HIV, AIDS, and Other Sexually Transmitted Infections Case File

HIV, AIDS, and Other Sexually Transmitted Infections Case File

Eugene C. Toy MD, Donald Briscoe, MD, FA  AFP, Bruce Britton, MD, Joel J. Heidelbaugh, MD, FA  AFP, FACG

Case 45

A 39-year-old homeless man presents to the emergency department (ED) with a nonproductive cough and subjective fever. He says that his illness has been worsening over the past 2 weeks, originally starting with dyspnea on exertion and now he is short of breath at rest. On questioning, he tells you that he lives in a homeless shelter when he can, but he frequently sleeps on the streets. He has used IV drugs (primarily heroin) "on and off" and has been sexually promiscuous with both men and women without barrier protection for many years. He denies any significant medical history, and only gets medical care when he comes to the ED for an illness or injury. On review of systems, he complains of chronic fatigue, weight loss, and diarrhea. On examination, he is a thin, disheveled man appearing much older than his stated age. His temperature is 100.4°F (38.0°C), his blood pressure is 100/50 mm Hg, his pulse is 105 beats/min, and his respiratory rate is 24 breaths/min. His initial oxygen saturation is 89% on room air, which comes up to 94% on 4 L of oxygen by nasal cannula. Significant findings on examination include dry mucous membranes, a tachycardic but regular cardiac rhythm, a soft and nontender abdomen, and generally wasted-appearing extremities. His pulmonary examination is significant for tachypnea and fine crackles bilaterally, but there are no visible signs of cyanosis on extremities. His chest x-ray reveals diffuse, bilateral, interstitial infiltrates that look like"ground glass:'

⯈ What is the most likely cause of this patient's current pulmonary complaints?

⯈ What underlying illnesses does this patient most likely has?

⯈ What diagnostic testing and treatment should be started?

ANSWER TO CASE 45

HIV, AIDS, and Other Sexually Transmitted Infections

Summary: A 39-year-old, homeless, IV drug abuser is seen with fever, cough, dyspnea, and fatigue. He is found to be tachypneic, febrile, and hypoxemic. His chest x-ray reveals bilateral interstitial infiltrates.

• • Most likely cause of current illness: Pneumocystis jiroveci (formerly known as Pneumocystis carinii) pneumonia.
• • Most probable underlying illness: AIDS.
• • Recommended current testing and treatment: Complete blood count (CBC ), serum electrolytes, arterial blood gas; HIV enzyme-linked immunosorbent assay with confirmatory Western blot; CD4/CD8 cell count; HIV RNA assay; sputum culture for P jiroveci and acidfast bacilli; urine culture for Chlamydia and Neisseria gonorrheae; serum rapid plasma reagin (RPR); start treatment with oral trimethoprim-sulfamethoxazole (TMP-SMX); and consider starting highly active antiretroviral therapy (HAART) with appropriate case management including intensive drug abuse treatment, counseling, and social work.

ANALYSIS

Objectives

1. Know the common risks and modes of transmission of human immunodeficiency virus (HIV)/ acquired immunodeficiency syndrome AIDS.
2. Be aware of common presentations of persons infected with HIV.
3. List the most common sexually transmitted infections (STIs).
4. Describe common treatment regimens for STIs.

Considerations

The case described is that of a 39-year-old man who is homeless, an intravenous drug abuser, bisexual, and sexually promiscuous. He has had chronic fatigue and weight loss, and now presents with fever, tachypnea, and hypoxemia. It is likely that he is infected with the HIV virus, and has an opportunistic infection, P jiroveci pneumonia. HIV infects the helper and cytotoxic T cells of the immune system, which are defined by the presence of the cell-signaling proteins CD4 and CD8 respectively, and causes a decline in both their number and their function in supporting the immune system. This decline in functional helper and cytotoxic T cells disables the cell-mediated arm of the immune system and leaves the body vulnerable to infection from multiple opportunistic organisms. This advanced stage of the HIV infection, in which such opportunistic infections occur, is known as AIDS.

P jiroveci (formerly known as P carinii) pneumonia is an AIDS-defining illness in persons infected with HIV. P jiroveci is a fungus that may colonize many people, but typically causes disease only in those with profound immune deficiencies, such as AIDS infections or cancers treated with chemotherapy. P jiroveci pneumonia usually presents with nonproductive cough, fever, and dyspnea that worsens over a few days to a few weeks. Patients usually are found to be febrile, tachypneic, and hypoxic, and their lung examination may be unremarkable (other than tachypnea). The presence of a bilateral interstitial infiltrates on chest x-ray, often described as having a "ground-glass" appearance, is classic for P jiroveci pneumonia. The identification of the organism in sputum, either spontaneously produced or induced, is diagnostic, but treatment is usually started prior to definitive diagnosis in those with a classic clinical picture and high suspicion.

As P jiroveci pneumonia occurs after the CD4 and CD8 counts have markedly reduced, patients often will have signs and symptoms of other AIDS-related complications as well. In patients with AIDS, it is common to see additional comorbid conditions including oral or esophageal candidiasis, chronic infectious diarrhea, Kaposi sarcoma, wasting syndrome, and weight loss. Although it presents in the setting of advanced disease, P jiroveci pneumonia remains a common presenting illness in patients who did not know that they were infected with HIV, and is a frequent initial opportunistic infection in those with known HIV disease.The incidence of P jiroveci pneumonia is decreasing in the United States with more widespread awareness of HIV disease, broader usage of antiretroviral therapy, and prophylactic use of TMP-SMX in patients with CD4 counts of less than 200 cells/μL.

Approach To:

HIV, AIDS, and Other Sexually Transmitted Infections

DEFINITIONS

ACQUIRED IMMUNODEFICIENCY SYNDROME: The advanced stage of the HIV infection, in which opportunistic infections occur with specific criteria for its designation.

HUMAN IMMUNODEFICIENCY VIRUS: A retrovirus that infects the helper T cells of the immune system, which are defined by the presence of the cell-signaling protein CD4, and causes a decline in both their number and their effectiveness.

CLINICAL APPROACH

HIV/AIDS

Epidemiology

As of 2013, over 35 million people in the world are living with HIV infection and/or AIDS. Over 1.5 million people died of AIDS-related illnesses worldwide in 2013, with a disproportionate share of the deaths occurring in sub-Saharan Africa. HIV disease is caused by the human retroviruses, HIV-1 and HIV-2. HIV-1 is more common worldwide, whereas HIV-2 has been reported in western Africa, Europe, South America, and Canada.

As of 2011, 1.2 million people in the United States were estimated to be infected with HIV, with approximately 25% of persons unaware of their infection. The highest prevalence of HIV occurs in men who have sex with other men and in IV drug users, although the occurrence in heterosexual sexual contact is increasing. African Americans are disproportionately affected with infection, both in total numbers of cases and in development of new infections.

Transmission

HIV is transmitted from person to person through contact with infected blood and body fluids. Sexual contact is the most common mechanism of transmission and, while anal intercourse has the highest rate of transmission, HIV can be acquired through vaginal and oral intercourse as well. Heterosexual transmission of HIV now accounts for 27% of new infection and 86% of cases in infected women. The risk of HIV transmission is also increased by the presence of genital or anal lesions caused by other sexually transmitted diseases, such as gonorrhea, syphilis, and genital herpes. The risk of transmission can be reduced by the proper and consistent use of latex condoms (either male or female condoms). Because HIV can pass through lambskin condoms, these are not recommended. Male circumcision has also been shown to decrease the rate of HIV transmission. Due to the large amount of undiagnosed HIV infections, the Centers for Disease Control and Prevention (CDC) expanded screening recommendations, which are summarized in Table45-1.

Sharing needles by IV drug users is the third most common source of transmission of HIV behind male-to-male and heterosexual transmission. Vertical transmission from an infected woman to her baby has been found to occur during pregnancy, during the process of delivery of a baby, and rarely from breast-feeding.

Reproduced from Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults,

adolescents and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55(RR-74J: 7-7 7.

Blood and blood-product transfusions have been linked to infection, although the routine screening of donor blood for HIV now makes this an extremely rare event.

Health-care workers have been infected with HIV through accidental punctures with needles or by infected blood entering through open skin wounds or mucous membranes. The risk of transmission to health-care workers is low and is related to the viral load of the patient, the amount of blood to which the worker is exposed, and the depth of the inoculum. Postexposure risk of developing HIV infection can be reduced by immediate and careful cleaning of the exposure/puncture site along with postexposure prophylactic (PEP) treatment with antiretroviral therapy started within 72 hours after exposure. Regimens for PEP include two to three antiretroviral medications taken for 28 days.

Clinical Course of HIV Infection

Following initial exposure to HIV, some patients will complain of nonspecific symptoms, such as low-grade fever, fatigue, sore throat, or myalgias. This illness typically occurs 6 to 8 weeks following the infection and is commonly self-limited. The primary infection is also known as acute seroconversion syndrome, as the symptoms are thought to be related to the development of antibodies to the virus.

Following the resolution of the primary infection symptoms (if any occur), there is a period of clinical latency. During this time, most infected persons are asymptomatic, although some may develop lymphadenopathy. This period can last from 6 months to up to 10 years following the transmission of the virus. However, while the patient is asymptomatic during this period, a relentless decline in helper and suppressor T-cell number and immune function usually occurs in the untreated patient, with the result that many patients initially present with profound immunodeficiency and opportunistic infections.

Clinical Categorization of HIV/AIDS Infections

The CDC defines four clinical stages for adults aged greater than or equal to 13.

Stage 1: No AIDS-defining illness and either CD4 cell count greater than or equal to 500 cells/ μL or percentage of total lymphocytes greater than 29

Stage 2: No AIDS-defining illness and either CD4 cell count of 200 to 499 cells/ μL or percentage between 14 and 28

Stage 3: (AIDS) CD4 cell count less than or equal to 200 cells/ μL or percentage less than 14 and documentation of AIDS-defining condition (Tables 45-2 and 45-3)

Stage 4: Unknown laboratory parameters with an AIDS-defining condition

For classification purposes, a patient's HIV is defined by the highest clinical stage in which the patient has ever qualified.

Diagnostic Evaluation

The standard screening test for HIV infection is the detection of HIV antibodies using the enzyme-linked immunosorbent assay (ELISA). Samples that are repeatedly positive on ELISA testing must be confirmed by Western blot testing, an

Data from Centers for Disease Control and Prevention. 1993 Revised classification system for HIV infection and expanded

surveillance case definition for AIDS among adolescents and adults. MMWR Recomm Rep. 1992;41 (RR-17):1-19.

electrophoresis assay that detects antibodies to HIV antigens of specific molecular weights.

When HIV is diagnosed, a complete history and physical examination should be performed. Emphasis should be placed on identifying possible mechanisms of exposure, comorbid conditions, presence of STIs, determining the presence of AIDS-defining conditions, reducing risky behaviors, and assisting with coping

Data from Centers for Disease Control and Prevention. Guidelines for the prevention and treatment of opportunistic

infections among HIV-exposed and HIV-infected children: recommendations from the National Institutes of Health, the

HIV Medicine Association of the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the

American Academy of Pediatrics, 2009. MMWR Recomm Rep. 2009;58(RR-11J:1-166.

strategies. HIV infection is reportable to local health authorities, but partner notification laws vary by state, so it is important to know both local and state regulations.

Before instituting therapy, laboratory testing should include HIV genotype testing to identify strains that may be resistant to therapy. A quantitative assay of HIV RNA levels (viral load) can help to assess disease activity. CD4 and CD8 lymphocyte counts and viral load should be measured at baseline and every 3 to 6 months thereafter to monitor for disease staging, progression, and the risk of complications and opportunistic infections. A CBC, comprehensive metabolic panel, and urinalysis should be performed at baseline and periodically thereafter to monitor for complications of HIV and of the medications that are used in treatment. Serology for toxoplasmosis and cytomegalovirus should also be obtained to identify organisms at risk for reactivation following immunosuppression.

Screening for other sexually transmitted diseases (syphilis, hepatitis B and C, N gonorrhea, Chlamydia trachomatis, herpes simplex) should be performed initially and repeated, if needed, because of any ongoing risks identified. Hepatitis A and B vaccination should be offered to those who lack immunity. A purified protein derivative (PPD) test should be done, and if initially negative, repeated annually. However, a PPD may be falsely negative if the patient is very immunosuppressed or very ill. If positive, a chest x-ray and Quantiferon Gold test should be performed for confirmation of potential active tuberculosis disease. Women should have regular Papanicolaou (Pap) smears and human papillomavirus (HPV) testing to evaluate for cervical dysplasia or cancer.

Late Disease

HIV and its comorbid opportunistic infections can affect every organ system in the body. Some infections, such as tuberculosis and pneumococcal pneumonia, also affect healthy people but are greatly increased in incidence and severity in the presence of HIV disease. Many mildly pathologic organisms, such as Candida species, cause unusual, severe infections in parts of the body, such as the esophagus and lungs, which they would rarely if ever affect without coinfection with HIV. Moreover, some AIDS-defining conditions, such as Kaposi sarcoma, can occur in persons with normal T-cell counts while other infections, such as cytomegalovirus retinitis and cryptococcal meningitis, are only seen in the presence of extreme immunodeficiency and very low T-cell counts. Many cancers are common in HIV-positive people, some of which, such as cervical carcinoma, are found in the non-HIV infected population while others, such as primary central nervous system (CNS) lymphoma, are extremely rare outside of persons infected with HIV. Moreover, HIV infection damages the body directly and leads to such conditions as HIV related dementia and HIV-associated nephropathy. Without antiretroviral therapy, AIDS is a universally fatal disease.

Treatment

Because of the complexity of treatment regimens and frequently changing treatment guidelines, patients with HIV/AIDS should be referred, in almost all cases, to a physician with expertise in treating these conditions, including an infectious disease specialist. In general, HAART, the combination of several antiretroviral drugs aimed at controlling the viral load of HIV and preventing HIV from multiplying, is used in patients who have AIDS (by laboratory or clinical criteria), who have symptoms of disease, or who are pregnant (to reduce the risk of vertical transmission). Updated guidelines on HIV/AIDS treatment and monitoring can be obtained by going to http://www.aidsinfo.nih.gov.

Prophylactic treatments to reduce the risk of infection are also important in immunosuppressed patients. HIV patients should receive annual attenuated influenza vaccination and should be offered pneumococcal vaccination (preferably before the CD4 count falls to less than 200 cells/μL). Live virus vaccines are contraindicated in both HIV patients, if CD4 counts are less than 200, and their close (household) contacts. Prophylaxis against P jiroveci pneumonia should be instituted using TMP-SMX when the CD4 count falls to less than 200 cells/ μL or if there is a history of oropharyngeal candidiasis. Mycobacterium avium-intracellulare complex prophylaxis, using azithromycin or clarithromycin, is recommended if the CD4 count falls to less than 50 cells/ μL.

OTHER SEXUALLY TRANSMITTED INFECTIONS

Chlamydia

Infection with C trachomatis is the most frequently reported sexually transmitted infection in the United States. Chlamydia can be passed from person to person by vaginal, anal, or oral intercourse. Infections are frequently asymptomatic, making screening necessary to identification. The United States Preventive Services Task Force (USPSTF) recommends screening for Chlamydia in all sexually active women age 24 or younger and in older women who are at increased risk for infection. Risk factors for infection include having multiple sexual partners, young age, history of other STI, and non-Hispanic Black race. The risk of transmission can be reduced by the proper use of latex condoms with every sexual encounter. Untreated Chlamydia infections in women can lead to ascending infections (ie, pelvic inflammatory disease [PID]), with an increased risk of ectopic pregnancy or infertility. Chlamydia can also cause cervicitis in women and epididymitis in men. It can cause urethritis and pharyngitis in men and women.

Testing for Chlamydia can be performed by collecting samples directly from the cervix, pharynx, or urethra, or by C trachomatis nucleic acid amplification testing of properly collected urine samples. Patients diagnosed with Chlamydia and their sexual partner(s) should be treated to reduce the risk of complications and to prevent further spread of the disease. Common treatment regimens for uncomplicated infection include azithromycin 1 g single dose PO or doxycycline 100 mg PO twice a day for a week. Doxycycline should not be used in a pregnant woman.

Gonorrhea

Gonorrhea is the common name for infection caused by N gonorrhoeae. This may also pass from person to person by vaginal, oral, or anal intercourse. Gonorrhea frequently leads to symptoms and signs of urethral infection in men, including dysuria and penile discharge. In women, the infection may be asymptomatic until complications, such as PID, occur. Because of this, the USPSTF recommends routinely screening sexually active women age 24 and less and older women at risk for gonorrhea. Testing for gonorrhea is performed similarly to, and usually in tandem with, testing for Chlamydia by sampling the cervix, urethra, anus, or pharynx or collecting urine for N gonorrhoeae nucleic acid amplification. Because of frequent coinfection, persons with gonorrhea should also routinely be treated for Chlamydia. T he recommended treatment for gonorrhea is ceftriaxone 250 mg IM X 1 dose (along with treatment for Chlamydia as described earlier).

Syphilis

Syphilis is the manifestation of infection by the spirochete Treponema pallidum. Syphilis infections may be symptomatic or asymptomatic (latent). Symptomatic syphilis is often divided into three stages based on the symptom and length of time from exposure.

• Primary: Characterized by a painless ulcer, or chancre, at the site of infection (usually on the genitalia)
• Secondary: Characterized by skin rash, neurologic symptoms, or ophthalmologic abnormalities
• Tertiary: Characterized by cardiac or granulomatous lesions (gummas)

Commonly, syphilis is diagnosed on serologic testing of an asymptomatic person and this is called latent syphilis. If latent syphilis can be diagnosed within a year of infection, it is known as "early latent;" all other latent syphilis is either "late latent" or "latent syphilis of unknown duration:'

Syphilis can be diagnosed either by direct identification of the Treponema spirochete or by serologic testing. Spirochetes can be identified by dark-field microscopy of tissue or exudate from a chancre. Serologic testing can be either a nontreponemal test, such as the RPR or Venereal Disease Research Laboratory (VDRL) test or a treponemal test, such as the fluorescent treponemal antibody absorbed (FTA-ABS) test. In general, initial screening is done with the RPR or VDRL test and confirmation testing done with the FTA-ABS. Screening for syphilis is recommended for all pregnant women in order to lower the risk of congenital syphilis. Screening should be performed for anyone with another STI or otherwise at high risk for infection.

Penicillin G is the recommended treatment for syphilis in all stages. The dosage, preparation used, and length of treatment will vary based on the stage of the disease. For penicillin-allergic patients, doxycycline, tetracycline, or ceftriaxone may be used as alternatives.

Herpes

Genital herpes is a viral infection caused by herpes simplex virus (HSV) type 1 or type 2. Most cases of recurrent genital herpes are caused by HSV-2. Clinically, HSV causes painful vesicles or ulcers. However, most persons infected with HSV-2 have not been clinically diagnosed because of the presence of mild or unrecognized infection. These persons may shed virus and therefore may transmit the infection to others while being asymptomatic.

HSV infections may be diagnosed by culture or polymerase chain reaction (PCR) testing of samples from clinically evident lesions. Serologic antibody testing  to both HSV-1 and HSV-2 is also available, although both false positive and false negative and cross-reactivity may occur. Testing positive for HSV-1 alone can also be difficult to interpret, as this is a common nonsexually transmitted infection of

childhood.

Antiviral therapy is available for HSV infections. Treatment can be used both for the acute management of symptomatic outbreaks and for suppression to reduce the frequency of outbreak or the risk of viral transmission to an uninfected partner. Pregnant women with a history of HSV should be placed on suppressive therapy late in pregnancy to reduce the risk of symptomatic outbreak or viral shedding at the time of delivery, so as to reduce the risk of neonatal herpes in the newborn. Women with clinically evident genital herpes at the time of delivery should be offered cesarean delivery.

Trichomoniasis

Trichomoniasis, or "trich," is a very common, curable sexually transmitted infection caused by the protozoan Trichomonas vaginalis. This infection is asymptomatic in approximately 70% of those infected. Symptomatic women may have vaginal itching, burning, or discharge. On examination, the physician may see a "frothy" discharge and the characteristic erythematous "strawberry" cervix. Symptomatic men may have urethral itching, burning, or discharge.

The diagnosis of trichomoniasis can be made by the direct visualization of the motile, flagellated trichomonads and many white blood cells on a wet mount of vaginal or penile discharge. Trich can be treated with a single, 2-g dose of oral metronidazole for the identified patient and sexual partner(s). Tinidazole is an alternative treatment.

HPV

HPV infection is the most common sexually transmitted infection. It can be passed during anal, vaginal, or oral intercourse or by skin to skin contact during sexual activity. There are many strains of HPV and the manifestation of the infection, if any, is related to the specific viral strain, the site of infection and host factors. Most infections with HPV are asymptomatic and cleared by the body's immune system. HPV infections can lead to genital warts, cervical cancer in women, penile cancer in men, and anal or oropharyngeal cancers in both.

Because of the ubiquity of the virus and the health risks related to exposure, vaccination against HPV is recommended routinely for both adolescent girls and boys. HPV vaccination has been shown to reduce the incidence of genital warts and of cervical cancer.

CASE CORRELATION

• See also Case 22 (Yaginitis ).

COMPREHENSION QUESTIONS

45.1 A 42-year-old woman who is known to be HIV positive is found to have a CD4 count of 125 cells/ mm3 and is taking HAART. She has not experienced any AIDS-defining illness. She continues to use IV heroin and abuse alcohol on a daily basis. She does not regularly take her antiretroviral medication and is often lost to follow-up. Which of the following treatments is most appropriate at this time?

A. Initiate fluconazole for candidiasis prophylaxis.

B. Initiate antiviral treatment for herpes zoster prophylaxis.

C. Initiate TMP-SMX for P jiroveci pneumonia prophylaxis.

D. Initiate clarithromycin for M avium-intracellulare complex prophylaxis.

45.2 A 25-year-old previously healthy man presents to the emergency room after experiencing a generalized tonic-clonic seizure that lasted 30 seconds. He has been experiencing headaches over the past 6 months but no other associated symptoms. His mother states that she witnessed him to have two previous seizures. The patient has a history of being sexually promiscuous and using IV illicit drugs. The result of his last HIV test is unknown. On neurologic examination, he is noted to have increased tone on the right and decreased right arm swing when walking. The remainder of his neurologic examination is unremarkable. A computed tomography (CT) scan of the head with contrast reveals that he has a ring-enhancing lesion measuring 15-mm over the left motor strip region and a 12-mm ring-enhancing lesion in the left basal ganglia. Which of the following would be an AIDS-defining condition in this patient?

A. Glioblastoma multiforme

B. Subarachnoid hemorrhage

C. Herpes zoster encephalitis

D. Listeriosis with brain abscess

E. Primary brain lymphoma

45.3 A 22-year-old woman tests positive for gonorrhea from routine screening during a well-woman examination. She was asymptomatic at the time of the testing. She has no known drug allergies. Which of the following treatments would be recommended for her?

A. Penicillin G 1.2 million units IM x 1

B. Ceftriaxone 250 mg IM X 1

C. Ciprofloxacin 250 mg PO X 1 dose

D. Ceftriaxone 250 mg IM X 1 and azithromycin 1 g PO X 1

45.4 A 45-year-old man has STI screening done at a screening fair at a local free clinic. He has never been tested for STIs before and is completely asymptomatic. He tests negative for HIV, gonorrhea, and Chlamydia but is notified that he has a positive RPR. What is the next appropriate step for him?

A. Treatment with penicillin G

B. FTA-ABS testing

C. Notification of his STI to the local health department

D. Repeat his STI panel as this is likely a false-positive test

ANSWERS

45.1 C. With this level of cell count, the patient should continue antiretroviral therapy and start P jiroveci pneumonia prophylaxis. The level is not yet low enough to recommend M avium-intracellulare complex prophylaxis.

45.2 D. Primary brain lymphoma is an AIDS-defining condition. Glioblastoma multiforme and subarachnoid hemorrhage may present with these symptoms, but are not AIDS-defining conditions. Listeriosis and herpes zoster encephalitis can be associated with HIV, but are not AIDS-defining conditions.

45.3 D. Patients who test positive for gonorrhea should be treated for both gonorrhea and Chlamydia. Ceftriaxone 250 mg IM is the appropriate treatment for gonorrhea and azithromycin is the appropriate treatment for Chlamydia. Her sexual partner(s) should also be offered treatment.

45.4 B. He has tested positive on his initial screening test for syphilis with a nontreponemal test. A confirmatory test with a treponemal test should be performed prior to making the diagnosis or implementing treatment. If he is confirmed as positive, he should then be treated with penicillin and notification should be made to the health department.

CLINICAL PEARLS

⯈ Because of the complexity of the drug regimens and the ever-changing guidelines, persons with HIV should be comanaged with an infectious disease specialist or other physician with expertise in treating HIV.

⯈ The risk of transmission of HIV to health-care workers by accidental needle sticks from HIV-infected patients is very low. It is important to report these injuries promptly, as early prophylactic treatment can significantly lower the risk of developing HIV disease .

⯈ Someone who tests positive for gonorrhea should be treated for both gonorrhea and Chlamydia, because of the high risk of coinfection.

REFERENCES

AIDS Education and Training Centers. Peer Education Trainer's Manual. 2015 ed. Available at: http:// www.aidsetc.org/ resource/peer-education-trainers-manual. Accessed March 14, 2015. 

Armstrong C. CDC updates guidelines on diagnosis and treatment of sexually transmitted diseases. Am Fam Physician. 2011; 84(1):123-125. 

Centers for Disease Control and Prevention. Available at: http://www.cdc.gov/hiv/library/reports/ surveillance. Accessed March 14, 2015. 

Centers for Disease Control and Prevention. Sexually transmitted diseases. Available at: http:/ /www. cdc.gov I std/. Accessed May 9, 2015. 

Chu C, Sdwyn PA. Diagnosis and initial management of acute HIV infection. Am Fam Physician. 2010; 81(10):1239-1244. 

Cohen MS, Shaw GM, McMichael AJ, Haynes BF. Acute HIV-1 infection. N Engl J Med. 2011;364:1943-1954. 

Fauci AS, Lane H. Human immunodeficiency virus disease: AIDS and rdated disorders. In: Kasper D, Fauci A, Hauser S, et al., eds. Harrison's Principles of Internal Medicine. 19th ed. New York, NY: McGraw-Hill Education; 2015. Available at: http://accessmedicine.mhmedical.com. Accessed May 25, 2015. 

Khalsa AM. Preventive counsding, screening, and therapy for the patient with newly diagnosed HN infection. Am Fam Physician. 2006; 73(2):271-280. 

Mattei PL, Beachkofsky TM, Gilson RT, Wisco OJ. Syphilis: a reemerging infection. Am Fam Physician. 2012; 86(5):433-440. 

Roett MA, Mayor MT, Uduhiri KA. Diagnosis and management of genital ulcers. Am Fam Physician. 2012; 85(3):254-262. 

World Health Organization. Global health observatory Data. Available at: http://www.who.int/gho/ hiv/en/. Accessed March 14, 2015. 

World Health Organization. Guidelines on post-exposure prophylaxis for HIV and the use of cotrimoxazole prophylaxis for HN-rdated infections among adults, adolescents, and children. Available at: http:/ /www.who.int/hiv/pub/ guidelines/ arv2013 / arvs2013upplement_dec2014/ en/. Accessed March 14, 2015.

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