S c re e n i n g an d P re v e n t i o n o f S e x u a l l y Tr a n s m i t t e d Infections Paul Hunter, MDa, Jessica Dalby, MDb, Jaime Marks, MDc, Geoffrey R. Swain, MD, MPHa, Sarina Schrager, MD, MSb,* KEYWORDS Sexually transmitted infections Screening Prevention Chlamydia Gonorrhea Syphilis Human immunodeficiency virus United States KEY POINTS Primary care clinicians should follow established guidelines for screening for sexually transmitted infection (STIs). The US Preventive Services Task Force, Centers for Disease Control and Prevention, American Academy of Family Physicians, American College of Obstetricians and Gynecologists, and American Academy of Pediatrics have all agreed on STI screening recommendations. Screening for an STI can also include counseling about risk-reduction behavior, and may be an opportune time to provide vaccinations to prevent other STIs. Each state has a list of different reportable STIs, so clinicians should be familiar with their state’s legally mandated reporting requirements. High-risk behaviors put people at risk of STIs. Guidelines are based on national norms; clinicians should know the local prevalence of STIs and local recommendations, if any, to make more patient-centered decisions about screening.
INTRODUCTION
Sexually transmitted infections (STIs) are among the most frequently reported and prevalent medical conditions in the United States (Table 1). In total, nearly 20 million new cases of STIs occur in the United States each year, contributing to more than Conflict of Interest: None. a Department of Family Medicine, University of Wisconsin School of Medicine and Public Health, Center for Urban Population Health, City of Milwaukee Health Department, 841 North Broadway Street, 3rd Floor, Milwaukee, WI 53202, USA; b Department of Family Medicine, University of Wisconsin School of Medicine and Public Health, 1100 Delaplaine Court, Madison, WI 53715-1896, USA; c Department of Family Medicine, University of Wisconsin School of Medicine and Public Health, 207 West Lincoln Street, Suite 1, Augusta, WI 54722, USA * Corresponding author. E-mail address: [email protected] Prim Care Clin Office Pract 41 (2014) 215–237 http://dx.doi.org/10.1016/j.pop.2014.02.003 primarycare.theclinics.com 0095-4543/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
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Table 1 Causes, complications, and burdena of selected sexually transmitted infections (STI) in the United States Incidence Estimates (New Cases)
Incidence Rate (per 100,000)
Prevalence Estimates (Total Cases)
Prevalence Rate (per 100,000)
STI
Description
Chlamydia
An obligate intracellular bacterium, Chlamydia trachomatis causes urethritis and cervicitis, as well as pharyngeal and anal infections. Complications include pelvic inflammatory disease (and subsequent risk for infertility, pelvic pain, tubal ectopic pregnancy) as well as neonatal conjunctivitis and pneumonia
2,860,000
926.2
1,570,000
508.4
Gonorrhea
Neisseria gonorrhoeae, also known as gonococcus, is a gram-negative diplococcus that causes urethritis and cervicitis, as well as pharyngeal and anal infections. Complications are essentially identical to those of Chlamydia
820,000
265.5
270,000
87.4
Syphilis (primary, secondary, and early latent)
The spiral bacterium Treponema pallidum manifests itself in several stages, including primary (typically a painless chancre), early latent (asymptomatic), secondary (typically a rash), and late latent (asymptomatic). Tertiary syphilis includes neurosyphilis (eg, dorsalis tabes and dementia), gummas, and cardiovascular syphilis (eg, aortitis, aneurysm, and rupture). Vertical transmission to newborns is common, resulting in congenital syphilis
55,400
17.9
117,000
—
Hepatitis B
This chronic viral infection is transmitted through sharing of blood and body fluids (including saliva) as well as vertically from mother to newborn. Sequelae include hepatocellular carcinoma and hepatic failure
19,000
6.2
442,000
143.1
This chronic retroviral infection, if not treated, creates immunesystem dysfunction, resulting in AIDS and its hallmark opportunistic infections (eg, Pneumocystis carinii, Kaposi sarcoma). It can be transmitted sexually or through other blood and body fluid exposure (eg, needle sharing), and vertically from mother to newborn (eg, through breastfeeding). About 75% of case reports are in men
50,000
19.7
1,148,200
453.4
Genital herpesc
Caused by herpes simplex viruses 1 and 2, genital herpes is a chronic viral infection that causes painful recurrent herpetic outbreaks at the original site of infection
776,000
251.3
24,100,000
7804.4
Trichomoniasis
Trichomoniasis is a flagellate parasitic infection of the urethra or vagina that can persist for months. Testing is insensitive, and complications of its associated mucosal irritation include urinary tract infections and increased risk for HIV infection
1,090,000
353.0
3,710,000
1201.4
Human papillomavirus (HPV)d
This viral infection of the penis or cervix is nearly ubiquitous after 2 or more lifetime sexual partners. There are nearly 100 viral subtypes, and while some infections are transient, infection with high-risk subtypes leads to cervical intraepithelial neoplasia. Chronic infection with types 16 and 18 cause about 70% of cervical cancers. HPV-related anal, penile, and especially oropharyngeal cancers are rising. Infections with other subtypes (eg, 6 and 11) cause visible genital warts
14,100,000
4566.1
79,100,000
25,615.3 (25.6%)
Except for human immunodeficiency virus (HIV), all incidence case and prevalence case estimates are for 2008, include both reported cases and estimates of unreported cases, use a 2008 US population denominator of 308,800,000, and are derived from the Centers for Disease Control and Prevention (CDC).50 b For HIV, incidence case and prevalence case estimates are for 2009, include both reported cases and estimates of unreported cases, use a 2009 US population denominator of the US population ages 13 years and older, and are derived from the CDC.51 c Incidence and prevalence estimates of herpes simplex virus are for type 2 only, even though genital herpes is also caused by type 1. d HPV prevalence may be more than 40% according to the American Sexual Health Association.52
Prevention of Sexually Transmitted Infections
a
HIVb (ages 13 and up)
217
218
Hunter et al
US$17 billion in health care costs.1 Most costs are due to human immunodeficiency virus (HIV), cervical cancer, and complications of pelvic inflammatory disease, such as infertility, chronic pelvic pain, and tubal ectopic pregnancy. Because of their high incidence, high prevalence, serious complications, lack of symptoms, ease of diagnosis, and availability of effective treatment, STIs are of great importance to primary care clinicians. Furthermore, primary care clinicians are in unique positions to prevent future infections by identifying and treating existing infections, by treating exposed partners, and by serving as effective change agents to help reduce patients’ risk behaviors. Although sexual images and themes are nearly inescapable in American popular culture, there can often be social, psychological, and political awkwardness surrounding frank and open discussions of sexuality in general and STIs specifically; this is in contrast to western European countries, where sexuality is often seen as part of a healthy life and is discussed more openly. Perhaps not coincidentally, Europe has Chlamydia and gonorrhea rates that are 60% to 90% lower than American rates.2 RISK GROUPS AND RISK BEHAVIORS
Behaviors that put patients at higher risk for STIs include multiple sexual partners; unprotected oral, anal, or vaginal sex; exchanging money, housing, or drugs for sex; engaging in commercial, survival (prostitution to earn money), or coerced sex; and using mind-altering drugs or alcohol during sex. Certain demographic groups also have higher rates of STIs; however, race and ethnicity are of much less relevance than risk behaviors in clinical encounters.3 Adolescents and Young Adults
Sexually active adolescents and young adults (ages 15–24 years) have particularly high rates of Chlamydia and gonorrhea. The risk for STI is even higher among young people who engage in high-risk behaviors, initiate sexual activity earlier in adolescence, are in detention facilities, have multiple sexual partners concurrently, or have multiple sequential sexual partnerships of limited duration. In addition, adolescents have increased biological susceptibility to infection (eg, immature cervical epithelium) and multiple obstacles to accessing health care. Clinicians treating adolescents frequently fail to inquire about sexual behaviors, assess STI risks, provide risk-reduction counseling, and screen for asymptomatic infections. Sexual health discussions should be appropriate for the patient’s developmental level and should be aimed at identifying high-risk behaviors. Careful, nonjudgmental, and thorough counseling is particularly vital for adolescents who might not feel comfortable acknowledging high-risk behaviors. Pregnant Women
Although pregnant women usually have been participating in unprotected sexual activity, many have no behavioral risks that increase the risk for STI. However, untreated STIs can result in serious, preventable complications for newborns. Therefore, recommendations to screen pregnant women for STIs are based on disease severity and sequelae, risk to the newborn, prevalence in the population, costs, medicolegal considerations (eg, state laws), and other factors. Men Who Have Sex with Men
Since the mid-1990s, men who have sex with men (MSM) have had increasing rates of early syphilis (primary, secondary, or early latent), gonorrhea, and Chlamydia. Unsafe
Prevention of Sexually Transmitted Infections
sexual behaviors, including the use of mind-altering drugs during sex (eg, methamphetamine and volatile nitrites or “poppers”) have also increased. These trends have in turn led to increased rates of HIV, especially in some urban centers, and particularly among racial and ethnic minority groups. The recent increases in HIV rates likely reflect the changing attitudes concerning HIV infection that have accompanied advances in HIV therapy. Because persons with HIV have improved quality of life and survival, fear of disease is no longer sufficient to motivate safe sexual practices. More MSM live longer while infectious, owing to medical management of HIV. New venues for partner acquisition (eg, Internet and smartphone apps) and increases in substance abuse have led to increased high-risk sexual behavior. This combination of factors has resulted in increased rates of STIs and HIV among MSM. Clinicians should assess STI and HIV-related risks for all male patients, including the sex of their sexual partners.4 MSM, including those with HIV infection, should receive nonjudgmental STI/HIV risk assessment and client-centered prevention counseling to reduce the likelihood of acquiring or transmitting HIV or other STIs. Clinicians should be familiar with the local community resources available to assist high-risk MSM in facilitating behavioral change and to enable partner notification activities. Clinicians should routinely ask sexually active MSM about the following: (1) symptoms consistent with common STIs, including urethral discharge, dysuria, genital and perianal ulcers, regional lymphadenopathy, and rash; and (2) anorectal symptoms consistent with proctitis, including discharge and pain on defecation or during anal intercourse. Injection Drug Users
Injection drug users (IDUs) are at particularly high risk for HIV and hepatitis B; they are also at risk for other STIs if they exchange money or drugs for sex, or if they have sex while drunk or high.5 Racial and Ethnic Groups
In aggregate, black and Hispanic persons have significantly higher rates of Chlamydia, gonorrhea, and syphilis; however, race and ethnicity serve as surrogate markers for the underlying social factors that increase STI risk6 among large populations. In addition to reduced access to health care, racial discrimination may also lead to elevated rates of STIs in blacks via intermediary factors7 such as poverty, chronic unemployment, drug and alcohol marketing tactics, social disorganization, and male incarceration. Therefore, it is important for clinicians to focus on individual risk behaviors when managing individual patients, rather than assuming that skin color of an individual provides causal information regarding that individual’s pretest likelihood of having an STI.8 SCREENING RECOMMENDATIONS
Screening means testing asymptomatic individuals. When a disease is prevalent and has serious complications, screening may be appropriate. Screening requires accurate tests and effective treatments that are available and affordable (Box 1). PROFESSIONAL GROUP RECOMMENDATIONS
Screening recommendations from various expert panels and authoritative institutions sometimes diverge because of differences in organizational mission and target audience; emphases on the harms of screening; methodology for evidence reviews; experts with vested interests (professional or economic); and demands by clinicians
219
220
Hunter et al
Box 1 Developing local screening criteria from national guidelines 1. The US Preventive Services Task Force uses national epidemiologic data and the prevalence of risk behaviors to provide clinical guidance about what age to begin screening and what age to stop screening.9 2. Clinicians should consult with local public health officials and use available local epidemiologic data to tailor screening programs based on the community and populations served.10 3. Communities with STI rates higher than the national averages should have local screening criteria, usually formulated by that jurisdiction’s local health department. 4. An example of evidence-based local screening criteria for a high-prevalence community is available at http://city.milwaukee.gov/ImageLibrary/Groups/healthAuthors/DCP/PDFs/STD_ Screen_Tx_Guide_updated_20080121.pdf.9
for guidance despite limited evidence or resources. In 2008, there was agreement on STI screening among the US Preventive Services Task Force (USPSTF), Centers for Disease Control and Prevention (CDC), American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), and American College of Obstetricians and Gynecologists (ACOG).10 The current guidelines from the USPSTF, CDC, AAFP, and ACOG were reviewed to develop the recommendations as outlined in Tables 2 and 3. These tables represent national guidance; however, local practice needs to be tailored to local conditions and prevalence of disease. Known Contacts
Known contacts of patients with STIs should receive screening for STIs to which they have been exposed.11 In addition, the following populations meet national criteria for routine screening for certain STIs.12 Sexually Active Adolescents and Young Adults
Nationally, Chlamydia screening is recommended annually for females aged 25 years and younger, but local prevalence sometimes warrants raising or lowering this age. Depending on local conditions, young men in high-prevalence settings such as adolescent clinics, correctional facilities, and STI clinics should also be considered for annual Chlamydia screening, despite national recommendations not including screening men. The CDC recommends targeted gonorrhea screening for women meeting 1 of more of the following criteria: younger than 25 years; previous gonorrhea infection; other STIs; new or multiple sex partners; inconsistent condom use; or involved in commercial sex work or illicit drug use. Young women living in high-prevalence communities should also be screened. HIV screening should be discussed with all adolescents, and encouraged for those who are sexually active or who use injection drugs. No screening of adolescents is recommended nationally for syphilis, trichomoniasis, herpes simplex virus (HSV), human papillomavirus (HPV), or hepatitis B virus (HBV), except for MSM and pregnant women. Pregnant Women Chlamydia
Screening for Chlamydia should occur at the first prenatal visit. Rescreening in the third trimester is recommended for women aged 25 years or younger, who tested
Prevention of Sexually Transmitted Infections Table 2 Screening and testing recommendations for STIs in the United States
Recommended Screening by Diseasea,b Chlamydia
Strength of Recommendation (USPSTF Evidence Gradec)
Testing Method
A
Annually for all sexually active women
INTRODUCTION
Sexually transmitted infections (STIs) are among the most frequently reported and prevalent medical conditions in the United States (Table 1). In total, nearly 20 million new cases of STIs occur in the United States each year, contributing to more than Conflict of Interest: None. a Department of Family Medicine, University of Wisconsin School of Medicine and Public Health, Center for Urban Population Health, City of Milwaukee Health Department, 841 North Broadway Street, 3rd Floor, Milwaukee, WI 53202, USA; b Department of Family Medicine, University of Wisconsin School of Medicine and Public Health, 1100 Delaplaine Court, Madison, WI 53715-1896, USA; c Department of Family Medicine, University of Wisconsin School of Medicine and Public Health, 207 West Lincoln Street, Suite 1, Augusta, WI 54722, USA * Corresponding author. E-mail address: [email protected] Prim Care Clin Office Pract 41 (2014) 215–237 http://dx.doi.org/10.1016/j.pop.2014.02.003 primarycare.theclinics.com 0095-4543/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
216
Hunter et al
Table 1 Causes, complications, and burdena of selected sexually transmitted infections (STI) in the United States Incidence Estimates (New Cases)
Incidence Rate (per 100,000)
Prevalence Estimates (Total Cases)
Prevalence Rate (per 100,000)
STI
Description
Chlamydia
An obligate intracellular bacterium, Chlamydia trachomatis causes urethritis and cervicitis, as well as pharyngeal and anal infections. Complications include pelvic inflammatory disease (and subsequent risk for infertility, pelvic pain, tubal ectopic pregnancy) as well as neonatal conjunctivitis and pneumonia
2,860,000
926.2
1,570,000
508.4
Gonorrhea
Neisseria gonorrhoeae, also known as gonococcus, is a gram-negative diplococcus that causes urethritis and cervicitis, as well as pharyngeal and anal infections. Complications are essentially identical to those of Chlamydia
820,000
265.5
270,000
87.4
Syphilis (primary, secondary, and early latent)
The spiral bacterium Treponema pallidum manifests itself in several stages, including primary (typically a painless chancre), early latent (asymptomatic), secondary (typically a rash), and late latent (asymptomatic). Tertiary syphilis includes neurosyphilis (eg, dorsalis tabes and dementia), gummas, and cardiovascular syphilis (eg, aortitis, aneurysm, and rupture). Vertical transmission to newborns is common, resulting in congenital syphilis
55,400
17.9
117,000
—
Hepatitis B
This chronic viral infection is transmitted through sharing of blood and body fluids (including saliva) as well as vertically from mother to newborn. Sequelae include hepatocellular carcinoma and hepatic failure
19,000
6.2
442,000
143.1
This chronic retroviral infection, if not treated, creates immunesystem dysfunction, resulting in AIDS and its hallmark opportunistic infections (eg, Pneumocystis carinii, Kaposi sarcoma). It can be transmitted sexually or through other blood and body fluid exposure (eg, needle sharing), and vertically from mother to newborn (eg, through breastfeeding). About 75% of case reports are in men
50,000
19.7
1,148,200
453.4
Genital herpesc
Caused by herpes simplex viruses 1 and 2, genital herpes is a chronic viral infection that causes painful recurrent herpetic outbreaks at the original site of infection
776,000
251.3
24,100,000
7804.4
Trichomoniasis
Trichomoniasis is a flagellate parasitic infection of the urethra or vagina that can persist for months. Testing is insensitive, and complications of its associated mucosal irritation include urinary tract infections and increased risk for HIV infection
1,090,000
353.0
3,710,000
1201.4
Human papillomavirus (HPV)d
This viral infection of the penis or cervix is nearly ubiquitous after 2 or more lifetime sexual partners. There are nearly 100 viral subtypes, and while some infections are transient, infection with high-risk subtypes leads to cervical intraepithelial neoplasia. Chronic infection with types 16 and 18 cause about 70% of cervical cancers. HPV-related anal, penile, and especially oropharyngeal cancers are rising. Infections with other subtypes (eg, 6 and 11) cause visible genital warts
14,100,000
4566.1
79,100,000
25,615.3 (25.6%)
Except for human immunodeficiency virus (HIV), all incidence case and prevalence case estimates are for 2008, include both reported cases and estimates of unreported cases, use a 2008 US population denominator of 308,800,000, and are derived from the Centers for Disease Control and Prevention (CDC).50 b For HIV, incidence case and prevalence case estimates are for 2009, include both reported cases and estimates of unreported cases, use a 2009 US population denominator of the US population ages 13 years and older, and are derived from the CDC.51 c Incidence and prevalence estimates of herpes simplex virus are for type 2 only, even though genital herpes is also caused by type 1. d HPV prevalence may be more than 40% according to the American Sexual Health Association.52
Prevention of Sexually Transmitted Infections
a
HIVb (ages 13 and up)
217
218
Hunter et al
US$17 billion in health care costs.1 Most costs are due to human immunodeficiency virus (HIV), cervical cancer, and complications of pelvic inflammatory disease, such as infertility, chronic pelvic pain, and tubal ectopic pregnancy. Because of their high incidence, high prevalence, serious complications, lack of symptoms, ease of diagnosis, and availability of effective treatment, STIs are of great importance to primary care clinicians. Furthermore, primary care clinicians are in unique positions to prevent future infections by identifying and treating existing infections, by treating exposed partners, and by serving as effective change agents to help reduce patients’ risk behaviors. Although sexual images and themes are nearly inescapable in American popular culture, there can often be social, psychological, and political awkwardness surrounding frank and open discussions of sexuality in general and STIs specifically; this is in contrast to western European countries, where sexuality is often seen as part of a healthy life and is discussed more openly. Perhaps not coincidentally, Europe has Chlamydia and gonorrhea rates that are 60% to 90% lower than American rates.2 RISK GROUPS AND RISK BEHAVIORS
Behaviors that put patients at higher risk for STIs include multiple sexual partners; unprotected oral, anal, or vaginal sex; exchanging money, housing, or drugs for sex; engaging in commercial, survival (prostitution to earn money), or coerced sex; and using mind-altering drugs or alcohol during sex. Certain demographic groups also have higher rates of STIs; however, race and ethnicity are of much less relevance than risk behaviors in clinical encounters.3 Adolescents and Young Adults
Sexually active adolescents and young adults (ages 15–24 years) have particularly high rates of Chlamydia and gonorrhea. The risk for STI is even higher among young people who engage in high-risk behaviors, initiate sexual activity earlier in adolescence, are in detention facilities, have multiple sexual partners concurrently, or have multiple sequential sexual partnerships of limited duration. In addition, adolescents have increased biological susceptibility to infection (eg, immature cervical epithelium) and multiple obstacles to accessing health care. Clinicians treating adolescents frequently fail to inquire about sexual behaviors, assess STI risks, provide risk-reduction counseling, and screen for asymptomatic infections. Sexual health discussions should be appropriate for the patient’s developmental level and should be aimed at identifying high-risk behaviors. Careful, nonjudgmental, and thorough counseling is particularly vital for adolescents who might not feel comfortable acknowledging high-risk behaviors. Pregnant Women
Although pregnant women usually have been participating in unprotected sexual activity, many have no behavioral risks that increase the risk for STI. However, untreated STIs can result in serious, preventable complications for newborns. Therefore, recommendations to screen pregnant women for STIs are based on disease severity and sequelae, risk to the newborn, prevalence in the population, costs, medicolegal considerations (eg, state laws), and other factors. Men Who Have Sex with Men
Since the mid-1990s, men who have sex with men (MSM) have had increasing rates of early syphilis (primary, secondary, or early latent), gonorrhea, and Chlamydia. Unsafe
Prevention of Sexually Transmitted Infections
sexual behaviors, including the use of mind-altering drugs during sex (eg, methamphetamine and volatile nitrites or “poppers”) have also increased. These trends have in turn led to increased rates of HIV, especially in some urban centers, and particularly among racial and ethnic minority groups. The recent increases in HIV rates likely reflect the changing attitudes concerning HIV infection that have accompanied advances in HIV therapy. Because persons with HIV have improved quality of life and survival, fear of disease is no longer sufficient to motivate safe sexual practices. More MSM live longer while infectious, owing to medical management of HIV. New venues for partner acquisition (eg, Internet and smartphone apps) and increases in substance abuse have led to increased high-risk sexual behavior. This combination of factors has resulted in increased rates of STIs and HIV among MSM. Clinicians should assess STI and HIV-related risks for all male patients, including the sex of their sexual partners.4 MSM, including those with HIV infection, should receive nonjudgmental STI/HIV risk assessment and client-centered prevention counseling to reduce the likelihood of acquiring or transmitting HIV or other STIs. Clinicians should be familiar with the local community resources available to assist high-risk MSM in facilitating behavioral change and to enable partner notification activities. Clinicians should routinely ask sexually active MSM about the following: (1) symptoms consistent with common STIs, including urethral discharge, dysuria, genital and perianal ulcers, regional lymphadenopathy, and rash; and (2) anorectal symptoms consistent with proctitis, including discharge and pain on defecation or during anal intercourse. Injection Drug Users
Injection drug users (IDUs) are at particularly high risk for HIV and hepatitis B; they are also at risk for other STIs if they exchange money or drugs for sex, or if they have sex while drunk or high.5 Racial and Ethnic Groups
In aggregate, black and Hispanic persons have significantly higher rates of Chlamydia, gonorrhea, and syphilis; however, race and ethnicity serve as surrogate markers for the underlying social factors that increase STI risk6 among large populations. In addition to reduced access to health care, racial discrimination may also lead to elevated rates of STIs in blacks via intermediary factors7 such as poverty, chronic unemployment, drug and alcohol marketing tactics, social disorganization, and male incarceration. Therefore, it is important for clinicians to focus on individual risk behaviors when managing individual patients, rather than assuming that skin color of an individual provides causal information regarding that individual’s pretest likelihood of having an STI.8 SCREENING RECOMMENDATIONS
Screening means testing asymptomatic individuals. When a disease is prevalent and has serious complications, screening may be appropriate. Screening requires accurate tests and effective treatments that are available and affordable (Box 1). PROFESSIONAL GROUP RECOMMENDATIONS
Screening recommendations from various expert panels and authoritative institutions sometimes diverge because of differences in organizational mission and target audience; emphases on the harms of screening; methodology for evidence reviews; experts with vested interests (professional or economic); and demands by clinicians
219
220
Hunter et al
Box 1 Developing local screening criteria from national guidelines 1. The US Preventive Services Task Force uses national epidemiologic data and the prevalence of risk behaviors to provide clinical guidance about what age to begin screening and what age to stop screening.9 2. Clinicians should consult with local public health officials and use available local epidemiologic data to tailor screening programs based on the community and populations served.10 3. Communities with STI rates higher than the national averages should have local screening criteria, usually formulated by that jurisdiction’s local health department. 4. An example of evidence-based local screening criteria for a high-prevalence community is available at http://city.milwaukee.gov/ImageLibrary/Groups/healthAuthors/DCP/PDFs/STD_ Screen_Tx_Guide_updated_20080121.pdf.9
for guidance despite limited evidence or resources. In 2008, there was agreement on STI screening among the US Preventive Services Task Force (USPSTF), Centers for Disease Control and Prevention (CDC), American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), and American College of Obstetricians and Gynecologists (ACOG).10 The current guidelines from the USPSTF, CDC, AAFP, and ACOG were reviewed to develop the recommendations as outlined in Tables 2 and 3. These tables represent national guidance; however, local practice needs to be tailored to local conditions and prevalence of disease. Known Contacts
Known contacts of patients with STIs should receive screening for STIs to which they have been exposed.11 In addition, the following populations meet national criteria for routine screening for certain STIs.12 Sexually Active Adolescents and Young Adults
Nationally, Chlamydia screening is recommended annually for females aged 25 years and younger, but local prevalence sometimes warrants raising or lowering this age. Depending on local conditions, young men in high-prevalence settings such as adolescent clinics, correctional facilities, and STI clinics should also be considered for annual Chlamydia screening, despite national recommendations not including screening men. The CDC recommends targeted gonorrhea screening for women meeting 1 of more of the following criteria: younger than 25 years; previous gonorrhea infection; other STIs; new or multiple sex partners; inconsistent condom use; or involved in commercial sex work or illicit drug use. Young women living in high-prevalence communities should also be screened. HIV screening should be discussed with all adolescents, and encouraged for those who are sexually active or who use injection drugs. No screening of adolescents is recommended nationally for syphilis, trichomoniasis, herpes simplex virus (HSV), human papillomavirus (HPV), or hepatitis B virus (HBV), except for MSM and pregnant women. Pregnant Women Chlamydia
Screening for Chlamydia should occur at the first prenatal visit. Rescreening in the third trimester is recommended for women aged 25 years or younger, who tested
Prevention of Sexually Transmitted Infections Table 2 Screening and testing recommendations for STIs in the United States
Recommended Screening by Diseasea,b Chlamydia
Strength of Recommendation (USPSTF Evidence Gradec)
Testing Method
A
Annually for all sexually active women
