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:

General Population

Gonorrhea and Chlamydia

• 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, consider screening young men in high prevalence clinical settings e.g. adolescent clinics, correctional facilities, STI/sexual health clinic
  • 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) at sites of contact (urethra, rectum)and every 3-6 months if at higher risk e.g. MSM on pre-exposure prophylaxis (PrEP), HIV infection, or if they or their sex partners have multiple partners
  • Transgender and Gender Diverse Persons screening adapted based on anatomy

The USPSTF 2021 Update: Chlamydia and Gonorrhea Screening

…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

Syphilis

• 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 sexually active MSM | 3 to 6 months if at increased risk
  • Annual screening for syphilis is recommended in transgender and gender diverse persons

HSV

• Consider type-specific HSV serologic testing in patients presenting for an STI evaluation (especially if multiple partners)

Note: USPSTF “recommends against routine serologic screening for genital HSV infection in asymptomatic adolescents and adults, including those who are pregnant”

Trichomonas

• 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)

Hepatitis B

• Screen all adults aged ≥18 years at least once during a lifetime (CDC recommendation)
• Use triple Panel: 3 main serologic markers used to determine HBV infection status
  • Hepatitis B surface antigen (HBsAg) | Antibody to hepatitis B surface antigen (anti-HBs) | Antibody to hepatitis B core antigen (anti-HBc)
• Test individuals with a history of risk for HBV infection, regardless of age, if they might have been susceptible during the period of risk
  • Susceptible persons include those who have never been infected with HBV (i.e., total anti-HBc negative) and either did not complete a HepB vaccine series per ACIP recommendations or who are known vaccine nonresponders
• Periodically test susceptible persons, regardless of age, who have ongoing risk | Offer testing if the risk for exposure occurred after previous HBV serologic testing and while the person was susceptible
• CDC expands risk-based testing recommendations to the following populations
  • Activities, exposures, or conditions associated with increased risk for HBV infection
  • Persons incarcerated or formerly incarcerated in a jail, prison, or other detention setting
  • Persons with a history of STIs or multiple sex partners
  • Persons with a history of hepatitis C virus infection
• Offer testing to anyone who requests HBV testing

Hepatitis C 

• 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

HIV

• Screening for HIV should be performed in all individuals aged 15 to 65 | Younger adolescents and older adults who are at increased risk of infection should also be screened
• Annual HIV screening is recommended for MSM with more than one sexual partner, with consideration for more frequent 3-6 month intervals for testing
• The USPSTF recommends screening for HIV in all pregnant persons, including those who present in labor or at delivery whose HIV status is unknown
• People who are at increased risk for HIV should be screened at least annually
  • People who inject drugs and their sex partners
  • People who exchange sex for money or drugs
  • Sex partners of people with HIV
  • Sexually active gay, bisexual, and other men who have sex with men (more frequent testing may be beneficial [e.g., every 3–6 months])
  • Heterosexuals who themselves or whose sex partners have had ≥1 sex partner since their most recent HIV test
  • People receiving treatment for hepatitis, tuberculosis, or STIs

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 years
  • For pregnant women: repeat testing during the third trimester in women with risk factors and in women living or receiving care in high-incidence settings who had a negative test result earlier in pregnancy | CDC notes that repeat testing in the third trimester may be considered for all women with a negative test result early in pregnancy

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 Hepatitis C
• CDC has updated guidelines to recommend universal Hepatitis C and Hepatitis B screening in all adults

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

CDC: Screening and Testing for Hepatitis B Virus Infection 2023

USPSTF: Screening for Chlamydia and Gonorrhea

USPSTF: Serologic Screening for Genital Herpes Infection

USPSTF: Recommendation: Human Immunodeficiency Virus (HIV) Infection Screening