USPSTF Recommends Universal Screening for Hepatitis C

SUMMARY:

  • USPSTF has reviewed available evidence and has updated its hepatitis C screening guidance. HCV is the most common chronic blood-borne pathogen in the US with potential for significant morbidity and mortality if left untreated. The prevalence of chronic HCV infection in the US is approximately 1.0% (2013 to 2016), with 44,700 new HCV infections in 2017. There has been an increase in acute infections over the last decade primarily due to increased injection drug use and better surveillance.
  • The USPSTF recommends screening for HCV infection in adults aged 18 to 79 years
  • Population: All asymptomatic adults aged 18 to 79 years without known liver disease
  • B level recommendation
    • Offer or provide this service
    • There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial

The USPSTF concludes with moderate certainty that screening for HCV infection in adults aged 18 to 79 years has substantial net benefit

Risk Assessment

  • Screen all adults ages 18 to 79 years
  • Risk factors to consider
    • Injection drug use: Consider screening adolescents <18 years or >79 years
      • Young adults (ages 18 to 30): Approximately 30% are infected
      • Older adults: 70% to 90% are infected
  • Pregnancy
    • Screen pregnant adults  

Because of the increasing prevalence of HCV in women aged 15 to 44 years and in infants born to HCV-infected mothers, clinicians may want to consider screening pregnant persons younger than 18 years

Screening Test

  • Anti-HCV antibody testing followed by polymerase chain reaction testing for HCV RNA
    • HCV infection can be detected by anti-HCV screening tests (enzyme immunoassay) 4 to 10 weeks after infection
    • Delayed seroconversion may occur in immunocompromised individuals (e.g., those with HIV infection)

Screening Intervals

  • “Most adults need to be screened only once”
    • Consider more frequent screening for individuals with ongoing risk (e.g., ongoing injection drug use)
    • Data is limited to determine optimal screening interval for those at continued risk or whether pregnancy impacts need for additional screening

KEY POINTS:

Hepatitis C Overview

  • Acute Hepatitis C occurs within the first 6 months after exposure to HCV
  • Many individuals will remain asymptomatic
  • 15% of patients will spontaneously clear the virus within 6 months
  • Signs and symptoms of acute HCV infection
    • Fever | Fatigue | Dark urine | Clay-colored stool | Abdominal pain | Loss of appetite | Nausea and vomiting | Joint pain | Jaundice
    • Most individuals with newly acquired HCV infection will be asymptomatic | 20 to 30% will exhibit symptoms
    • Symptoms will usually appear within 2 to 12 weeks (range: 2–26 weeks) 
  • Signs and of chronic HCV infection
    • Most people are asymptomatic or have non-specific symptoms (e.g., chronic fatigue and depression)
    • Many eventually develop chronic liver disease, which can range from mild to severe, including cirrhosis and liver cancer
    • Chronic HCV infection is typically not recognized until asymptomatic people are identified as HCV-positive when screened for blood donation or liver function tests return an abnormal result (e.g., elevated ALT), often during routine evaluation 

Hepatitis C Treatment

Acute

  • No treatment required
  • Consider treatment if HCV RNA persists after 6 months

Chronic

  • Current antiviral therapies can result in sustained virologic response (SVR; absence of detectable virus 12 weeks after completion of treatment)
    • SVR is indicative of a cure of HCV infection
    • Over 90% of HCV infected persons can be cured of HCV infection regardless of HCV genotype with 8-12 weeks of oral therapy
    • CDC provides a link to currently approved FDA therapies to treat hepatitis C (see ‘Learn More – Primary Sources’ below)

Other Professional Recommendations

  • AASLD/IDSA
    • One-time, routine, opt out HCV testing is recommended for all individuals aged 18 years and older
    • One-time HCV testing should be performed for all persons less than 18 years old with behaviors, exposures, or conditions or circumstances associated with an increased risk of HCV infection
    • Periodic repeat HCV testing should be offered to all persons with behaviors, exposures, or conditions or circumstances associated with an increased risk of HCV exposure
    • Annual HCV testing is recommended for all persons who inject drugs and for HIV-infected men who have unprotected sex with men
    • As part of prenatal care, all pregnant women should be tested for HCV infection, ideally at the initial visit
  • CDC
    • All adults 18 years and older (except in settings where the prevalence is > 0.1%)
    • All pregnant persons should be screened for HCV during each pregnancy (except in settings where the prevalence of HCV infection is > 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
  • SMFM (see ‘Related ObG Topics’ below) has released new guidance supporting the USPSTF/CDC recommendations and states

…we recommend that obstetrical providers screen all pregnant patients for HCV by testing for anti-HCV antibodies in every pregnancy

The timing of when to screen during pregnancy is somewhat arbitrary; screening in the first trimester would theoretically bring the most patients to attention at the earliest time

Learn More – Primary Sources:

Screening for Hepatitis C Virus Infection in Adolescents and Adults – US Preventive Services Task Force Recommendation Statement

AASLD / IDSA: HCV Testing and Linkage to Care

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

CDC link to FDA therapies to treat hepatitis C

Hepatitis C Questions and Answers for Health Professionals

Reported Prevalence of Maternal Hepatitis C Virus Infection in the United States

SMFM Consult Series #56: Hepatitis C in pregnancy—updated guidelines

Is it Time for Universal Prenatal Hepatitis C Screening?

BACKGROUND AND PURPOSE:

  • SMFM recommends screening for hepatitis C in pregnancy in women who are at high risk (see ‘Related ObG Topics’ below)
  • New medications can result in 95–99% Hepatitis C virus (HCV) cure
  • Due to opioid epidemic, incidence of HCV is rising in younger individuals
  • Tasillo et al. (Obstetrics & Gynecology, 2019) sought to determine the clinical effects and cost-effectiveness of universal prenatal hepatitis C screening using computer modeling

METHODS:

  • Stochastic individual-level micro-simulation model to simulate the lifetimes of 250 million pregnant women
  • Women were matched at baseline with the U.S. childbearing population for
    • Age
    • Injection drug use behaviors
    • Hepatitis C virus (HCV) infection status
  • Modeled outcomes included
    • Hepatitis C diagnosis | Treatment | Cure | Lifetime health care costs | Quality-adjusted life years (QALY) | Incremental cost-effectiveness ratios comparing universal prenatal hepatitis C screening to current practice
  • Authors also modeled the identification of neonates exposed to maternal HCV at birth

RESULTS:

  • Universal prenatal hepatitis C screening compared to current practice resulted in
    • Pregnant women with hepatitis C infection living 1.21 years longer and 16% lower HCV-attributable mortality
    • an incremental cost-effectiveness ratio of $41,000 per QALY gained
  • Incremental cost-effectiveness ratios remained below $100,000 per QALY gained in most additional analyses
    • Notable exceptions included
      • Incremental cost-effectiveness ratios above $100,000 when assuming mean time to cirrhosis of 70 years
      • A cost greater than $500,000 per false positive diagnosis
      • Population HCV infection prevalence below 0.16%
    • Universal prenatal hepatitis C screening increased identification of neonates exposed to HCV at birth from 44% to 92%

CONCLUSION:

  • Universal prenatal hepatitis C screening would result in
    • Improved health outcomes in women with HCV infection
    • Improved identification of at risk HCV-exposed newborns
  • The authors demonstrated that universal hepatitis C screening is cost effective and further state

Universal prenatal HCV testing should be considered in plans for the elimination of viral hepatitis C as a public health threat.

Learn More – Primary Sources:

Short-Term Effects and Long-Term Cost-Effectiveness of Universal Hepatitis C Testing in Prenatal Care

SMFM Releases Guidelines on Screening and Management of Hepatitis C in Pregnancy 

SUMMARY:

SMFM has released guidance on the screening, treatment and management of women infected with hepatitis C virus (HCV) in pregnancy. HCV is a global problem with at least 1% to 2.5% of women infected in the US alone. 8% of pregnant women are infected and there is a risk of transmission to the fetus.

KEY POINTS:

  • Acute Hepatitis C  occurs within the first 6 months after exposure to HCV
  • Most women will remain asymptomatic, with only 25% exhibiting symptoms | Symptoms typically appear within 2 to 12 weeks (range of 2 to 26 weeks) 
  • 15% of patients will spontaneously clear the virus within 6 months
  • Signs and symptoms of acute HCV infection
    • Fever | Fatigue | Dark urine | Clay-colored stool | Abdominal pain | Loss of appetite | Nausea and vomiting | Joint pain | Jaundice
    • Most individuals with newly acquired HCV infection will be asymptomatic 
  • Signs and of chronic HCV infection
    • Most people are asymptomatic or have non-specific symptoms (e.g., chronic fatigue and depression)
    • Many eventually develop chronic liver disease, which can range from mild to severe, including cirrhosis and liver cancer
    • Chronic HCV infection is typically not recognized until asymptomatic people are identified as HCV-positive when screened for blood donation or liver function tests return an abnormal result (e.g., elevated ALT), often during routine evaluation 

HCV and Pregnancy 

  • Pregnancy may be associated with a decrease in HCV liver damage, however data is conflicting 
  • HCV is associated with poor pregnancy outcomes 
    • Small for gestational age 
    • Fetal growth restriction  
    • Low birthweight 
    • Increased NICU admissions  
    • Preterm birth 
    • Intrahepatic cholestasis of pregnancy (odds with HCV are increased 20-fold over non-HCV population)
  • Congenital anomalies and GDM have also been reported 
  • Above findings are associations only and more research is required to determine causation

HCV and Vertical Transmission 

  • The risk of transmission is approximately 5%  
  • Risk only for women with detectable HCV RNA during pregnancy 
  • A pooled meta-analysis of 17 studies demonstrated the following risks in women with chronic HCV 
    • HIV neg: 5.8% 
    • HIV pos: 10.8% but may be lower in women using modern antiretroviral therapies 

Screening for HCV in Pregnancy 

SMFM recommends risk-based HCV screening in pregnancy

  • Screen high risk women at the first prenatal visit 
    • Past or current injection drug use (even once) 
    • Blood transfusion or transplants before July 1992 
    • Unregulated tattoo 
    • Long-term hemodialysis 
    • Intranasal drug use and other percutaneous exposures 
    • Long-term hemodialysis 
    • Recipients of clotting factor concentrates produced before 1987 
    • Recipients of blood products from donor who later tested positive for HCV 
    • History of incarceration 
    • Women seeking evaluation or care for sexually transmitted infection including HIV 
    • Unexplained chronic liver disease (including persistently elevated ALT) 

SMFM recommendations (Grade 1B) 

  • Test for anti-HCV antibodies at their first prenatal visit 
  • Negative anti-HCV antibodies 
    • Repeat later in pregnancy in women with persistent or new risk factors 
    • If HCV exposure < 6 months, perform HCV RNA as patient may not have seroconverted  
    • Positive anti-HCV antibodies: Follow up with HCV RNA 
  • Universal HCV screening is not recommended 

Obstetrical Management 

  • Invasive prenatal diagnosis 
    • Data on risk of invasive testing appears ‘reassuring but limited’ 
    • Amniocentesis recommended over CVS (Grade 2C) 
  • HCV is not an indication for cesarean section in isolation (Grade 1B) 
  • Avoid internal fetal heart monitoring, prolonged rupture of membranes and episiotomy (Grade 1B) 

Treatment  

  • Screen for other for other STDs (Grade 1B) 
    • Overlapping risk factors between HCV and HBV  
  • Counsel patients to avoid alcohol (Best Practice)  
  • No antiviral therapies for HCV infection are approved in pregnancy 
    • Direct-acting antiviral (DAA) agents should only be used in pregnancy in the setting of a clinical trial or defer to postpartum (Grade 1C) 
  • Ribavirin is contraindicated in pregnancy due to potential teratogenicity 

Postpartum  

  • Breast feeding should NOT be discouraged (Grade 1A) 
  • Presence of anti-HCV antibodies in newborn is not diagnostic 
  • The CDC recommends that  
    • Children should be tested for anti-HCV > age 18 months because anti-HCV from the mother might last until this age 
    • If diagnosis is desired before the child turns 18 months, testing for HCV RNA could be performed at or after the infant’s first well-child visit at age 1–2 months 
      • HCV RNA testing should then be repeated at a subsequent visit, independent of the initial HCV RNA test result 

Other Guidance on Prenatal Screening for HCV

  • ACOG also currently advise risk-based screening
  • USPSTF recommends universal screening, including pregnant women,  between ages 18 and 79|The USPSTF guidelines include the following data and rationale for potentially offering screening to pregnant women <18 years of age
    • HCV prevalence has doubled in women aged 15 to 44 years (2006 to 2014)
    • 0.73% of pregnant women tested had an HCV infection (2011 to 2014), with a 68% increase in the proportion of infants born to HCV-infected mothers
    • Approximately 1700 infected infants are born annually to 29,000 HCV-infected mothers
    • “Because of the increasing prevalence of HCV in women aged 15 to 44 years and in infants born to HCV-infected mothers, clinicians may want to consider screening pregnant persons younger than 18 years.” 
  • CDC recommends universal screening for HCV
  • AASLD and IDSA (2018) recommend universal screening in pregnancy, ideally at the initiation of prenatal care (see ‘Learn More – Primary Sources’ below)

Learn More – Primary Sources:  

SMFM Consult Series #43, Hepatitis C in pregnancy: screening, treatment, and management

AASLD / IDSA: HCV in Pregnancy

CDC: Hepatitis C FAQs for Health Professionals

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

Reported Prevalence of Maternal Hepatitis C Virus Infection in the United States

USPSTF: Screening for Hepatitis C Virus Infection in Adolescents and Adults US Preventive Services Task Force Recommendation Statement

What is the Effect of Hepatitis C on Fertility and Pregnancy Outcomes?

BACKGROUND AND PURPOSE:

  • Hepatitis C in premenopausal women can lead to failing ovarian function
  • Karampatou (Journal of Hepatology, 2017) assessed fertility and adverse pregnancy outcomes in HCV+ women

METHODS:

  • 3 different cohorts were studied:
    • 100 HCV+ women with chronic liver disease (CLD), were age matched in a 2:1 proportion with 50 HBV+ women with CLD and 1:1 proportion with 100 healthy women (Italian GI unit)
    • 1,998 HCV+ women enrolled in the Italian Platform for the Study of Viral Hepatitis Therapies (PITER)
    • 6,085 HCV+; 20,415 HCV-/HIV-; 305 HCV+/HIV+ women from a large de-identified insurance database from US
  • Total fertility rate (TFR) was defined as the average number of children that a woman would bear during her lifetime
  • Anti-mullerian hormone (AMH) and 17β-Estradiol were used to define reproductive stage

RESULTS:

  • Data from group 1
    • HCV+ and HBV+ women had similar CLD and age at first pregnancy
    • HCV+ women had higher risk of miscarriage than HBV+ (odds ratio [OR] 6.905; 95% CI 1.771-26.926)
    • HCV infection alone (OR 9.363; 95% CI 2.569-34.123, P<0.001) was significantly associated with miscarriage (multivariate analysis)
    • HCV+ women more likely to have AMH levels in the menopausal range compared to HBV+ women
    • Achieving sustained virologic response after antiviral treatment reduced the risk of miscarriage (OR 0.255; 95% CI 0.090–0.723) compared to women who failed antiviral therapy
  • PITER cohort
    • Miscarriage occurred in 42.0% of women (44.6% had multiple miscarriages)
  • TFR for HCV+ women between 15 and 49 years was 0.7 vs. 1.37 of Italian population of the same age range
  • US cohort
    • HCV+ compared to HCV- women had a significantly higher probability of
      • Infertility (OR 2.439; 95% CI 2.130-2.794)
      • Premature birth (OR 1.34; 95% CI 1.06-1.69)
      • Gestational diabetes (OR 1.24; 95% CI 1.02-1.51)
      • Less likely to report a live birth (OR 0.754; 95% CI 0.622-0.913)

CONCLUSION:

  • HPV+ women are more likely to suffer from a number of adverse pregnancy outcomes and impaired fertility and miscarriage
  • These outcomes may be positively influenced by the newer generation of antiviral drugs

Learn More – Primary Sources:

Premature ovarian senescence and high miscarriage rate impair fertility in women with hepatitis C virus infection

Practical obstetrics info for your women's healthcare practice

STI Screening in Pregnancy: CDC Recommendations

CLINICAL ACTIONS:  

Pregnant women are considered a ‘special population’ by the CDC. Due to the potential burden to pregnant women, offspring and partners, providers should ask all pregnant women and their partners about STIs, and ensure counseling, screening and treatment are available.

SPECIFIC STIs: 
HIV
SYPHILIS
HEPATITIS B
CHLAMYDIA
GONORRHEA
HEPATITIS C
BACTERIAL VAGINOSIS
TRICHOMONAS
HSV-2

SCREENING RECOMMENDATIONS INFOGRAPHIC

Recommended Screening Tests for ALL Pregnant Women

HIV

  • ‘Opt-out screening’ – screen at first prenatal visit after notifying patient of the need to be screened, unless patient declines
    • Screen in prepregnancy or as early as possible in pregnancy
  • If patient declines, address concerns and discuss the following
    • A previous negative HIV test does not mean patient is still negative
    • Health benefit not only to patient but to fetus/offspring as treatment available to reduce perinatal transmission
  • Retest in the 3rd trimester (before 36 weeks, if possible) if at high risk
    • Illicit drug use
    • STI during pregnancy
    • Multiple sex partners during pregnancy
    • Live in areas of high HIV incidence
    • Receiving care in facilities with an HIV incidence in pregnant women ≥1/1,000 per year
    • Partner has HIV
    • Signs or symptoms of acute HIV infection
      • Fever | Lymphadenopathy | Skin rash | Myalgias | Arthralgias | Headache | Oral Ulcers | Leukopenia | Thrombocytopenia | Elevated transaminase
  • Rapid HIV testing should be performed on any woman in labor who has not been screened during pregnancy, unless she declines
    • If rapid HIV test positive, antiretroviral prophylaxis should be administered prior to receiving confirmatory test results
    • AAP recommends expedited HIV testing as soon as possible after birth for infants born to women with unknown HIV status
  • NOTE: The USPSTF (June 2019) continues to recommend screening for HIV infection in all pregnant persons, including those who present in labor or at delivery whose HIV status is unknown. (A recommendation)

SYPHILIS

  • Serologic tests should be performed at first prenatal visit
  • Screening for syphilis infection is a 2-step process | Antepartum screening can be performed by manual nontreponemal antibody testing (e.g., RPR) by using the traditional syphilis screening algorithm or by treponemal antibody testing (e.g., immunoassays)
    • Traditional screening: Initial “nontreponemal” antibody test (ie, Venereal Disease Research Laboratory test or rapid plasma reagin [RPR] test) to detect biomarkers released from damage caused by syphilis infection, followed by a confirmatory “treponemal” antibody detection test (ie, fluorescent treponemal antibody absorption [FTA-ABS] or T pallidum particle agglutination test [TP-PA])
    • Reverse sequence screening algorithm: Automated treponemal test (such as an enzyme-linked [EIA], chemiluminescence [CIA], or multiplex flow immunoassay [immunoblot]) performed first, followed by a nontreponemal test
      • If the test results of the reverse sequence algorithm are discordant, a second treponemal test (preferably using a different treponemal antibody) is performed
    • Pregnant women with positive treponemal screening tests (e.g., EIA, CIA, or immunoblot) should have additional quantitative nontreponemal testing because titers are essential for monitoring treatment response
  • If access to prenatal care is suboptimal, RPR test and treatment should be performed at time of pregnancy confirmation
  • Serologic retesting in the 3rd trimester (28 weeks) and at delivery if the patient for patients at high risk including
    • Sex with multiple partners | Sex in conjunction with drug use or transactional sex
    • Late entry to prenatal care (i.e., first visit during the second trimester or later) or no prenatal care
    • Methamphetamine or heroin use
    • Incarceration of the woman or her partner
    • Unstable housing or homelessness
  • Test any woman who delivers a stillborn or in the case of infant death
    • Untreated syphilis has a 40% infant death rate
  • Do NOT discharge neonate if serologic status is unknown
    • Newborn infection may not be immediately obvious
    • Within a few weeks may develop
      • Developmental delay
      • Seizures
      • Birth defects such as bone deformation, blindness and deafness

Note: In September 2018, the USPSTF reaffirmed previous guidance and “recommends early screening for syphilis infection in all pregnant women.” (Grade A – Offer or Provide this Service)

HEPATITIS B (HBV)

  • Test for hepatitis B surface antigen (HBsAg) at the first prenatal visit regardless of previous testing or vaccination
  • At time of admission for delivery, retest if patient:
    • Is at high risk – more than one sex partner in previous 6 months, evaluation or treatment for STI, injection-drug use, HBsAG-positive sex partner
    • Was not screened prenatally
    • Has clinical hepatitis
  • Always do HBsAg testing prior to giving the HBV vaccine to avoid misinterpretation
  • Report HBsAg positive women to local or state health departments to ensure they are entered into a case management program to arrange access to appropriate vaccinations for contacts and prophylaxis for infants
    • If HBsAg positive, test for hepatitis B virus deoxyribonucleic acid (HBV DNA) to guide the use of antiviral medication to prevent perinatal transmission
    • If HBV DNA >200,000 IU/mL (7.6 log10 IU/mL): The American Association for the Study of Liver Diseases suggests antiviral therapy during pregnancy to further reduce perinatal HBV transmission

Recommended Screening Tests for Pregnant Women at Risk

CHLAMYDIA 

  • Test all pregnant women who are <25 years old for Chlamydia trachomatis at the first prenatal visit
  • Test all older women if at high risk:
    • More than one sex partner
    • A sex partner with concurrent partners or has an STI
  • Retest in the 3rd trimester to prevent maternal postnatal complications and chlamydia infection in the neonate
  • Test of cure by NAAT 3 to 4 weeks after treatment and retest within 3 months

GONORRHEA 

  • Test all pregnant women who are <25 years old for N. gonorrhoeae at the first prenatal visit
  • Test all older women if at high risk:
    • More than one sex partner
    • A sex partner with concurrent partners or has an STI
    • Inconsistent condom use in non-monogamous relationships
    • Previous or co-existing sexually transmitted infections
    • Exchanging sex for money or drugs
    • Consider consulting local public health authorities for further guidance on identifying those at high risk related to geographic location 
  • Treat all positive patients immediately and retest in 3 months
  • Retest in the 3rd trimester to prevent maternal postnatal complications and chlamydia infection in the neonate

HEPATITIS C (HCV) 

  • The CDC has updated HepC guidelines (2020)
    • Hepatitis C screening at least once in a lifetime for all adults aged ≥18 years, except in settings where the prevalence of HCV infection (HCV RNA-positivity) is <0.1%
    • Hepatitis C screening for all pregnant women during each pregnancy, except in settings where the prevalence of HCV infection (HCV RNA-positivity) is <0.1%
  • USPSTF also calls for universal screening for HCV infection, including pregnancy

Screen Only if Symptomatic

Bacterial Vaginosis (BV)

  • Evidence does not support routine screening
  • Evaluate and screen symptomatic women
  • The USPSTF addresses BV screening during pregnancy and states the following

The USPSTF addresses BV screening during pregnancy and states the following
The USPSTF recommends against screening for bacterial vaginosis in pregnant persons not at increased risk for preterm delivery. (D recommendation)

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for bacterial vaginosis in pregnant persons at increased risk for preterm delivery. (I statement)

Trichomonas

  • Evidence does not support routine screening 
  • Evaluate and screen symptomatic women

HSV-2

  • Evidence does not support routine screening
  • In the absence of lesions during the 3rd trimester, routine cultures for HSV are not indicated for women in the 3rd trimester who have a history of recurrent genital herpes
  • Type-specific serologic tests may help identify pregnant women at risk for HSV and to help guide counseling regarding the risk of acquiring herpes during pregnancy

SYNOPSIS:

Recommendations for STI testing can vary based on certain considerations, including state laws. The CDC recommendations are considered broader, such that more women will potentially be screened, but are consistent with other CDC guidance with the intention of preventing adverse outcomes for pregnant women, partners and fetuses.

KEY POINTS:

  • All pregnant women and their partners should be asked about STIs and counseled regarding personal risks as well as pregnancy and outcomes
  • Pap Smears should be performed in pregnancy at the same frequency as nonpregnant women
    • Management of abnormal Pap tests differ in pregnancy

Screening at Delivery

SYPHILIS 

  • Select groups of pregnant women, including women who are at high risk for syphilis or live in areas of high syphilis morbidity
  • Pregnant women with no previously established status
  • Pregnant women who deliver a stillborn infant

HIV

  • Pregnant women not screened during pregnancy

HBV

  • Women admitted for delivery at a health care facility without documentation of HBsAg test results should have blood drawn and tested as soon as possible after admission
  • Women at high risk
    • Having had more than one sex partner during the previous 6 months, an HBsAg-positive sex partner, evaluation or treatment for a sexually transmitted disease, or recent or current injection-drug use
  • Women with signs or symptoms of hepatitis

Note: CDC recommends universal hepatitis B vaccination within 24 hours of birth for medically stable infants >2000 grams

  • Permissive language that allowed the vaccine to be delayed until after hospital discharge has been removed
  • Administer hepatitis B vaccination and hepatitis immune globulin regardless of birth weight within 12 hours of birth for infants born to hepatitis b-infected mothers

CHLAMYDIA

  • Pregnant women less than 25 years of age
  • Continued high risk
    • New or multiple sex partners, sex partner with concurrent partners, sex partners who have a sexually transmitted disease

GONORRHEA 

  • Continued high risk
    • Past or current injection-drug use, having had a blood transfusion before July 1992, receipt of an unregulated tattoo, having been on long-term hemodialysis, intranasal drug use, and other percutaneous exposures

Learn More – Primary Sources:

CDC: Sexually Transmitted Infections Treatment Guidelines 2021

CDC: Syphilis Fact Sheet (Detailed)

Current Perspectives on Prevention of Mother-to-Child Transmission of Syphilis

ACOG Committee Opinion 752: Prenatal and Perinatal Human Immunodeficiency Virus Testing: Expanded Recommendations

CDC: A Guide to Taking a Sexual History

CDC: Prevention of Hepatitis B Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices

ACOG Practice Advisory: Hepatitis B Prevention

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

Screening for Syphilis Infection in Pregnant Women: US Preventive Services Task Force Reaffirmation Recommendation Statement

Screening for HIV Infection: US Preventive Services Task Force Recommendation Statement

Screening for Hepatitis B Virus Infection in Pregnant Women: US Preventive Services Task Force Reaffirmation Recommendation Statement

USPSTF: Screening for Bacterial Vaginosis in Pregnant Persons to Prevent Preterm Delivery

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