Update on new recommendations By Dr. Joel Doughten What % of new recommendations recommended by the USPSTF is out of date by the time it is published? • • • • A. 5% B. 9% C. 12% D. 15% Answer • B. 9% What is the average length of time that a recommendation made by the USPSTF in in effect before it is revised? • • • • A. 5.4 years B. 7 years C. 7.5 years D. 10 years Answer • A. 5.4 years Should you vaccinate a 25 yo smoker with Pneumovac? • A. Yes • B. No • C. Consider Current Change by the USPSTF • Asthma and cigarette smoking have been added as indications for pneumococcal polysaccharide vaccination #7. Also, text has been added to clarify vaccine use in Alaska Natives and American Indians. Pneumococcal polysaccharide vaccine (Pneumovax) • ACIP recommendations—smokers 19 to 64 yr of age • Relative risk for pneumococcal invasive disease higher in smokers • smoking, diabetes, and asthma have comparable risk • among smokers, risk 1 per 10,000; • problems—when to administer and frequency • vaccine wears off with time • hyporesponsiveness occurs after second dose • if smokers revaccinated every 5 to 10 yr, low responsiveness expected by age 65 yr Case: patient—man 61 yr of age; smoker; last tetanus vaccine 15 yr ago; never given Tdap; he is adopting a daughter from Guatemala in 1 month. What vacines should you give him? recommended vaccines • Tdap based on high risk (smoker) and need for tetanus booster • pneumococcal polysaccharide based on age and high risk (smoker) • inactivated influenza vaccine • herpes zoster based on age • hepatitis A, based on daughter adopting from Guatemala • varicella not indicated (born before 1980) • hepatitis B risk not identified • Meningococcal conjugate not indicated A girl 12 yr of age presents with sports injury. She has no chronic illnesses and is in good health. She had all her childhood vaccines by age 5 yr. What vaccines do you recommend? recommended vaccines • tetanus and diphtheria toxoids and acellular pertussis (Tdap) for adolescents • influenza (universal annual administration 6 mo through 18 yr of age) • varicella (catch-up if second dose not received) • quadrivalent meningococcal conjugate vaccine (all children 11-12 yr of age) • human papillomavirus (HPV all girls 11-12 yr of age) • hepatitis A (catch-up for ages 11-12 yr [depending on state regulations] and universally for ages 1-2 yr) Identify the correct statement about the Gardasil human papillomavirus (HPV) vaccine. (A) Licensed for males and females 9 to 26 yr of age (B) Protects against HPV strains 6, 11, 16, and 18 (C) Protects against HPV infection even if patient has been infected with HPV in the past (D) Licensed for pregnant women Answer • (B) Protects against HPV strains 6, 11, 16, and 18 Which of the following is(are) true about meningococcal vaccines? 1. Meningococcal conjugate vaccine is recommended for routine use in adolescents 2. Meningococcal polysaccharide vaccine is recommended for adults <50 yr of age 3. Meningococcal vaccines are recommended for freshmen college students, molecular biologists, and travelers 4. Meningococcal vaccines can be administered to those with a history of Guillain-Barré syndrome (A) 1, 2, 3, 4 (B) 1, 2, 3 (C) 1, 3 (D) 2, 3, 4 Answer • 1. Meningococcal conjugate vaccine is recommended for routine use in adolescents • 3. Meningococcal vaccines are recommended for freshmen college students, molecular biologists, and travelers • (C) 1, 3 Identify the correct statement about the herpes zoster vaccine. (A) Recommended for both adolescents and adults (B) Prevents herpes zoster and postherpetic neuralgia (C) Indicated for pregnant women (D) Stored at room temperature Answer • (B) Prevents herpes zoster and postherpetic neuralgia Hepatitis A vaccine is recommended for which of the following? 1. 30-yr-old man backpacking in South America 2. 28-yr-old woman adopting a child from Guatemala 3. 25-yr old man addicted to drugs 4. 35-yr-old homosexual man (A) 1 (B) 1, 2 (C) 1, 2, 3 (D) 1, 2, 3, 4 Answer • Hepatitis A vaccine is recommended for which of the following? • 1. 30-yr-old man backpacking in South America • 2. 28-yr-old woman adopting a child from Guatemala • 3. 25-yr old man addicted to drugs • 4. 35-yr-old homosexual man • (D) 1, 2, 3, 4 Whom of the following should receive the influenza vaccine? 1. 6-yr-old schoolboy 2. Mother of 2-yr-old twins 3. Nurse who works in the emergency department 4. 60-yr-old diabetic (A) 1 (B) 1, 2 (C) 1, 2, 3 (D) 1, 2, 3, 4 Answer • 1. 6-yr-old schoolboy • 2. Mother of 2-yr-old twins • 3. Nurse who works in the emergency department • 4. 60-yr-old diabetic • (D) 1, 2, 3, 4 The risk for pneumococcal invasive disease is higher for: (A) Smokers, but not for diabetics or asthmatics (C) Smokers and asthmatics, but not for diabetics (B) Diabetics, but not for smokers or asthmatics (D) Smokers, diabetics, and asthmatics Answer • (D) Smokers, diabetics, and asthmatics • • • • • • • • • The USPSTF Updated: December 2009 Summary of Recommendations The USPSTF recommends biennial screening mammography for women aged 50 to 74 years. Grade: B recommendation. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms. Grade: C recommendation. "So, what does this mean if you are a woman in your 40s? You should talk to your doctor and make an informed decision about whether mammography is right for you based on your family history, general health, and personal values." Diana Petitti, MD, MPH Vice Chair, U.S. Preventive Services Task Force November 19, 2009 The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older. Grade: I Statement. The USPSTF recommends against teaching breast self-examination (BSE). Grade: D recommendation. The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older. Grade: I Statement. The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer. Grade: I Statement. On December 4, 2009, the USPSTF unanimously voted to update the language of their recommendation regarding women under 50 years of age to clarify their original and continued intent. Studies suggest that clinicians would need to perform mammography on _______ women 40 to 49 yr of age to avert a single death from breast cancer. (A) 25 (B) 250 (C) 2500 (D) 25,000 Answer • (C) 2500 Benefits of screening mammography • • • • • • • • • • • • • • Women 40-49 yr of age trial in United Kingdom (2006)— 11-yr follow-up 16% decrease in breast cancer mortality among screened vs nonscreened women at 10 to 11 yr Canadian trial (1980s)—showed no effect Takehome message—modest benefit observable only with long follow-up; number needed to screen (NNS)—2500 women 40 to 49 yr of age to avert 1 death (25,000 annual mammograms) most studies done in United Kingdom US case-control studies (Elmore 2005 and Norman 2007)—no difference in mortality case-control studies usually overestimate benefit Women 50 yr of age: 30% reduction in mortality in screened women benefit seen in 5 yr tighter confidence intervals and benefit persists over long period 270 women every 2 yr for 20 yr to avert 1 death (ie, 2700 mammograms) Women 70 yr of age and older little data is available on mortality in randomized controlled trials (RCTs) population-based data—better detection in screened group, but no significant difference in mortality Question: How often should women 50 to 69 yr of age undergo mammography? A) every year; B) every 1 to 2 yr; C) every 2 yr; D) every 3 yr Answer • C) every 2 yr RCTs comparing annual vs biennial screening • — no difference in breast cancer mortality • population-based data (Breast Cancer Surveillance Consortium)— from United States • looked for increase in late-stage disease with biennial vs annual screening • Proportion of advanced-stage disease decreases with age (tumors not as aggressive in older women) • in women over 50 yr of age the proportion of advanced-stage cancer was the same with annual and biennial screening • for younger women (40-49 yr of age), 21% of cancers late-stage disease in annual group vs 28% in biennial • 7% difference may warrant annual • Screening • Canadian study—annual vs biennial screening in women 50 to 69 yr of age the 10-yr survival was the same Recommendations to reduce the frequency of mammography from once per year to once every 2 yr for women 50 to 69 yr of age are based on: (A) Data showing no increase in breast cancer mortality with biennial vs annual screening (B) Data showing no increase in late-stage breast cancer with biennial vs annual screening (C) Data showing no difference in 10-year breast cancer survival rates with biennial vs annual screening (D) All the above Answer • (D) All the above Patient characteristics and breast cancer • Hormone therapy (HT): taking estrogen and progestin for >5 yr increases rate of cancer and advanced disease • explanations—estrogen and progestin promote tumor growth, increase breast density, and mask tumors • Only 15% of postmenopausal women now using hormone therapy • decreased use associated with lower incidence of breast cancer (particularly estrogen receptor– positive disease [13% per year]) Use of estrogen and progestin therapy for 5 yr increases the risk for breast cancer and for latestage disease due to the hormones’ potential to: (A) Promote tumor growth (B) Increase breast density (C) Decrease breast density (D) A and B Answer • (A) Promote tumor growth • (B) Increase breast density • (D) A and B Answer Breast density • It is reported with some mammograms (eg, • fatty, scattered fibroglandular densities, heterogeneously dense, very dense) • most women in middle of range • effect of breast density on detection—higher density both increases risk for breast cancer and makes it more difficult to detect • unpublished data—higher density correlates with more advanced disease • consider annual screening, or use of digital mammography Family history and Obesity • Family history (first-degree relative) • no effect on ability to detect cancer • more abnormalities noted and biopsies performed, possibly due to clinician bias • survival study—no difference with positive family history • screening—not necessary to screen more often than others • Obesity: increases risk for breast cancer and advanced disease • attributed to extra estrogen in adipose tissue, rather than to difficulties with detection Choose the correct statement about patients with a first-degree relative who has had breast cancer. (A) It is more difficult to detect breast cancer in these patients (B) They are no more likely than other patients to be referred for further investigation of abnormalities found on mammography (C) Studies show no difference in survival rates for these patients (D) They should undergo twice-yearly mammography Answer • (C) Studies show no difference in survival rates for these patients Minimizing false positives and negatives • limit hormone use • avoid biopsy by using comparison films • Encourage weight loss (increased breast tissue leads to more false positives) • refer to high-volume facilities (have better specificity) • counsel patients that breast augmentation decreases sensitivity of mammography To prevent false-positives and false-negatives in breast cancer screening, the patient should do which of the following? (A) Avoid hormone therapy (B) Obtain comparison films (C) Obtain screening at a highvolume facility( D) All the above Answer • (D) All the above Sensitivity of digital mammography is higher than that of film mammography for women 40 to 49 yr of age who are both _______ and who have _______. (A) Premenopausal; dense breasts (B) Premenopausal; fatty breasts (C) Postmenopausal; dense breasts (D) Postmenopausal; fatty breasts Answer • (A) Premenopausal; dense breasts Cost-effectiveness • compare benefit to harm • women 50 to 69 yr of age • most cost-effective at $21,400/yr of life saved • smoking cessation much more effective way to reduce clinical burden of disease and costs The sensitivity of digital mammography is higher than film mammography for which groups of women? A) premenopausal B) 40 to 49 yr of age; C) with dense breasts; D) all of these Answer • D) all of these (must fall into all 3 categories • women >65 yr of age with fatty • breast tissue—film mammography gives better contrast A women at high risk for breast cancer should undergo which screening tests? A) mammography; B) clinical breast examination (CBE) C) ultrasonography D) mammography and ultrasonography E) mammography and magnetic resonance imaging (MRI) F) mammography, CBE and MRI Answer • Answer: no correct answer • depends on definition of high risk • mammography and MRI—standard of care for carriers of breast cancer mutation • MRI twice as sensitive as mammography, but less than half as specific • tests usually alternated every 6 mo for mutation carriers For women at average risk for breast cancer, screening should include mammography and: (A) Clinical breast examination (C) A and B (B) Breast self-examination (D) Neither A nor B Answer • (D) Neither A nor B D) none of these • CBE—sensitivity 54% • does not decrease mortality when combined with mammography • increases false positives • Effectiveness of BSE • 3 large RCTs in China, Russia, and United Kingdom—BSE vs usual care; after long follow-up • no difference in mortality • to teach BSE the potential consequences are an increase in benign biopsies and physician visits Possible recommendations • inform women of potential benefits and consequences of screening • in women 50 to 69 yr of age, mammography every 2 yr • consider CBE in women who refuse • in women over 70 yr of age, stop mammography • consider CBE in patients who request it A study mandated by the US Food and Drug Administration found that: (A) Women with silicone breast implants had fewer complications than those with saline implants (B) Women with silicone implants had less severe complications than those with saline (C) Silicone and saline implants were associated with similar types and severity of complications (D) Silicone implants were unsafe in certain age groups of women Answer • (C) Silicone and saline implants were associated with similar types and severity of complications HIV in United States: in 2008 • 56,000 people newly infected with HIV • 1.3 million people in United States living with HIV; • 25% of HIV-infected individuals unaware of infection • Twice as many infections transmitted before diagnosis (>50% of new HIV infections transmitted by those with undiagnosed disease) Centers for Disease Control and Prevention (CDC) HIV screening recommendations (2006): • test all persons 13 to 64 yr of age in all health care settings • especially where other tests routinely done • patients notified of HIV testing on general consent form (opt-out screening) • test patients with high-risk behaviors (eg, multiple sex partners, intravenous drug users1 time/yr • no testing interval for individuals without known risk factors • but test all patients 1 time Rationale for Routine Screening for HIV Infection • Previous CDC and U.S. Preventive Services Task Force guidelines for HIV testing recommended routine counseling and testing for persons at high risk for HIV and for those in acute-care settings in which HIV prevalence was >1% (9,10,24). These guidelines proved difficult to implement because 1) the cost of HIV screening often is not reimbursed, 2) providers in busy health-care settings often lack the time necessary to conduct risk assessments and might perceive counseling requirements as a barrier to testing, and 3) explicit information regarding HIV prevalence typically is not available to guide selection of specific settings for screening (25--29). Screening for HIV Infection • In all health-care settings, screening for HIV infection should be performed routinely for all patients aged 13--64 years. Health-care providers should initiate screening unless prevalence of undiagnosed HIV infection in their patients has been documented to be <0.1%. In the absence of existing data for HIV prevalence, health-care providers should initiate voluntary HIV screening until they establish that the diagnostic yield is <1 per 1,000 patients screened, at which point such screening is no longer warranted. • All patients initiating treatment for TB should be screened routinely for HIV infection (108). • All patients seeking treatment for STDs, including all patients attending STD clinics, should be screened routinely for HIV during each visit for a new complaint, regardless of whether the patient is known or suspected to have specific behavior risks for HIV infection. Repeat Screening • Health-care providers should subsequently test all persons likely to be at high risk for HIV at least annually. Persons likely to be at high risk include injection-drug users and their sex partners, persons who exchange sex for money or drugs, sex partners of HIV-infected persons, and MSM or heterosexual persons who themselves or whose sex partners have had more than one sex partner since their most recent HIV test. • Health-care providers should encourage patients and their prospective sex partners to be tested before initiating a new sexual relationship. • Repeat screening of persons not likely to be at high risk for HIV should be performed on the basis of clinical judgment. • Unless recent HIV test results are immediately available, any person whose blood or body fluid is the source of an occupational exposure for a health-care provider should be informed of the incident and tested for HIV infection at the time the exposure occurs. Consent and Pretest Information • • • • Screening should be voluntary and undertaken only with the patient's knowledge and understanding that HIV testing is planned. Patients should be informed orally or in writing that HIV testing will be performed unless they decline (opt-out screening). Oral or written information should include an explanation of HIV infection and the meanings of positive and negative test results, and the patient should be offered an opportunity to ask questions and to decline testing. With such notification, consent for HIV screening should be incorporated into the patient's general informed consent for medical care on the same basis as are other screening or diagnostic tests; a separate consent form for HIV testing is not recommended. Easily understood informational materials should be made available in the languages of the commonly encountered populations within the service area. The competence of interpreters and bilingual staff to provide language assistance to patients with limited English proficiency must be ensured. If a patient declines an HIV test, this decision should be documented in the medical record. Communicating test results • The central goal of HIV screening in health-care settings is to maximize the number of persons who are aware of their HIV infection and receive care and prevention services. Definitive mechanisms should be established to inform patients of their test results. HIV-negative test results may be conveyed without direct personal contact between the patient and the health-care provider. Persons known to be at high risk for HIV infection also should be advised of the need for periodic retesting and should be offered prevention counseling or referred for prevention counseling. HIV-positive test results should be communicated confidentially through personal contact by a clinician, nurse, mid-level practitioner, counselor, or other skilled staff. Because of the risk of stigma and discrimination, family or friends should not be used as interpreters to disclose HIVpositive test results to patients with limited English proficiency. Active efforts are essential to ensure that HIV-infected patients receive their positive test results and linkage to clinical care, counseling, support, and prevention services. If the necessary expertise is not available in the health-care venue in which screening is performed, arrangements should be made to obtain necessary services from another clinical provider, local health department, or community-based organization. Health-care providers should be aware that the Privacy Rule under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) prohibits use or disclosure of a patient's health information, including HIV status, without the patient's permission. Partner Counseling and Referral • When HIV infection is diagnosed, health-care providers should strongly encourage patients to disclose their HIV status to their spouses, current sex partners, and previous sex partners and recommend that these partners be tested for HIV infection. Health departments can assist patients by notifying, counseling, and providing HIV testing for partners without disclosing the patient's identity (114). Providers should inform patients who receive a new diagnosis of HIV infection that they might be contacted by health department staff for a voluntary interview to discuss notification of their partners. HIV in the United States geography—mainly in metropolitan areas • • rates in rural areas increasing; • infection rates highest in Miami, followed by Baltimore and Washington DC • Ethnicity and sex—although blacks 13% of US population, in 2006, blacks comprised 50% of new US AIDS cases and 90% of • new AIDS cases in Maryland • HIV predominantly in black men, but rates of HIVpositive Hispanic men and black women increasing • data from Africa indicate that infection in women will equal and perhaps exceed those in men over time HIV transmission patterns • heterosexual contact—fastest increasing route of transmission • more efficient in women than men (transmission to receptive sexual partner more efficient than to insertive partner) • accounts for 80% of new cases in women • receptive anal intercourse—most common route of transmission in men Diagnosis of AIDS often missed • claims data from 8 US health maintenance organizations reviewed; • Dentified >7500 cases with potentially AIDS-defining diagnoses (eg, Pneumocystis pneumonia [PCP], cryptococcal meningitis, lymphoma, invasive cervical cancer) with no diagnosis of HIV • 4% tested for HIV during period from 5 mo before to 2 mo after AIDS-defining diagnosis made • conclusion— primary care physicians not testing for HIV in inpatient and outpatient care • several major organizations of internists and obstetricians/gynecologists recommend universal HIV screening • American Academy of Family Physicians (AAFP) has not yet taken position • goal to make HIV testing as routine as cholesterol screening • CDC recommends that specific written consent no longer be required • Federal government denies Ryan White HIV funding to states requiring specific written consent Criteria for screening • • • • • • HIV meets all criteria 1) serious health problem 2) can be diagnosed before symptoms Develop 3) diagnosis inexpensive and noninvasive 4) major health gains when treated before symptoms develop • 5) screening cost-effective (dollars saved by avoiding acute care exceed testing costs) Reasons for reluctance to screen • my patients do not want HIV test • patients assume HIV testing done when blood drawn for other tests • routine testing eliminates stigma associated with testing and decreases need to screen for risk factors (determining risk factors still important for prevention) • there is little HIV in my practice— Testing • • • • • • • • • • • • • • • • • • recommended in areas where prevalence >0.1% (most areas in United States) patients routinely screened for low-prevalence diagnoses, eg, invasive cervical cancer Discussing HIV testing takes too much time—pretest counseling not required inform patients about opt-out consent on general consent form (opting-out indication for further discussion) Retesting at provider's discretion (previous recommendation to retest after 3 mo, but not necessary if no risky behaviors) Negative results may be given by phone or letter we do too many screening tests—simple test (eg, serum, saliva, or fingerstick blood test) can order when blood drawn for common laboratory tests in-office tests cost $8 to $16 what do I do if it is positive? discuss with patient; have supportive other present, if possible explain health status and benefits of immediate treatment Notify partner anonymously or in office educate about preventing transmission (eg, condoms, safer sex) recommend limited disclosure of status (potential sex partners and supportive others) offer social work and mental health support obtain laboratory tests and schedule 2- to 3-wk follow-up visit Initial work-up of HIV • • • • • • • • • • CD4 (absolute number and percent) viral load baseline genotype complete blood count (CBC; anemia common in HIV patients) metabolic profile (look for hepatitis and kidney disease) fasting lipid profile (for cholesterol baseline, because ARVs affect cholesterol) test for other sexually transmitted diseases (STDs) Screen for hepatitis A, B, and C and immunize against hepatitis A and B if patient not immune) skin test for tuberculosis Annual Papanicolaou test Interpretation of results • CD4 count—determines stage of disease and whether OIP and/or ARVs needed • CD4 count <200/mL—AIDS defined • OIP and ARVs needed • CD4 count 200/mL to 350/mL—ARVs needed • OIP not needed • CD4 count 350/mL to 500/mL—consider ARVs • CD4 >500/mL— may defer ARVs • possible indicators to start ARV when CD4 count >350/mL—any stage of pregnancy (to prevent transmission to fetus) • HIV-associated nephropathy (refer patient • with any renal impairment to nephrologist for biopsy) • VL >100,000 indicates rapid HIV progression • CD4 count falling >100 points/yr • active chronic hepatitis B or C • 50 yr of age, due to age-accelerated effect (however, no evidence of benefits in treating older HIV patients at earlier stages) Interpretation of results • • • • • • • • • • • • • • • • • • Percent CD4—indicates proportion of WBCs that are CD4 cells Less variable than absolute CD4 count CD4 percent <14 defines AIDS VL—maps disease over time useful in monitoring therapy monitor VL progression goal is undetectable VL by ultrasensitive tests women have lower VLs than men at same stage of disease (eg, women at risk for rapid progression with VL 50,000 baseline HIV genotype—checks for resistance before choosing treatment 10% of patients initially infected with resistant virus transmitted from patient taking ARVs (in HIV patient not on ARVs, virus mutates back to wild type) In some cases, multiple HIV strains present due to virus mutation in viral subpopulations, genotype may not show resistance, as one strain dominant (usually wild type; resistance will likely occur when treatment implemented) Hepatitis panel—if hepatitis B virus (HBV) surface antigen (HbsAg) present (ie, active HBV infection), check HBV DNA, which indicates stage of HBV infection and quantity present if hepatitis C virus (HCV) antibody present, check HCV RNA 10% of patients with HCV infections recover VL indicates active HCV infection or past infection VL helps physician choose medications and timing of initiation coinfection (HIV with HBV or HCV) speeds progression of both diseases Prophylaxis of opportunistic infections • start if indicated • no resistance, even if patient partially compliant • CD4 <200/μL—co-trimoxazole (Bactrim) single or double strength once daily for PCP prophylaxis; if allergic to Bactrim, and mycobacterium avium intracellulare complex (MAC) prophylaxis • treat MAC with azithromycin 1200 mg once weekly or 600 mg twice weekly (if patient has nausea) • Do not give prophylaxis if patient already has MAC (risk for resistance) • if signs of MAC infection present (eg, unexplained fever or anemia), take culture for MAC • if culture negative, start prophylaxis Starting ARVs • do not start until patient ready • Increased risk for resistance with missed doses • MAC prophylaxis one way for patient to practice taking medications daily • Increases probability of compliance with treatment • Address barriers (eg, depression, substance abuse) • 85% to 90% compliance required for ARV effectiveness • Resources: San Francisco Warm Line (800-9333413)— • http://www.nccc.ucsf.edu/; open 24 hr; questions answered by phone or email For which of the following types of patients should antiretroviral medications (ARVs) be prescribed? (A) Pregnant woman, CD4 count 400/mL (B) Man who has sex with men, CD4 count 360/mL, viral load (VL) >100,000 (C) Black woman, CD4 count >500, active hepatitis C virus (HCV) infection (D) All the above Answer • (D) All the above Which of the following gives information about resistance to ARVs? (A) VL (B) CD4 count (C) Genotype (D) CD4 percentage Answer • (C) Genotype All the following statements are true, except: (A) During prophylaxis for opportunistic infections, resistance can develop if doses are missed (B) Prophylaxis for Pneumocystis pneumonia should be started when the CD4 count is <200/mL (C) It is acceptable to substitute dapsone for co-trimoxazole if the patient is allergic to cotrimoxazole (D) Start prophylaxis for Mycobacterium avium-intracellulare complex when the CD4 count is <50/mL Answer • (A) During prophylaxis for opportunistic infections, resistance can develop if doses are missed All the following statements about Chlamydia trachomatis are true, except: (A) C trachomatis can infect the throat and cause symptoms (B) Cultures may be used to test for Chlamydia in throat and rectum (C) The recommended treatment for pregnant women is levofloxacin (1-g oral dose) (D) Azithromycin is the standard treatment for chlamydial infections Answer • (C) The recommended treatment for pregnant women is levofloxacin (1-g oral dose) Choose the true statement about gonorrhea. (A) The Gram stain is recommended for screening in women (B) Ceftriaxone is recommended treatment in all adults and adolescents (C) Quinolones are recommended for treatment of men who have sex with men and for recent immigrants (D) Culture on Thayer-Marten plates is not recommended by the Centers for Disease Control and Prevention (CDC) Answer • (B) Ceftriaxone is recommended treatment in all adults and adolescents A CD4 count <200 cells/μL signifies a(an) _______ stage of HIV infection. (A) Early (B) Intermediate (C) Late (D) Very late Answer • (C) Late In an HIV-positive patient not on highly active antiretroviral therapy (HAART), a CD4 count more than _______ old is not reliable. (A) 4 wk (B) 2 mo (C) 3 mo (D) 4 mo Answer • (C) 3 mo In the HAART era, which of the following organisms is the most common cause of pneumonia in the HIV patient? (A) Streptococcus pneumoniae (B) Pneumocystis jerovici (C) Haemophilus influenzae (D) Klebsiella pneumoniae Answer • (A) Streptococcus pneumoniae HIV itself is a significant independent risk factor for cerebrovascular disease. (A) True (B) False Answer • A) True Which of the following statements about HAART and psychiatric illness are true? 1. Depression and demoralization extremely common in HIV patients and significant factors in compliance 2. Common early side effects of efavirenz include nightmares and irritability 3. Psychosis not an uncommon side effect of efavirenz 4. Most psychiatric side effects resolve within 4 wk of discontinuation of medication (A) 1,3 (B) 2,4 (C) 1,2,3 (D) 1,2,3,4 Answer • 1. Depression and demoralization extremely common in HIV patients and significant factors in compliance • 2. Common early side effects of efavirenz include nightmares and irritability • 3. Psychosis not an uncommon side effect of efavirenz • 4. Most psychiatric side effects resolve within 4 wk of discontinuation of medication • (D) 1,2,3,4 Adolescents’ perception of sex • oral sex precedes or substitutes for intercourse • black and Hispanic boys almost twice as likely as whites to engage in anal intercourse • anal and oral sex perceived as abstinence by some Study of adult sexual practices • 12,571 men and women 15 to 44 yr of age surveyed (79% response rate) • results—one-third of men and women have had anal sex • Threequarters of men and women have had oral sex • condom use during last oral or anal sex uncommon Effect of values on behavior • condoms worn only for vaginal sex to prevent pregnancy and HIV • oral sex not considered adultery • prostitutes require condoms for vaginal sex, but not oral sex • friends require condoms for vaginal sex, but not oral sex • female can engage in oral and anal sex and still be considered virgin Questions to ask when patients say, “I always use a condom” • • • • for all sexual activity? for vaginal and/or anal, but not oral sex? for vaginal sex only? importance of sexual history—how and what questions asked and responses determine • nature of screening for STDs