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Screening for sexually transmitted infections

Authors
Heidi Swygard, MD, MPH
Myron S Cohen, MD
Section Editor
Noreen A Hynes, MD, MPH, DTM&H
Deputy Editor
Allyson Bloom, MD
Disclosures: Heidi Swygard, MD, MPH Nothing to disclose. Myron S Cohen, MD Nothing to disclose. Noreen A
Hynes, MD, MPH, DTM&H Nothing to disclose. Allyson Bloom, MD Nothing to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed
by vetting through a multi-level review process, and through requirements for references to be provided to support the
content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of
evidence.
Conflict of interest policy

All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Jun 2015. | This topic last updated: Oct 08, 2014.
INTRODUCTION Sexually transmitted infections (STIs) are a major public health problem in
developed and developing countries. Complications of untreated STIs include upper genital tract
infections, infertility, cervical cancer, and enhanced transmission and acquisition of herpesviruses,
hepatitis viruses, and the human immunodeficiency virus (HIV).
The approach to STI diagnosis and management is based upon disease or symptom-specific
syndromes, including vaginal discharge, urethral discharge, ulcerative genital disease,
nonulcerative genital disease, and pelvic pain. However, many patients have asymptomatic
disease, which increases the risk of complications and sustained transmission in the community.
Unfortunately, routine screening for all potential STIs in all patients is cost-prohibitive, particularly in
resource-poor countries [1]. Targeted screening of asymptomatic patients in specified risk groups is
important and has been shown to be effective.
STI screening, including targeted screening and prevention, will be discussed here. In its 2010
guidelines on the treatment of sexually transmitted infections, the United States Centers for Disease
Control and Prevention (CDC) also made recommendations on screening [2]. The
recommendations in this topic are largely consistent with those guidelines.
The approaches to patients with specific genitourinary symptoms and signs are discussed
elsewhere (see "Approach to women with symptoms of vaginitis" and "Clinical features and
diagnosis of pelvic inflammatory disease" and "Approach to the patient with genital
ulcers" and "Acute uncomplicated cystitis and pyelonephritis in women"). The prevention of STIs is
discussed elsewhere. (See "Prevention of sexually transmitted infections".)
Information on the clinical presentation, diagnosis, and treatment of specific STIs are reviewed in
detail separately. (See related topics). Sexually transmitted infections and HIV infection in
adolescents are also discussed separately. (See "Sexually transmitted diseases: Overview of issues
specific to adolescents" and "The adolescent with HIV infection".)

TAKING A SEXUAL HISTORY In the assessment of sexually transmitted infection (STI) risk, it is
important to obtain a thorough sexual history including:
Any new sexual partner(s)
History of multiple sexual partners
History of genital ulceration (which can increase the risk of HIV acquisition)
History of sexual intercourse with trauma (which can increase the risk of acquisition of
hepatitis B or C)
Types of sexual exposures (which will guide decisions about which mucosal sites to test
diagnostically)
Frequency of condom use
The history should be straightforward and non-judgmental with appropriate counseling regarding
risk-taking behaviors, as necessary [3]. Some medical providers do not routinely obtain a sexual
history. In one study, only 70 percent reported "always" or "almost always" obtaining a sexual
history in adolescent females [4]. One reason for this omission may be related to provider comfort
with this part of the patient interview [2]. Suggestions for open-ended, non-judgmental questions, as
suggested by the Centers for Disease Control and Prevention (CDC), are found in the following
table (table 1) [2].
RISK FACTORS Risk factors for sexually transmitted infections include [5-13]:
Young age (15 to 24 years old)
African-American race
Unmarried status
Geographical residence
New sex partner in past 60 days
Multiple sexual partners
History of a prior STI
Illicit drug use
Admission to correctional facility or juvenile detention center [7]
Meeting partners on the internet [12,13]
Contact with sex workers
GENERAL PRINCIPLES All patients who seek screening for sexually transmitted infections
(STIs) should receive testing and counseling for HIV infection. (See'Human immunodeficiency virus
(HIV)' below.)
The optimal interval for screening of STIs is uncertain. For women with prior negative screening, the
interval for reevaluation will be influenced by a change in risk factor profile. For previously infected
women, rescreening at three to four months is appropriate due to high rates of reinfection [5]. The
incidence of reinfection was examined in 2419 men and women who were evaluated in three urban
STI clinics [14]. Patients had follow-up visits scheduled at 3, 6, 9, and 12 months with the following
results [14]:
Among 1236 women, 26 percent had acquired one or more new infections
(including Chlamydia trachomatis, Neisseria gonorrhea, and Trichomonas vaginalis).

Among 1183 men, 15 percent had acquired one or more new infections (including C.
trachomatis and N. gonorrhea).
Furthermore, 66 percent of patients with new STIs were asymptomatic.
The authors concluded that men and women with newly diagnosed chlamydial, gonococcal, or
trichomonas infections should be rescreened in three months for new asymptomatic infections.
Clinicians should also consider the characteristics of the communities they serve when determining
appropriate screening strategies for their particular patient population. Local public health
authorities can be a source of valuable information regarding local patterns of infection and disease
prevalence.
The advent of urine-based tests and utility of self-collected vaginal swabs has increased the
acceptance of STI screening among patients and providers since it allows for routine specimen
collection without a pelvic examination [15,16]. Urine screening has also led to increased screening
of men.
Other clinical considerations for STI screening include the diagnosis of an STI in the sex partner.
PATHOGENS
Human immunodeficiency virus (HIV) All patients being evaluated for sexually transmitted
infections (STIs) should be offered counseling and referral for HIV testing [2,17-19]. Counseling
provides an opportunity for risk reduction education as well as diagnosis of HIV infection. Diagnosis
of HIV benefits the patient who may need to initiate antiretroviral therapy due to advanced
immunosuppression and the public's health when the source patient is counseled regarding
preventive measures.
Recommendations for HIV screening in the Centers for Disease Control (CDC) guidelines include
opt-out screening and annual screening for those at high risk for HIV infection. For pregnant
women, HIV testing is recommended in the first trimester and again in the third trimester in areas
with increased rates of HIV infection [2]. These recommendations are discussed in detail elsewhere.
(See "Screening and diagnostic testing for HIV infection".)
Antibody screening can be accomplished either through a rapid test or enzyme immunoassay (EIA).
Reactive antibody tests need to be confirmed by supplemental testing. (See "Screening and
diagnostic testing for HIV infection".)
It is important to recognize that some patients with STIs may also have very recently acquired HIV
infection (acute HIV). Patients with acute HIV infection often have complaints of a fever, "mono-like
illness", or diarrhea not common among STI patients. Diagnosis of acute HIV infection during this
"window period" is made by measuring HIV RNA [20]. Although fourth-generation tests can detect
p24 antigen, these tests are but less sensitive than measurement of HIV RNA in the very acute
period after infection. (See "Acute and early HIV infection: Treatment".)
Gonorrhea During 2012, a total of 334,826 cases of gonorrhea were reported in the United
States; the reported gonorrhea rate among women (108.7 per 100,000) was greater than that
reported for men (105.8 per 100,000) [6]. In the United States, the highest attack rates are seen in
sexually active 20- to 24-year-old women (578.5 cases per 100,000) and 20- to 24-year-old men
(462.8 cases per 100,000). Overall, rates in African-Americans continue to decline but are still
almost 15 times higher than those seen in whites.

Gonococcal infection can lead to urethritis, cervicitis, pharyngitis, and anorectal infection. Since
untreated gonococcal infection can lead to serious complications in women, including pelvic
inflammatory disease and infertility, testing for N. gonorrhoeae should be performed annually in
asymptomatic women with one or more of the following risk factors [2,21]:
Sexually active women younger than 25 years
Inconsistent condom use
A history of multiple partners or a partner with multiple contacts
Sexual contact with a partner with culture-proven STI
A history of repeated episodes of STI
Sex work or drug use
Pregnancy
Most gonorrhea infections in men produce overt symptoms that lead to medical evaluation. While
less common, asymptomatic disease in men contributes to sustained transmission in women.
Among symptomatic heterosexual men, gonorrhea prevalence can be as high as 28 percent in
some settings; however, the prevalence drops to 1.5 percent in asymptomatic men [22].
The US Preventive Services Task Force (USPSTF) found insufficient evidence to argue for or
against routine gonorrhea screening in men [21,23]. However, MSM may benefit from routine
screening, which should include screening at extra-genital sites. (See 'Screening special
populations' below.)
Regardless of symptoms, sexual partners should be evaluated, tested, and treated if they had
sexual contact with the index patient during the 60 days preceding onset of symptoms or diagnosis
of gonorrhea [2].
The diagnostic tests used for screening for gonorrhea are discussed elsewhere. (See "Clinical
manifestations and diagnosis of Neisseria gonorrhoeae infection in adults and adolescents", section
on 'Asymptomatic patients'.)
Chlamydia C. trachomatis is the most commonly reported STI in the United States, with
1,422,976 infections reported in 2012, a case rate of 456.7 per 100,000 population, a nearly 20
percent increase from 2007 (367.5 cases per 100,000) [6]. Chlamydia infection can lead to
urethritis, cervicitis, epididymitis, and proctitis. Untreated infections in women can lead to tubal
pregnancy, infertility, and chronic pelvic pain [6,24]. In men, chlamydial infection can result in
infertility, chronic prostatitis, reactive arthritis, and urethral strictures.
Since the majority of infected women do not exhibit clinical symptoms, the USPSTF and the CDC
recommend annual screening of asymptomatic women for C. trachomatis infection in the following
risk groups [6,21]:
All sexually active women age 25 years or younger (including pregnant women)
Sexually active women older than 25 years with risk factors (eg, a new sex partner in prior 60
days, more than one sex partner, inconsistent condom use, unmarried, or history of STI)
Screening programs have been demonstrated to decrease rates of pelvic inflammatory disease
[23,25]. The USPSTF makes no recommendation for or against routine screening of asymptomatic
low-risk women in the general population and cites insufficient evidence for or against routine

screening of asymptomatic men [21]. The USPSTF clinical practice guideline for screening for
chlamydial infection, as well as other USPSTF guidelines, can be accessed through the website for
the Agency for Healthcare Research and Quality at www.ahrq.gov/clinic/uspstfix.htm.
(See "Screening for Chlamydia trachomatis".)
The CDC suggests focused screening of sexually active men in settings associated with a high
prevalence of chlamydia infections (eg, correctional facilities and STI clinics) [2]. Screening of
sexually active men who have sex with men (MSM) can also be considered. (See 'Men who have
sex with men' below.)
The diagnostic tests used for screening for chlamydia are discussed elsewhere. (See "Clinical
manifestations and diagnosis of Chlamydia trachomatis infections", section on 'Diagnosis of
chlamydial infections'.)
Trichomoniasis Trichomoniasis is caused by the protozoan T. vaginalis. Symptoms can include
urethritis in males and diffuse malodorous vaginal discharge with vulvar irritation in females.
Infection can also be asymptomatic in men and women [2]. One prospective, multicenter study
among male partners of women with trichomoniasis demonstrated that 72 percent of male partners
were infected with T. vaginalis, and of those infected, the vast majority (77 percent) were
asymptomatic [26]. Detection of this organism in the male partners was optimized using PCR of
urine samples; urine cultures detected 8 percent of infections compared to 70 percent with PCRbased techniques. The only factor that predicted T. vaginalis infection in the male partner was a
high vaginal pH in the female partner; the mechanism by which pH alterations might enhance T.
vaginalis acquisition or transmission is unknown.
The CDC recommends screening for T. vaginalis in women: a) with new or multiple partners; b) with
a history of STIs; c) who trade sex for drugs or money; d) who use injection drugs [2]. The diagnosis
of trichomonas in a female patient can be made by microscopy, rapid antigen testing, nucleic acid
amplification testing, and culture. Among men, microscopy has poor sensitivity; culture or NAATs is
preferred for male patients [2]. Diagnostic testing is discussed elsewhere. (See "Trichomoniasis".)
Some studies have suggested that vaginal trichomoniasis is also a risk factor for HIV acquisition:
In one study, 1335 HIV-seronegative women in Kenya were monitored for a median of 566
days for HIV seroconversion and acquisition of T. vaginalis [27]. There were 806 incident T.
vaginalis infections and 265 women seroconverted to HIV. Trichomoniasis was associated with
a 1.5-fold (95% CI 1.04-2.24-fold) increased risk of HIV acquisition after adjustment for
potential confounding factors. (See "Trichomoniasis".)
In another longitudinal study performed in Uganda and Zimbabwe, PCR testing for T.
vaginalis infection was performed on cervical samples from 213 women who experienced HIV
seroconversion (cases) and in cervical samples from 4450 HIV-uninfected women (controls)
[28]. In a multivariate analysis controlling for hormonal contraception, other STIs, and
behavioral and demographic factors, the adjusted odds ratio for HIV acquisition was 2.7 for
women who had evidence of T. vaginalisinfection.
Diagnosis and treatment is discussed elsewhere. (See "Approach to women with symptoms of
vaginitis" and "Trichomoniasis".)

Syphilis Data from the CDC demonstrated an increase of over 25 percent in the number of
cases of primary and secondary syphilis from 2007 to 2012 (up from 11,466 to 15,667 cases) [6].
Among men who have sex with men (MSM), the number of cases increased 46 percent from 2008
to 2012 (5872 cases in 2008 to 8553 cases in 2012). The male to female ratio of primary and
secondary cases was 10.3, reflecting the higher rates among men, primarily MSM. In fact, three
quarters of all primary and secondary syphilis cases now occur among MSM. Syphilis rates among
blacks continue to be higher than all other race or ethnicity categories [6]. There is also a relatively
high rate of HIV coinfection in persons with syphilis. (See 'HIV-infected patients' below.)
The following groups are at increased risk for syphilis and should be screened [29,30]:
All pregnant women at the first prenatal visit (and during the third trimester and at delivery for
women in high-risk groups) (see 'Pregnant women' below)
Commercial sex workers
Persons in correctional facilities
Persons diagnosed with another STI
MSM who engage in high-risk behaviors
The USPSTF recommends against routine screening of asymptomatic persons who are not at
increased risk of syphilis, since most positive tests in this setting represent false positives [29].
Testing algorithms for syphilis are discussed in detail elsewhere. (See "Diagnostic testing for
syphilis", section on 'Testing algorithms'.)
Herpes simplex virus type 1 and type 2 An estimated 25 percent of the US population has
serological evidence of herpes infection [31]. Asymptomatic shedding of the virus is not uncommon,
although many infected patients are also unaware of being infected [32]. Since active disease
causes ulcerative lesions, herpes infection is believed to increase the risk of HIV transmission and
acquisition [33,34]. HSV-2 has also been associated with other sexually transmitted infections [35].
However, the USPSTF recommends against routine serological screening for herpes in
asymptomatic persons [36]. Serologic testing may be useful in certain situations, such as for
counseling HSV discordant couples, particularly during pregnancy. (See "Genital herpes simplex
virus infection and pregnancy", section on 'Screening pregnant women with no HSV history'.)
Serologic testing for HSV is discussed elsewhere. (See "Epidemiology, clinical manifestations, and
diagnosis of genital herpes simplex virus infection", section on 'Serology'.)
Hepatitis A Although hepatitis A is more commonly a cause of food-borne outbreaks, it can be
transmitted through some forms of intimate and sexual contact. Hepatitis A screening should be
offered to MSM and injection drug users (IDU). If susceptible, vaccination should be offered in these
patient groups. (See "Hepatitis A virus vaccination and postexposure prophylaxis" and "Prevention
of sexually transmitted infections".)
Hepatitis B Hepatitis B is efficiently transmitted by percutaneous or mucous membrane
exposure to infected blood or body fluids that contain blood. Hepatitis B screening (hepatitis B
surface antigen with anti-HBc or anti-HBs) should be offered to patients with multiple sex partners,
MSM, and injection drug users. If the patient is susceptible, vaccination should be offered.

(See "Hepatitis B virus vaccination" and "Prevention of sexually transmitted


infections" and "Diagnosis of hepatitis B virus infection".)
Hepatitis C Sexual transmission of hepatitis C is much less efficient than through injection drug
use. Risk factors for sexual transmission include exposure to an infected partner or exposure to
multiple sex partners. Case reports of acute hepatitis C among HIV-positive MSM have suggested
that the risk of HCV transmission may be increased in the setting of genital ulcerative disease (eg,
syphilis). (See "Epidemiology, natural history, and diagnosis of hepatitis C in the HIV-infected
patient".)
Routine screening with Hepatitis C antibody testing is recommended for asymptomatic persons
based on their risk for infection or recognized exposure (eg, IDU, hemodialysis) and, in the United
States, for individuals born between 1945 and 1965 [2]. Another setting in which HCV antibody
screening may be considered is the sex partner of a patient who has been diagnosed with hepatitis
C, particularly if there is a history of traumatic anal receptive sexual intercourse. Screening for
hepatitis C is discussed in detail elsewhere. (See "Screening for chronic hepatitis C virus infection",
section on 'Patient selection'.)
No vaccine is available for hepatitis C. Those individuals who are HCV-seropositive should be
referred for further evaluation to determine if their disease is active. Information should also be
given regarding transmission to decrease the risk of HCV transmission to others.
(See "Epidemiology and transmission of hepatitis C virus infection".)
Human papillomavirus Persistent viral infection with specific high-risk genotypes of human
papillomavirus (HPV) causes virtually all cancers of the cervix. In the United States, guidelines
issued by various professional organizations strongly recommend screening for cervical cancer,
although there are minor differences in the recommended screening parameters (table 2). Cervical
cancer screening policies in other countries also differ by starting age, stopping age, and frequency
(table 3). These recommendations are discussed in detail elsewhere. (See "Screening for cervical
cancer".)
Specific screening recommendations for HIV-infected women are also discussed elsewhere.
(See "Screening for cervical cancer in HIV-infected women" and "HIV and women", section on
'Abnormal cervical cytology'.)
If a woman (aged >21) has not had a Pap test within the recommended screening interval, cervical
cancer screening should be considered at the time of evaluation for an STI [2,37]. In a review of
1000 female STI clinic attendees who had a Pap smear performed as part of their clinical
evaluation, 5.7 percent had an abnormal result [38]. Increasing age, genital warts, and chlamydia
infections were independently associated with an abnormal Pap smear in multivariate analysis.
The presence of a mucopurulent discharge should not delay cervical cytologic examination; women
who are menstruating should return for screening at the earliest opportunity [2]. The sequence of
Pap testing in relation to collection of other cervicovaginal specimens does not appear to influence
the Pap test results.
HPV infection is also associated with anal intraepithelial neoplasia (AIN), and high-grade AIN is a
precursor lesion for anal cancer analogous to lesions observed in the cervix. The role of screening
for AIN in individuals at increased risk for HPV infection is discussed separately. (See "Anal

squamous intraepithelial lesions: Diagnosis, screening, prevention, and treatment", section on


'Screening for anal SIL'.)
HPV vaccination can prevent HPV infection and its sequelae. Vaccination status does not change
recommendations for screening. This is discussed in detail elsewhere. (See "Recommendations for
the use of human papillomavirus vaccines".)
SCREENING SEXUALLY ACTIVE PATIENTS As noted above, all sexually active men and
women should be offered routine testing for HIV infection. Also serologic screening for hepatitis B
should be performed; if the patient has no evidence of prior exposure or vaccination, then
immunization against hepatitis B should be offered. (See 'Human immunodeficiency virus
(HIV)' above and 'Hepatitis B' above.)
Women with a history of unprotected sex or multiple sex partners should be screened annually for
gonorrhea and chlamydia. Cervical cancer screening should be included if not previously performed
within the recommended interval [2]. Females between the ages of 9 and 26 years should be
offered human papillomavirus vaccine. (See"Recommendations for the use of human
papillomavirus vaccines" and "Screening for Chlamydia trachomatis".)
Men with a history of unprotected sex or multiple sex partners should be screened annually for
chlamydia. (See "Screening for Chlamydia trachomatis".)
Some proponents have argued that school-based health centers should implement systematic
screening programs in adolescents, who are at high risk of STI acquisition [39].
Because of high rates of reinfection, patients diagnosed with gonorrhea should be advised to retest
in three months; for patients who fail to be retested in that time period, clinicians should consider
repeating gonorrhea testing in the 12 months following the initial diagnosis. Retesting should not be
confused with a test of cure; test of cure is not recommended [2].
SCREENING SPECIAL POPULATIONS Screening recommendations vary by risk group.
Pregnant women Intrauterine or perinatally transmitted sexually transmitted infections (STIs)
can have grave effects on pregnant women, their partners, and their fetuses. Infections of concern
include herpes, hepatitis B, chlamydia and gonorrhea, syphilis, HIV, and hepatitis C [40]. Screening
for these infections is discussed elsewhere. (See "Initial prenatal assessment and first trimester
prenatal care".)
Men who have sex with men The following screening tests should be offered to sexually active
men who have sex with men (MSM) on at least an annual basis [2]:
HIV antibody.
Urethral or urine test (culture or nucleic acid amplification) for gonorrhea and chlamydia. The
choice of test will depend on issues of cost, convenience, and feasibility, which may vary in
different settings.
Pharyngeal culture for gonorrhea in men with history of oral-genital exposure; testing for
chlamydia pharyngeal infection is not recommended.
Rectal gonorrhea and chlamydia screening in MSM who have had receptive anal intercourse
in the past year.
Syphilis serology.

More frequent screening (eg, every three to six-month intervals) is recommended by the Centers for
Disease Control (CDC) for MSM who have multiple or anonymous partners [2]. Frequent HIV
screening is also essential in high-risk MSM who are taking pre-exposure prophylaxis for HIV.
(See "Pre-exposure prophylaxis against HIV infection", section on 'Patient monitoring'.)
Evaluation for infection at non-genital sites is important in this population. One study determined the
proportion of N. gonorrhoeae infections in MSM that would be missed if only urethral or urine
specimens were tested [41]. Over a seven-year period, 7333 MSM attending a STI clinic in the
United States underwent culture and/or NAAT sampling of multiple sites. The study demonstrated
that one-third of the total number of gonorrhoeae cases would have been missed if only urethral or
urine samples were tested. Similar findings have been reported in HIV-infected MSM [42].
Screening for evidence of past hepatitis B and hepatitis A infection should also be performed in this
population as well; if the patient is seronegative, immunization with both vaccines should be offered.
(See "Hepatitis B virus vaccination" and "Hepatitis A virus vaccination and postexposure
prophylaxis".)
Patients should also be offered testing for hepatitis C antibody, since there is increasing evidence of
sexual transmission among MSM [43]. For those MSM who are HIV-infected, ongoing screening for
hepatitis C is warranted to detect acute infection. (See 'HIV-infected patients' below.)
Routine testing for anal cytologic abnormalities or anal HPV infection is not recommended until
more data are available on the reliability of screening methods [2].
Women who have sex with women The risk of infection with STIs among women who have
sex with women varies widely, depending upon number of partners, if the patient is bisexual, and
specific sexual practices. As an example, practices involving digital-vaginal or digital-anal contact,
particularly with shared penetrative sex items, are a possible means for transmission of infection.
Diagnostic testing for sexually transmitted infections should be performed in women with symptoms
and annual screening for chlamydia and syphilis should be performed among WSW who are
sexually active [2].
HPV DNA has been detected from the cervix, vagina, and vulva in approximately one-third of
women who have sex with women and high and low-grade squamous intraepithelial lesions have
been reported [44]. Thus, women who have sex with women should undergo routine cervical cancer
screening and HPV immunization according to standard guidelines [2].
This topic is discussed elsewhere. (See "Medical care of women who have sex with women".)
HIV-infected patients High rates of STIs have been found through screening programs of HIVinfected patients in the United States and abroad [45]. As examples:
In a study of routine screening for syphilis, gonorrhea, and chlamydia among 814
asymptomatic HIV-infected patients, 1.8 percent of patients were diagnosed with syphilis and
10 percent were diagnosed with chlamydia or gonorrhea; 88 percent of these cases occurred
at nonurethral sites [46].
In a 10-year prospective study of female sex workers in Kenya, 238 women of a cohort of
1215 subjects had documented HIV seroconversion [47]. HIV infection was associated with a

significantly higher incidence of genital ulcer disease, which increased with progressive levels
of immunosuppression.
The estimated rate of primary and secondary syphilis in persons with HIV is higher than that
of the general population. Of 6862 reported cases of syphilis in 2002 in the United States, 25
percent occurred in persons coinfected with HIV [48].
Routine STI screening of HIV-infected patients in order to reduce the spread of STIs is
recommended, particularly because STIs in turn can increase HIV transmission. Specifically, testing
for the following infections is recommended [2,49]:
N. gonorrhoeae, at initial evaluation then annually
C. trachomatis, at initial evaluation then annually
Syphilis, at initial evaluation then annually
Hepatitis A (for MSM, those who are chronically infected with hepatitis B and/or C, and
injection drug users), at initial evaluation with vaccination if susceptible
Hepatitis B, at initial evaluation with vaccination if susceptible
Hepatitis C, at initial evaluation with antibody testing with at least annual screening for MSM,
active injection drug or intranasal cocaine users, those who engage in unprotected sex, and
those undergoing hemodialysis
In areas of high STI prevalence, biannual STI testing may be prudent. More frequent screening for
gonorrhea, chlamydia, and syphilis is indicated in HIV-infected MSM who have multiple or
anonymous partners, as well as in patients who exchange sex for money, drugs, or basic needs.
(See 'Men who have sex with men' above.)
However, up to 42 percent of healthcare providers (HCP) providing HIV care reported "never" or
"almost never" performing initial STI screening in HIV-infected patients, and many healthcare
providers do not ask patients about ongoing risk-taking behaviors [50]. Of the 58 percent reporting
some initial STI screening, almost one-third of these same HCP reported "never" to "almost never"
performing annual gonorrhea or chlamydia testing in their HIV-infected women and men,
respectively [51].
Sexual transmission of hepatitis C among HIV-infected MSM has increased internationally [52-55].
Ongoing periodic screening in these men with liver function tests (LFTs) followed by hepatitis C
antibody (HCV Ab) and RNA testing if abnormal is recommended to identify acute infection, which
has a higher response rate to therapy than in the chronic setting. In a cost-effectiveness analysis, a
screening strategy with yearly HCV Ab testing and LFTs with reflex RNA every six months was cost
effective when the incidence of hepatitis C is below 1.25 percent [56]. When the incidence is above
1.25 percent, screening with LFTs every three months was most cost effective.
The incidence of anal cancer is also increasing among HIV-infected MSM. Screening is discussed
in detail elsewhere. (See "Anal squamous intraepithelial lesions: Diagnosis, screening, prevention,
and treatment".)
Women with HIV should have cervical screening twice in the first year after diagnosis of HIV
infection, and if the results are normal, annually thereafter. Women with abnormal cytology should
be managed with colposcopy and gynecological consultation. (See "HIV and women".)

HEALTH DEPARTMENT NOTIFICATION Local and state public health practices of partner
notification and disease reporting are important in addition to individual sexually transmitted disease
case management. Notifiable infections include chancroid, C. trachomatis, gonorrhea, acute
hepatitis B, acute hepatitis C, HIV, and syphilis [57].
PARTNER NOTIFICATION Partners should be notified, examined, and treated for the sexually
transmitted infection (STI) identified or suspected in the index patient. In some settings, patientdelivered partner medication (PDPM) has been used. With this system, the patient directly provides
their sexual contacts with medications and prescriptions to be filled. The PDPM approach does not
give the sexual contact a chance to ask questions, or receive counseling or additional STD
screening, but does prevent recurrent gonococcal and chlamydial infections [58]. Clinicians need to
be aware that PDPM is not legal in all states.
Patients and their sex partners should abstain from sexual intercourse until seven days after a
single-dose treatment or upon completion of a seven-day regimen.
INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, "The
Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language,
at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might
have about a given condition. These articles are best for patients who want a general overview and
who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer,
more sophisticated, and more detailed. These articles are written at the 10 th to 12th grade reading
level and are best for patients who want in-depth information and are comfortable with some
medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or
e-mail these topics to your patients. (You can also locate patient education articles on a variety of
subjects by searching on "patient info" and the keyword(s) of interest.)
Basics topics (see "Patient information: Chlamydia and gonorrhea (The Basics)" and "Patient
information: Genital herpes (The Basics)" and "Patient information: Screening for sexually
transmitted infections (The Basics)")
Beyond the Basics topics (see "Patient information: Gonorrhea (Beyond the
Basics)" and "Patient information: Chlamydia (Beyond the Basics)" and "Patient information:
Testing for HIV (Beyond the Basics)" and "Patient information: Genital herpes (Beyond the
Basics)" and "Patient information: Genital warts in women (Beyond the Basics)" and "Patient
information: Hepatitis B (Beyond the Basics)" and "Patient information: Hepatitis C (Beyond
the Basics)")
SUMMARY AND RECOMMENDATIONS Risk factors for sexually transmitted infection (STI)
acquisition include young age, unmarried status, residence in an urban area, new sex partner,
multiple sex partners, history of STIs, illicit drug use, contact with sex workers, imprisonment, and
meeting partners on the internet. (See 'Risk factors' above.)
Our recommendations for screening are consistent with those of the Centers for Disease Control
and Prevention, as outlined in the 2010 treatment guidelines for STIs:
All patients being evaluated for STIs should be offered counseling and testing for HIV.
(See 'Human immunodeficiency virus (HIV)' above.)

Hepatitis B screening should be offered to men who have sex with men (MSM), injection
drug users (IDU), persons attending an STI clinic or seeking STI treatment, and persons with a
history of multiple sex partners. Patients who are not immune should be offered vaccination.
(See 'Hepatitis B' above.)
Hepatitis A screening should be offered to MSM and injection drug users. Those who are not
immune should be offered vaccination. (See 'Hepatitis A' above.)
Asymptomatic women with risk factors for STIs should be screened for gonococcal or
chlamydial infection annually. Males and females between the ages of 9 and 26 years should
be offered human papillomavirus vaccination. (See 'Gonorrhea' above and 'Chlamydia' above
and 'Human papillomavirus' above.)
The following screening tests for sexually active MSM are recommended on at least an
annual basis: HIV antibody, testing for gonorrhea and chlamydia, and syphilis serology. More
frequent screening may be indicated in patients at high risk. (See 'Men who have sex with
men' above.)
Syphilis screening is recommended for commercial sex workers, persons who exchange sex
for drugs, and persons in correctional facilities. (See 'Syphilis' above.)
Pregnant women should be screened for gonorrhea, chlamydia, HIV, hepatitis B, and syphilis
infections. (See 'Screening special populations' above.)
HIV-infected patients should be screened annually for N. gonorrhoeae, C. trachomatis,
syphilis, and hepatitis B and C. Vaccination against hepatitis A and B is recommended for
nonimmune patients. HIV-infected patients who actively use injection drugs or intranasal
cocaine, engage in unprotected sex, are men who have sex with men, or are undergoing
hemodialysis should have ongoing screening for hepatitis C. (See 'HIV-infected
patients' above.)
Local and state public health departments should be kept informed of notifiable infections,
which include chancroid, chlamydia, gonorrhea, acute hepatitis A, acute hepatitis B, acute
hepatitis C, HIV, and syphilis. (See 'Health department notification' above.)
Partners should be notified, examined, and treated for the STI identified in the index patient.
Patients and their sex partners should abstain from sexual intercourse until therapy is
completed. (See 'Partner notification' above.)
Use of UpToDate is subject to the Subscription and License Agreement.
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