Evaluation and Management of Genital Ulcer Disease: Non-Adherence to CDC Guidelines

Background: CDC sexually transmitted disease (STD) treatment guidelines recommend that all persons presenting with a genital, anal or perianal ulcer (GUD) be tested for herpes simplex virus (HSV), syphilis, and HIV and receive empiric treatment while awaiting diagnostic tests.  It is unknown what proportion of patients with GUD are appropriately managed according to these guidelines.

Methods: We analyzed administrative claims data from the 2011 MarketScan database. The database included enrollment and claims data for inpatient and outpatient encounters and prescription services for approximately 15 million privately insured persons in the United States.  We included all initial encounters with an ICD-9 code for genital herpes, primary or secondary syphilis, or unspecified genital, anal, or perianal ulcer.  We used CPT and NDC codes to identify laboratory testing and prescribed pharmacotherapy, respectively. We defined appropriate management as testing for syphilis and HIV, and testing for HSV or provision of antivirals, within 30 days of initial presentation. Either testing or provision of antivirals was considered appropriate management for HSV because it can recur.

Results: Among initial encounters by 84,919 patients with GUD, 78.3% were for HSV, 20.8% for unspecified ulcers, and 0.9% for syphilis; 0.1% were for both HSV and syphilis. Among all GUD patients, only 5.3% (n=4520) were tested for syphilis and managed for HSV, and only 0.2% (n=174) were also tested for HIV. The percentage of patients receiving appropriate management for HSV and syphilis was not significantly different by sex (both 5.3%, p=0.89).  When considering HIV testing, men were significantly more likely to be managed appropriately than women (0.32% v. 0.16%, respectively, p≤0.0001).

Conclusions: Despite CDC GUD management guidelines, few patients with GUD received appropriate care. Patients with GUD have an increased risk of HIV transmission and acquisition. Interventions are needed to assure high quality healthcare services for patients with GUD.