New STD recommendations include HIV management
Treatment hindered by lack of services, expertise
The Centers for Disease Control and Prevention has updated its 1993 Sexually Transmitted Diseases Treatment Guidelines, adding new recommendations for the treatment of primary and recurrent genital warts and expanding sections that include management of patients with asymptomatic HIV infection. And while the guidelines are the most popular of all CDC guidelines, improved treatment of STDs will require more service resources in the public sector and better provider education in the private sector, CDC officials note.
The guidelines were published in the Jan. 22, 1998, Morbidity and Mortality Weekly Report. The updating process began in 1996 with experts systematically reviewing literature for each of the major STDs. In early 1997, the CDC invited consultants to a three-day meeting to focus questions on four areas of STD therapy: microbiologic cure, alleviation of signs and symptoms, prevention of sequelae, and prevention of transmission.1
With the majority of STDs treated by private physicians — an estimated 60% — the CDC made an effort to get input from the private sector by including representatives from managed care organizations, says Judith Wasserheit, MD, MPH, director of the division of STD Prevention.
"One of the things we are trying to do is get managed care providers involved in developing all guidelines now, and this is a good example of including them for the first time," she tells AIDS Alert.
The guidelines expand the section on HIV infection, putting a greater emphasis on the interplay between HIV and STDs. The section notes that "because of its effect on the immune system, HIV affects the diagnosis, evaluation, treatment and follow-up of many other diseases and may affect the efficacy of antimicrobial therapy for some STDs."
The guidelines recommend that people seeking evaluation and treatment for STDs should be offered HIV testing, with pre- and post-test counseling made available. The CDC doesn’t recommend routine testing for HIV-2 infection because of its low prevalence in the United States.
Because of the growing emphasis on early treatment of HIV, STD clinicians should be alert for the symptoms and signs of acute retroviral syndrome or primary HIV infection. If testing reveals HIV infection, the patient should be counseled for immediate treatment with antiretroviral therapy or referred to emergency expert consultation.
HIV-positive patients in an STD treatment setting should be educated about the type of medical care to expect. In non-emergency situations, the initial evaluation should include:
• a detailed medical history, including sexual and substance-abuse history, previous STDs, and specific HIV-related symptoms and diagnoses;
• a physical exam, including a gynecological exam for women;
• testing in women for N. gonorrhea and C. trachomatis, and a Pap smear;
• complete blood and platelet counts and blood chemistry profile;
• CD4 and viral-load analysis;
• tuberculin skin test and chest radiography;
• thorough psychosocial evaluation, including behavior risks and information on exposed partners, both sexual partners and injection-drug users. Patient should be informed about two types of patient referral notification processes — patient referral and provider referral. (The guidelines cite trial results showing that provider referral is more effective, with 50% of partners notified through that process compared to 7% for patient referral.)
Other aspects of the guidelines include the need for offering routine HIV testing for all pregnant women, and a special section on the treatment response to patients who have been sexually assaulted. The guidelines raise the issue of postexposure prophylaxis in the likelihood that a patient was exposed to HIV. However, the CDC concludes that efficacy data are lacking for making a recommendation.
For those health care workers considering whether to offer such therapy, the timeliness of the exposure is an important consideration, the CDC notes, as efficacy declines rapidly with time. Before offering postexposure therapy, the patient should be told about the potential risks of therapy, the need for frequent dosing of medications, the close follow-up required, the importance of drug compliance, and the need for immediate initiation of therapy.
Problems of access, quality of services
While the guidelines provide clinicians with the latest knowledge on STD treatment, the infrastructure for delivering STD services is often inadequate, Wasserheit says. She mentions a recent survey by the Alan Guttmacher Institute in New York, the first to provide a national representative sample of public health STD programs.2 Among its more disturbing findings was the fact that in 1995, only 50% of all local health departments directly provided STD services. Of those that did, 24% reported that their clients had to wait one to two days to be seen, and 15% reported waiting periods of three days or more."That is taking a precious subset of patients that are actually motivated enough to come into a public health clinic, and therefore, having a high likelihood of being infected, and turning them away," Wasserheit says. "We are turning them away not because providers don’t want to see them, but because they don’t have the resource capacity — not enough clinicians and exam rooms — to see them."
Other pertinent findings of the survey include:
• Only 66% to 78% of STD clinics routinely inquire about substance abuse, counsel clients about effective contraception, or teach condom negotiation with partners.
• STD clinics dedicate little or no staff time to educating the community about STD prevention, either through street outreach or community presentations.
• While federal funding is earmarked almost entirely for prevention, diagnosis, and treatment of syphilis, gonorrhea, and chlamydia, about one-third of patients have other STDs as well.
• About three-quarters (74%) of public health departments provide HIV/AIDS services as part of STD services. However, up to 10% of the health departments provide no HIV/AIDS services.
Curiously, the survey found that most agencies that integrated STD treatment and other services were more likely to be found in small rural public health departments. "It is unclear whether integrated care suggests a developing trend or is simply an efficient way to provide care in settings with little obvious demand for specific services," the authors note. Indeed, while integrated clinics tend to be more responsive to patients’ broader health needs, these agencies were less likely to know how many STD visits they provided or how much money was allocated to STD services. The study also found they were less likely to provide community education.
These shortfalls in rural clinics are responsible in part for the wide geographic disparity in STD incidence. The public-health impact of STDs is greatest in the South, which has had higher rates of chlamydia, syphilis, and gonorrhea than any other region in the country throughout the 1980s and 1990s. In addition to inadequate health care services, CDC officials attribute the disparity to racial and ethnic differences of the population and to poverty.
"Two things happen in rural areas," Wasserheit says. "One, STD services, if provided at all, are only provided for half-day sessions per week by nurses who go place to place. And second, confidentiality becomes a greater issue because small-town people feel strongly they don’t want to be seen [getting treatment] in their own town, and they often have to go miles away if they go at all."
In the private sector, where the majority of STDs are treated, access to services is not as much of a concern as quality of care, Wasserheit notes. Traditionally, private physicians haven’t put much emphasis on STDs because of the perception that these diseases weren’t prevalent in their patient population. Today, however, some of the fastest-growing STDs, chlamydia and genital herpes in particular, are being spread across a wide spectrum of the population. Another concern is that under managed care, providers will be less vigilant in diagnosing STDs, Wasserheit adds.
References
1. Centers for Disease Control and Prevention. 1998 guidelines for treatment of sexually transmitted diseases. MMWR 1998; 47(No. RR-1).
2. Landry D, Forrest J. Public health departments providing sexually transmitted disease services. Fam Plann Perspect 1996; 28:261-266.
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