiency virus (HIV) transmission
Assess and ensure timely access to high-quality STD clinical care for persons seeking medical services for symptoms of STDs in private and public
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 detected in pilot screening efforts.
Establish or expand STD screening in nonmedical settings where persons at
high risk for HIV infection and curable STDs are encountered and can be
treated efficiently, including jails and other correctional facilities, substance
abuse treatment centers, and hospital emergency departments.
Provide cross-training to program and management staff, including HIV
prevention community planning groups, on the role of STD detection and treatment
in HIV prevention.
Improving Access to and Quality of STD Clinical Services
A basic step toward implementing this strategy is to provide timely, good-quality
STD clinical care to persons who recognize or suspect symptoms of STDs or who
suspect they have been exposed and seek STD clinical care on their own. A major
component of the randomized controlled trial in Mwanza was the simple enhancement
of the quality of clinical STD services for symptomatic persons, which was
recognized by the population and translated rapidly into increased use of services.
(24) Better and faster methods are needed to assess effective access to STD clinical care in communities, and strategies are needed to extend services rapidly to those in need and at risk for HIV and STD transmission. Accordingly, ACHSP makes the following recommendations:
Basic clinical services (i.e., STD diagnosis and treatment) should be readily available to all sexually active adults and adolescents in the United States who believe they have been exposed to or have symptoms of an STD. These services should
be accessible without fees or with only nominal fees (i.e., clients with symptoms
should not be denied care because of inability to pay), available at least five days per week, and available the same day that care is sought (i.e., without advanced appointments being required). These services can be provided in categorical public STD clinics but also should be available in other primary-care settings, including hospital walk-in clinics, community and migrant-worker health centers, family-planning clinics, clinics for adolescents, primary-care physicians' offices, and clinics in MCOs or integrated inpatient/outpatient provider institutions. In particular, HIV-infected persons with STD symptoms need to be able to obtain STD diagnosis and treatment easily, and STD services should be a routine part of quality HIV care. Furthermore, presumptive treatment should be available at no cost or nominal cost to sex partners of persons with STDs.
In particular, MCOs should provide treatment services to sex partners of enrollees with STDs, even if these sex partners are not themselves enrollees. Family-planning clinics also should provide STD diagnosis and treatment services to sex partners of their clients.
All health-care providers who care for persons with or at risk for STDs should be aware of current national guidelines for STD treatment (76) and should provide care according to those guidelines or to local adaptations of those guidelines. Also, although guidelines exist for STD clinical management, (76,93 ) a substantial gap often exists between published guidelines and actual practice. (94) Therefore, CDC's STD treatment guidelines (69) should be disseminated to practitioners who treat STDs, as well as to those who help establish policies for clinical practice (e.g., clinical quality promotion and assurance committees, formulary committees, and other groups whose activities support good clinical care).
All health-care providers should receive adequate training for early detection and treatment of STDs. Because of the ongoing rapid evolution of health care in the United States, training needs are evolving continually. The aforementioned shift to managed care and other changes in health delivery and financing will require that MCO and other primary-care clinicians in diverse disciplines provide an increasing proportion of STD clinical care. Thus, training needs for STD clinical management will broaden, and new strategies will be needed to train the expanding base of providers of STD clinical care. To support these changes, the STD training needs of primary-care practitioners should be assessed in all jurisdictions of the United States with a prevalence of treatable STDs. Training plans can be developed and implemented based on this assessment. CDC supports a national network of STD prevention training centers to consult on STD clinical management training needs, which is accessible via the World Wide Web.
Enhanced Screening for STDs in Medical Settings
Because most STDs are asymptomatic, voluntary care-seeking specifically for
STD-related symptoms is unlikely to lead to detection of most infections. Thus,
STD screening programs are a critical component of expanding early detection and
treatment. Although many persons at risk for STDs cannot or do not access health-care services specifically for STD testing and treatment, they often do visit several health-care settings for other purposes. Such visits currently represent missed opportunities to diagnose and treat STDs and to decrease transmission of HIV infection. In 1996, the U.S. Public Health Service published national guidelines for screening for syphilis, gonorrhea, chlamydial infection, and genital herpes. (93) Other national organizations also have issued guidelines for screening specific population groups, such as adolescents. (95) These guidelines were developed to prevent the complications of STDs themselves and generally do not account for the individual or population-level risk for HIV infection caused by the presence of these STDs in individuals or communities. Because of the impact of HIV disease on individuals and communities, ACHSP endorses the existing screening guidelines and extends them to include the following recommendations:
All sexually active females aged <25 years visiting health-care providers for any reason should be screened for chlamydia and gonorrhea at least once per year, unless screening in that setting has been documented to yield a low prevalence of infection (e.g., <2% using sensitive tests). In a low-prevalence population, more selective screening criteria (96) or more sensitive laboratory tests can be used. Examples of health-care settings in which this screening can occur are family-planning clinics, prenatal clinics, emergency rooms and walk-in clinics, community and migrant-worker health centers, clinics for adolescents, school-based clinics, clinics in correctional facilities, and primary-care provider offices (during routine physical examinations).
All young, sexually active men should be screened routinely for chlamydial and gonococcal infections, which is increasingly feasible and acceptable because of
new diagnostic tests that allow the use of urine as a specimen for screening. In
the absence of well-defined screening criteria, the prevalence of infections can be
assessed in clinical settings where young men are accessible, and routine
screening should be implemented in settings or subpopulations in which the
prevalence is high (e.g., >2%). Examples of health-care settings in which this screening can occur are emergency departments, walk-in clinics, community and migrant-worker health centers, clinics for adolescents, school-based clinics, clinics in correctional facilities, and primary-care provider offices (during routine physical examinations). Adolescent and young MSM particularly are at high risk for HIV infection and other STDs and constitute a critically important population for routine STD screening. (48,59)
In addition to routinely screening adolescents and young adults, clinicians also should provide chlamydia and gonorrhea screening at least once per year
to older, higher-risk males and females visiting health-care providers for any
reason. Examples of higher-risk persons are those who abuse substances, persons
with a history of STDs or more than one sex partner per year, those in
correctional facilities, and persons from communities with high rates of STDs.
Determination of high-risk status also should take into account the prevalence of
HIV infection in the subpopulation being considered. Health-care providers and
public health agencies should use these screenings to collect sufficient data
about the local prevalence of STDs and the risk factors for positivity to develop
locally relevant definitions of high-risk status.
Serologic screening for syphilis should be conducted in high-risk persons (e.g., those with multiple sex partners or who have exchanged sex for money or drugs, persons admitted to jails, and users of illicit drugs). Because syphilis rates in the United States vary considerably by region and among subpopulations within high incidence regions, local epidemiologic data and pilot testing can be used to guide local screening efforts. Syphilis screening should be more routine in jurisdictions with high incidence rates (e.g., notified rates greater than the Healthy People 2000 goal of 4/100,000 cases of primary and secondary syphilis). It also should be expanded rapidly during outbreaks and extended to personsencountered in emergency departments of public hospitals and other clinical orcommunity venues with an appreciable prevalence of syphilis.
Persons already infected with HIV should be screened routinely for STDs. Early STD detection and treatment in this subpopulation could be particularly effective and cost-beneficial in reducing HIV transmission for three reasons: most STDs promote increased shedding of HIV; (1,
20) the number of HIV-infected persons is smaller than the number of persons at risk for becoming infected; and HIV-infected persons often are receiving regular medical care.
Specifically, all HIV-infected persons who might be at risk for STD acquisition should be screened regularly for curable STDs, including gonorrhea, chlamydial infection, syphilis, and -- among women -- trichomoniasis. In addition, persons with HIV/AIDS should be assessed for genital herpes, educated about symptoms of herpes, and counseled to particularly avoid sex during periods with symptoms of reactivation of genital herpes, which are associated with higher rates of HIV viral shedding. (16) Screening frequency should depend on the person's risk behavior, the potential risk behavior of the person's partner(s), and the incidence of STDs in the local population, but generally should occur at least yearly if any potential risk exists for STD acquisition. It should be performed more frequently if any incident STDs are detected by symptoms or screening. These services should be provided as part of and at the site of routine, quality HIV care.
Counseling Persons with HIV/AIDS and a New STD
The presence of a new STD in a person with HIV/AIDS strongly suggests
unprotected sex, a behavior that could place another person or persons at risk for HIV infection. Counseling should consist of several components, including the following:
Determining the type and frequency of sexual behaviors that have occurred.
Determining the number and HIV-infection status of the partner(s) with whom the person with HIV/AIDS and a new STD has had sex.
Counseling the person with HIV/AIDS and a new STD on the need to eliminate
unprotected sex, especially with persons of unknown or negative HIV-infection
status, and on the role other STDs play in facilitating HIV transmission to other
Counseling the person with HIV/AIDS and a new STD on issues related
specifically to STD treatment and prevention, including avoidance of future STDs,
proper screening and evaluation for STDs, and adherence to all aspects of
prescribed STD treatment (e.g., abstaining completely from sex for the appropriate
period following treatment with a recommended antimicrobial regimen for the
diagnosed STD). (76)
Assisting with notification of the partner(s) (HIV-infected, uninfected, or unknown status) about exposure to STD and HIV infection and the need to be evaluated, tested, and treated.
In addition to these counseling messages, any newly or previously identified
person with HIV/AIDS who is not in a high-quality HIV/AIDS treatment program should be referred to one.
Expanded STD Screening in Nonmedical Settings
Many persons at increased risk for STDs and HIV infection visit health-care
providers infrequently, and some populations are easier to reach outside traditional clinical settings. Newer screening tests (i.e., those using urine samples or self-obtained swabs) make screening in nonmedical settings increasingly feasible. ACHSP makes the following recommendations for STD screening in nonmedical settings:
Persons entering correctional and detention facilities should be screened for
syphilis, gonorrhea, and chlamydia. When possible, females also should be screened for trichomoniasis and bacterial vaginosis. This recommendation includes state and federal prisons, local jails and holding centers, and juvenile detention centers. STD screening could be particularly important in jails and other short-term facilities where many persons at high risk (e.g., those detained for charges related to commercial sex) stay for short periods before being released. (77) Therefore, such screening should occur as soon as possible after a person enters a correctional or detention facility, preferably within the first 24 hours.
Adolescents should be screened for gonorrhea and chlamydia in institutions that serve them, including schools, community-based programs for at-risk
populations, and employment/training (e.g., Job Corps), sports, and summer youth
programs. The disease prevalence found after pilot screening should determine
the extent and frequency of screening. In general, adolescents should be tested
for these diseases at every visit if the prevalence of infection is >2%.
High-risk persons in street settings should be screened for gonorrhea, chlamydia, and syphilis whenever feasible during community outreach programs designed to prevent HIV infection. This type of screening often is best accomplished through partnerships between health agencies and community-based organizations or representatives of the target communities. Noninvasive diagnostic
tests (e.g., urine tests), self-obtained specimens, and mobile clinics can help facilitate testing in street settings. The yield or prevalence of infection
detected through these programs can be used to verify that appropriate groups
have been reached through outreach, with a goal of targeting screening activities
at communities or populations that yield a prevalence of >2%.
Presumptive Treatment for STDs
Persons with positive tests for STDs often are difficult to locate when the results become available, and even when they are found, they have had the opportunity to transmit the infection during the interval between testing and treatment. Because of this risk and because of the safety of the antibiotics used to treat curable STDs, persons likely to have these STDs should be treated presumptively while awaiting laboratory confirmation. Presumptive antibiotic treatment for STDs has been part of CDC's STD treatment guidelines for many years. (69) ACHSP endorses these guidelines, viewing them now as part of a national. strategy for HIV prevention, especially in settings where the likelihood of STD infection is high or prompt follow-up for subsequent treatment is in question. These guidelines include the following recommendations:
When doubts exist about whether a patient will follow up for test results or adhere to recommendations to avoid sexual activity while potentially infected with
an STD, men with urethral discharge and sexually active females with mucopurulent
cervical discharge should be treated presumptively with antibiotics for gonorrhea and chlamydial infection. (76) Presumptive treatment for primary syphilis is recommended in persons who have new onset genital ulcers and are from communities or groups with high syphilis rates. HIV-infected persons with genital ulcers or urethritis also should receive such empiric treatment, to decrease the load of excreted virus as quickly as possible.
Medical providers also should consider presumptive treatment for other STDs
(e.g., trichomoniasis) and genital infections (e.g., bacterial vaginosis), depending on clinical findings and disease prevalence in the population served. When presumptive treatment is administered, laboratory testing should be undertaken
whenever possible to confirm the nature of the infection.
Sex partners of persons treated presumptively for curable STDs also should be treated presumptively for these diseases. This recommendation is based on
a) the likelihood that sex partners are infected with the same organism(s) as
index patients, b) the high risk for reinfection of the treated index patients by their partners if the partners are not treated quickly, and c) the possibility that confirmatory laboratory tests on the index patients will give false negative results. When presumptive treatment is administered to sex partners, laboratory testing should be undertaken whenever possible to confirm the nature of the infection.
Behavioral Issues Related to Early Detection and Treatment of STDs
Although early STD detection and treatment essentially represents a biomedical
tool for lowering the risk for sexual transmission of HIV infection, important associated behavioral issues exist. The most important new messages for persons at risk for HIV infection and other STDs include a) other STDs facilitate HIV transmission, and early STD detection and treatment is an HIV prevention strategy; b) recognizing and watching for the symptoms of STDs is important; and c) most STDs produce no symptoms, so routine screening is crucial. A complementary set of messages should be developed and disseminated to health-care providers, and specific information on where to obtain quality STD services should be available to persons who need it.
These behavioral messages should supplement, not supplant, messages already emphasized in HIV-prevention counseling, such as the advantages of reducing the number of sex partners, the importance of knowing the HIV serostatus of one's partner(s), the importance of consistent and correct condom use, and the need to develop and implement strategies for avoiding risky sexual and other behaviors.
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