Levels of evidence (I-IV) and grades of recommendation (A-C) are defined at the end of the "Major Recommendations" field.
Sexual Risk Assessment and Screening
All human immunodeficiency virus (HIV) service providers should be able to provide ready access to staff trained in taking a sexual history and who can make an appropriate sexual health assessment (Evidence level III, Grade B recommendation).
Frequency of Syphilis Serology Tests, Sexual History Taking, and Sexual Health Screening
A sexual health assessment including a sexual history should be documented at first presentation and at 6 monthly intervals for all HIV-positive people receiving long-term care. If appropriate, a full sexual health screen (including annual cytology in women) should be offered (regardless of reported history) and the outcome documented in the HIV case notes (Evidence level IIb, Grade B recommendation).
Syphilis serology should be incorporated into the routine HIV blood set and checked at 3 monthly clinic visits to detect asymptomatic cases (Evidence level IIb, Grade B recommendation).
Sexual Health Care Pathways
There should be documented local care pathways for diagnosis, treatment, and partner work for sexually transmitted infections in people with HIV which can be actively communicated to all members of clinic staff and to HIV-positive people (Evidence level IIb, Grade B recommendation).
The majority of sexually transmitted infections (STIs) in people with HIV including gonorrhoea and Chlamydial infection can be managed the same as in people without HIV (Evidence level IIb, Grade B recommendation). STIs should be considered in the differential diagnosis of presentations such as skin rash or proctitis in HIV-positive people.
Management of Syphilis in People with HIV
Primary or secondary syphilis can be treated with 2 doses of intramuscular Benzathine Penicillin G one week apart in HIV-positive people who are not profoundly immunosuppressed and in whom adequate follow-up can be maintained to detect relapses. (Evidence level Ib, Grade A recommendation).
Management of Genital Herpes in People with HIV
First Episode of Genital Herpes
First episode genital herpes in HIV-positive people should be treated with aciclovir 400 mg five times daily for 7 to 10 days. Alternative oral regimens include valaciclovir 1 gram twice daily for 10 days or famciclovir 250-750 mg x3/day for 10 days (Evidence level IIb, B). In severe cases, initiating therapy with aciclovir 5-10 mg/kg body weight intravenously (IV) every 8 hours may be necessary (Evidence level IV, Grade C recommendation).
Episodic Herpes Therapy
Aciclovir, famciclovir, and valaciclovir can all be used as episodic herpes therapy in people with HIV (PWHIV) (Evidence level Ib, Grade A recommendation). In controlled trials in herpes simplex virus (HSV) and HIV co-infected persons, famciclovir 500 mg twice daily for 7 days was as effective as aciclovir 400 mg five times daily for 7 days (Romanowski et al., 2000) (Evidence level Ib, Grade A recommendation).
Valaciclovir 1 g twice daily for 5 days was no less effective than aciclovir 200 mg five times daily for 5 days (Schacker, 1999) (Evidence level Ib, Grade A recommendation).
The US Centers for Disease Control and Prevention ("Sexually transmitted diseases," 2002) recommend the following drug regimens for episodic herpes (Evidence level IV, Grade C recommendation):
- Aciclovir 400 mg orally three times daily for 5 to 10 days
- Aciclovir 200 mg five times daily for 5 to 10 days
- Famciclovir 500 mg twice daily for 5 to 10 days
- Valaciclovir 1 g twice daily for 5 to 10 days
There is no clear evidence of superiority for any of the above regimens for episodic herpes.
Suppressive Herpes Therapy
It is recommended that intermittent cessation of suppressive antiviral therapy for genital herpes should occur, especially in those in whom there is also adequate inhibition of HIV replication and rising CD4 cell counts. In some PWHIV with less frequent outbreaks of genital herpes, episodic treatment may be substituted. In others, where the pre-treatment pattern of recurrences resumes, suppressive treatment may need to restart (Evidence level IV, Grade C recommendation).
Drug Resistant Genital Herpes
If lesions persist or recur in a PWHIV receiving herpes antiviral therapy, herpes resistance should be suspected and a viral isolate should be obtained for sensitivity testing (Hill, Hunter, & Ellis, 1991; Safrin, 1992; Gnann et al., 2000) (Evidence level Ib, Grade A recommendation).
Both topical 1% foscarnet cream (Gateley et al., 1990) and 1% cidofovir gel (Lalezari et al., 1997) have been shown to produce significant benefits in lesion healing, pain reduction, and virological effect in drug resistant herpes in PWHIV (Evidence level Ib, Grade A recommendation).
There is limited evidence to support the use of topical trifluorothymidine alone or in combination with interferon-alpha (Birch et al., 1992; Kessler et al., 1996) (Evidence level IIb, Grade B recommendation).
Systemic therapy with either foscarnet or cidofovir is generally preferred to treat drug resistant herpes in those with HIV. There is evidence for:
- Foscarnet 40 mg/kg IV daily (Kessler et al., 1996; Safrin et al., 1991; Bestman-Smith & Boivin, 2002) (Evidence level Ib, Grade A recommendation)
- Cidofovir 5 mg/kg body weight weekly IV infusion for 2 weeks (LoPresti et al., 1998; Snoek, 2000; Morfin & Thouvenot, 2003) (Evidence level IV)
Management of Genital Human Papilloma Virus (HPV) Infection in People with HIV
HIV infected women should undergo annual cervical cytology (Evidence level IV, Grade C recommendation).
Treatment of low grade cervical intraepithelial neoplasia (CIN) should be considered, particularly in women with low CD4 cell counts, in view of the risk of disease progression (Evidence level IV, Grade C recommendation).
After full explanation, proctoscopy should be performed in people with HIV who are found to have ano-genital warts and any atypical lesions should be biopsied and sent for histological examination. The role of anal cytology as a screening method is not yet known (Evidence level IV, Grade C recommendation).
Imiquimod 5% cream can be used as a topical treatment for genital warts and may prove more effective than other treatments; however comparative studies have not yet been performed. Surgical methods of wart removal (e.g., diathermy, scissor excision, laser ablation) may be effectively used at an earlier stage of disease management compared to immunocompetent patients (Evidence level IV, Grade C recommendation).
Definitions
Levels of Evidence:
Ia
- Evidence obtained from meta-analysis of randomised controlled trials
Ib
- Evidence obtained from at least one randomised controlled trial
IIa
- Evidence obtained from at least one well designed controlled study without randomisation
IIb
- Evidence obtained from at least one other type of well designed quasi-experimental study
III
- Evidence obtained from well designed non-experimental descriptive studies such as comparative studies, correlation studies, and case control studies
IV
- Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities
Grading of Recommendations:
A (Evidence Levels Ia, Ib)
- Requires at least one randomised controlled trial as part of the body of literature of overall good quality and consistency addressing the specific recommendation
B (Evidence Levels IIa, IIb, III)
- Requires availability of well conducted clinical studies but no randomised clinical trials on the topic of recommendation
C (Evidence Level IV)
- Requires evidence from expert committee reports or opinions and/or clinical experience of respected authorities
- Indicates absence of directly applicable studies of good quality
