- Patients reporting oral sex: Consider pharyngeal culture for N. gonorrhoeae.
REPEAT TESTS : Consider repeating these tests annually in sexually active patients and at 3- to 6-month intervals if at high risk. The purpose is to detect high-risk behavior that might not otherwise be apparent for enhanced counseling, contact tracing, and for treatment.
Chest X-Ray: The frequency of lung disease with HIV infection is high even in the HAART era (Am Rev Respir Crit Care Med 2001;164:21; Chest 2001;120:1888). A routine baseline chest x-ray is sometimes recommended for detection of asymptomatic tubercu losis and as a baseline for patients who are at high risk for pulmonary disease. Nevertheless, in a longi tudinal study of 1,065 patients at various stages of HIV infection, showed routine x-rays performed at 0, 3, 6, and 12 months (Arch Intern Med 1996;156:191) detected an abnormality in only 123 (2%) of 5,263 x-rays. None of the asymptomatic PPD negative patients had evi dence of active tuberculosis, and only 1 of 82 with a positive PPD had an abnormality on x-ray. The authors con cluded that routine chest x-rays in asymptomatic HIV-infected patients with negative PPD skin tests are not warranted. In resource-limited regions the WHO policy is to obtain a chest x-ray to exclude active TB in patients with a positive PPD, but a study of 563 asymptomatic HIVinfected patients in Botswana showed only one (0.02%) with active disease (Lancet 2003;362:1551). The authors argued that in resourcelimited areas, x-rays could be limited to those with symptoms.
Tuberculin Skin Test and IFN-Gamma Release Assays: The CDC recommends the Mantoux method TST (tuberculin skin test), using 5 TU of PPD, for HIV-infected patients who have not had a prior positive test. TST should be repeated annually if initial test(s) were negative and if the patient belongs to population with a high risk of tuberculosis (such as residents of prisons or jails, injection drug users, and homeless individuals. The PPD should also be repeated following immune reconstitution when the CD4 count increases to >200cells/mm3. Induration of ≥5 mm at 48 to 72 hours constitutes a positive test. Anergy testing is not recommended. Tests that measure production of interferon-gamma (IGRAs) in vitro include the Quanti- FERON-TB Gold and T-SPOT TB assays. The IGRAs show better specificity than TST (92-97% vs 55-95%) and do not have crossreactivity with BCG (PLoS ONE 2008;16:e2665). Other advantages are reduced variability in interpretation, lack of boosting effect and the requirement for only one visit. (Ann Intern Med 2007;146:340; MMWR 54 RR15:49; Proc Am Thorac Soc 2006;3:103; Curr Opin Infect Dis 2006;19:189). Disadvantages of IGRAs are cost, complexity, need for laboratory resources and trained personnel, paucity of follow-up data to document benefit of detection and limited data
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