HIV Prevention Through Early Detection and Treatment of Other Sexually Transmitted Diseases -- United States
Recommendations of the Advisory Committee for HIV and STD Prevention
July 31, 1998
Additional Supportive Activities
HIV Screening Among Persons with Other STDs
Screening for HIV infection among persons with other STDs is an important HIV prevention strategy. Although HIV counseling and testing among persons with other STDs has long been recommended and applied in the United States, (97) the extent of the practice of this preventive service varies and is limited in many jurisdictions. A person could be more receptive to HIV prevention messages delivered when an STD is diagnosed. Therefore, broader practice of HIV counseling and testing among STD patients, although not strictly pertinent to the strategy of early STD detection and treatment, could provide an opportunity to reinforce awareness of the cofactor role of STDs for HIV transmission and the importance of seeking timely medical care for STD symptoms. It also provides an important opportunity to assess coinfection rates for HIV infection and other STDs. However, these services should be implemented with scrupulous attention to the quality of the counseling and with adequate referral systems to redirect HIV-seropositive and at-risk HIV-seronegative persons into long-term primary-care, prevention, and drug treatment services, as appropriate.
Community-Level Prevention of the Highest Risk STDs
Some less common STDs in the United States have been associated with a higher than-average prevalence of HIV coinfection and transmission risk. Examples include rectal gonorrhea among MSM and the bacterial genital ulcer diseases (syphilis and chancroid). Rectal gonorrhea in men should be monitored carefully, and its persistence should be considered a community-level sentinel event reflecting a mixture of higher-risk behavior, STD cofactor effects, and other HIV transmission risk factors. It should prompt an urgent HIV prevention response, including but not restricted to enhanced STD detection and treatment among MSM.
Also, because of the strong impact of syphilis and chancroid on HIV transmission, U.S. public health officials are developing and implementing plans to eliminate domestic transmission of syphilis. (98) This program could be particularly important because of the apparent cyclical nature of syphilis epidemics in the United States in the absence of concerted efforts toward elimination of this disease. (49,55) Therefore, ACHSP supports syphilis elimination as a potentially high-impact activity leading to reduced STD-facilitated HIV transmission in the United States. It recommends that STD and HIV prevention programs collaborate in the development and implementation of syphilis elimination plans in their jurisdictions.
Improving and Using STD Surveillance for HIV Prevention
Early detection and treatment of curable STDs as an HIV prevention strategy also has implications for public health surveillance of STDs. Improved quality, completeness, and timeliness of STD surveillance can provide critical information to target early STD detection and treatment and help target HIV prevention strategies. If reporting requirements are met, expanded early detection of STDs within a jurisdiction should lead to more complete STD surveillance data, which could be an important element of the epidemiologic profile used by HIV prevention community planning groups. (99) Although it also could lead to an increase in reported STD rates in the initial years of expanded services, this result should be seen as a positive indicator of enhanced early detection of STDs. The rates should decline in subsequent years.
In addition to these general concerns, several surveillance issues are important to improving early STD detection and treatment for HIV prevention. In many areas of the United States and nationally, data are not collected systematically on the anatomic site of infection for persons with gonorrhea. However, gonorrhea among MSM, especially rectal gonorrhea, can be an important indicator of the potential for HIV transmission. Therefore, the anatomic site of gonococcal infection should be reported consistently as part of routine notifiable disease surveillance in all jurisdictions.
Enhanced STD surveillance also should include monitoring the prevalence of STDs and HIV infection in settings where there are persons at high risk for both (e.g., correctional facilities and drug treatment centers). (77,86,100,101) This latter surveillance strategy complements the expanded early detection and treatment of STDs in settings where higher-risk persons are encountered. The observed prevalence of STD and HIV infections in these specific venues, as well as additional data when available on STD/HIV coinfections, should be used to guide further program interventions. (100) Finally, HIV counseling and testing data systems should be modified to ensure that STD diagnoses are captured.
Cross-Training HIV and STD Prevention Staff
Implementing the strategy of enhanced STD detection and treatment for HIV prevention is likely to require or be enhanced by greater mutual familiarity and sense of shared purpose within state and local HIV and STD prevention programs. Cross-training program and management staff in the current practices, technology, and guidelines of the other program should mutually strengthen both HIV and STD prevention programs. In many jurisdictions and/or for certain subpopulations, cross-training could be an initial activity to help adapt these general recommendations to the specific epidemiologic, health-care, and prevention service needs of the local population.
Potential Role of Other STDs
Although this report has emphasized early detection and treatment of curable, especially bacterial, STDs, other STDs and related conditions also warrant appropriate management and could constitute equally important opportunities for HIV prevention. For example, evidence exists for a cofactor role of vaginitis caused by the common, sexually transmitted parasite T. vaginalis, so including T. vaginalis in screening protocols for women whenever feasible is likely to lower the risk for HIV transmission. Infections with HSV-2 are highly prevalent in the U.S. population (45) and occur in at least half of individuals in some subpopulations at high risk for HIV infection (e.g., MSM). As a persistent, latent infection causing recurring genital ulcers and associated with greater genital tract HIV shedding, (16) HSV-2 coinfection could represent a major STD cofactor effect. At a minimum, persons with both HIV infection and genital herpes should be counseled especially to avoid sex when herpes is symptomatic because HIV viral shedding is more active during such periods. However, the optimal detection and treatment strategy corresponding to this particular STD/HIV interaction has not been well-defined and, for the moment, remains a critical area for needed research. Emerging data on bacterial vaginosis as a risk factor for HIV acquisition in women (13,102) likewise represent a major potential opportunity, as well as a challenge. Although bacterial vaginosis is a highly prevalent condition, no well-defined effective strategies for long-term prevention exist beyond treating individual patients.
This article was provided by U.S. Centers for Disease Control and Prevention. It is a part of the publication Morbidity and Mortality Weekly Report. Visit the CDC's website to find out more about their activities, publications and services.