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Current Trends Additional Recommendations to Reduce Sexual and Drug
Abuse-Related Transmission of Human T-Lymphotropic Virus Type III/
Lymphadenopathy-Associated Virus
BACKGROUND
Human T-lymphotropic virus type III/lymphadenopathy-associated
virus
(HTLV-III/LAV), the virus that causes acquired immunodeficiency
syndrome
(AIDS), is transmitted through sexual contact, parenteral exposure
to
infected blood or blood components, and perinatally from mother to
fetus or
neonate. In the United States, over 73% of adult AIDS patients are
homosexual or bisexual men; 11% of these males also had a history
of
intravenous (IV) drug abuse. Seventeen percent of all adult AIDS
patients
were heterosexual men or women who abused IV drugs (1,2). The
prevalence of
HTLV-III/LAV antibody is high in certain risk groups in the United
States
(3,4).
Since a large proportion of seropositive asymptomatic persons
have been
shown to be viremic (5), all seropositive individuals, whether
symptomatic or
not, must be presumed capable of transmitting this infection. A
repeatedly
reactive serologic test for HTLV-III/LAV has important medical, as
well as
public health, implications for the individual and his/her
health-care
provider. The purpose of these recommendations is to suggest ways
to
facilitate identification of seropositive asymptomatic persons,
both for
medical evaluation and for counseling to prevent transmission.
Previous U.S. Public Health Service recommendations pertaining
to
sexual, IV drug abuse, and perinatal transmission of HTLV-III/LAV
have been
published (6-8). Reduction of sexual and IV transmission of
HTLV-III/LAV
should be enhanced by using available serologic tests to give
asymptomatic,
infected individuals in high-risk groups the opportunity to know
their status
so they can take appropriate steps to prevent the further
transmission of
this virus.
Since the objective of these additional recommendations is to
help
interrupt transmission by encouraging testing and counseling among
persons in
high-risk groups, careful attention must be paid to maintaining
confidentiality and to protecting records from any unauthorized
disclosure.
The ability of health departments to assure confidentiality -- and
the public
confidence in that ability -- are crucial to efforts to increase
the number
of persons requesting such testing and counseling. Without
appropriate
confidentiality protection, anonymous testing should be considered.
Persons
tested anonymously would still be offered medical evaluation and
counseling.
PERSONS AT INCREASED RISK OF HTLV-III/LAV INFECTION
Persons at increased risk of HTLV-III/LAV infection include:
(1)
homosexual and bisexual men; (2) present or past IV drug abusers;
(3) persons
with clinical or laboratory evidence of infection, such as those
with signs
or symptoms compatible with AIDS or AIDS-related complex (ARC); (4)
persons
born in countries where heterosexual transmission is thought to
play a major
role *; (5) male or female prostitutes and their sex partners; (6)
sex
partners of infected persons or persons at increased risk; (7) all
persons
with hemophilia who have received clotting-factor products; and (8)
newborn
infants of high-risk or infected mothers.
RECOMMENDATIONS
Community health education programs should be aimed at members
of high-
risk groups to: (a) increase knowledge of AIDS; (b) facilitate
behavioral changes to reduce risks of HTLV-III/LAV infection;
and (c)
encourage voluntary testing and counseling.
Counseling and voluntary serologic testing for HTLV-III/LAV
should be
routinely offered to all persons at increased risk when they
present to
health-care settings. Such facilities include, but are not
limited to,
sexually transmitted disease clinics, clinics for treating
parenteral
drug abusers, and clinics for examining prostitutes.
Persons with a repeatedly reactive test result (see
section on Test
Interpretation) should receive a thorough medical
evaluation, which
may include history, physical examination, and
appropriate
laboratory studies.
High-risk persons with a negative test result should be
counseled
to reduce their risk of becoming infected by:
(1) Reducing the number of sex partners. A stable,
mutually
monogamous relationship with an uninfected person
eliminates
any new risk of sexually transmitted HTLV-III/LAV
infection.
(2) Protecting themselves during sexual activity with
any possibly
infected person by taking appropriate precautions to
prevent
contact with the person's blood, semen, urine,
feces, saliva,
cervical secretions, or vaginal secretions.
Although the
efficacy of condoms in preventing infections with
HTLV-III/LAV
is still under study, consistent use of condoms
should reduce
transmission of HTLV-III/LAV by preventing exposure
to semen
and infected lymphocytes (9,10).
(3) For IV drug abusers, enrolling or continuing in
programs to
eliminate abuse of IV substances. Needles, other
apparatus,
and drugs must never be shared.
Infected persons should be counseled to prevent the
further
transmission of HTLV-III/LAV by:
(1) Informing prospective sex partners of his/her
infection with
HTLV-III/LAV, so they can take appropriate
precautions.
Clearly, abstention from sexual activity with
another person
is one option that would eliminate any risk of
sexually
transmitted HTLV-III/LAV infection.
(2) Protecting a partner during any sexual activity by
taking
appropriate precautions to prevent that individual
from coming
into contact with the infected person's blood,
semen, urine,
feces, saliva, cervical secretions, or vaginal
secretions.
Although the efficacy of using condoms to prevent
infections
with HTLV-III/LAV is still under study, consistent
use of
condoms should reduce transmission of HTLV-III/LAV
by
preventing exposure to semen and infected
lymphocytes (9,10).
(3) Informing previous sex partners and any persons with
whom
needles were shared of their potential exposure to
HTLV-
III/LAV and encouraging them to seek
counseling/testing.
(4) For IV drug abusers, enrolling or continuing in
programs to
eliminate abuse of IV substances. Needles, other
apparatus,
and drugs must never be shared.
(5) Not sharing toothbrushes, razors, or other items
that could
become contaminated with blood.
(6) Refraining from donating blood, plasma, body organs,
other
tissue, or semen.
(7) Avoiding pregnancy until more is known about the
risks of
transmitting HTLV-III/LAV from mother to fetus or
newborn (8).
(8) Cleaning and disinfecting surfaces on which blood or
other
body fluids have spilled, in accordance with
previous
recommendations (2).
(9) Informing physicians, dentists, and other
appropriate health
professionals of his/her antibody status when
seeking medical
care so that the patient can be appropriately
evaluated.
Infected patients should be encouraged to refer sex partners
or persons
with whom they have shared needles to their health-care
provider for
evaluation and/or testing. If patients prefer, trained health
department professionals should be made available to assist in
notifying
their partners and counseling them regarding evaluation and/or
testing.
Persons with a negative test result should be counseled
regarding their
need for continued evaluation to monitor their infection
status if they
continue high-risk behavior (8).
State and local health officials should evaluate the
implications of
requiring the reporting of repeatedly reactive HTLV-III/LAV
antibody
test results to the state health department.
State or local action is appropriate on public health grounds
to
regulate or close establishments where there is evidence that
they
facilitate high-risk behaviors, such as anonymous sexual
contacts and/or
intercourse with multiple partners or IV drug abuse (e.g.,
bathhouses,
houses of prostitution, "shooting galleries").
TEST INTERPRETATION
Commercially available tests to detect antibody to
HTLV-III/LAV are
enzyme-linked immunosorbant assays (ELISAs) using antigens derived
from
disrupted HTLV-III/LAV. When the ELISA is reactive on initial
testing, it is
standard procedure to repeat the test on the same specimen.
Repeatedly
reactive tests are highly sensitive and specific for HTLV-III/LAV
antibody.
However, since falsely positive tests occur, and the implications
of a
positive test are serious, additional more specific tests (e.g.,
Western
blot, immunofluorescent assay, etc.) are recommended following
repeatedly
reactive ELISA results, especially in low-prevalence populations.
If
additional more specific test results are not readily available,
persons in
high-risk groups with strong repeatedly reactive ELISA results can
be
counseled before any additional test results are received regarding
their
probable infection status, their need for medical follow-up, and
ways to
reduce further transmission of HTLV-III/LAV.
OTHER CONSIDERATIONS
State or local policies governing informing and counseling sex
partners
and those who share needles with persons who are
HTLV-III/LAV-antibody
positive will vary, depending on state and local statutes that
authorize such
actions. Accomplishing the objective of interrupting transmission
by
encouraging testing and counseling among persons in high-risk
groups will
depend heavily on health officials paying careful attention to
maintaining
confidentiality and protecting records from unauthorized
disclosure.
The public health effectiveness of various approaches to
counseling,
sex-partner referral, and laboratory testing will require careful
monitoring.
The feasibility and efficacy of each of these measures should be
evaluated by
state and local health departments to best utilize available
resources.
Developed by Center for Prevention Svcs and Center for Infectious
Diseases,
CDC, in consultation with persons from numerous other organizations
and
groups.
References
Curran JW, Morgan WM, Hardy AM, Jaffe HW, Darrow WW, Dowdle
WR. The
epidemiology of AIDS: current status and future prospects.
Science
1985;229:1352-7.
CDC. Recommendations for preventing transmission of infection
with human
T-lymphotropic virus type II/lymphadenopathy-associated virus
in the
workplace. MMWR 1985;34:682-6, 691-5.
CDC. Update: acquired immunodeficiency syndrome in the San
Francisco
cohort study, 1978-1985. MMWR 1985;34:573-5.
CDC. Heterosexual transmission of human T-lymphotropic virus
type
III/lymphadenopathy-associated virus. MMWR 1985;34:561-3.
CDC. Provisional public health services inter-agency
recommendations for
screening donated blood and plasma for antibody to the virus
causing
acquired immunodeficiency syndrome. MMWR 1985;34:1-5.
CDC. Prevention of acquired immune deficiency syndrome (AIDS):
report of
inter-agency recommendations. MMWR 1983;32:101-4.
CDC. Antibodies to a retrovirus etiologically associated with
acquired
immunodeficiency syndrome (AIDS) in populations with increased
incidences of the syndrome. MMWR 1984;33:377-9.
CDC. Recommendations for assisting in the prevention of
perinatal
transmission of human T-lymphotropic virus type
III/lymphadenopathy-
associated virus and acquired immunodeficiency syndrome. MMWR
1985;
34:721-32.
Judson FN, Bodin GF, Levin MJ, Ehret JM, Masters HB. In vitro
tests
demonstrate condoms provide an effective barrier against
chlamydia
trachomatis and herpes simplex virus. Abstract in Program of
the
International Society for STD Research, Seattle, Washington,
August 1-3,
1983:176.
Conant MA, Spicer DW, Smith CD. Herpes simplex virus
transmission:
condom studies. Sex Transm Dis 1984;11:94-5.
* e.g., Haiti, Central African countries.
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