dmcanzi@watdcsu.waterloo.edu (David Canzi) (10/05/89)
Volume 2, Number 36 October 1, 1989
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Editor: David Dodell, D.M.D.
St. Joseph's Hospital and Medical Center
10250 North 92nd Street, Suite 210, Scottsdale, Arizona 85258-4599 USA
Telephone (602) 860-1121
(c) 1989 - Distribution on Commercial/Pay Systems Prohibited without
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Medical News
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Medical News for Week Ending October 1, 1989
Copyright 1989: USA TODAY/Gannett National Information Network
Reproduced with Permission
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Sept. 26, 1989
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AIDS DRUG BEING IMPORTED:
The People With AIDS Health Group said Monday that it was bringing an AIDS
drug from Europe into the USA to undercut the high cost of the drug by
Lyphomed, Inc. of Rosemont, Ill. The group said a monthly dose of aerosol
pentamidine costs $30 in Europe. It will be sold for $40 by the group,
compared to $99.45 for the drug sold in the USA. (From the USA TODAY Life
section.)
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Sept. 28, 1989
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AIDS TESTS URGED FOR PATIENTS:
The American Academy of Orthopaedic Surgeons said Thursday it recommended
voluntary, confidential AIDS testing of all patients and health care workers.
Reason: Potential health risk to health care works. Recommendations: Surgeons
wear waterproof gowns, eyegear, knee-high waterproof surgical shoe covers,
pass sharp instruments by tray only.
LOUISIANA AIDS STATISTICS OUT:
The Louisiana Department of Health and Hospitals said in New Orleans
Wednesday that about 12 of every 10,000 Louisiana women of childbearing age
have the AIDS virus. Of 56,270 mothers, 69 - 57 of them black - were positive
in the first statewide test of AIDS among heterosexuals.
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Sept. 29-Oct. 1, 1989
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AIDS DRUG TO GET WIDER USE:
The government announced Thursday that DDI, a promising but unproven drug
to treat AIDS, will be widely available. The drug has undergone less testing
than drugs released in the past, but AIDS patients want to be able to decide
for themselves whether to take it or not. Bristol-Myers Co. will distribute
free DDI to patients, who can't tolerate or don't benefit from AZT.
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Articles
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Sexually Transmitted Diseases
Treatment Guidelines
U.S. Department of Health and Human Services
Public Health Service
Division of Sexually Transmitted Diseases
Center for Prevention Services
Centers for Disease Control
Atlanta, Georgia 30333
The MMWR series of publications is published by the Epidemiology Program
Office, Centers for Disease Control, Public Health Service, U.S. Department of
Health and Human Services, Atlanta, Georgia 30333.
SUGGESTED CITATION
Centers for Disease Control. 1989 Sexually Transmitted Diseases Treatment
Guidelines. MMWR 1989;38(No. S-8):(inclusive page numbers).
Centers for Disease Control Walter R. Dowdle, Ph.D.
Acting Director
The material in this report was prepared for publication by:
Center for Prevention Services Alan R. Hinman, M.D.
Director Division of Sexually Transmitted Diseases
Willard Cates, Jr., M.D., MPH Director
Jonathan M. Zenilman, M.D. Project Coordinator
Martha S. Mayfield Consulting Editor Center for Infectious Diseases
Frederick A. Murphy, D.V.M., Ph.D. Director
Sexually Transmitted Diseases Laboratory Program
Stephen A. Morse, Ph.D.
Director
The production of this report as an MMWR serial publication was coordinated
in:
Epidemiology Program Office Stephen B. Thacker, M.D., M.Sc.
Director
Richard A. Goodman, M.D., M.P.H.
Editor, MMWR Series
Editorial Services R. Elliott Churchill, M.A.
Chief
Suzanne M. Hewitt
Writer-Editor
Ruth C. Greenberg
Editorial Assistant
The use of trade names and commercial sources is for identification purposes
only and does not constitute endorsement by the Public Health Service or the
U.S. Department of Health and Human Services.
Introduction
These guidelines for the treatment of patients with sexually transmitted
diseases (STD) were established after consultation with a group of outside
experts and staff of CDC.* These guidelines are based on available efficacy
data, practical applicability, and cost. The recommendations should not be
construed as rules, but rather as a source of clinical guidance within the
United States. The guidelines focus on the treatment and counseling of
individual patients and do not address other community services and
interventions that may play roles in STD prevention. Clinical and laboratory
diagnosis are briefly alluded to when appropriate in the context of therapy.
[ The article is extremely long. AIDS and HIV are mentioned frequently
througout it, in connection with other sexually transmitted diseases.
Only the part of the article specifically about AIDS and HIV is
excerpted here. -- DMC ]
AIDS and HIV Infection in The General STD Setting
The acquired immunodeficiency syndrome (AIDS) is a late manifestation of
infection with human immunodeficiency virus (HIV). Most people infected with
HIV remain asymptomatic for long periods. HIV infection is most often diagnosed
by using HIV antibody tests. Detectable antibody usually develops within 3
months after infection. A confirmed positive antibody test means that a person
is infected with HIV and is capable of transmitting the virus to others.
Although a negative antibody test usually means a person is not infected,
antibody tests cannot rule out infection from a recent exposure. If antibody
testing is related to a specific exposure, the test should be repeated 3 and 6
months after the exposure.
Antibody testing for HIV begins with a screening test, usually an
enzyme-linked immunosorbent assay (ELISA). If the screening test is positive,
it is followed by a more specific confirmatory test, most commonly the Western
blot assay. New antibody tests are being developed and licensed that are either
easier to perform or more accurate. Positive results from screening tests must
be confirmed before being considered definitive.
The time between infection with HIV and development of AIDS ranges from a
few months to greater than or equal to 10 years. Most people who are infected
with HIV will eventually have some symptoms related to that infection. In one
cohort study, AIDS developed in 48% of a group of gay men less than or equal to
10 years after infection; but additional AIDS cases are expected among those
who have remained AIDS-free for greater than 10 years.
Therapy with zidovudine (ZDV--previously known as azidothymidine) has been
shown to benefit persons in the later stages of disease (AIDS or AIDS-related
conditions along with a CD4 (T4) lymphocyte count less than 200/mm3). Serious
side effects, usually anemias and cytopenias, have been common during therapy
with ZDV; therefore, patients taking ZDV require careful follow-up in
consultation with physicians who are familiar with ZDV therapy. Clinical trials
are currently evaluating ZDV therapy for persons with asymptomatic HIV
infection to see if it decreases the rate of progression to AIDS. Other trials
are evaluating new drugs or combinations of drugs for persons with different
stages of HIV infection, including asymptomatic infections. The complete
therapeutic management of HIV infection is beyond the scope of this document.
Preventing the Sexual Transmission of HIV
The only way to prevent AIDS is to prevent the initial infection with HIV.
Prevention of sexual transmission of HIV can be ensured in only two situations:
1) sexual abstinence or 2) choosing only sex partners who are not infected with
HIV.
Many HIV-infected persons are asymptomatic and are unaware that they are
infected. Therefore, without an antibody test, infected persons are difficult
to identify. AIDS case surveillance and HIV seroprevalence studies allow
estimation of risk for persons in different areas; however, these population
estimates may have a limited impact on an individual's sexual decisions.
Although knowledge of antibody status is desirable before a sexual relationship
is initiated, this information may not be available. Therefore, individuals
should be counseled that when they initiate a sexual relationship they should
use sexual practices that reduce the risk of HIV transmission.
Sexual practices may influence the likelihood of HIV transmission during
sexual contact with an infected partner. Women who practice anal intercourse
with an infected partner are more likely to acquire infection than women who
have only vaginal intercourse. The relative risk of transmission by
oral-genital contact is probably somewhat lower than the risk of transmission
by vaginal intercourse. Other STD or local trauma that breaks down the mucosal
barrier to infection would be expected to increase the risk of HIV
transmission. Condoms supplement natural barriers to infection and therefore
reduce the risk of HIV transmission (see "Clinician Guidelines and Public
Health Considerations").
When to Test for HIV
Voluntary, confidential, HIV antibody testing should be done routinely when
the results may contribute either to the medical management of the person
being tested or to the prevention of further transmission.
Testing is important for persons with symptoms of HIV-related illnesses or
with diseases such as syphilis, chancroid, herpes, or tuberculosis, for which a
positive test result might affect the recommended diagnostic evaluation,
treatment, or follow-up. HIV counseling and testing for persons with STD is a
particularly important part of an HIV prevention program, because patients who
have acquired an STD have demonstrated their potential risk for acquiring HIV.
Because no vaccine or cure is available, HIV prevention requires changes in
behavior by people at risk for transmitting or acquiring infection. Therefore,
patient counseling must be an integral part of any HIV testing program in an
STD clinic. Counseling should be done both before and after HIV testing.
Pretest Counseling
Pretest counseling should include assessment of the patient's risk for HIV
infection and measures to reduce that risk. Intravenous (IV) drug users should b
do not stop, they should not share needles. If needle-sharing continues,
injection equipment should be cleaned with bleach between uses. Sexually active
persons who have multiple partners should be advised to consider sexual
abstinence or to enter a mutually monogamous relationship with a partner who
has also been tested for HIV. Condoms should be used consistently if either or
both partners are infected or have other partners. Similarly, heterosexuals
with STD other than HIV should be encouraged to bring their partners in for HIV
testing and to use condoms if they are not in a mutually monogamous
relationship with an uninfected partner.
Posttest Counseling and Evaluation
Persons who have negative HIV antibody tests should be told their test resul
behaviors and can explain ways to modify sexual practices to reduce risks.
Antibody tests cannot detect infections that occurred in the several weeks
before the test (see above). Persons who have negative tests should understand
that the negative test result does not signify protection from acquiring
infection. They should be advised about the ways the virus is transmitted and
how to avoid infection. Their partners' risks for HIV infection should be
discussed, and partners at risk should be encouraged to be tested for HIV.
Persons who test positive for HIV antibody should be told their test result
by a person who is able to discuss the medical, psychological, and social
implications of HIV infection. Routes of HIV transmission and methods to
prevent further transmission should be emphasized.
Risks to past sexual and needle-sharing partners of HIV antibody-positive
patients should be discussed, and they should be instructed in how to notify
their partners and to refer them for counseling and testing. If they are unable
to notify their partners or they are not sure that their partners will seek
counseling, physicians or health department personnel should assist, using
confidential procedures, to ensure that the partners are notified. Infected
women should be advised of the risk of perinatal transmission (see below), and
methods of contraception should be discussed and provided. Additional
follow-up, counseling, and support systems should be available to facilitate
psychosocial adjustment and changes in behavior among HIV antibody-positive
persons.
Perinatal Infections
Infants born to women with HIV infection may also be infected with HIV;
this risk is estimated to be 30%-40%. The mother in such a case may be
asymptomatic and her HIV infection not recognized at delivery. Infected
neonates are usually asymptomatic, and currently HIV infection cannot be
readily or easily diagnosed at birth. (A positive antibody test may reflect
passively transferred maternal antibodies, and the infant must be observed over
time to determine if neonatal infection is present.) Infection may not become
evident until the child is 12-18 months of age. All pregnant women with a
history of STD should be offered HIV counseling and testing. Recognition of HIV
infection in pregnancy permits health-care workers to inform patients about the
risks of transmission to the infant and the risks of continuing pregnancy.
Asymptomatic HIV Infections
As more HIV-infected persons are identified, primary health-care providers
will need to assume increased responsibility for these patients. Most
internists, pediatricians, family practitioners, and gynecologists should be
qualified to provide initial evaluation of HIV-infected individuals and
follow-up of those with uncomplicated HIV infection. These services should be
available in all public health clinics.
Health-care professionals who identify HIV-positive patients should provide
posttest counseling; medical evaluation (either on site or by
referral)--including a physical examination, complete blood count,
lymphocyte subset analysis, syphilis serology, and a purified protein
derivative (PPD) skin test for tuberculosis. Psychosocial counseling
resources should also be available.
All clinics and providers should establish and maintain contacts with
resources in their regions for persons concerned about HIV infection, and they
should refer patients when necessary. Possible resources for referral include
counseling services, support groups, social workers, physicians, and clinics.
--
David Canzi