CDC Issues New STD Treatment, Counseling Guidelines That Call for Annual HIV/STD Testing for All Men Who Have Sex With Men

Health care providers should administer annual testing for HIV and other sexually transmitted diseases to all of their male patients who have sex with other men, according to new CDC STD treatment and counseling guidelines released yesterday, the San Francisco Chronicle reports (Heredia, San Francisco Chronicle, 5/10). The recommendations, titled "The 2002 Guidelines for the Treatment of Sexually Transmitted Diseases," are an updated version of STD management guidelines issued by the agency approximately every four years. The recommendations include the following:

• Risk assessment and STD testing for men who have sex with men: Recent data have indicated that rates of syphilis and gonorrhea infection are increasing among men who have sex with men, and the CDC is urging health care providers to gauge male patients' "sexual risk" by asking them about the sex of their partner or partners. The guidelines state that MSM who are sexually active should be screened annually for HIV, chlamydia, syphilis and gonorrhea and should be vaccinated against hepatitis A and hepatitis B. Providers may want to provide more frequent screening for patients who have multiple anonymous partners or who have sex while using drugs, the guidelines state.
• Chlamydia: The new guidelines recommend that providers screen sexually active young women between adolescence and age 25 for chlamydia every year, even if the patients do not exhibit symptoms of the disease. Older women who exhibit risk factors for the disease, such as multiple sexual partners or a new sex partner, should also be tested for chlamydia. The guidelines also state that all women who have been treated for chlamydial infection should be rescreened for chlamydia three to four months after the completion of treatment. This recommendation marks the first time that the CDC has recommended rescreening for women who have been treated for chlamydia, and the agency issued the suggestion in reaction to the high rates of reinfection.
• Gonorrhea: Due to the rise of drug-resistant strains of gonorrhea on the West Coast, the CDC now advises California providers against using fluoroquinolone antibiotics to treat the disease (CDC release, 5/9). Fluoroquinolone antibiotics, including Cipro, have been "top-line" treatments for gonorrhea since the 1980s, when the disease became resistant to tetracycline (Kaiser Daily HIV/AIDS Report, 3/6). But fluoroquinolone-resistant gonorrhea has been on the rise in Hawaii and the Pacific Islands, and the CDC previously advised against treating the disease with fluoroquinolones in those areas. The new guidelines mark the first time that the agency has recommended against fluoroquinolone treatment in the continental United States. The CDC now recommends that Hawaii and California providers use cefixime and ceftriaxone as "first-line" drugs to treat gonorrhea. The CDC is also requesting that local and state public health officials across the country report any cases of drug-resistant gonorrhea.
• Counseling: Providers should adopt "client-centered [STD] counseling" that conforms to the individual patient, the guidelines state. The guidelines also suggest that patients abstain from oral, vaginal or anal sex and that patients who are sexually active be counseled to either use a condom for each sex act or be in a mutually monogamous relationship with an uninfected partner.
• Nonoxynol-9: Spermicides containing nonoxynol-9 should not be used for STD prevention because recent studies have shown that nonoxynol-9 can facilitate HIV transmission. Condoms that contain nonoxynol-9 are not recommended, the guidelines say (CDC release, 5/9). But Stuart Berman, chief of epidemiology and surveillance in the CDC's division of STD prevention, said that those who must choose between a condom containing nonoxynol-9 and unprotected sex should use the condom. "Undoubtedly, the use of nonoxynol-9 condoms is safer than no condom at all," he said (Meredith McGroarty, Kaiser Daily HIV/AIDS Report, 5/10).

Asking Difficult Questions
Dr. Kimberly Workowski, lead author of the guidelines, said that although doctors are hesitant to ask patients about the sex of their partners, such questions are necessary (AP/Richmond Times-Dispatch, 5/10). She suggested that providers ask "open-ended questions," such as whether a patient has sex "with men, women or both" (Meredith McGroarty, Kaiser Daily HIV/AIDS Report, 5/10). AIDS activists welcomed the CDC's call for more open dialogue between providers and patients. Shana Krochmal, a spokesperson for the Stop AIDS Project in San Francisco, said that the guidelines demonstrate "a new tone on the part of federal health officials, who in the past have appeared skittish about talking about sexual health, particularly gay men's issues" (San Francisco Chronicle, 5/10). Tony Braswell, executive director of AID Atlanta, added, "The CDC is to be applauded for mainstreaming preventive health care among gay men and recognizing that sometimes the relationship between a doctor and especially a young gay man doesn't allow a doctor to encourage testing" (Tate, Atlanta Journal-Constitution, 5/10).

Treatment for Partners
Berman emphasized the need for providers to include the sex partners of patients in STD treatment regimens. It is "critical" that providers make every effort to see that patients' partners get tested and treated for STDs, he said. He also advocated proposals similar to that advocated by the California Department of Health Services, which earlier this year proposed expanding Medicaid coverage to include chlamydia medication for the partners of Medicaid beneficiaries, even if the partners are not eligible for Medicaid (Meredith McGroarty, Kaiser Daily HIV/AIDS Report, 5/10). The federal Centers for Medicare and Medicaid Services rejected California's proposal in March, stating that the plan does not comply with Medicaid program rules (Kaiser Daily Reproductive Health Report, 3/12). Berman, however, said he supported such a plan. "To the extent that Medicaid could pay for that treatment, that would be great," he said (Meredith McGroarty, Kaiser Daily HIV/AIDS Report, 5/10). The new treatment guidelines and related STD material from the CDC are available online on the CDC Web site. NPR's "All Things Considered" yesterday reported on drug-resistant gonorrhea in California. The segment is available online in RealPlayer Audio.