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HIV Guide
 Zambia HIV National Guidelines
 


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General Principles of Antiretroviral Therapy for Chronic HIV Infection in Adults and Adolescents  

When to Start ARV Therapy for Chronic HIV Infection in Adults and Adolescents  

Initial Regimen for ARV Therapy  

Adherence  

Baseline evaluation and Monitoring  

Calculations: Ideal Body Weight, Body Mass Index and Creatinine Clearance  

ARV Therapy for Individuals with Tuberculosis Co-Infection  

Adverse Effects and Toxicity  

Immune Reconstitution Inflammatory Syndrome (IRIS)  

Changing or Stopping ART  

Treatment Failure  

Stopping ARV Therapy  

Post Exposure Prophylaxis  

Cotrimoxazole Prophylaxis  

WHO Staging in Adults and Adolescents  

Nutrition Care and Support  

Palliative Care in HIV and AIDS  

 Guide Editors
 Editor In Chief
    Joel E. Gallant, MD, MPH

Pharmacology Editor
    Paul Pham, PharmD, BCPS

Zambia Guideline Team
   Peter Mwaba MMed PhD FRCP
   Alywn Mwinga MMed
   Isaac Zulu MMed MPH
   Velepie Mtonga MMed
   Albert Mwango MBChB
   Jabbin Mulwanda MMed FCS
 

 

 

Diagnosis>Opportunistic Infections>
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Syphilis

Emily J. Erbelding, M.D., M.P.H.What about Khalil? and Khalil G. Ghanem, M.D.
04-29-2009

  • Recent national survey from Zambia found syphilis prevalence 6.5% for women and 7.4% for men; Copperbelt, Eastern and Lusaka provinces had higher rates for both men and women (no data on rates of HIV coinfection).   
  • Given synergy between syphilis and HIV, all pts Dx'd with syphilis should be referred for HIV testing, and all pts diagnosed with HIV should be screened for syphilis.
  • Dx and management of syphilis in Zambia similar to that in other countries.
  • RPR is test of choice, as darkfield examination, DFA, and FTA not readily available.
  • Rx recommendations in this module are same as in Zambia's National Guidelines on Management and Care for HIV/AIDS.
  • Rx for children in Zambia: benzathine penicillin 50,000 units/kg IM (up to adult dose of 2.4 million units IM weekly x 3 doses).

REFERENCES

Zambia Information Author: David Riedel, M.D.

PATHOGENS

  • Treponema pallidum: a spirochete

CLINICAL

  • HIV+ pts may have abnormal serologic results (unusually high titers, false negatives, delayed seroreactivity, higher rates of serologic failure after therapy), but serology can usually be interpreted in usual manner. Occurs at any CD4 count.
  • Staging at time of Dx determines therapy; clinical stages may overlap and manifestations are protean; neurologic manifestations can occur with any stage.
  • Primary: Usually evident 14-21 days after exposure; indurated ulcer at site of inoculation (chancre); most commonly anogenital or oral.
  • Secondary: Usually 4-10 weeks after chancre; maculopapular or papulosquamous eruption, often involves palms/soles (60%); other: fever, alopecia, mucous patches, condyloma lata; rarely arthritis, glomerulonephritis, hepatitis.
  • Tertiary: 1/3 of those left untreated develop late sequelae, including cardiovascular syphilis, gummas, paresis, tabes dorsalis.
  • Latent: No clinical findings but reactive serology; early latent <1 yr duration; late latent >1 yr duration.
  • Neurosyphilis should be considered in DDx when neurologic signs or symptoms in HIV+ pts; ocular syphilis should be considered in DDx of visual loss.
  • Early neurosyphilis (i.e. occurring within the first year after infection) is frequent in HIV+ patients
  • Worsening of lab markers of HIV stage (decline in CD4 count and increased VL) with early stage syphilis.
  • Parenteral penicillin is drug of choice in ALL stages of syphilis; no resistance observed despite decades of PCN use.
  • Higher risk of neurosyphilis with HIV+, CD4 < 350, and RPR > 1:32. Consider LP with any of these factors, and also with any neuro findings or serologic treatment failure.
  • Immune reconstitution using ART may help decrease risk of serological failure and neurosyphilis

DIAGNOSIS

  • Definitive: visualization of motile T. pallidum (darkfield examination) or positive DFA test in fluid from clinically compatible lesion or on histopathology
  • Serologic testing: Nontreponemal serology (RPR, VDRL) followed by reflex treponemal testing (FTA-Abs or MHA-TP) establishes presumptive Dx; EIA testing (followed by nontreponemal test titer) becoming more common.
  • Neurosyphilis: Reactive CSF VDRL (30-70% sensitive) or elevated WBC (>5) or protein (>) 50; treatment for neurosyphilis indicated if reactive FTA-Abs in CSF and CSF WBC >5 or CSF protein >45, OR reactive CSF VDRL.

TREATMENT

Primary or secondary syphilis

  • Preferred: benzathine PCN G 2.4 million units IM x1.
  • Alternative (PCN allergic): doxycycline 100 mg twice-daily x 14 days
Latent and tertiary syphilis excluding neurosyphilis

  • Early latent syphilis (<1 yr duration): benzathine PCNG 2.4 million units IM x1
  • Late latent (>1 yr duration), latent of unknown duration, or tertiary syphilis, excluding neurosyphilis: benzathine PCN G-2.4 million units IM q wk x 3 doses. Experts recommend LP to evaluate for asymptomatic neurosyphilis.
  • Alternative: doxycycline 100 mg twice-daily x 28 days
Neurosyphilis

  • Preferred: aqueous crystalline PCN G 18-24 million units daily as 3-4 million units q4 hrs (or continuously) x10-14 d.
  • Alternative: procaine PCN 2.4 million units IM once-daily x10-14 d (along with probenecid 500 mg four times a day).
  • Alternative: ceftriaxone 2 gm IM/IV once-daily x 10-14 d (less clinical experience than with PCN regimens)
  • Doxycycline not recommended.
  • Some experts recommend benzathine PCN G 2.4 million units q wk for 1-3 doses after completion of IV PCN regimen.
Azithromycin

  • Use should generally be avoided. Azithromycin 1 or 2 gm single dose effective in preventing syphilis in exposed contacts, but macrolide resistance documented.

Drug Comments

DrugRecommendations/Comments
Azithromycin Data suggest equivalence to PCN in preventing syphilis infection in partners of infectious cases; resistance to macrolides reported, causing concern for use in both incubating syphilis and syphilis infection.
Doxycycline Has been used for years as alternative when PCN contraindicated, though no data to support use in treating neurosyphilis; use in HIV infection not studied.
PenicillinPreferred drug for treatment of all stages of syphilis; only therapy indicated for treatment of syphilis in pregnancy.
CeftriaxoneMore limited clinical experience compared to PCN, but may be more effective and more convenient parenteral therapy for neurosyphilis.

FOLLOW UP

Assessing 'cure' after treatment

  • Resolution of clinical Sx and appropriate serologic response (decline in nontreponemal titer) are best measures of therapeutic response.
Primary/secondary syphilis

  • RPR (or other non-treponemal test titer) at 3, 6, 9, 12, 24 mos; 4-fold decline from baseline titer 6 mos after therapy expected. Treatment failure requires LP and re-treatment with 3 weekly doses of benzathine PCN G if LP is negative.
Latent syphilis and neurosyphilis

  • RPR (or other non-treponemal test titer) at 6, 12, 24 mos; 4-fold decline from initially high baseline titer (>1:32) at 12-24 mos after therapy expected.
  • If follow-up RPR (or other non-treponemal test titer) fails to decline as above, or declines then rises, evaluate for reinfection and for neurosyphilis, then re-treat.
  • Neurosyphilis: repeat LP every 6 mos until cell count normal. Consider retreatment if cell count has not decreased after 6 mos or if not entirely normal after 2 yrs.

OTHER INFORMATION

  • Errors in Bicillin formulation (use of benzathine penicillin G/procaine penicillin G rather than benzathine penicillin G) have led to inadequate treatment of syphilis cases and FDA alert.

Basis for Recommendations

  • Centers for Disease Control and Prevention ; Sexually transmitted diseases treatment guidelines 2006. Centers for Disease Control and Prevention.; MMWR Recomm Rep; 2006; Vol. 55; pp. 22-35 ;
    ISSN: 1057-5987;
    PUBMED: 16888612
    Rating: Basis for recommendation
    Comments:These consensus panel guidelines should provide a basis for managing nearly all syphilis cases encountered.

REFERENCES

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