Clinician Advisory: 

Human Immunodeficiency Virus & Other Sexually Transmitted Infections

june 24, 2021

Actions Requested:

• Provide empiric treatment for bacterial sexually transmitted infections (STI) among patients presenting with compelling clinical syndromes while laboratory results are pending—especially in settings where or among patients for whom risk of loss to follow-up is high.
• Always check syphilis and human immunodeficiency virus (HIV) serology along with other routine prenatal laboratory tests when a woman first presents for prenatal care.  If the initial test occurred early in pregnancy and the patient is at risk for STI acquisition, consider repeating this serologic testing during the third trimester.
• Be aware of an increase in delayed presentation of HIV infection and involvement of groups not traditionally thought of as high-risk.  
• In these and analogous endeavors, communicate the routine nature of HIV and other STI testing to reduce patients’ potential sense of being judged or stigmatized and consequently declining current or future STI-related care.  
• Consult CDC’s STD Treatment Guidelines for details on diagnosis and treatment.  
• Contact SHD the Health District’s STD/HIV Program at 425-339-5261 for consultation or assistance following up with untreated cases.
• Report all notifiable STIs (e.g., HIV, syphilis, gonorrhea, genital herpes first episode) by completing a case report form and faxing it to (425) 339-8707.

Background

• Seven (88%) of the last eight newly reported HIV cases in Snohomish County presented with AIDS-defining features; two (25%) died shortly after diagnosis.  Five (63%) lacked traditionally recognized risk factors for infection (e.g., men who have sex with men, drug injection, homelessness).  
• Health District disease investigators are also reporting an increase in cases that have had significant delays in treatment or who have received inadequate treatment following a positive test, particularly among patients with gonorrhea and chlamydia.  

Recommendations

Delays in treatment due to patient-related factors can be difficult to overcome, especially among patients who present for asymptomatic screening and then cannot be reached.  Furthermore, increasing attention to antimicrobial stewardship warrants judicious use of anti-STI agents.  Notwithstanding these considerations, prompt and correct treatment is within our grasp in many (if not most) situations and the Health District consequently recommends the following practices during bacterial STI-related encounters in accord with prevailing national guidelines:

• Evaluation of symptomatic patients should generally include nucleic acid amplification testing of a urogenital specimen for both chlamydia and gonorrhea PLUS serologic testing for both syphilis and HIV, regardless of the specific syndrome the patient is presenting with.   
• Always provide treatment at the first visit for patients who present as a sexual partner to a specific bacterial STI—even if they are asymptomatic.  Conduct appropriate testing as set forth above, but do not wait for test results to treat sex partners.  When partners are unable or unwilling to present for evaluation and treatment of chlamydia or gonorrhea, offer expedited partner therapy with the assistance of the source case patient.  This practice is supported by the Centers for Disease Control and Prevention (CDC), the Washington State Department of Health, and the Washington State Medical Quality Assurance Commission.
• Whenever feasible, perform Gram’s stain testing of genital specimens and provide empiric treatment for detected syndromes (e.g., non-gonococcal urethritisàchlamydia coverage; gram-negative intracellular diplococciàgonorrhea; pelvic inflammatory disease or epididymitisàboth chlamydia and gonorrhea).  
• If available, perform darkfield microscopy on genital ulcers to detect spirochetes, and consider providing empiric anti-syphilis treatment for painless, indurated genital ulcers while serologic results are pending.  
• Ensure that all adults have been tested at least once for HIV infection and, furthermore, maintain a low threshold for repeat testing among sexually active adults, even if they are not in traditionally recognized risk categories.  
• Offer pre-exposure HIV chemoprophylaxis (PrEP; daily emtricitabine-plus-tenofovir) to appropriately selected high-risk patients.  CDC reports that PrEP reduces the risk of HIV acquisition through sex by 99% and through drug injection by 74%.