Sexually Transmitted Infections: Human Immunodeficiency Virus

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Chapter 51 Sexually Transmitted Infections: Human Immunodeficiency Virus

INTRODUCTION

Description: Infection by the human immunodeficiency virus (HIV) preferentially involves the immune system and leads to progressive deterioration in immune function. Infection produces a spectrum of disease that progresses from a clinically latent, asymptomatic state to acquired immune deficiency syndrome (AIDS) as a late manifestation. The speed of this progression varies. In untreated patients, the time between infection and the development of AIDS ranges from a few months to 17 years (median: 10 years). Women make up the fastest-growing group of individuals with HIV. Many states have specific laws governing HIV screening, reporting, disclosure, and breach of confidence. All care providers should become familiar with the requirements imposed in their area.
Prevalence: Two million Americans, or 0.7% of the entire population.
Predominant Age: Median age 35 years; 84% of cases occur at ages 15 to 44. In the United States in 2004, HIV/AIDS was the leading cause of death among African American women ages 25 to 34 years.
Genetics: No genetic pattern.

ETIOLOGY AND PATHOGENESIS

Causes: Infection with HIV, a retrovirus that preferentially infects helper lymphocytes but may infect macrophages, cells of the central nervous system, and possibly the placenta. Incubation from infection to clinical symptoms ranges from 5 days to 3 months, with an average of 2 to 4 weeks.
Risk Factors: Sexual activity (multiple partners or infected partner—37% of all infections), parenteral exposure to blood (sharing needles, inadvertent needle stick), perinatal exposure of infants. There is no evidence that HIV infection may be transmitted by casual contact, immune globulin preparations, hepatitis B vaccine, or contact with biting insects. HIV infection following donor insemination has been reported.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Nonspecific symptoms, often mimicking mononucleosis with aseptic meningitis (90%) (Febrile pharyngitis is the most common, with fever, sweats, lethargy, arthralgia, myalgia, headache, photophobia, and lymphadenopathy lasting up to 2 weeks.)
• Signs of loss of immune function: fever, weight loss, malaise, lymphadenopathy, central nervous system dysfunction, abnormal Pap test result, recurrent cervical intraepithelial neoplasia (CIN), oral or vaginal candidiasis

Patients are often diagnosed late in the progress of the disease (up to 40% within 1 year of developing full-blown AIDS).

DIAGNOSTIC APPROACH

Differential Diagnosis

• Mononucleosis

Associated Conditions: Gynecologic—abnormal Pap test results, cervical intraepithelial neoplasia and cervical cancer, condyloma acuminata, increased risk of pregnancy loss.

Workup and Evaluation

Laboratory: Enzyme-linked immunosorbent assay (ELISA) with positive results confirmed by Western blot analysis (sensitivity and specificity >99%). (Informed consent is recommended before testing. False-positive Western blot test results are uncommon and are found on the order of less than 1 in 130,000.) Antibodies may not be detectable until 6 to 12 weeks after infection. Other tests include complete blood count, with differential white count, electrolytes, glucose 6-phosphate dehydrogenase, hepatitis B screen, liver and renal function tests, platelet count, Venereal Disease Research Laboratory (VDRL), or rapid plasma reagent (RPR) test.
Imaging: No imaging indicated.
Special Tests: Tests for tuberculosis (tuberculin skin test with control [Candida, mumps, tetanus]) and other infections should be considered in individuals with HIV, Pap test.
Diagnostic Procedures: Enzyme-linked immunosorbent assay and Western blot analysis.

Pathologic Findings

Reduced CD4 counts and diffuse evidence of immunocompromise.

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Health maintenance, avoidance of stress and infection.
Specific Measures: Management is focused on stabilization of HIV disease, prevention of opportunistic infections, and prevention of perinatal transmission. When CD4 counts are less than 200, antibiotic prophylaxis should be started.
Diet: No specific dietary changes indicated.
Activity: No restriction.
Patient Education: American College of Obstetricians and Gynecologists Patient Education Pamphlet AP009 (How to Prevent Sexually Transmitted Diseases). Patient counseling should include the risk of infections associated with sexual behavior, intravenous drug use, the risk of transmission to an infant, the availability of treatment to reduce that risk, and the risk and benefits of treatment for the patient.

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Drug(s) of Choice

Zidovudine (ZVD, 100 mg PO five times daily) is used to reduce vertical transmission during pregnancy. Multiple drug therapy is common for individuals with HIV, but the best combination has yet to be determined, and guidelines are rapidly changing. Referral to a specialist is recommended.
Prophylactic drugs—trimethoprim (160 mg) sulfamethoxazole (800 mg) daily as prophylaxis for those at risk (CD4 <200). (Significant infections must be treated specifically and aggressively.)

FOLLOW-UP

Patient Monitoring: Increased frequency of monitoring, including periodic assessment of blood and CD4 counts.
Prevention/Avoidance: Avoidance of risky behaviors such as intravenous drug use or multiple sexual partners, universal precautions for health care workers, consistent use of condoms, substance abuse prevention and treatment programs, and counseling programs. Prophylaxis after acute exposure (e.g., needle stick) with zidovudine singly or in combination with other agents has been shown to reduce the risk of infection.
Possible Complications: Opportunistic infections (bacterial, mycotic, and viral), increased risk of malignancy (cervical, Kaposi sarcoma, lymphoma), central nervous system dysfunction.
Expected Outcome: After recovery from the initial infection, the patient enters a carrier state during which symptoms are absent, but viral shedding occurs. Immune dysfunction generally becomes apparent roughly 10 years after the initial infection. The development of immunocompromise is rare before 3 years after infection, and less than 35% develop symptoms of AIDS before 5 years. Despite continuing progress in treatment of HIV infection and AIDS, the outcome is generally poor.

MISCELLANEOUS

Pregnancy Considerations: Significant risk of vertical transmission and worsening of maternal disease. Prenatal screening and suppressive strategies have reduced the risk of vertical transmission to approximately 2%.
ICD-9-CM Codes: V08, 042 (With symptoms).

REFERENCES

Level I

Catanzaro AT, Koup RA, Roederer M, et alVaccine Research Center 006 Study Team. Phase 1 safety and immunogenicity evaluation of a multiclade HIV-1 candidate vaccine delivered by a replication-defective recombinant adenovirus vector. J Infect Dis. 2006;194:1638. Epub 2006 Nov 8

Gallant JE, DeJesus E, Arribas JR, et alStudy 934 Group, Tenofovir DF. emtricitabine, and efavirenz vs. zidovudine, lamivudine, and efavirenz for HIV. N Engl J Med. 2006;354:251.

Gulick RM, Ribaudo HJ, Shikuma CM, et alAIDS Clinical Trials Group (ACTG) A5095 Study Team. Three- vs four-drug antiretroviral regimens for the initial treatment of HIV-1 infection: a randomized controlled trial. JAMA. 2006;296:769.

Hurwitz BE, Klaus JR, Llabre MM, et al. Suppression of human immunodeficiency virus type 1 viral load with selenium supplementation: a randomized controlled trial. Arch Intern Med. 2007;167:148.

Lockman S, Shapiro RL, Smeaton LM, et al. Response to antiretroviral therapy after a single, peripartum dose of nevirapine. N Engl J Med. 2007;356:135.

Pitisuttithum P, Gilbert P, Gurwith M, et alBangkok Vaccine Evaluation Group. Randomized, double-blind, placebo-controlled efficacy trial of a bivalent recombinant glycoprotein 120 HIV-1 vaccine among injection drug users in Bangkok, Thailand. J Infect Dis. 2006;194:1661. Epub 2006 Nov 3

Level II

Nagot N, Ouedraogo A, Foulongne V, et alANRS 1285 Study Group. Reduction of HIV-1 RNA levels with therapy to suppress herpes simplex virus. N Engl J Med. 2007;356:790.

Pilcher CD, Eron JJJr, Vemazza PL, et al. Sexual transmission during the incubation period of primary HIV infection. JAMA. 2001;286:1713.

Strategies for Management of Antiretroviral Therapy (SMART) Study Group, El-Sadr WM, Lundgren JD, Neaton JD, et al. CD4+ count-guided interruption of antiretroviral treatment. N Engl J Med. 2006;355:2283.

Waller SC. A meta-analysis of condom effectiveness in reducing sexually transmitted HIV. Soc Sci Med. 1993;36:1635.

Wawer MJ, Gray RH, Sewankambo NK, et al. Rates of HIV-1 transmission per coital act, by stage of HIV-1 infection, in Rakai, Uganda. J Infect Dis. 2005;191:1403.

Level III

Bardequez AD. Management of HIV infection for the childbearing age woman. Clin Obstet Gynecol. 1996;39:344.

Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2006. MMWR. 2006;55:10.

Letvin NL. Progress in the development of an HIV-1 vaccine. Science. 1998;280:1875.

Panel on Antiretroviral Guidelines for Adult and Adolescents Guidelines for the use of antiretroviral agents in HIV-infected adults and adolescents 2006 Department of Health and Human Services 1 Available at http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentsGL.pdf Accessed June 1, 2007.

Piot P. AIDS: from crisis management to sustained strategic response. Lancet. 2006;368:526.

Simon V, Ho DD, Abdool Karim Q. HIV/AIDS epidemiology, pathogenesis, prevention, and treatment. Lancet. 2006;368:489.

U.S. Department of Health and Human Services Treatment of opportunistic infections 2006 U.S. Department of Health and Human Services, National Institutes of Health, CDC Washington, DC Available at http://www.aidsinfo.nih.gov Accessed June 1, 2007.

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