• • Because new sexually transmitted diseases (STDs) are common in HIV-infected patients, regular screening and timely treatment are essential.
  
• • Counseling of HIV-positive patients should include discussion of HIV-STD interactions and risks.
  
• • Both genital ulcer–causing diseases and non–ulcer-causing STDs increase HIV transmission.
  
• • Clinical and laboratory findings of syphilis in HIV-infected patients can be challenging to interpret, and these patients require close follow up.
  
• • Prevention of human papillomavirus (HPV)– associated malignancies requires active surveillance in HIV-infected persons.
  
• • Genital herpes and syphilis may increase HIV viral load, lower CD4 count, and hasten HIV disease progression.

Symptomatic Assessment

At the initial evaluation of a patient with HIV infection, the clinician should actively screen for typical symptoms and signs of STDs. These include the presence of genital, oral, or anal lesions; pain or burning with urination; new or unusual skin rash; lymphadenopathy and rectal symptoms of discharge, burning, or itching. In addition, men should be screened for urethral discharge or groin pain and women for bloody or foul-smelling vaginal discharge, itching, lower abdominal pain, missed menses, and pregnancy status. Any patient reporting symptoms and signs of STDs should have appropriate diagnostic testing regardless of reported sexual behavior or other risk factors.

Routine Laboratory Assessment

All HIV-infected patients should undergo serologic testing for syphilis, herpes simplex virus type 2 (HSV-2), and hepatitis as well as gonorrhea and chlamydia testing at all exposed anatomic sites (urogenital, anal, oral) at the initial visit. HSV-2 serologic testing should utilize newer, glycoprotein G–specific tests (see Table 21–1). HIV-infected women should undergo speculum-guided pelvic examination with microscopic evaluation of vaginal fluid (wet mount) and Papanicolaou (Pap) smear. Pap smears should be repeated at 6 months and then annually thereafter. Although no national guidelines exist, some experts recommend that HIV-infected men should also undergo regular anal cancer screening (anal Pap smear). Newly diagnosed HIV-infected patients should also receive a broad medical evaluation, which is beyond the scope of discussion in this chapter.

Repeat testing should be based on reported sexual risk behavior and may need to occur as often as every 3 months (see Table 21–2). Given recent increases in syphilis in HIV-infected men who have sex with men (MSM), most experts recommend syphilis testing for sexually active HIV-infected persons at 3- to 6-month intervals along with routine laboratory studies.

Strategies for Effective Assessment of STD Risks in HIV-Infected Patients

Discussing sexual practices with patients can be challenging, but it is essential to providing comprehensive care to HIV-infected patients. When discussing these topics, the mnemonic “Know the CODES” (Confidentiality; Open-minded approach and open-ended questions; Direct questions about specific behaviors; Explanation of implications of the elicited information; Specific informations and advice) is a helpful guide.

Specific terms such as “men who have sex with men” should be used, rather than “gay.” Assumptions about sexual behaviors and risk-taking should be avoided, including monogamy or heterosexuality among married people. Explanation of unfamiliar practices should be requested: “I don’t know what you mean, could you explain …?” Clinicians should ask about sex partners, including questions about number, where the patient meets sex partners, how well the patient knows the sex partners, HIV status (infected, not infected, or unknown) of sex partners, and any possible STD-related symptoms among sex partners. Questions should also focus on sexual activities and protection methods, use of condoms (and with what type of activities), use of drugs or alcohol, and sexual assault or coercion.

For patients acknowledging the use of drugs or alcohol, discussion of their impact on decision making and risk for further STDs or HIV transmission is appropriate and the responsibility of every treating medical provider. Use of drugs for enhanced erectile function (eg, sildenafil [Viagra]) may likewise be markers for sexual risk-taking behavior.

For injection drug users, discussion should include options to help with cessation or harm reduction, and advice regarding use of only sterile equipment and how to obtain such materials via needle exchange, local pharmacies, or harm reduction centers. Clinicians should ask the patient if all sex and needle-sharing partners have been informed of their possible exposure to HIV. Patients can be referred to appropriate services for facilitation of partner notification.

In women of childbearing age, clinicians should ask about pregnancy-related issues; these include possible current pregnancy (if so, test), past history of pregnancies and terminations, interest in future pregnancy, sexual activity, and contraception use.

Risk Reduction Counseling

The diagnosis of a new STD in a patient with HIV-infection should initiate a discussion about sexual risk behavior and the spread of STDs and HIV. The prevention of HIV transmission can be promoted during the patient visit by discussing safer behaviors to protect both the patient’s own health and the health of sex and needle-sharing partners. Patients should be advised that there can be an significant adverse impact on their own health (increased HIV viral load or decreased CD4 T cell count, or both) as well as on the health of others should they practice high-risk sexual or injection behaviors.

The risk of HIV transmission to partners should also be discussed (see Table 21–3). Risks can be reduced in the following ways: abstinence from sexual or injection drug use; alteration of specific sexual behaviors for harm reduction (oral sex versus anal or vaginal sex; no ejaculation versus ejaculation); safer sex or injection practices (consistent and correct condom or barrier method use, bleaching or not sharing injection equipment); and sexual or injection activity only with others who are also HIV-infected (although as discussed later, this practice is not without risk).

Although effective highly active antiretroviral therapy (HAART) decreases plasma viral load and is thought to decrease risk of HIV transmission from the HIV-infected person taking HAART to an HIV-uninfected sex partner (see Table 21–4

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