Primary Prevention Methods
- Pre-exposure Vaccination
- Cervical Diaphragms
- Multipurpose Prevention Technologies
- Topical Microbicides and Spermicides
- Nonbarrier Contraception, Female Surgical Sterilization, and Hysterectomy
- Emergency Contraception
- Male Circumcision
Pre-exposure vaccination is one of the most effective methods for preventing transmission of HPV, HAV, and HBV, all of which can be sexually transmitted. HPV vaccination is recommended routinely for males and females aged 11 or 12 years and can be administered beginning at age 9 years. HPV vaccination is recommended through age 26 years for those not previously vaccinated (11). Sharing clinical decision-making about HPV vaccination is recommended for certain adults aged 27–45 years who are not adequately vaccinated in accordance with existing guidance (https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/hpv.html).
Hepatitis B vaccination is recommended for all unvaccinated, uninfected persons who are sexually active with more than one partner or are being evaluated or treated for an STI (12). In addition, hepatitis A and B vaccines are recommended for MSM, persons who inject drugs, persons with chronic liver disease, and persons with HIV or hepatitis C infections who have not had hepatitis A or hepatitis B (12). HAV vaccine is also recommended for persons who are homeless (13). Details regarding HAV and HBV vaccination, including routine childhood vaccination, are available at https://www.cdc.gov/hepatitis and at the ACIP website (https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/index.html).
When used consistently and correctly, external latex condoms, also known as male condoms, are effective in preventing the sexual transmission of HIV infection (http://www.ashasexualhealth.org/pdfs/Male_and_Female_Condoms.pdf). In heterosexual HIV mixed-status relationships (i.e., those involving one infected and one uninfected partner) in which condoms were used consistently, HIV-negative partners were 71%–80% less likely to become infected with HIV, compared with persons in similar relationships in which condoms were not used (14,15). Two analyses of MSM mixed-status couple studies estimated the protective effect of condom use to be 70% and 91%, respectively (16,17). Moreover, studies demonstrate that consistent condom use reduces the risk for other STIs, including chlamydia, gonorrhea, hepatitis B, and trichomoniasis (18–21). By limiting lower genital tract infections, condoms also might reduce the risk for pelvic inflammatory disease (PID) among women (22). In addition, consistent and correct use of latex condoms reduces the risk for HPV infection and HPV-associated diseases, genital herpes, syphilis, and chancroid when the infected area or site of potential exposure is covered (24–27, 489). Additional information is available at https://www.cdc.gov/condomeffectiveness/index.html and http://www.factsaboutcondoms.com/professional.php. Condoms are regulated as medical devices and are subject to random sampling and testing by the Food and Drug Administration (FDA). Each latex condom manufactured in the United States is tested electronically for holes before packaging. The rate of condom breakage during sexual intercourse and withdrawal in the United States is approximately two broken condoms per 100 condoms.
Rates of breakage and slippage might be slightly higher during anal intercourse (28,29). The failure of condoms to protect against STIs or unintended pregnancy usually results from inconsistent or incorrect use rather than condom breakage (30). Users should check the expiration or manufacture date on the box or individual package. Latex condoms should not be used beyond their expiration date or >5 years after the manufacturing date. Condoms made of materials other than latex are available in the United States and can be classified into two general categories: 1) polyurethane, polyisoprene, or other synthetic condoms and 2) natural membrane condoms.
Polyurethane external condoms provide protection against STIs and HIV and pregnancy comparable to that of latex condoms (20,31). These can be substituted for latex condoms by persons with latex sensitivity, are typically more resistant to deterioration, and are compatible with use of both oil-based and water-based lubricants. The effectiveness of other synthetic external condoms to prevent STIs has not been extensively studied, and FDA labeling restricts their recommended use to persons who are sensitive to or allergic to latex. Natural membrane condoms (frequently called natural skin condoms or [incorrectly] lambskin condoms) are made from lamb cecum and can have pores up to 1,500 nm in diameter. Although these pores do not allow the passage of sperm, they are more than 10 times the diameter of HIV and more than 25 times that of HBV. Moreover, laboratory studies demonstrate that sexual transmission of viruses, including HBV, herpes simplex virus (HSV), and HIV, can occur with natural membrane condoms (31). Therefore, natural membrane condoms are not recommended for prevention of STIs and HIV.
Providers should advise that condoms must be used consistently and correctly to be effective in preventing STIs and HIV while noting that any condom use is better than no condom use. Providing instructions about the correct use of condoms can be useful. Communicating the following recommendations can help ensure that patients use external condoms correctly:
- Use a new condom with each sex act (i.e., oral, vaginal, and anal).
- Carefully handle the condom to avoid damaging it with fingernails, teeth, or other sharp objects.
- Put the condom on after the penis is erect and before any genital, oral, or anal contact with the partner.
- Use only water-based or silicone-based lubricants (e.g., K-Y Jelly, Astroglide, AquaLube, or glycerin) with latex condoms. Oil-based lubricants (e.g., petroleum jelly, shortening, mineral oil, massage oils, body lotions, or cooking oil) can weaken latex and should not be used; however, oil-based lubricants typically can be used with polyurethane or other synthetic condoms.
- Ensure adequate lubrication during vaginal and anal sex, which might require using exogenous water-based lubricants.
- Hold the condom firmly against the base of the penis during withdrawal, and withdraw while the penis is still erect to prevent the condom from slipping off.
Additional information about external condoms is available at https://www.cdc.gov/condomeffectiveness.
Condoms for internal vaginal use, also known as female condoms, are available worldwide (e.g., the FC2 Female Condom, Reddy condom, Cupid female condom, and Woman’s condom) (31,32). Use of internal condoms can provide protection from acquisition and transmission of STIs, although data are limited. Internal condoms are more costly compared with external condoms; however, they offer the advantage of being controlled by the receptive partner as an STI and HIV prevention method, and the newer versions might be acceptable to all persons. Although the internal condom also has been used during receptive anal intercourse, efficacy associated with this practice remains unknown (33). Additional information about the internal condom is available at http://www.ashasexualhealth.org/pdfs/Male_and_Female_Condoms.pdf.
In observational studies, diaphragm use has been demonstrated to protect against cervical gonorrhea, chlamydia, and trichomoniasis (34). However, a trial examining the effect of a diaphragm plus lubricant on HIV acquisition among women in Africa reported no additional protective effect when compared with the use of male condoms alone. Likewise, no difference by study arm in the rate of acquisition of chlamydia, gonorrhea, or herpes occurred (35,36). Diaphragms should not be relied on as the sole source of protection against HIV and other STIs.
Methods that combine STI and HIV prevention with pregnancy prevention are known as multipurpose prevention technologies (MPTs) (37) (https://www.who.int/ reproductivehealth/topics/linkages/mpts/en). Internal and external condoms are both examples of MPTs because they are effective prevention measures when used correctly for STI and HIV transmission or pregnancy prevention. The multicenter Evidence for Contraception Options and HIV Outcomes (ECHO) trial observed no statistically significant differences in HIV incidence rates among women randomly assigned to one of three contraceptive methods (depot medroxyprogesterone acetate [DMPA], levonorgestrel implant, and copper-containing intrauterine device [IUD]); however, rates of HIV infection were high in all groups, indicating a need for MPTs (38). Development of MPTs is complex and ongoing; products under study include microbicides with contraceptive devices (e.g., tenofovir with a vaginal ring contraceptive delivery package) and other innovative methods (39).
Nonspecific topical microbicides are ineffective for preventing HIV infection (40–45). Tenofovir gel has been studied for prevention of herpes simplex virus 2 (HSV-2) and HIV infections (46,47). Adherence can be low (48), and prevention of HIV infection, especially among women, has not been demonstrated (47,49).Vaginal rings containing dapivirine have provided some reduction in HIV infection (50,51). For men and transgender women who have anal intercourse, tenofovir gel appears safe when applied before and after anal sex (52). Spermicides containing nonoxynol-9 (N-9) might disrupt genital or rectal epithelium and have been associated with an increased risk for HIV infection. Condoms with N-9 are no more effective than condoms without N-9; therefore, N-9 alone or in a condom is not recommended for STI and HIV prevention (40). N-9 use also has been associated with an increased risk for bacterial urinary tract infections among women (53,54).
Contraceptive methods that are not mechanical barriers offer no protection against HIV or other STIs. The ECHO study observed no differences in HIV incidence rates among women randomly assigned to DMPA, levonorgestrel implant, or copper-containing IUD contraceptive methods (38). A systematic review of epidemiologic evidence reported that the majority of studies demonstrated no association between use of oral contraceptives and HIV acquisition among women (55). Whether hormonal contraception alters a woman’s risk for other STIs is uncertain (56,57).
Sexually active women who use contraceptive methods other than condoms should be counseled about STI and HIV infection prevention measures. These include pre-exposure prophylaxis (PrEP) and postexposure prophylaxis (PEP), limiting the number of sex partners, and correct and consistent use of condoms.
Unprotected intercourse exposes women to risks for STIs and unplanned pregnancy. Providers should offer counseling about the option of emergency contraception if pregnancy is not desired. Options for emergency contraception in the United States include copper-containing IUDs and emergency contraceptive pills (ECPs) (58,59). More information is available at https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2015/09/emergency-contraception?utm_ source=redirect&utm_medium=web&utm_campaign=otn. ECPs are available in the following formulations: ulipristal acetate in a single dose (30 mg) available by prescription, levonorgestrel in a single dose (1.5 mg) available over the counter or by prescription, or a combined estrogen and progestin pill regimen. Insertion of a copper-containing IUD ≤5 days after unprotected sex can reduce pregnancy risk from a sex act by approximately 99% (60). ECPs are most efficacious when initiated as soon as possible after unprotected sex. Ulipristal acetate is effective ≤5 days after unprotected sex, and levonorgestrel is most effective ≤3 days after unprotected sex but has some efficacy at ≤5 days. ECPs are ineffective (but not harmful) if the woman is already pregnant (61). A 2019 Cochrane review summarized the efficacy, safety, and convenience of different emergency contraception methods (61).
More information about emergency contraception is available in Contraceptive Technology, 21st Edition (31), in the 2016 U.S. Selected Practice Recommendations (U.S. SPR) for Contraceptive Use (emergency contraception) available at https://www.cdc.gov/reproductivehealth/contraception/mmwr/spr/emergency.html, and in the 2016 U.S. Medical Eligibility Criteria (U.S. MEC) for Contraceptive Use (copper IUDs for emergency contraception) available at https://www.cdc.gov/reproductivehealth/contraception/mmwr/mec/appendixj.html.
Providers should educate males and females about emergency contraception, especially if other methods of contraception were used incorrectly or not at all and pregnancy is not desired (62). An advance supply of ECPs can be provided or prescribed so that ECPs will be available when needed (59).
Male circumcision reduces the risk for HIV infection and certain STIs among heterosexual men. Three randomized, controlled trials performed in regions of sub-Saharan Africa, where generalized HIV epidemics involving predominantly heterosexual transmission were occurring, demonstrated that male circumcision reduces the risk for HIV acquisition among men by 50%–60% (63–65). In those trials, circumcision also was protective against other STIs, including high-risk genital HPV infection and genital herpes (66–68). Follow-up studies have demonstrated sustained benefit of circumcision for HIV prevention (69) and that the effect is not mediated solely through a reduction in HSV-2 infection or genital ulcer disease (GUD) (70).
The World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) recommend that male circumcision efforts be scaled up as an effective intervention for preventing heterosexually acquired HIV infection (71) in countries with hyperendemic and generalized HIV epidemics within the context of ensuring universal access to comprehensive HIV prevention, treatment, care, and support (https://www.afro.who.int/publications/voluntary-medical-male-circumcision-hiv-prevention). In the United States, the American Academy of Pediatrics (AAP) recommends that newborn male circumcision be available to families that desire it because the benefits of the procedure, including prevention of penile cancers, urinary tract infections, GUD, and HIV infection, outweigh the risks. ACOG has also endorsed AAP’s policy statement. In light of these benefits, the American Urological Association states that male circumcision should be considered an option for risk reduction, among other strategies (72). Additional information for providers counseling male patients and parents regarding male circumcision for preventing HIV, STIs, and other adverse health outcomes is available at https://www.cdc.gov/hiv/risk/male-circumcision.html.
No definitive data exist to determine whether male circumcision reduces HIV acquisition among MSM, although one meta-analysis of 62 observational studies reported that circumcision was protective against HIV acquisition in low- to middle-income countries but not in high-income countries (73). Further studies are needed to confirm any potential benefit of male circumcision for this population.
Daily oral antiretroviral PrEP with a fixed-dose combination of emtricitabine (FTC) and either tenofovir disoproxil fumarate (TDF) or tenofovir alafenamide (TAF) have demonstrated safety (74) and a substantial reduction in the rate of HIV acquisition for MSM (75). TDF/FTC has demonstrated safety and efficacy for mixed-status heterosexual couples (76) and heterosexual men and women recruited individually (77); however, no evidence is yet available regarding TAF/ FTC among heterosexually active women. In addition, one clinical trial involving persons who inject drugs (78) and one involving heterosexual mixed-status couples (76) demonstrated substantial efficacy and safety of daily oral PrEP with TDF alone. High adherence to oral PrEP was strongly associated with protection from HIV infection. Studies conducted with MSM have demonstrated that taking PrEP at specific times before and after sexual intercourse was effective in preventing HIV; however, less experience exits with this regimen, it is not FDA cleared, and it has not been studied among other populations (79).
Comprehensive clinical practice guidelines are available for providers in prescribing PrEP to reduce the risk for HIV infection (80). Among HIV-negative sexually active men and women, bacterial STIs are key indicators of risk for HIV acquisition. Studies have documented the risk for HIV acquisition among MSM within 1 year after infection with rectal gonorrhea or chlamydia (one in 15 men), primary or secondary syphilis (one in 18), and among men with no rectal STI or syphilis infection (one in 53) (81–83). Sexually active adults and adolescents should be screened for STIs (e.g., chlamydia, gonorrhea, and syphilis) in accordance with recommendations, and persons with infection should be offered PrEP. The USPSTF recommends that persons at risk for HIV acquisition be offered PrEP (84). Persons at risk for HIV acquisition include HIV-negative persons whose sexual partner or partners have HIV infection (especially if viral load is detectable or unknown), persons who have had gonorrhea or syphilis during the previous 6 months, and injecting drug users who share injection equipment (84). Clinical practice guidelines recommend STI screening for persons taking PrEP (80) because increased rates of STI acquisition have been described (85–87).
Providing HSV treatment to persons with HIV and HSV infection has not demonstrated benefit in reducing HIV acquisition among uninfected partners. A large randomized controlled trial evaluated mixed-status heterosexual couples among the partners with HIV infection who also were seropositive for HSV-2 (88). Use of acyclovir had no effect on HIV transmission. These findings are consistent with a previous trial that reported no benefit of acyclovir in preventing HIV acquisition among persons seropositive for HSV-2 (89).
Doxycycline prophylaxis has been examined for preventing bacterial STIs. In a pilot study, 30 MSM living with HIV with previous syphilis (two or more episodes since HIV diagnosis) were randomly assigned to doxycycline 100 mg for 48 weeks versus a financial incentive–based behavioral intervention (90). That study demonstrated a 73% reduction in any bacterial STI at any site, without substantial differences in sexual behavior. Additional studies examining doxycycline prophylaxis are under way or in development (91).
Guidelines for using PEP aimed at preventing HIV and other STIs as a result of sexual exposure are available at https://www.cdc.gov/hiv/pdf/programresources/cdc-hiv-npep-guidelines.pdf. Sexually active persons seeking HIV PEP should be evaluated for PrEP after completing their PEP course and testing negative for HIV. HIV PEP is also discussed elsewhere in this report (see Sexual Assault and Abuse and STIs). Genital hygiene methods (e.g., vaginal washing and douching) after sexual exposure are ineffective in protecting against HIV and STIs and might increase the risk for bacterial vaginosis (BV), certain STIs, and HIV infection (92).
STI PEP in the form of doxycycline 200 mg taken after unprotected anal sex has been studied among MSM and transgender women; results demonstrated reduction in incident chlamydia and syphilis by 70% and 73%, respectively, but no effect on gonorrhea (93). Other studies are under way or in development regarding doxycycline prophylaxis for bacterial STIs (91). No long-term data are available regarding the impact of STI PEP on antimicrobial resistance and the microbiome. Further studies are needed to determine whether STI PEP is an effective and beneficial strategy for STI prevention.
As CDC and others work quickly to evaluate data to inform clinical guidance on the safe and effective use of doxycycline post-exposure prophylaxis (doxy-PEP) to prevent gonorrhea, chlamydia, and syphilis, we acknowledge there are individuals and clinicians who are already engaged in the off-label use of doxycycline as bacterial STI post-exposure prophylaxis or considering it. As such, we are providing the following considerations to inform those decisions:
- Current efficacy data only applies to gay and bisexual men and transgender women. Studies among heterosexual cis-gender women are ongoing.
- Doxycycline 200 mg administered within 24-72 hours of condomless sex was the regimen evaluated in this study. Other antibiotics should not be considered for PEP.
- In addition to informing patients about the potential STI prevention benefits of doxy-PEP, providers should also counsel patients about potential adverse side effects of doxycycline including phototoxicity, gastrointestinal symptoms, and more rarely esophageal ulceration.
- Providers should continue to screen, test, and treat for bacterial STIs in accordance with CDC’s STI Treatment Guidelines and CDC’s PrEP for the Prevention of HIV guidelines, even among people who may be using doxycycline as PEP or PrEP.
HIV Treatment as Prevention: Antiretroviral Treatment of Persons with HIV to Prevent HIV Among Partners
In 2011, the randomized controlled trial HPTN 052 demonstrated that, among HIV mixed-status heterosexual couples, HIV antiretroviral therapy (ART) for the infected partner decreased the risk for transmission to the uninfected partner by 96% (94). Therefore, ART not only is beneficial to the health of persons with HIV infection, it also reduces the risk for transmission. Additional studies of HIV mixed-status couples, heterosexual and MSM couples (PARTNER study), and MSM couples (Opposites Attract and PARTNERS2 studies) reported that patients with HIV taking ART who maintain an undetectable viral load demonstrate no risk for transmitting HIV to their HIV-negative sex partners (95–97). For those reasons, ART should be offered to all persons with HIV infection to obtain viral suppression. Detailed guidance regarding ART regimens is available in the U.S. Department of Health and Human Services’ HIV treatment guidelines (98).
Seroadaptive strategies for HIV prevention have largely originated within communities of MSM. They are predicated on knowledge of self and partner HIV status. One specific seroadaptive practice is serosorting, which includes limiting anal sex without a condom to partners with the same HIV status as their own or choosing to selectively use condoms with HIV mixed-status partners. Another practice among mixed-status couples is seropositioning, in which the person with HIV infection is the receptive partner for anal intercourse. Observational studies have consistently reported that serosorting confers greater risk for HIV infection than consistent condom use but has lower risk compared with anal intercourse without a condom and without serosorting (99– 101). Serosorting practices have been associated with increased risk for STIs, including chlamydia and gonorrhea (102,103).
Serosorting is not recommended for the following reasons: many MSM who have HIV infection do not know they have HIV because they have not been tested recently, men’s assumptions about the HIV status of their partners might be wrong, and some men with HIV infection might not disclose or might misrepresent their HIV status. All of these factors increase the risk that serosorting can lead to HIV infection. Serosorting has not been studied among heterosexually active persons.
Abstinence from oral, vaginal, and anal sex and participating in a long-term, mutually monogamous relationship with a partner known to be uninfected are prevention approaches to avoid transmission of STIs. For persons who are being treated for an STI (or whose partners are undergoing treatment), counseling that encourages abstinence from sexual intercourse until completion of the entire course of medication is vital for preventing reinfection. A trial conducted among women regarding the effectiveness of counseling messages when patients have cervicitis or vaginal discharge demonstrated that women whose sex partners have used condoms might benefit from a hierarchical message that includes condoms but women without such experience might benefit more from an abstinence-only message (104). A more comprehensive discussion of abstinence and other sexual practices that can help persons reduce their risk for STIs is available in Contraceptive Technology, 21st Edition (31).