Screening for Sexually Transmitted Infections – Who, When and How Often?

SYNOPSIS:

There are an estimated 2.8 million new chlamydia infections each year in the US and 1.5 million new cases of gonorrhea diagnosed. The highest rates of both gonorrhea and chlamydia are reported in women aged 15 to 24. Symptoms are vague and sequelae can include pelvic inflammatory disease, ectopic pregnancy and infertility.  A full comprehensive sexual history may identify other risk factors to prompt more comprehensive screening for sexually transmitted infections

CLINICAL ACTIONS:

Sexually transmitted infections (STIs) are common with potential for serious long term outcomes, and remain a serious public health concern.  Here, we outline the recommendations for screening for STIs by population:

Adults

• Annual screening for gonorrhea and chlamydia is recommended for all sexually active women <25 years | evidence is insufficient for routine testing of gonorrhea and chlamydia in heterosexual men
  • Re-testing is recommended 3 months after treatment due to high re-infection rates
  • Screening is recommended for adults >25 years old at increased risk for infection (new partner, multiple partners, or a partner who has an STI
  • Consider testing for rectal chlamydia and pharyngeal gonorrhea based on sexual history practices
  • Annual testing is recommended for men who have sex with men (MSM) and every 3-6 months if at higher risk
• Screening for syphilis is based on risk profile, with higher risk including history of incarceration, transactional sex work, geography, or male younger than 29 years old
  • Annual screening for syphilis is recommended in transgender and gender diverse persons
• Screening for HIV should be performed in all adults aged 13-64 and who seek evaluation and treatment for STIs | Annual HIV screening is recommended for MSM with more than one sexual partner, with consideration for more frequent 3-6 month intervals for testing
• Consider type-specific HSV serologic testing in patients presenting for an STI evaluation
• Consider screening for trichomonas in high-prevalence settings or patients at higher risk for infection (multiple sex partners, transactional sex, drug misuse, or a history of STI or incarceration)
• Adults at increased risk of Hepatitis B should be screened (more than one sex partner in the previous 6 months, evaluation or treatment for an STI, past or current injection-drug use, or a partner with Hepatitis B)
• Screening for hepatitis C infection (HCV) should take include all adults over age 18 years except in settings with HCV positivity < 0.1%
  • All persons with risk factors (eg., persons with HIV, prior recipients of blood transfusions, persons who ever injected drugs and shared needles, and persons who are born to an HCV-infected mother) should be tested for HCV, with periodic testing while risk factors persist

Pregnant Patients

• All pregnant patients less than 25, or older than 25 with risk factors, should be screened for gonorrhea and chlamydia and re-tested in the third trimester if at risk
• Pregnant women should be screened at the first prenatal visit for HIV and syphilis
  • Repeat screening for syphilis and HIV is recommended at 28 weeks (see ‘Related ObG Topics’ for more on screening in pregnancy) | More states are mandating third trimester repeat syphilis screening due to increasing prevalence
• Hepatits B screening with Hepatitis B surface antigen at first prenatal visit is recommended regardless of prior testing
• All pregnant women should undergo screening for Hepatitis C

Persons living with HIV

• At first HIV evaluation and annually afterwards, screen for
  • Gonorrhea
  • Chlamydia
  • Syphilis
  • Hepatitis B surface antigen and Hepatitis B immunity
  • Hepatitis C screening for all persons with HIV and subsequent annual testing for MSM
• Specifically for women with HIV
  • Screen for trichomonas for women at first evaluation and annually afterwards
  • Women should be screened within 1 year of sexual activity with testing repeat 65 months later | 3 normal and consecutive pap tests, screening can be spaced out to every 3 yeras

The USPSTF 2021 update

…recommends screening for chlamydia in all sexually active women 24 years or younger and in women 25 years or older who are at increased risk for infection. (B recommendation)

…recommends screening for gonorrhea in all sexually active women 24 years or younger and in women 25 years or older who are at increased risk for infection. (B recommendation)

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for chlamydia and gonorrhea in men

KEY POINTS:

• Screen sexually active women ≥25 for gonorrhea and chlamydia if at increased risk
• More comprehensive screening for STIs include evaluation for trichomonas, syphilis, HIV, Hepatitis B and Hepaittis C
• Increased risk for hepatitis B include those born in a region of high endemicity (see map in ‘Learn More – Primary Sources’ below), such as sub-Saharan Africa, East Asia, the Amazon, southern parts of Eastern and Central Europe or US-born persons not vaccinated with prevalence of Hepatitis B virus >8%
• CDC has updated guidelines to recommend universal Hepatitis C screening in pregnant patients and all adults (except where prevalence is < 0.1%)

Learn More – Primary Sources:

CDC: Sexually Transmitted Infections Treatment Guidelines 2021

CDC: A Guide to Taking a Sexual History

CDC Recommendations for Hepatitis C Screening Among Adults — United States, 2020

USPSTF: Screening for Hepatitis B Virus Infection in Adolescents and Adults

Map: Prevalence of hepatitis B virus infection

USPSTF: Screening for Chlamydia and Gonorrhea