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Current Trends Additional Recommendations to Reduce Sexual and Drug Abuse-Related Transmission of Human T-Lymphotropic Virus Type III/ Lymphadenopathy-Associated Virus

BACKGROUND

Human T-lymphotropic virus type III/lymphadenopathy-associated virus (HTLV-III/LAV), the virus that causes acquired immunodeficiency syndrome (AIDS), is transmitted through sexual contact, parenteral exposure to infected blood or blood components, and perinatally from mother to fetus or neonate. In the United States, over 73% of adult AIDS patients are homosexual or bisexual men; 11% of these males also had a history of intravenous (IV) drug abuse. Seventeen percent of all adult AIDS patients were heterosexual men or women who abused IV drugs (1,2). The prevalence of HTLV-III/LAV antibody is high in certain risk groups in the United States (3,4).

Since a large proportion of seropositive asymptomatic persons have been shown to be viremic (5), all seropositive individuals, whether symptomatic or not, must be presumed capable of transmitting this infection. A repeatedly reactive serologic test for HTLV-III/LAV has important medical, as well as public health, implications for the individual and his/her health-care provider. The purpose of these recommendations is to suggest ways to facilitate identification of seropositive asymptomatic persons, both for medical evaluation and for counseling to prevent transmission.

Previous U.S. Public Health Service recommendations pertaining to sexual, IV drug abuse, and perinatal transmission of HTLV-III/LAV have been published (6-8). Reduction of sexual and IV transmission of HTLV-III/LAV should be enhanced by using available serologic tests to give asymptomatic, infected individuals in high-risk groups the opportunity to know their status so they can take appropriate steps to prevent the further transmission of this virus.

Since the objective of these additional recommendations is to help interrupt transmission by encouraging testing and counseling among persons in high-risk groups, careful attention must be paid to maintaining confidentiality and to protecting records from any unauthorized disclosure. The ability of health departments to assure confidentiality -- and the public confidence in that ability -- are crucial to efforts to increase the number of persons requesting such testing and counseling. Without appropriate confidentiality protection, anonymous testing should be considered. Persons tested anonymously would still be offered medical evaluation and counseling.

PERSONS AT INCREASED RISK OF HTLV-III/LAV INFECTION

Persons at increased risk of HTLV-III/LAV infection include: (1) homosexual and bisexual men; (2) present or past IV drug abusers; (3) persons with clinical or laboratory evidence of infection, such as those with signs or symptoms compatible with AIDS or AIDS-related complex (ARC); (4) persons born in countries where heterosexual transmission is thought to play a major role *; (5) male or female prostitutes and their sex partners; (6) sex partners of infected persons or persons at increased risk; (7) all persons with hemophilia who have received clotting-factor products; and (8) newborn infants of high-risk or infected mothers.

RECOMMENDATIONS

  1. Community health education programs should be aimed at members of high- risk groups to: (a) increase knowledge of AIDS; (b) facilitate behavioral changes to reduce risks of HTLV-III/LAV infection; and (c) encourage voluntary testing and counseling.

  2. Counseling and voluntary serologic testing for HTLV-III/LAV should be routinely offered to all persons at increased risk when they present to health-care settings. Such facilities include, but are not limited to, sexually transmitted disease clinics, clinics for treating parenteral drug abusers, and clinics for examining prostitutes.

    1. Persons with a repeatedly reactive test result (see section on Test Interpretation) should receive a thorough medical evaluation, which may include history, physical examination, and appropriate laboratory studies.

    2. High-risk persons with a negative test result should be counseled to reduce their risk of becoming infected by: (1) Reducing the number of sex partners. A stable, mutually

      monogamous relationship with an uninfected person eliminates any new risk of sexually transmitted HTLV-III/LAV infection. (2) Protecting themselves during sexual activity with any possibly

      infected person by taking appropriate precautions to prevent contact with the person's blood, semen, urine, feces, saliva, cervical secretions, or vaginal secretions. Although the efficacy of condoms in preventing infections with HTLV-III/LAV is still under study, consistent use of condoms should reduce transmission of HTLV-III/LAV by preventing exposure to semen and infected lymphocytes (9,10). (3) For IV drug abusers, enrolling or continuing in programs to

      eliminate abuse of IV substances. Needles, other apparatus, and drugs must never be shared.

    3. Infected persons should be counseled to prevent the further transmission of HTLV-III/LAV by: (1) Informing prospective sex partners of his/her infection with

      HTLV-III/LAV, so they can take appropriate precautions. Clearly, abstention from sexual activity with another person is one option that would eliminate any risk of sexually transmitted HTLV-III/LAV infection. (2) Protecting a partner during any sexual activity by taking

      appropriate precautions to prevent that individual from coming into contact with the infected person's blood, semen, urine, feces, saliva, cervical secretions, or vaginal secretions. Although the efficacy of using condoms to prevent infections with HTLV-III/LAV is still under study, consistent use of condoms should reduce transmission of HTLV-III/LAV by preventing exposure to semen and infected lymphocytes (9,10). (3) Informing previous sex partners and any persons with whom

      needles were shared of their potential exposure to HTLV- III/LAV and encouraging them to seek counseling/testing. (4) For IV drug abusers, enrolling or continuing in programs to

      eliminate abuse of IV substances. Needles, other apparatus, and drugs must never be shared. (5) Not sharing toothbrushes, razors, or other items that could

      become contaminated with blood. (6) Refraining from donating blood, plasma, body organs, other

      tissue, or semen. (7) Avoiding pregnancy until more is known about the risks of

      transmitting HTLV-III/LAV from mother to fetus or newborn (8). (8) Cleaning and disinfecting surfaces on which blood or other

      body fluids have spilled, in accordance with previous recommendations (2). (9) Informing physicians, dentists, and other appropriate health

      professionals of his/her antibody status when seeking medical care so that the patient can be appropriately evaluated.

  3. Infected patients should be encouraged to refer sex partners or persons with whom they have shared needles to their health-care provider for evaluation and/or testing. If patients prefer, trained health department professionals should be made available to assist in notifying their partners and counseling them regarding evaluation and/or testing.

  4. Persons with a negative test result should be counseled regarding their need for continued evaluation to monitor their infection status if they continue high-risk behavior (8).

  5. State and local health officials should evaluate the implications of requiring the reporting of repeatedly reactive HTLV-III/LAV antibody test results to the state health department.

  6. State or local action is appropriate on public health grounds to regulate or close establishments where there is evidence that they facilitate high-risk behaviors, such as anonymous sexual contacts and/or intercourse with multiple partners or IV drug abuse (e.g., bathhouses, houses of prostitution, "shooting galleries").

TEST INTERPRETATION

Commercially available tests to detect antibody to HTLV-III/LAV are enzyme-linked immunosorbant assays (ELISAs) using antigens derived from disrupted HTLV-III/LAV. When the ELISA is reactive on initial testing, it is standard procedure to repeat the test on the same specimen. Repeatedly reactive tests are highly sensitive and specific for HTLV-III/LAV antibody. However, since falsely positive tests occur, and the implications of a positive test are serious, additional more specific tests (e.g., Western blot, immunofluorescent assay, etc.) are recommended following repeatedly reactive ELISA results, especially in low-prevalence populations. If additional more specific test results are not readily available, persons in high-risk groups with strong repeatedly reactive ELISA results can be counseled before any additional test results are received regarding their probable infection status, their need for medical follow-up, and ways to reduce further transmission of HTLV-III/LAV.

OTHER CONSIDERATIONS

State or local policies governing informing and counseling sex partners and those who share needles with persons who are HTLV-III/LAV-antibody positive will vary, depending on state and local statutes that authorize such actions. Accomplishing the objective of interrupting transmission by encouraging testing and counseling among persons in high-risk groups will depend heavily on health officials paying careful attention to maintaining confidentiality and protecting records from unauthorized disclosure.

The public health effectiveness of various approaches to counseling, sex-partner referral, and laboratory testing will require careful monitoring. The feasibility and efficacy of each of these measures should be evaluated by state and local health departments to best utilize available resources.

Developed by Center for Prevention Svcs and Center for Infectious Diseases, CDC, in consultation with persons from numerous other organizations and groups.

References

  1. Curran JW, Morgan WM, Hardy AM, Jaffe HW, Darrow WW, Dowdle WR. The epidemiology of AIDS: current status and future prospects. Science 1985;229:1352-7.

  2. CDC. Recommendations for preventing transmission of infection with human T-lymphotropic virus type II/lymphadenopathy-associated virus in the workplace. MMWR 1985;34:682-6, 691-5.

  3. CDC. Update: acquired immunodeficiency syndrome in the San Francisco cohort study, 1978-1985. MMWR 1985;34:573-5.

  4. CDC. Heterosexual transmission of human T-lymphotropic virus type III/lymphadenopathy-associated virus. MMWR 1985;34:561-3.

  5. CDC. Provisional public health services inter-agency recommendations for screening donated blood and plasma for antibody to the virus causing acquired immunodeficiency syndrome. MMWR 1985;34:1-5.

  6. CDC. Prevention of acquired immune deficiency syndrome (AIDS): report of inter-agency recommendations. MMWR 1983;32:101-4.

  7. CDC. Antibodies to a retrovirus etiologically associated with acquired immunodeficiency syndrome (AIDS) in populations with increased incidences of the syndrome. MMWR 1984;33:377-9.

  8. CDC. Recommendations for assisting in the prevention of perinatal transmission of human T-lymphotropic virus type III/lymphadenopathy- associated virus and acquired immunodeficiency syndrome. MMWR 1985; 34:721-32.

  9. Judson FN, Bodin GF, Levin MJ, Ehret JM, Masters HB. In vitro tests demonstrate condoms provide an effective barrier against chlamydia trachomatis and herpes simplex virus. Abstract in Program of the International Society for STD Research, Seattle, Washington, August 1-3, 1983:176.

  10. Conant MA, Spicer DW, Smith CD. Herpes simplex virus transmission: condom studies. Sex Transm Dis 1984;11:94-5.

* e.g., Haiti, Central African countries.

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