Offer presumptive treatment for STIs to gay men testing HIV-positive

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Gay men testing HIV-positive at point-of-care testing centres (which provide test results the same day) should be given presumptive treatment for gonorrhoea and chlamydia, investigators in the US are recommending in a study published in the May 1st edition of the Journal of Acquired Immune Deficiency Syndromes. The investigators issued this recommendation after finding a high prevalence of these sexually transmitted infections amongst gay men testing HIV-positive in San Francisco.

Individuals at risk of infection with HIV through unprotected sex also have a risk of other sexually transmitted infections, and in people with HIV, many sexually transmitted infections - expecially those that cause inflammation or ulceration in the genital tract - can increase HIV levels in semen or vginal fluids, and so increase the risk of onward transmission.

Routine, rapid point-of-care HIV testing is recommended for patients attending sexual health clinics in the US. As gonorrhoea and chlamydia occur frequently in patients testing HIV-positive, the investigators theorised that providing presumptive treatment for these infections at the time of HIV diagnosis would streamline patient care, reduce waiting times and make “more efficient use of limited health resources.”

Glossary

chlamydia

Chlamydia is a common sexually transmitted infection, caused by bacteria called Chlamydia trachomatis. Women can get chlamydia in the cervix, rectum, or throat. Men can get chlamydia in the urethra (inside the penis), rectum, or throat. Chlamydia is treated with antibiotics.

rectum

The last part of the large intestine just above the anus.

inflammation

The general term for the body’s response to injury, including injury by an infection. The acute phase (with fever, swollen glands, sore throat, headaches, etc.) is a sign that the immune system has been triggered by a signal announcing the infection. But chronic (or persisting) inflammation, even at low grade, is problematic, as it is associated in the long term to many conditions such as heart disease or cancer. The best treatment of HIV-inflammation is antiretroviral therapy.

point-of-care test

A test in which all stages, including reading the result, can be conducted in a doctor’s office or a community setting, without specialised laboratory equipment. Sometimes also described as a rapid test.

They therefore conducted a study to determine the prevalence of gonorrhoea and chlamydia in gay men testing for HIV. The men in the study had swabs from the anus, throat and urethra. The investigators compared the rates of these infections in HIV-positive and HIV-negative men. They also looked at how long it took, using existing treatment protocols, to provide treatment to men infected with gonorrhoea and/or chlamydia who were newly diagnosed with HIV.

Their study involved 6864 gay men who had an HIV test at San Francisco’s municipal sexual health clinic between 2004 and 2006.

A total of 205 men (3%) were diagnosed as having recent HIV infection. The proportion of men having a point-of-care HIV test increased from below 1% in 2004 to almost 26% in late 2006.

In all, 62% of men were screened for rectal infections, 79% had throat swabs, and 87% provided urine samples to check for urethral infections. But the investigators found that approximately 12% of men with recent HIV infection and 11% of HIV-negative men had no tests to screen for bacterial sexually transmitted infections.

The investigators further established that 26% of men testing HIV-positive also had gonorrhoea and that 19% were also infected with chlamydia. This was significantly higher than the prevalence in HIV-negative men: 11% with gonorrhoea (p < 0.001) and 8% with chlamydia. HIV-positive men were more likely than HIV-negative men to have rectal infection with gonorrhoea or chlamydia, and to be infected with gonorrhoea in the urethra or throat.

Same-day treatment for gonorrhoea was provided to 59% of men with this infection and HIV and to 37% of the men diagnosed with chlamydia and HIV. The median time between diagnosis of these sexually transmitted infections was seven days.

The investigators comment that the prevalence of both gonorrhoea and chlamydia amongst gay men testing HIV-positive in their study was “substantial…and significantly higher than in the men who have sex with men testing HIV-negative.”

They add, “because gonococcal and chlamydial infections are often asymptomatic, under current treatment protocols, half of those coinfections in men who have sex with men newly diagnosed with HIV infection were not treated until after laboratory results became available…expanding same-day presumptive treatment for all men who have sex men with newly diagnosed HIV infection would ensure treatment of patients who are currently not being treated, decrease overall time to treatment, and streamline clinic care.”

References

Scott KC et al. High prevalence of gonococcal and chlamydial infection in men who have sex with men with newly diagnosed HIV infection. An opportunity for same-day presumptive treatment. J Acquir Immune Defic Syndr 48: 109 – 112, 2008.