ESSENTIALS OF DIAGNOSIS
Privacy, confidentiality, and legal disease reporting concerns affect detection and treatment.
Suspicion or diagnosis of one sexually transmitted disease (STD) should prompt screening tests for others.
Diagnosis of an STD should always include identification and treatment of partners, and education to reduce risk of future infection.
Sexually transmitted diseases (STDs) include sexually transmitted infections and the clinical syndromes they cause. There are an estimated 20 million new STDs in the United States annually, almost half of them among persons aged 15–24 years.
Although all sexually active individuals are susceptible to infection, adolescents and young adults are most commonly affected. Reasons for this include: (1) an attitude of invincibility, (2) lack of knowledge about the risks and consequences of STDs, and (3) barriers to health care access.
This chapter emphasizes the clinical presentation, diagnostic evaluation, and treatment of STDs commonly found in the United States. Readers of this chapter should be able to:
Differentiate common STDs on the basis of clinical information and laboratory testing.
Treat STDs according to current guidelines.
Intervene in patients’ lives to reduce risk of future STD acquisition.
The discussion draws greatly from the most recent Centers for Disease Control and Prevention (CDC) guidelines for treatment of STDs. The authors are indebted to the individuals who worked to develop these recommendations.
Federal and state laws create disease-reporting requirements for many STDs. Gonorrhea; Chlamydia; chanchroid; syphilis; Hepatitis A, B, C; and HIV (including AIDS) are all nationally notifiable. Clinicians should contact their local health department for pertinent reporting information.
Privacy and confidentiality concerns are different for STDs than for general medical information. Patients generally experience greater anxiety about information pertaining to a possible diagnosis of an STD, and this may limit their willingness to disclose clinically pertinent information. Conversely, legal requirements for disease reporting and health department partner notification programs can inadvertently compromise patient confidentiality if not handled with the utmost professionalism. Furthermore, although minors generally require parental consent for nonemergent medical care in all states, minors can be diagnosed and treated for STDs without parental consent. Additionally, many US states’ legislations may permit physicians to prescribe treatment for the heterosexual partners of men or women with Chlamydia or gonorrhea without examining the partner. Thus, laws in different jurisdictions create additional options and complexities in treating STDs. Practitioners need to be familiar with local requirements.
Centers for Disease Control and Prevention; Workowski
SM Sexually transmitted disease treatment guidelines, 2010. MMWR Recomm Rep. 2010;59(RR-12):1–110.
Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2011. Atlanta, GA: US Department of Health and Human Services; 2012.
et al.. Prevalence of sexually transmitted infections among female adolescents aged 14 to 19 in the United States. Pediatrics.
[PubMed: [PMID: 19933728]]
Intervening in patients’ lives to reduce their risk of disease due to STDs is no less important than reducing risk due to smoking, inadequate exercise, poor nutrition, and other health risks. STD risk assessment should prompt providers to undertake discussion of risk reduction, and thus disease prevention. Physicians’ effectiveness depends on their ability to obtain an accurate sexual history employing effective counseling skills. Specific techniques include creating a trusting, confidential environment; obtaining permission to ask questions about STDs; demonstrating a nonjudgmental, optimistic attitude; and combining information collection with patient education, using clear, mutually understandable language (see Chapter 17). Prevention is facilitated by an environment of open, honest communication about sexuality.
The US Preventive Services Task Force (USPSTF) recommends high-intensity behavioral counseling to prevent sexually transmitted infections (STIs) for all sexually active adolescents and for adults at increased risk for STIs, for example, adults with current STIs or infections within the past year who have multiple current sexual partners, or who are members of a population with a high rate of STIs. Recommendations for changes in behavior should be tailored to the patient’s specific risks and needs; simple suggestions such as keeping condoms available have been shown to be effective. Brief counseling using personalized risk reduction plans and culturally appropriate videos can significantly increase condom use and prevent new STDs, and can be conducted even in busy public clinics with minimal disruption to clinic operations. Effective interventions to reduce STDs in adolescents can extend beyond the examination room and include school-based and community-based education programs. Characteristics of successful interventions include multiple sessions, most often in groups, with total duration from 3 to 9 hours, or two 20-minute counseling sessions before and after HIV testing. Individuals with chronic infections [eg, herpes simplex virus (HSV) and HPV] will need counseling tailored to help them accurately understand their infection and effectively manage symptoms and transmission risk.
V Behavioral counseling to prevent sexually transmitted infections: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2008; 149(7):497–508, W96-9. (Summary for patients in Ann Intern Med.)
USPSTF. The Guide to Clinical Preventive Services 2012: Recommendations of the US Preventive Services Task Force
(available at www.ahrq.gov
2008 Oct 7 ;149(7):I36.
[PubMed: [PMID: 18838722]]
For sexually active patients, male condoms are effective in reducing the sexual transmission of HIV infection. When used correctly and consistently, male latex condoms can reduce the risk of other STIs, including Chlamydia, gonorrhea, and Trichomonas. Condoms may afford some protection against transmission of HSV, and may mitigate some adverse consequences of infection with HPV, as their use has been associated with higher rates of regression of cervical intraepithelial neoplasia and clearance of HPV in women.
Effectiveness depends on correct, consistent use. Patients should be instructed to use only water-based lubricants. Providers may need to demonstrate how to place a condom on the penis via a suitable model, especially for persons who may be inexperienced with condom use.
Spermicide is not recommended for STI/HIV prevention. Some may confuse contraception with disease prevention; nonbarrier methods of contraception such as hormonal contraceptives or surgical sterilization do not protect against STDs. Women employing these methods should be counseled about the role of condoms in prevention of STDs.
Vaccination for hepatitis B virus (HBV) is indicated for all unvaccinated adolescents, all unvaccinated adults at risk for HBV infection, and all adults seeking protection from HBV infection. Other settings where all unvaccinated persons should receive vaccination include correctional facilities, drug abuse treatment and prevention services centers, health care settings serving men who have sex with men, and HIV testing and treatment facilities. Additionally, individuals with chronic liver disease (including chronic HBV or hepatitis C infection), end-stage renal disease, diabetes mellitus, and potential occupational or travel exposure should be vaccinated. The prevalence of past exposure to HBV in homosexual men and injection drug users may render prevaccination testing cost effective, although it may lower compliance. For this reason, if prevaccination testing is employed, patients should receive their first vaccination dose when tested. If employed, HBV core antibody testing is an effective screen for immunity.
Vaccination for hepatitis A virus (HAV) is indicated for homosexual or bisexual men, persons with chronic liver disease (including hepatitis B and C), and IV drug users; additionally, some individuals with occupational or travel exposure should be vaccinated. In cases of sexual or household contact with someone with HAV, hepatitis A vaccine or immune globulin should be administered as soon as possible after exposure. (For additional information on hepatitis A and B, see Chapter 31.)
Two HPV vaccines are available and licensed for females aged 9-26 years to prevent cervical precancers and cancers, the quadrivalent HPV (Gardasil) and the bivalent HPV vaccine (Cervarix). Universal vaccination of females aged 11–12 years is recommended with either vaccine, as is catchup vaccination for females aged 13–26 years. In order to prevent genital warts and anal cancers, all males may receive the quadrivalent HPV vaccine at ages 9–26. The quadrivalent HPV vaccine (Gardasil) is universally recommended for males aged 11–12 years, as is catchup vaccination for males aged 13–21 years. Gardasil is also recommended for high risk males (men who have sex with men and those who are immunocompromised) ages 22–26. Experimental vaccines are also being explored for other STDs.
Society of Teachers of Family Medicine. Shots by STFM 2013 (available at http://www.immunizationed.org/shotsonline.aspx; accessed April 6, 2013).
Following treatment of an individual patient, treatment of asymptomatic partners of a diagnosed patient is commonly employed in STD treatment. For patients with multiple partners, it may be difficult to identify the source of infection. Partner treatment should be recommended for sexual contacts occurring prior to diagnosis within the time intervals indicated for each disease:
Chancroid, 10 days
Granuloma inguinale, 60 days
Lymphogranuloma venereum, 60 days
Syphilis, 3 months plus the duration of symptoms for patients diagnosed with primary syphilis (even if the contact tests seronegative); 6 months plus the duration of symptoms for patients diagnosed with secondary syphilis, and 1 year for patients with early latent syphilis
Chlamydial infection, 60 days
Gonorrhea, 60 days
Epididymitis, 60 days
Pelvic inflammatory disease (PID), 60 days
Pediculosis pubis, 30 days
Scabies, 30 days
Although in general physicians must examine a patient directly before prescribing treatment, when prior medical evaluation and counseling is not feasible, or resource limitations constrain evaluation and diagnosis, other partner management options may be considered. One of these is partner-delivered therapy, in which patients diagnosed with Chlamydia or gonorrhea deliver the prescribed treatment to their partners; this option is affected by state laws and regulations.
Repeat testing at 3 months following treatment is indicated for persons with Chlamydia or gonorrhea, due to the increased incidence of reinfection. Patients should also be instructed to avoid sexual contact for the duration of therapy to prevent further transmission. Patients taking single-dose azithromycin for Chlamydia infection should be instructed to avoid sexual contact for 7 days. Patients must also be instructed to avoid contact with their previous partner(s) until both patient and partner complete treatment.
Some form of STD screening, such as questions asked during the history interview or included in routine history forms, should be a universal practice for all patients, with periodic and regular updating. Content, frequency, and additional screening should be determined by individual patient circumstances, local disease prevalence, and research documenting effectiveness and cost-benefit. Table 14-1 summarizes current recommendations for STD screening from the USPSTF.
Table 14–1.US Preventive Services Task Force (USPSTF) recommendations for STD screening.a ||Download (.pdf) Table 14–1.US Preventive Services Task Force (USPSTF) recommendations for STD screening.a
|Infection ||Recommendation |
|Chlamydia ||Screen all pregnant women and sexually active women aged ≤24 years; screen all sexually active or pregnant women aged ≥25 years who are at increased risk for sexually transmitted infection (eg, having a prior history of STD, having new or multiple sex partners, inconsistent condom use, or who exchange sex for money or drugs) |
|Gonorrhea ||Screen all sexually active women, including those who are pregnant, for gonorrhea infection if they are at increased risk for infection (eg, aged <25 years), previous gonorrhea, or other STD, new or multiple sex partners, inconsistent condom use, sex work, and drug use |
|Hepatitis B ||Screen all pregnant women at their first prenatal visit |
|HIV || |
Screen all pregnant women
Screen all adolescents and adults aged 15-65 years for HIV
Screen younger adolescents and older adults believed to be at increased risk for HIV infection
|Syphilis || |
Screen all pregnant women
Screen persons at increased risk for syphilis infection (eg, men who have sex with men and engage in high-risk sexual behavior, commercial sex workers, persons who exchange sex for drugs, and those in adult correctional facilities)
1. Chlamydia and gonorrhea
Annual screening of all sexually active women aged <25 years is recommended, as is screening of older women with risk factors (eg, those who have a new sex partner or multiple sex partners).
The benefits of Chlamydia trachomatis screening in women have been demonstrated in areas where screening programs have reduced both the prevalence of infection and rates of PID. Evidence is insufficient to recommend routine screening for C. trachomatis in sexually active young men, based on feasibility, efficacy, and cost-effectiveness. However, screening of sexually active young men should be considered in clinical settings with a high prevalence of Chlamydia (eg, adolescent clinics, correctional facilities, and STD clinics).
Recommendations for screening pregnant women vary somewhat depending on the source. According to the CDC, pregnant women should receive a serologic test for syphilis, Hepatitis B surface antigen, and HIV at the onset of prenatal care. High-risk women should repeat HIV and syphilis testing early in the third trimester, and should repeat hepatitis B surface antigen and syphilis testing again at delivery. Furthermore, pregnant women at risk for HBV infection should be vaccinated for hepatitis B.
Providers of obstetric care should test for Neisseria gonorrhoeae at the onset of care if local prevalence of gonorrhea is high or if the woman is at increased risk, and testing should be repeated in the third trimester if the woman is at continued risk. Providers should test for Chlamydia at the first prenatal visit. Women aged <25 years and those at increased risk for chlamydial infection (ie, those who have multiple partners or who have a partner with multiple partners) should also be tested again in the third trimester. Evidence does not support routine testing for bacterial vaginosis. For asymptomatic pregnant women at high risk for preterm delivery, the current evidence is insufficient to assess the balance of benefits and harms of screening for bacterial vaginosis. Symptomatic women should be evaluated and treated.
HIV screening is recommended for patients aged 15–65 years in all health care settings after the patient is notified that testing will be performed unless the patient declines. CDC recommends that younger adolescents and older adults at increased risk also be screened. Repeat annual testing for HIV is indicated for any high-risk patient, including patients with a diagnosed STD or with a history of behaviors that could expose them to HIV. Testing is also indicated for patients who present with a history and findings consistent with the acute retroviral syndrome (ARS), symptoms of which are listed in Table 14-2. Appropriate testing regimens include an HIV1 screening antibody test such as enzyme immunoassay, with a confirmatory test such as the Western immunoblot. HIV2 prevalence in the United States is very low, so routine testing is not indicated, although several commercial antibody tests screen for both HIV1 and HIV2; HIV2 should be considered for persons coming from areas of high HIV2 prevalence (eg, parts of West Africa, particularly Cape Verde, Ivory Coast, Gambia, Guinea-Bissau, Mali, Mauritania, Nigeria, and Sierra Leone).
Table 14–2.Acute retroviral syndrome: associated signs and symptoms. ||Download (.pdf) Table 14–2.Acute retroviral syndrome: associated signs and symptoms.
Early diagnosis of ARS may present a very narrow window of opportunity to alter the course of HIV infection in the recently infected patient, and to block the source of most presumed new HIV transmission. Symptoms are common and nonspecific, rendering diagnosis difficult without a high index of suspicion; they include fever, malaise, lymphadenopathy, pharyngitis, and skin rash. Appropriate testing should include a nucleic acid test for HIV such as HIV-RNA polymerase chain reaction (PCR); routine HIV antibody tests are not sufficient, because they seldom will have become positive during ARS. Individuals with positive HIV tests should be referred immediately to an expert in HIV care.
All HIV-infected individuals pose particular challenges for STD risk reduction. Reducing high-risk behaviors of known HIV-infected patients is a top priority, both to decrease the further spread of HIV and to limit the exposure of HIV patients to additional STDs. Persons with HIV also have substantial medical, psychological, and legal needs that are beyond the scope of this chapter.
Accepted national guidelines directing screening for other STDs do not exist. If undertaken, additional screening should be guided by local disease prevalence and an individual patient’s risk behaviors.
Centers for Disease Control and Prevention; Workowski
SM Sexually transmitted disease treatment guidelines, 2010. MMWR Recomm Rep. 2010;59(RR-12):1–110.
US Preventive Services Task Force. The Guide to Clinical Preventive Services 2013. AHRQ. 2013. (accessed March 27, 2013).