The MMWR series of publications is published by the Office of Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services, Atlanta, GA 30333.

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Sexually transmitted diseases treatment guidelines.

These guidelines for the treatment of persons who have or are at risk for sexually transmitted diseases (STDs) were updated by CDC after consultation with a group of professionals knowledgeable in the field of STDs who met in Atlanta on April 18-30, 2009. The information in this report updates the 2006 Guidelines for Treatment of Sexually Transmitted Diseases (MMWR 2006;55[No. RR-11]). Included in these updated guidelines is new information regarding 1) the expanded diagnostic evaluation for cervicitis and trichomoniasis; 2) new treatment recommendations for bacterial vaginosis and genital warts; 3) the clinical efficacy of azithromycin for chlamydial infections in pregnancy; 4) the role of Mycoplasma genitalium and trichomoniasis in urethritis/cervicitis and treatment-related implications; 5) lymphogranuloma venereum proctocolitis among men who have sex with men; 6) the criteria for spinal fluid examination to evaluate for neurosyphilis; 7) the emergence of azithromycin-resistant Treponema pallidum; 8) the increasing prevalence of antimicrobial-resistant Neisseria gonorrhoeae; 9) the sexual transmission of hepatitis C; 10) diagnostic evaluation after sexual assault; and 11) STD prevention approaches.

Sexually transmitted diseases treatment guidelines, 2010.

These guidelines for the treatment of persons who have or are at risk for sexually transmitted diseases (STDs) were updated by CDC after consultation with a group of professionals knowledgeable in the field of STDs who met in Atlanta on April 30-May 2, 2013. The information in this report updates the Sexually Transmitted Diseases Treatment Guidelines, 2010 (MMWR Recomm Rep 2010;59 [No. RR-12]). These updated guidelines discuss 1) alternative treatment regimens for Neisseria gonorrhoeae; 2) the use of nucleic acid amplification tests for the diagnosis of trichomoniasis; 3) alternative treatment options for genital warts; 4) the role of Mycoplasma genitalium in urethritis/cervicitis and treatment-related implications; 5) updated HPV vaccine recommendations and counseling messages; 6) the management of persons who are transgender; 7) annual testing for hepatitis C in persons with HIV infection; 8) updated recommendations for diagnostic evaluation of urethritis; and 9) retesting to detect repeat infection. Physicians and other health-care providers can use these guidelines to assist in the prevention and treatment of STDs.

Sexually transmitted diseases treatment guidelines, 2015.

This report updates and combines earlier versions of guidelines for the prevention and treatment of opportunistic infections (OIs) in HIV-infected adults (i.e., persons aged >/=18 years) and adolescents (i.e., persons aged 13--17 years), last published in 2002 and 2004, respectively. It has been prepared by the Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH), and the HIV Medicine Association (HIVMA) of the Infectious Diseases Society of America (IDSA). The guidelines are intended for use by clinicians and other health-care providers, HIV-infected patients, and policy makers in the United States. These guidelines address several OIs that occur in the United States and five OIs that might be acquired during international travel. Topic areas covered for each OI include epidemiology, clinical manifestations, diagnosis, prevention of exposure; prevention of disease by chemoprophylaxis and vaccination; discontinuation of primary prophylaxis after immune reconstitution; treatment of disease; monitoring for adverse effects during treatment; management of treatment failure; prevention of disease recurrence; discontinuation of secondary prophylaxis after immune reconstitution; and special considerations during pregnancy. These guidelines were developed by a panel of specialists from the United States government and academic institutions. For each OI, a small group of specialists with content-matter expertise reviewed the literature for new information since the guidelines were last published; they then proposed revised recommendations at a meeting held at NIH in June 2007. After these presentations and discussion, the revised guidelines were further reviewed by the co-editors; by the Office of AIDS Research, NIH; by specialists at CDC; and by HIVMA of IDSA before final approval and publication. The recommendations are rated by a letter that indicates the strength of the recommendation and a Roman numeral that indicates the quality of evidence supporting the recommendation, so that readers can ascertain how best to apply the recommendations in their practice environments. Major changes in the guidelines include 1) greater emphasis on the importance of antiretroviral therapy for the prevention and treatment of OIs, especially those OIs for which no specific therapy exists; 2) information regarding the diagnosis and management of immune reconstitution inflammatory syndromes; 3) information regarding the use of interferon-gamma release assays for the diagnosis of latent Mycobacterium tuberculosis (TB) infection; 4) updated information concerning drug interactions that affect the use of rifamycin drugs for prevention and treatment of TB; 5) the addition of a section on hepatitis B virus infection; and 6) the addition of malaria to the list of OIs that might be acquired during international travel. This report includes eleven tables pertinent to the prevention and treatment of OIs, a figure that pertains to the diagnois of tuberculosis, a figure that describes immunization recommendations, and an appendix that summarizes recommendations for prevention of exposure to opportunistic pathogens.

Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America.

OBJECTIVE:: To estimate the sex-specific effect of herpes simplex virus type 2 (HSV-2) on the acquisition of HIV infection. BACKGROUND:: The increased number of longitudinal studies available since the last meta-analysis was published allows for the calculation of age- and sexual behaviour-adjusted relative risks (RR) separately for men and women. DESIGN:: Systematic review and meta-analysis of longitudinal studies. METHODS:: PubMed, Embase and relevant conference abstracts were systematically searched to identify longitudinal studies in which the relative timing of HSV-2 infection and HIV infection could be established. Where necessary, authors were contacted for separate estimates in men and women, adjusted for age and a measure of sexual behaviour. Summary adjusted RR were calculated using random-effects meta-analyses where appropriate. Studies on recent HSV-2 incidence as a risk factor for HIV acquisition were also collated. RESULTS:: Of 19 eligible studies identified, 18 adjusted for age and at least one measure of sexual behaviour after author contact. Among these, HSV-2 seropositivity was a statistically significant risk factor for HIV acquisition in general population studies of men [summary adjusted RR, 2.7; 95% confidence interval (CI), 1.9-3.9] and women (RR, 3.1; 95% CI, 1.7-5.6), and among men who have sex with men (RR, 1.7; 95% CI, 1.2-2.4). The effect in high-risk women showed significant heterogeneity, with no overall evidence of an association. CONCLUSIONS:: Prevalent HSV-2 infection is associated with a three-fold increased risk of HIV acquisition among both men and women in the general population, suggesting that, in areas of high HSV-2 prevalence, a high proportion of HIV is attributable to HSV-2.

Herpes simplex virus 2 infection increases HIV acquisition in men and women: systematic review and meta-analysis of longitudinal studies.

Background Nucleoside analogues against herpes simplex virus (HSV) have been shown to suppress shedding of HSV type 2 (HSV-2) on genital mucosal surfaces and may prevent sexual transmission of HSV. Methods We followed 1484 immunocompetent, heterosexual, monogamous couples: one with clinically symptomatic genital HSV-2 and one susceptible to HSV-2. The partners with HSV-2 infection were randomly assigned to receive either 500 mg of valacyclovir once daily or placebo for eight months. The susceptible partner was evaluated monthly for clinical signs and symptoms of genital herpes. Source partners were followed for recurrences of genital herpes; 89 were enrolled in a substudy of HSV-2 mucosal shedding. Both partners were counseled on safer sex and were offered condoms at each visit. The predefined primary end point was the reduction in transmission of symptomatic genital herpes. Results Clinically symptomatic HSV-2 infection developed in 4 of 743 susceptible partners who were given valacyclovir, as compared w...

https://www.nejm.org/doi/pdf/10.1056/NEJMoa035144

Once-Daily Valacyclovir to Reduce the Risk of Transmission of Genital Herpes

This randomized, placebo-controlled trial was conducted to determine the efficacy of daily antiviral therapy (valacyclovir) in preventing the transmission of herpes simplex virus type 2 (HSV-2) in monogamous couples with 1 infected partner. Heterosexual couples over 18 years of age, with 1 noninfected partner and 1 HSV-2-seropositive partner who had fewer than 10 outbreaks of genital herpes per year, were identified and recruited from participating medical centers. They were enrolled for an 8-month study period during which the infected partner took 500 mg valacyclovir or placebo once daily. Susceptible partners had monthly clinical examinations for the presence of HSV-2. Infected partners were seen during each outbreak of genital herpes and treated with 500 mg valacyclovir twice daily for 5 days. Couples were given a free supply of condoms and instructed to use them. In addition, 89 infected participants were recruited to participate in a substudy of mucosal shedding. Everyday for 2 months, they swabbed their genital area and placed the swabs in polylmerase chain reaction (PCR) buffer, which was delivered to the clinic with the next monthly visit. One thousand four hundred eighty-four couples, including 488 women and 996 men who were not HSV-2-seropositive, met the requirements for inclusion in the analysis. There were 743 couples randomized to the valacyclovir group and 741 in the placebo group. Seventy-one susceptible partners developed symptoms suggestive of HSV-2 infection. Clinical and laboratory evidence confirmed the diagnosis in 20, including 4 from the valacyclovir group (4 of 743; 1.9%) and 16 (16 of 741; 3.6%) in the placebo group (hazard ratio, 0.52; 95% confidence interval, 0.27-0.99; P = 0.01). Among those with symptoms, 3 were determined to have become infected before the development of symptoms, and 48 had no evidence of infection on clinical examination. Of the susceptible subjects who reported no symptoms, 18 were found to have laboratory evidence of HSV-2 infection. Overall, there were 41 subjects who acquired HSV-2 during the course of the study, including 14 with partners taking valacyclovir and 27 who were partners of subjects receiving placebo. Among the 20 susceptible partners who had symptoms of genital herpes, the time to development of symptoms was found to be significantly longer in those whose partners were taking valacyclovir compared with the partners of placebo recipients. Female partners of those taking placebos were more likely to acquire HSV-2 infection than male partners (7.4% vs. 1.9%). Recurrence of symptoms was twice as common among the placebo recipients than among those taking valacyclovir (77.3% vs. 38.8%; P <0.001). The 89 participants in the mucosal shedding substudy collected genital swabs for an average of 58 days. HSV DNA was detected on 2.9% of the days in the samples of valacyclovir recipients compared with 10.8% in placebo recipients (P <0.001). Overall, shedding was detected in 19 of 39 in the valacyclovir group and 41 of 50 in the placebo group (P = 0.002). HSV DNA was detected at least 10% of the time in 3 of those taking valacyclovir compared with 25 of those taking placebo (P <0.001). In both the treatment group and the cohtrol group, the rate of HSV-2 transmission was associated with the frequency of sexual contact, but the overall rate of infection was less in the valacyclovir couples than in placebo couples (0.35 per 1000 sexual contacts vs. 0.60 per 1000 sexual contacts, respectively). The rate of acquisition of HSV-2 was greater for women than for men in both the valacyclovir couples and the placebo couples (0.60 and 1.27 per 1000 and 0.23 and 0.35 per 1000, respectively). After multivariate analysis of possible risk factors for transmission of HSV-2 infection in monogamous couples, female sex of the susceptible partner, greater number of sexual contacts, and duration of genital herpes episodes were all found to be contributing variables.

Leonid S. Stratchounsky

Papers

Once-Daily Valacyclovir to Reduce the Risk of Transmission of Genital Herpes

Once-daily valacyclovir to reduce the risk of transmission of genital herpes