Am Fam Physician. 2022;105(5):553-557
Related article: Sexually Transmitted Infections: Updates From the 2021 CDC Guidelines
Author disclosure: No relevant financial relationships.
Key Points for Practice
• Most states permit expedited partner therapy, including provision of packaged medications or prescriptions without evaluation, to limit the spread of STIs.
• For chlamydial infections affecting the urethra, rectum, or pharynx, doxycycline, 100 mg orally twice daily for seven days, is most effective.
• For gonorrheal infection, ceftriaxone, 500 mg intra-muscularly as a single dose, is recommended for most people, with azithromycin cotreatment no longer recommended.
• For pelvic inflammatory disease, metronidazole is added to ceftriaxone and doxycycline treatment to eradicate anaerobic organisms.
From the AFP Editors
Evidence-based prevention and treatment of sexually transmitted infections (STIs) continue to evolve. The Centers for Disease Control and Prevention (CDC) released updated recommendations for STI management. These recommendations are summarized in a point-of-care application available at https://www.cdc.gov/std/treatment-guidelines, and recommendations for providing quality STI clinical services are summarized at https://www.cdc.gov/std/qcs.
Prevention efforts include preexposure vaccination for hepatitis A, hepatitis B, and human papillomavirus; provision of HIV pre- and postexposure prophylaxis; and partner services. Prevention also continues to include discussions about condom use, decreasing the number of sex partners, abstinence from intercourse during STI treatment, and emergency contraceptives.
HIV PREEXPOSURE PROPHYLAXIS
HIV preexposure prophylaxis with a daily combination of emtricitabine with tenofovir disoproxil fumarate (Truvada) is safe and effective for men who have sex with men (MSM), mixed-status heterosexual couples, and heterosexually active people at high risk due to a high number of sex partners or inconsistent or no condom use. An alternative combination of emtricitabine and tenofovir alafenamide (Descovy) has demonstrated effectiveness for MSM.
Expedited partner therapy allows clinicians to treat sex partners of their patients, without seeing the partners directly, with patient-facilitated delivery of prepackaged medication or prescription. Expedited partner therapy is legal in most states, with state-specific information at https://www.cdc.gov/std/ept. Expedited partner therapy with doxycycline is appropriate for people with chlamydial infection who are uncertain whether sex partners will seek care. Although it is an alternative regimen, expedited partner therapy with single-dose cefixime (Suprax), 800 mg orally, can be used to treat sex partners of those with gonorrheal infection. The CDC recommends people diagnosed with an STI notify sex partners except in situations of intimate partner violence.
The CDC recommends obtaining sexual histories with a nonjudgmental attitude and respectful language. STI- and HIV-focused prevention counseling is most important for adults with a recent STI diagnosis or multiple partners, as well as all sexually active adolescents. Syphilis, gonorrhea, chlamydia, chancroid, and HIV are reportable infections in every state.
Sexually active adolescents and young adults are at particular risk of chlamydia and gonorrhea infection and other STIs, especially those in vulnerable groups, including young MSM, transgender youth, and those with mental health conditions, multiple sex partners, early sexual experiences, or engagement in exchange sex (e.g., for money). Screening for chlamydia and gonorrhea is recommended for all females younger than 25 years, and HIV screening should be offered to all adolescents. Multiple medical societies recommend that clinicians privately assess patients' sexual behaviors and have awareness of challenges in protecting confidentiality. All states explicitly allow minors to consent for their own STI care.
Although MSM are at high risk for STIs, including HIV, some are at higher risk. Disparities research suggests that approximately one in two Black/African American and one in four Latino/Hispanic MSM acquire HIV during their lifetime. Counseling should be tailored based on assessed risk. HIV testing is recommended for patients with unknown HIV status and HIV-negative patients who have had more than one sex partner since their previous test. Routine testing for gonococcal and chlamydial infections is recommended at least annually and as frequently as every three months. Urethral testing by urine, as well as rectal and pharyngeal sampling by patient- or clinician-collected swabs, is recommended depending on sex practices. Approximately 70% of infections are missed by urogenital-only testing strategies. Hepatitis B and C testing is recommended at least once for all adults except in those at extremely low risk. Routine stool culture for enteric pathogens should be considered in MSM with diarrhea due to elevated risk.
Women who have sex exclusively with women have lower STI risk than women who have sex with women and men or exclusively with men.
Recommendations for transgender and gender-diverse people are guided by current anatomy and sexual behaviors.
During pregnancy, universal screening for HIV, syphilis, and hepatitis B is recommended, with risk-based screening for chlamydia, gonorrhea, and hepatitis C.
Given patient risk profiles, opt-out recommendations for STI screening for persons in correctional facilities and other high-risk settings are generally recommended.
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