CDC Releases 2002 Guidelines for Treating STDs: Part II. Human Papillomavirus and Hepatitis
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Am Fam Physician. 2002 Nov 15;66(10):1996-1999.
The Centers for Disease Control and Prevention (CDC) has published the 2002 guidelines for treating sexually transmitted diseases (STDs). The full report is available online (www.cdc.gov) and in the May 10, 2002 recommendations and reports series of Morbidity and Mortality Weekly Report.
This report updates the guidelines from 1998, focusing on the information that has become available since then. The updates include new alternative regimens for scabies, bacterial vaginosis, early syphilis, and granuloma inguinale; an expanded section on the diagnosis of genital herpes; new recommendations for treatment of recurrent genital herpes among persons infected with human immunodeficiency virus (HIV); a revised approach to the management of victims of sexual assault; expanded regimens for the treatment of urethral meatal warts; and inclusion of hepatitis C as an STD.
More than 30 types of human papillomavirus (HPV) can infect the genital tract. Most infections are asymptomatic, unrecognized, or subclinical. Diagnosis of genital warts, usually caused by HPV types 6 or 11, can be confirmed by biopsy if necessary. Depending on the size and anatomic location, genital warts can be painful, friable, and pruritic, although they are more commonly asymptomatic. Patients who have visible warts can be infected with multiple HPV types.
The primary goal of treatment is the removal of symptomatic warts. Existing data indicate that current therapies may reduce, but probably do not eradicate, infectivity. No evidence indicates that the presence or treatment of genital warts is associated with developing cervical cancer. Treatment should be guided by the preference of the patient, available resources, and experience of the physician. Many patients require a course of therapy rather than a single treatment. In general, warts located on moist surfaces or in intertriginous areas respond better to topical treatment than warts on drier surfaces. The therapy should be changed if the patient has not improved substantially after three physician-administered treatments or if warts have not completely cleared after six treatments. Follow-up visits are not required for patients using self-administered therapy, but may be useful several weeks into therapy to determine appropriateness of medication use and response to treatment. Patients should be cautioned to watch for recurrences, which occur most frequently during the first three months.
Examination of sex partners is not necessary for the management of genital warts because no data indicate that reinfection plays a role in recurrences. Female sex partners of patients who have genital warts should be reminded that cytologic screening for cervical cancer is recommended for all sexually active women. Because genital warts can proliferate and become friable during pregnancy, they should be removed.
The most effective way to prevent transmission of infectious diseases, including hepatitis A and B, is through pre-exposure immunization.
Hepatitis A virus (HAV) has an incubation period from time of exposure to onset of symptoms of approximately four weeks. HAV most commonly is transmitted by the fecal-oral route. Antibody produced in response to HAV infection persists for life and protects against reinfection. The most frequently reported source of infection is household or sexual contact with a person who has HAV.
Patients with HAV usually require only supportive care, with no restrictions on diet or activity. Hospitalization may be necessary for patients who become dehydrated because of nausea and vomiting, and for patients with signs or symptoms of acute liver failure. Acute liver failure is rare, but occurs more frequently in older persons and persons with underlying chronic liver disease. Persons in the following groups should be offered the HAV vaccine: men who have sex with men, including those who report having minimal or no current sexual activity; illegal drug users; and persons with chronic liver disease. Previously unvaccinated persons exposed to HAV should be administered a single intramuscular dose of immune globulin as soon as possible, but no more than two weeks after exposure.
For hepatitis B virus (HBV), the incubation period from time of exposure to onset of symptoms is six weeks to six months. HBV is efficiently transmitted by percutaneous or mucous membrane exposure to infectious body fluids. Sexual transmission among adults accounts for most HBV infections in the United States. The most common risk factors for heterosexual transmission include having multiple sex partners (more than one partner in six months) or a recent history of an STD. Risk factors for men who have sex with men include having multiple sex partners, engaging in unprotected receptive anal intercourse, and having a history of other STDs.
Laboratory testing should be used to confirm suspected acute or chronic HBV infection, and infected persons should be referred for medical follow-up and possible treatment of chronic infection. Contacts should be vaccinated and receive postexposure prophylaxis. No specific therapy, only supportive care, is available for persons with acute HBV infection. The recommended vaccine dose varies by product and age of recipient. The intramuscular vaccine should be administered in the deltoid muscle and can be administered with other vaccines. The HBV vaccine has been shown to be safe, and it is well tolerated by most recipients. Pain at the injection site or low-grade fever is reported by a minority of recipients.
Previously unvaccinated sex partners of persons with acute hepatitis B should receive postexposure immunization with hepatitis B immunoglobulin and hepatitis B vaccine within 14 days after the most recent sexual contact. Nonsexual household contacts of patients who have acute hepatitis B are not at increased risk of infection unless they have other risk factors or are exposed to the patient's blood (e.g., sharing a toothbrush or razor blade). Vaccination is encouraged, especially for children and adolescents. If the patient becomes chronically infected, all household contacts should be vaccinated. HBV-negative pregnant women seeking treatment for an STD who have not been vaccinated should receive hepatitis B vaccine. Patients infected with HIV who are vaccinated should be tested for anti-HBs one to two months after the third vaccine dose. Revaccination with three more doses should be considered in patients who do not respond to the initial vaccination.
Fully vaccinated victims of sexual assault are protected from HBV infection. For a victim who is not fully vaccinated, the vaccine series should be completed as scheduled. Unvaccinated persons in this setting should be administered active postexposure prophylaxis. Unless the offender is known to have acute hepatitis B, hepatitis B immunoglobulin is not required. When sexual abuse is identified, hepatitis B vaccination should be started in previously unvaccinated children.
Chronic hepatitis C virus (HCV) infection develops in most persons after acute infection. The average time from exposure to seroconversion is eight to nine weeks, and antibodies can be detected in 97 percent of patients by six months after exposure. HCV is most efficiently transmitted by direct percutaneous exposure to infected blood. Occupational, perinatal, and sexual exposures also can result in transmission of HCV. Current approved therapy for HCV-related chronic liver disease includes alpha inter-feron alone or combined with oral ribavirin for six to 12 months. Because of advances in antiviral therapy, standards of practice might change, and physicians should consult with subspecialists about this virus. No vaccine for HCV is available, and prophylaxis with immune globulin is not effective in preventing infection after exposure. Women who are HCV-positive do not need to avoid pregnancy or breastfeeding.
Patients seeking treatment for an STD should be screened for risk factors for HCV infection. Those with the following risk factors should be offered counseling and testing: illegal injection drug use; blood transfusion or solid organ transplant before July 1992; receipt of clotting factor concentrates produced before 1987; and long-term hemodialysis.
This is the second of a two-part series summarizing the 2002 sexually transmitted diseases treatment guidelines from the Centers for Disease Control and Prevention. The first report, on diseases characterized by vaginal discharge and pelvic inflammatory disease, appeared in the previous issue.
Copyright © 2002 by the American Academy of Family Physicians.
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