The CDC recently published an update to its 2010 sexually transmitted disease (STD) treatment guidelines in order to address key questions regarding the treatment and clinical management of these diseases. Published in the Morbidity and Mortality Weekly Report (MMWR), the guideline addresses several key updates, including:
- Alternative treatment regimens for Neisseria gonorrhoeae.
- The use of nucleic acid amplification tests for the diagnosis of trichomoniasis.
- Alternative treatment options for genital warts.
- The role of Mycoplasma genitalium in urethritis/cervicitis and treatment-related implications.
- Updated HPV vaccine recommendations and counseling messages.
- The management persons who are transgender.
- Annual testing for hepatitis C in individuals with HIV infection.
- Updated recommendations for diagnosing urethritis.
- Retesting for chlamydia, gonorrhea, and trichomoniasis to detect repeat infections.
A Focus on Risk Assessment
As the guideline indicates, primary prevention of STDs should include behavioral and biologic risk assessment. As part of the clinical encounter, the CDC recommends that clinicians routinely obtain sexual histories and address risk reduction using the “Five Ps” approach (Table).
“Regarding partners, clinicians should ask patients if they have sex with men, women, or both,” explains Kimberly A. Workowski, MD, FACP, FIDSA, lead author of the guideline update. “They should also ask about how many partners they’ve had in the last 2 and 12 months and whether it’s possible that their partners have other partners.”
In terms of practices, Dr. Workowski says it is important to know if patients are engaging in vaginal, oral, or anal sex because certain infections can reside in certain anatomic sites of exposure and, in many instances, may infect patients without symptoms. Additional questions pertain to past history of sexually transmitted infections and whether any sexual partners have ever had a sexually transmitted infection. Clinicians should also address the methods that patients are using to prevent pregnancy.
According to Dr. Workowski, performing a behavioral risk assessment should be accompanied by screening tests, because sexually transmitted infections are biologic markers of risk. Identification of risk behaviors may also encourage clinicians to provide risk reduction by providing prevention counseling. Clinicians can use resources from the CDC’s Division of STD Prevention and review the curriculum provided by the division’s training centers for additional guidance when obtaining sexual history.
“Many STDs affect patients without noticeable symptoms, which may come as a surprise to patients and lead them to be unaware of an infection” explains Dr. Workowski. “For this reason, it’s important for clinicians to ask the right questions regarding sexual activity and behaviors. We must then provide the appropriate screening tests in patients suspected to be at risk. It’s also important for clinicians to educate sexually active patients that many STDs don’t have symptoms. Empowering patients with this information can help them think about how they can practice safer sexual practices and ensure that they are aware of methods to prevent the transmission of STDs to sexual partners.”
The prevention and control of STDs are important themes in the guideline. Dr. Workowski and colleagues note that this should be based on five major strategies:
- Accurate risk assessment and education and counseling of at-risk people on ways to avoid STDs through changes in sexual behaviors and use of recommended prevention services.
- Pre-exposure vaccination of people at risk for vaccine-preventable STDs.
- Identification of both asymptomatic and symptomatic STDs.
- Effective diagnosis, treatment, counseling, and follow-up of infected people.
- Evaluation, treatment, and counseling of sex partners of people infected with STDs.
A Multimedia Experience
Multiple formats of the CDC’s guideline are available to meet clinicians’ preferences, according to Dr. Workowski. “Aside from the print version that was published in MMWR, there are wall charts that can be displayed in clinics, pocket guides for quick referencing, a smartphone and tablet app, and a bound guideline that can all be ordered through the CDC website,” she says. A webinar is also available on the CDC website that discusses the revised guidance and STD prevention; epidemiologic trends related to STD prevention; and key screening, treatment, and emerging antimicrobial resistance recommendations.
“If clinicians still have questions regarding the prevention and management of STDs, they can access the National Network of STD Clinical Prevention Training Centers for access to experts in the management and treatment of sexually transmitted infections,” says Dr. Workowski. “Clinicians can get answers to consultation requests quickly if they have difficulty obtaining information on the evaluation and management of a particular infection or syndrome.”
Workowski K, Bolan. Sexually transmitted disease treatment guidelines, 2015. MMWR. 2015;64:1-137. Available at www.cdc.gov/std/tg2015/tg-2015-print.pdf.
O’Connor E, Lin J, Burda B, et al. USPSTF: behavioral sexual risk-reduction counseling in primary care to prevent sexually transmitted infections. Ann Intern Med. 2014;161:874-883.
LeFevre ML. USPSTF: behavioral counseling interventions to prevent sexually transmitted infections. Ann Intern Med. 2014;161:894-901.
Metsch L, Feaster D, Gooden L, et al. Effect of risk-reduction counseling with rapid HIV testing on risk of acquiring sexually transmitted infections: the AWARE randomized clinical trial. JAMA. 2013;310:1701-1710.