First comprehensive HIV/STI management guidelines now available

Syphilis: two single injections once weekly now recommended

A major change from the 2002 guidelines on the management of syphilis in people with HIV is the change of focus in the treatment of primary or secondary syphilis from the use of consecutive daily intramuscular injections of procaine penicillin for up to three weeks to a more manageable and less painful treatment using two doses of intramuscular benzathine penicillin G one week apart.

The proviso is that this easier option should be only offered to individuals in whom syphilis is detected early, who are not profoundly immunosuppressed, and who can be adequately followed-up in order to detect relapses since there is a potential risk with this treatment. The pros and cons of the different approaches to syphilis treatment are covered in more depth in this recent aidsmap news feature.

The first ever comprehensive set of guidelines for the management of sexually transmitted infections (STIs) in HIV-positive individuals have been published by the British Association for Sexual Health and HIV (BASHH). These include an update to the 2002 syphilis guidelines; the management of genital herpes (HSV-2); ano-genital warts, cervical and anal cancer caused the human papilloma virus (HPV); and a discussion of the legal and ethical issues surrounding onward HIV transmission. The guidelines complement previously published BASHH guidelines on post-exposure prophylaxis (PEP) after possible sexual exposure to HIV, as well as BASHH guidelines on individual STIs.

Good sexual health is especially important for people with HIV because some untreated STIs can cause disease progression, increase the risk of certain cancers, and may be harder to treat than in HIV-negative individuals. Untreated STIs also increase the risk of HIV transmission. The aims of the new BASHH STI/HIV guidelines are to both support people with HIV to enjoy good sexual health for their own personal well-being, as well as to help clinicians when providing treatment and care for people with HIV. A further aim is to prevent onward transmission of both HIV and STIs.

Key general recommendations include:

• All HIV service providers should be able to provide ready access to staff who are trained in taking a sexual history and who can make an appropriate sexual health assessment.
• A sexual health assessment including a sexual history should be documented at first presentation and at six-monthly intervals for all HIV-positive people receiving long-term care.
• A full sexual health screen (including annual PAP smear in women) should be offered, regardless of reported history, and the outcome documented in the HIV case notes.
• Syphilis serology should be incorporated into routine HIV blood tests and checked at three-monthly clinic visits to detect asymptomatic cases.
• Local care pathways for diagnosis, treatment and partner work for STIs in people with HIV should be documented and actively communicated to all members of clinic staff, as well as to HIV-positive people.

The guidelines authors write that the majority of STIs in HIV-positive individuals can be managed in the same way as in HIV-negative individuals.

These include:

• gonorrhoea
• non-gonoccocal urethritis
• chlamydia
• LGV (Lymphogranuloma venereum)
• Trichomonas vaginalis
• bacterial vaginosis

HIV/HSV-2 management guidelines

The natural history of untreated genital herpes (HSV-2) in HIV-positive individuals is significantly different from HIV-negative individuals. There is some evidence to show that herpes viruses activate HIV, making it easier for HIV to infect certain cells. Genital herpes infection also increases the risk of sexual HIV transmission. The most important risk factor for herpes reactivation is a low CD4 count.

Key recommendations for the management of HSV-2 include:

• First episode genital herpes in HIV-positive people should be treated with aciclovir 400mg five times daily for seven to ten days. Alternative oral regimens include valaciclovir 1g twice daily for ten days or famciclovir 250-750mg three times a day for ten days.
• In severe cases, initiating therapy with intravenous aciclovir 5-10mg/kg body weight every eight hours may be necessary.
• Aciclovir, famciclovir and valaciclovir can all be used as episodic herpes therapy in people with HIV, and there is no clear evidence of superiority between them.

The guidelines also include information regarding the detailed management of drug-resistant genital herpes.

HIV/HPV management guidelines

Human papilloma virus, or HPV, refers to a group of viruses that cause warts on the skin and the genital region and are associated with both cervical and anal cancers. Men and women with HIV are at increased risk of HPV-related cancers.

Key recommendations for the management of HPV include:

• Imiquimod 5% cream can be used as a topical treatment for genital warts, although comparative studies have not been performed.
• Surgical methods of wart removal may be used at an earlier stage of disease management compared to HIV-negative individuals.
• HIV-positive women should undergo annual cervical cytology (Pap smear), and treatment of low grade CIN should be considered, particularly in women with low CD4 cell counts, due to the risk of disease progression.
• HIV-positive men and women with ano-genital warts should undergo a rectal exam (via a proctoscope) after the reasons for the procedure are fully explained. Unusual lesions should be biopsied and sent for histological examination.

However, the guidelines say that since "the role of anal cytology (anal Pap smear) as a screening method is not yet known" they do not recommend it, despite an increasing prevalence of anal cancer in HIV-positive gay men. Currently, both the British HIV Association (BHIVA) and the UK National Screening Committee are examining the pros and cons of anal cancer screening for HIV-positive individuals.

Legal and ethical implications of onward transmission

The guidelines also include a discussion on the relative risks of HIV transmission - including recognising the risks of oral sex, and concern over transmitted drug-resistant HIV in the UK.

There is also discussion of the issues around disclosure. "Healthcare workers have a duty to maintain the confidentiality of patient information,"the guidelines authors write, "unless the patient has consented to disclosure, or disclosure is necessary in the public interest....In exceptional circumstances, it become necessary to consider disclosing information to a known sexual contact of a PWHIV where there is reason to think that the patient has not informed that person, and cannot be persuaded to do so."

The issue of confidentiality, disclosure and the law is currently a hot topic. BHIVA is preparing new guidelines for its members about how to respond to the recent changes in UK law.