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without HIV (Int J STD AIDS 2005;16:722). Nontreponemal tests give antibody titers that correlate with disease activity. Positive screening tests are confirmed with a fluorescent treponemal antibody adsorbed (FTA-ABS) or T. pallidum particle agglutination (TP-PA test). Many patients will have positive treponemal tests for life, but the VDRL and RPR usually become negative or persist at low titer. Some HIVinfected patients have"atypical serology"with unusually high, unusually low, or fluctuating titers, but "for most HIV-infected patients, serologic tests are accurate and reliable for the diagnosis of syphilis and for the response to therapy" (MMWR 2002;51[RR-6]:19). For management guidelines see pg ____.
Screening for Other Sexually Transmitted Infections (STIs): Infections with N. gonorrhoeae and/or C. trachomatis are common in HIV-infected patients (AIDS 2000;14:297) and are often asymptomatic in both men and women (Sex Transm Dis 2001;28:33; CID 2002:35: 1010). Diagnosis of STIs is important because 1) they usually indicate ongoing high-risk behavior, 2) they may enhance transmission of HIV, and 3) detection and treatment can reduce likelihood of transmission (Sex Transm Infect 1999;75:3; Lancet 1995;346:530). Urine-based nucleic acid amplifi cation tests (NAATs) are now generally available for N. gonorrhoeae and C. trachomatis for screening men and women with advantages of good sensitivity, good specificity and ease of specimen collection (MMWR 2006;55 [RR11]:1-9). The usual cost is $60-$ 100 /test. Screening for N. gonorrhoeae and C. trachomatis is advocated for sexually active patients and those with symptoms. Alternative often less expensive tests include endocervical and urethral swabs to detect N. gonorrhoeae and/or C. trachomatis by culture, nucleic acid hybridization, DFA or EIA. NAAT tests are not FDA-cleared for rectal swabs and C. trachomatis and cultures are not widely available. CDC guidelines for screening of HIV-infected patients are softened to "consider" because NAAT testing is expensive and has no proven efficacy in preventing HIV transmission (MMWR 2006;55;RR11:1). The 2006 CDC HIV-STD Guidelines recommend the following tests on the first visit for patients with HIV (MMWR 2006;55:RR11):
- RPR, VDRL or treponemal EIA for syphilis
- Consider screening for N. gonorrhoeae and C. trachomatis with urethral culture (men) or cervical culture (women) or urine (first 10- 30 mL) for NAAT testing to detect either or both pathogens. NAAT tests are the most sensitive but also expensive.
- Trichomoniasis screen in women with wet mount or culture of vaginal secretions
- Patients reporting anal sex: consider anal swab for culture for N. gonorrhoeae and C. trachomatis. Note that NAAT tests are not FDAcleared for rectal specimens and cultures for C. trachomatis are not widely available.
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