- • Because new sexually transmitted diseases (STDs)
are common in HIV-infected patients, regular screening and timely
treatment are essential.
- • Counseling of HIV-positive patients should include
discussion of HIV-STD interactions and risks.
- • Both genital ulcer–causing diseases and
non–ulcer-causing STDs increase HIV transmission.
- • Clinical and laboratory findings of syphilis in
HIV-infected patients can be challenging to interpret, and these
patients require close follow up.
- • Prevention of human papillomavirus (HPV)– associated
malignancies requires active surveillance in HIV-infected persons.
- • Genital herpes and syphilis may increase HIV viral
load, lower CD4 count, and hasten HIV disease progression.
At the initial evaluation of a patient with HIV infection, the
clinician should actively screen for typical symptoms and signs
of STDs. These include the presence of genital, oral, or anal lesions; pain
or burning with urination; new or unusual skin rash; lymphadenopathy
and rectal symptoms of discharge, burning, or itching. In addition,
men should be screened for urethral discharge or groin pain and
women for bloody or foul-smelling vaginal discharge, itching, lower
abdominal pain, missed menses, and pregnancy status. Any patient
reporting symptoms and signs of STDs should have appropriate diagnostic
testing regardless of reported sexual behavior or other risk factors.
Routine Laboratory Assessment
All HIV-infected patients should undergo serologic testing for
syphilis, herpes simplex virus type 2 (HSV-2), and hepatitis as
well as gonorrhea and chlamydia testing at all exposed anatomic
sites (urogenital, anal, oral) at the initial visit. HSV-2 serologic
testing should utilize newer, glycoprotein G–specific tests
(see Table 21–1). HIV-infected
women should undergo speculum-guided pelvic examination with microscopic evaluation
of vaginal fluid (wet mount) and Papanicolaou (Pap) smear. Pap smears
should be repeated at 6 months and then annually thereafter. Although
no national guidelines exist, some experts recommend that HIV-infected
men should also undergo regular anal cancer screening (anal Pap
smear). Newly diagnosed HIV-infected patients should also receive
a broad medical evaluation, which is beyond the scope of discussion
in this chapter.
Table 21–1. Initial STD Screenings in HIV-Infected Patients. |Favorite Table|Download (.pdf)
Table 21–1. Initial STD Screenings in HIV-Infected Patients.
|Patient Population||Test||Site or Source|
|All||RPR or VDRL||Serum|
|Chlamydia trachomatis NAATa,b||First-catch urine or urethral or cervical secretions, or both|
|Gonorrhea culture or NAATa||First-catch urine or urethral or cervical secretions, or both|
|Women||Wet mount or culture for Trichomonas vaginalis||Vaginal or cervical secretions|
|Patients engaging in receptive anal sex||Gonorrhea culture or NAAT (preferred), if available||Anal swab|
|C trachomatis culture, if available or NAAT (preferred), if available||Anal swab|
|Patients engaging in receptive oral sex||Gonorrhea culture or NAAT (preferred), if available||Pharyngeal swab|