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STD Screening
Questions & Answers - 2010 Treatment Guidelines

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Question 1: When treating asymptomatic heterosexual patients with a history of oral and anal sex, in addition to genital sex, should screening involve collecting pharyngeal and/or rectal swabs, or only collecting genital swabs, but treating for all sites?

Answer: In general, individuals at risk for GC should be screened at all exposed mucosal sites, including pharyngeal and rectal sites. For those patients diagnosed with GC at other sites, prior to treatment clinicians should inquire about oral sexual exposure and if reported, treat these patients with ceftriaxone because of this drug’s well-documented efficacy in treating pharyngeal infection. All recommended regimens have excellent efficacy in treating rectal gonorrhea, though in some cases screening for and confirming rectal infection may aid in risk assessment regarding potential acquisition of other STDs, particularly HIV.

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Question 2: Is chlamydia screening recommended for men who have sex with men (MSM) and HIV-positive individuals? What other STIs should MSM or HIV-positive individuals be screened for?

Answer: Chlamydia screening is recommended for sexually active MSM and for sexually active HIV-positive persons. Irrespective of the presence or absence of symptoms, routine STD screening (for syphilis, gonorrhea, and chlamydia) is recommended at least annually for all sexually active, HIV-positive persons; more frequent screening might be appropriate depending on individual risk. See 2010 STD Treatment Guidelines, page 12, for a discussion of the specific screening tests recommended for sexually active MSM, and page 16 for discussion of screening tests for HIV-positive patients.

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Question 3: Is the use of urine aptima tests for annual gonorrhea/chlamydia screening with HIV positive clients still appropriate?

Answer: Routine screening for gonorrhea and chlamydia is recommended at least annually for all sexually-active, HIV-infected persons; more frequent screening may be indicated, depending on individual risk (2010 STD Treatment Guidelines, page 16). HIV-infected men who have sex with men (MSM) should be screened per the recommendations for all MSM (2010 STD Treatment Guidelines, pages 12–13). For males, urine is the preferred specimen type when using nucleic acid amplification tests (NAATs) for screening. Urethral swabs may be less sensitive and are equal in specificity to urine. Based on the performance characteristics and noninvasiveness of testing, first-catch urine is the specimen of choice for gonorrhea/chlamydia NAAT in males. For females, self-collected vaginal swabs are the specimen of choice for NAAT. They are as sensitive and specific as cervical swabs. Female urine is acceptable, but may have reduced performance compared to genital swabs ( 2010 STD Treatment Guidelines, page 45, and APHL, "Laboratory Diagnostic Testing for Chlamydia trachomatis and Neisseria gonorrhoeae").

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Question 4: When patients want to be tested for “everything” does CDC suggest testing for syphilis and herpes simplex virus (HSV) as well?

Answer: Screening for syphilis is recommended for all pregnant women (USPSTF, 5/2009) and should be considered for individuals at increased risk — commercial sex workers, persons who exchange sex for drugs, men who have sex with men (MSM), and those in adult correctional facilities (USPSTF, 7/2004). CDC recommends routine screening for syphilis at least annually for MSM and HIV-infected patients who are sexually active (2010 STD Treatment Guidelines, pages 12, 16). HSV serologic testing should be considered for persons presenting for an STD evaluation (especially those with multiple sex partners), persons with HIV infection, and MSM at increased risk for HIV acquisition. Screening for herpes simplex virus-1, (HSV-1) and herpes simplex virus-2 (HSV-2) in the general population is not indicated (2010 STD Treatment Guidelines, page 21). When clients request testing for "everything" it is important to inform them what is and is not being tested for, including HSV.

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Question 5: Why are there not specific recommendations for more frequent HIV/chlamydia screening for at-risk individuals?

Answer: Frequency of screening, as with other recommendations in the 2010 STD Treatment Guidelines, is evidence-based and should be influenced by local disease prevalence and characteristics of the population being served.

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Question 6: Recent study showed STDs in those claiming abstinence. Should we ignore self-reported high risk and screen everyone? 

Answer: Sexual history-taking continues to be a key component of the provider's role in the primary prevention of STDs. Routine screening, irrespective of self-reported risk is recommended for some STDs (e.g., chlamydia in sexually active women <26), or in certain situations (e.g., pregnancy or HIV infection). In other cases, appropriate screening and testing for STDs hinges on the assessment of individual patient risk factors. Blanket screening is not recommended, because testing patients at low-risk may increase the rate of false positive results (and may explain positive tests among individuals who are not sexually active).

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Question 7: What specific screening should be done in military recruit settings?

Answer: For women in the military, screening for STDs should be conducted per recommendations for all sexually active women. For men in the military, screening for chlamydia infection should be considered in sexually active men < 30 years of age (CDC Male Chlamydia Screening Consultation, 2007). Screening for men who have sex with men (MSM) should be conducted per recommendations for all sexually active MSM (2010 STD Treatment Guidelines, pages 12–13).

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Question 8: Do you recommend use of anoscopy routinely in screening men who have sex with men (MSM)?

Answer: Anoscopy is not a recommended test for STD screening. Anoscopy is a diagnostic tool that should be used in the evaluation of any patient (male or female) who has practiced receptive anal intercourse and presents with symptoms of proctitis (2010 STD Treatment Guidelines, page 88).

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Question 9: What are the recommendations for asymptomatic college students who come in for STI testing and who want to be tested for “everything"?

Answer: Sexually active young females (<25 yrs. of age) should be screened at least annually for chlamydia (CT). Those at risk should be screened for gonorrhea (GC) and syphilis. Cervical cancer screening should begin at age 21 and continue at two-year intervals until age 29 (2010 STD Treatment Guidelines, pages 74–75). Screening for CT among sexually active adolescent males should be considered in clinical settings with high prevalence of CT (2010 STD Treatment Guidelines, page 10). Adolescent men who have sex with men (MSM) should be screened for STDs per guidelines for all MSM (2010 STD Treatment Guidelines, pages 12–13). HIV screening should be discussed with all patients ages 13–64 (2010 STD Treatment Guidelines, pages 14–15). Herpes simplex virus (HSV) serologic testing should be considered for persons presenting for an STD evaluation, persons with HIV infection, and MSM at increased risk for HIV acquisition (2010 STD Treatment Guidelines, page 21). When clients request testing for "everything" it is important to inform them what is and is not being tested for, including HSV.

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Corrections Settings

Question 10: In the Iowa Department of Corrections we automatically screen females <25 years of age and between ages 25 and 35 if they have risk factors. There is no automatic screening for men. There is no age restriction; screening depends entirely on risk factors. Why do you think this is?

Answer: CDC recommends universal screening for gonorrhea and chlamydia among adolescent females in juvenile detention or jails; universal screening at intake is also recommended for adult females up to age 35 years (2010 STD Treatment Guidelines, page 12). Such screening in women is important since several sequelae can result from C. trachomatis and gonorrhea infection in women, including pelvic inflammatory disease (PID), ectopic pregnancy, and infertility (2010 STD Treatment Guidelines, pages 44, 49). Clinicians should assess the STD-related risks for all male patients, including a routine inquiry about the gender of sex partners. Men who have sex with men (MSM), including those with HIV infection, should routinely undergo nonjudgmental STD/HIV risk assessment and client-centered prevention counseling to reduce the likelihood of acquiring or transmitting HIV or other STDs (2010 STD Treatment Guidelines, page 12). Even though there is insufficient evidence to recommend routine screening for C. trachomatis in sexually active young men, chlamydia screening should be considered in correctional facilities since it is a clinical setting with a high chlamydia prevalence. An age cut-off is not defined (2010 STD Treatment Guidelines, page 10). Since the prevalence of gonorrhea varies in different communities and populations, healthcare providers should consider local gonorrhea epidemiology when making screening decisions. Universal screening is not recommended since the majority of urethral infections in males caused by N. gonorrhoeae produce symptoms that result in those individuals seeking curative treatment soon enough to prevent serious sequelae (2010 STD Treatment Guidelines, page 49). Universal HIV screening for males should be discussed with all adolescents and encouraged for those who are sexually active and those who use injection drugs (2010 STD Treatment Guidelines, page 10). Universal syphilis screening should be conducted on the basis of the local area and institutional prevalence of early (primary, secondary, and early latent) infectious syphilis (2010 STD Treatment Guidelines, page 12).

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Question 11: Are correctional health providers generally doing STD follow-up for women under 35 who are incarcerated? If a patient has recently been released from a correctional facility, is a screening within a specific number of days a recommendation by the CDC, or is this screening recommendation based solely upon individual risk factors?

Answer: Capacity to provide STD care varies by the type of correctional facility. Most institutions do not routinely screen for STDs (2010 STD Treatment Guidelines, pages 11–12). There are currently no specific guidelines for STD screening among individuals recently released from correctional facilities. Primary care providers caring for this population should conduct screening per recommendations for all females and males, and according to individual risk factors.

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Chlamydia

Question 12: Should all sexually active women under 24 be screened for chlamydia, regardless of how long they have been with their partner? For example, a 22-year-old who states she has had the same partner for two years and had a negative test one year prior.

Answer: Annual screening for chlamydia infection among all sexually active women < 25 years of age is recommended, irrespective of other factors, because of the high prevalence of the disease in this population and because asymptomatic infection is common (2010 STD Treatment Guidelines, pages 44–45).

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Question 13: What female age groups are recommended for chlamydia screening?

Answer: Annual chlamydia screening of all sexually-active females < 25 years of age is recommended, as is screening older women with risk factors (e.g., new sex partner or multiple partners) (2010 STD Treatment Guidelines, pages 44–45).

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Gonorrhea and Chlamydia

Question 14: In addition to nucleic acid amplification testing (NAAT) of urine for gonorrhea and chlamydia, is there any guidance on when individuals should have rectal and/or oral testing for gonorrhea and chlamydia? Is it recommended for all individuals? Does it depend on other factors?

Answer: Routine pharyngeal and rectal screening is recommended for sexually active men who have sex with men (MSM) only. Routine screening for pharyngeal gonorrhea is recommended at least annually for MSM who have had receptive oral intercourse during the preceding year. Use of NAAT is the preferred approach; however, NAATs are not FDA-approved for pharyngeal screening, but may be used by labs that have met the regulatory requirements. There are no routine screening recommendations for pharyngeal infections among other populations and risk groups. Screening for pharyngeal chlamydia is not recommended (2010 STD Treatment Guidelines, page 12). Routine screening for anal chlamydia and gonorrhea infection is recommended at least annually for sexually active MSM who have had receptive anal intercourse within the preceding year.

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Gonorrhea

Question 15: Are there alternatives for gonorrhea (GC) testing?

Answer: Gram stain is sensitive and specific for GC in male urethral specimens, but is not a sufficient test of endocervical, pharyngeal or rectal specimens. In addition to nucleic acid amplification tests (NAATs), culture and nucleic acid hybridization tests are available for GC testing (2010 STD Treatment Guidelines, page 49).

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Question 16: Most pharyngeal gonorrhea (GC) infections are asymptomatic. What is the risk of transmission (to genitals, to other pharynx)?

Answer: Although well described, GC transmission from the pharynx to the genitals is thought to be less efficient than from anal or vaginal sex. However, the prevalence of pharyngeal GC can be relatively common in certain populations [e.g., among some men who have sex with men (MSM) communities] and studies have shown the presence of urethral GC among men who reported practicing only receptive oral sex.

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Question 17: The guidelines seem to recommend screening all sexually active women age <26 for gonorrhea, even in the absence of other risk factors. The guidelines do not mention high-risk geographic area or race as risk factors, therefore, I'm concerned that this recommendation is not a cost-effective strategy.

Answer: Gonorrhea (GC) screening is currently recommended for sexually active women at increased risk. Increased risk may include age < 25 years. It also includes factors such as history of prior GC infection, other STDs, sex work, drug use, etc. GC screening is not recommended in men and women who are at low risk of infection (2010 STD Treatment Guidelines, page 49).

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Men Who Have Sex with Men (MSM)

Question 18: Is there any recommendation on screening men who have sex with men (MSM) with anal cytologic exams?

Answer: Screening for anal intraepithelial neoplasia (AIN) by anal cytology can be considered for HIV-infected MSM. There is currently no recommendation for routine screening with anal cytology among non-HIV-infected MSM (2010 STD Treatment Guidelines, page 13).

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Specimen Type

Question 19: When performing nucleic acid amplification testing (NAAT), is one testing site preferred or more sensitive than another (i.e., urethral more sensitive than urine)?

Answer: For males, urine is the preferred specimen type when using NAATs for screening. Urethral swabs may be less sensitive and are equal in specificity to urine. Based on the performance characteristics and noninvasiveness of testing, first-catch urine is the specimen of choice for gonorrhea/chlamydia NAAT in males. For females, self-collected vaginal swabs are the specimen of choice for NAAT. They are as sensitive and specific as cervical swabs. Female urine is acceptable, but may have reduced performance compared to genital swabs (2010 STD Treatment Guidelines, page 45, and APHL, "Laboratory Diagnostic Testing for Chlamydia trachomatis and Neisseria gonorrhoeae").

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Question 20: When should patient collected vaginal swabs be used?

Answer: For gonorrhea/chlamydia screening, vaginal swab specimens are preferred for nucleic acid amplification testing (NAAT) and can be self-collected by the patient or collected by the provider during a full pelvic exam. Vaginal swabs are as sensitive and specific as endocervical specimens for NAAT, and women find this screening strategy highly acceptable. Some NAATs are FDA-cleared for use with vaginal swab specimens (e.g., Gen-Probe APTIMA Combo 2) (2010 STD Treatment Guidelines, page 45, and APHL, "Laboratory Diagnostic Testing for Chlamydia trachomatis and Neisseria gonorrhoeae"").

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Question 21: If a female gets chlamydia (CT) from rectal penetration without any vaginal penetration will it show up on a cervical culture?

Answer: Rectal CT infection occurs among individuals who practice receptive anal intercourse. Rectal CT can be diagnosed by testing a rectal swab specimen with nucleic acid amplification tests (NAATs). NAATs are not FDA-approved for rectal testing, but may be used by labs that have met the regulatory requirements. Testing at the anatomic site of exposure is usually required to diagnose infection at that site.

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More Q & A - Syphilis

 

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