Sexually Transmitted Disease Clinical Preventive Services for HIV-Infected Patients (2001)

To the Editor: The recent article by Rothenberg et al 1 estimated that “about 27% of HIV transmissions from persons who are dually infected with HIV and an STD could be averted through adequate treatment of the sexually transmitted disease (STD), independent of behavioral change.”1p414 They cautioned that their methods provide only a general approach that would require some important refinements. Although there is uncertainty about the overall proportion of HIV transmissions related to dual infection with STDs in the United States, numerous studies have shown that genital ulcer disease, nonulcerative inflammatory STD, and bacterial vaginosis increase the risk of HIV transmission two- to fivefold. 2,3 In July 1998, the Centers for Disease Control and Prevention CDC Advisory Committee for HIV and STD Prevention recommended that STD prevention and control services be incorporated into HIV prevention programs, and that patients infected with HIV be screened routinely for STDs. 4 There have been a few reports of STD prevalence among patients infected with HIV. 1,5,6 However, to our knowledge, no published evaluations of community-wide STD screening and related clinical preventive services for such patients exist. In May 1999, we surveyed 15 clinicians who provided most of the HIV care in San Diego, California about STD screening practices. In December 1999, we asked them to estimate both the number of patients infected with HIV for whom they provided care in the preceding year and the number of those who had gonorrhea or chlamydia. Nine physicians completed the first survey. More than 75% of them reported that they assessed their patients’ risk behaviors and STD history, discussed risk reduction, and recorded the information in their medical records. However, only one clinician used a preprinted form to record such information. All the clinicians tested for syphilis, but 44% never screened asymptomatic patients for chlamydial infection of the genital tract, and 33% never screened them for gonorrheal infection of the genital tract. For male patients who had sex with men, 22% of the clinicians never did rectal or pharyngeal gonorrhea screening cultures (Table 1). Table 1: Sexually Transmitted Disease (STD) Screening, Vaccination, and Other Clinical Preventive Services at Initial Medical Examination by Physicians (n = 9) Providing Care to HIV-Infected Patients, San Diego, California, May 1999The second survey was returned by eight clinicians. During the preceding year, these clinicians estimated that they provided care for 1510 patients infected with HIV; 20 (1.3%) patients had chlamydia, and 31 patients (2.4%) had gonorrhea. More than 90% of these patients had symptoms compatible with gonorrhea or chlamydia infection. Among the patients infected with HIV, the estimated annual incidence per 100,000 was 1324 for chlamydia and 2384 for gonorrhea. The rates for both conditions were considerably higher than the rates reported in San Diego County for individuals 20 to 45 years of age (chlamydia 223 and gonorrhea 68 per 100,000). Although clinicians reported a considerable amount of STD screening, chlamydia and gonorrhea screening as well as trichomoniasis and bacterial vaginosis screening among women were far from optimal, needing considerable improvement. We have developed a guidance document for the care of patients infected with HIV that describes recommended STD clinical preventive services (copy available from author). Most of these recommendations have been incorporated into the recommendations developed by the HIV Standards of Care Working Group of the HIV Planning Council in San Diego. After final approval, these recommendations will be considered standard of care for individuals infected with HIV. The estimated incidence of chlamydia and gonorrhea among these HIV-infected patients was much higher than among the general population, indicating that some patients infected with HIV are practicing unsafe sex. Men infected with HIV who have symptomatic gonorrhea may experience a 10-fold increase in HIV in their genital tract secretions that remains elevated for 1 to 2 weeks after treatment. 7 Patients infected with HIV should receive information about STD symptom recognition and have access to prompt diagnosis and treatment. The information obtained in this survey allows only very limited generalization. Larger geographically diverse surveys and quality assurance programs with medical record review are needed to determine what STD clinical preventive services are provided for patients infected with HIV and what barriers inhibit service delivery. The survey conducted in San Diego initiated a dialogue between HIV care providers and the Health Department’s STD control program. This dialogue led to the development of an e-mail network that enhances the dissemination of information (i.e., syphilis outbreak among men who have sex with men), providing an efficient way to obtain feedback from practicing clinicians in the community. ROBERT A. GUNN, MD, MPH,*† STEVE L. ELDRED, MPH,† AND CHRISTOPHER MATHEWS, MD‡