Clinical update in sexually transmitted disease –2014

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ABSTRACTSexually transmitted diseases (STDs) and their associated syndromes are extremely common in clinical practice. Early diagnosis, appropriate treatment, and partner management are important to ensure sexual, physical, and reproductive health in our patients.


  • Anyone can have an STD, although the prevalence is higher in some groups, such as younger sexually active people, certain racial and ethnic minorities, men who have sex with men, and people who engage in risky sexual behavior.
  • Preexposure vaccination is one of the most effective ways to prevent human papillomavirus, hepatitis A virus, and hepatitis B virus infections.
  • The risk of acquiring human immunodeficiency virus is two to five times higher if the patient has a genital ulcerative disease such as syphilis or herpes at the time of exposure.
  • Chlamydia trachomatis and Neisseria gonorrhoeae are major players in urethritis, cervicitis, and proctitis.
  • The most common conditions associated with vaginitis include bacterial vaginosis, trichomoniasis, and candidiasis.



With nearly 20 million new infections annually, sexually transmitted diseases (STDs) are very common in the United States.1,2 And with recent changes to the national health care landscape, including the passage of the Affordable Care Act and state budget cuts resulting in the closure of STD and human immunodeficiency virus (HIV) clinics, primary care providers can expect to encounter more patients with STDs.

For women and infants, STDs can have serious and long-term consequences, including infertility, facilitation of HIV infection, reproductive tract cancer, pelvic inflammatory disease, and poor perinatal outcomes.2 STDs cost the US health care system nearly $16 billion every year.3

STD prevention and control strategies traditionally include surveillance, screening, behavioral interventions, treatment, and partner management.4 This paper will review patient management by syndrome and provide guidance to clinicians to facilitate timely diagnosis and treatment, important components of any effective STD prevention strategy.


STDs affect people of all races, ages, and sexual orientations. That said, some groups are at greater risk:

Adolescents and young adults. Persons ages 15 through 24 represent 25% of the sexually experienced population in the United States but account for nearly half of all incident STDs.1

Racial and ethnic minorities. STD disparities are one of the five greatest health disparities for African American communities.4

Men who have sex with men number approximately 2% to 4% of the US male population, yet account for approximately 70% of reported cases of primary and secondary syphilis and more than 50% of persons with HIV infection.3,5,6


A thorough sexual history will reveal behaviors that place a person at risk of infection. The US Preventive Services Task Force (USPSTF) defines high-risk sexual behavior as having multiple current partners, having a new partner, using condoms inconsistently, having sex while under the influence of alcohol or drugs, or exchanging sex for money or drugs.7

An effective strategy for obtaining a sexual history is the “five Ps”8:

  • Partners (eg, Do you have sex with men, women, or both?)
  • Prevention of pregnancy (eg, What are you doing to prevent pregnancy?)
  • Protection from STDs (eg, What do you do to protect yourself from STDs?)
  • Practices (eg, To understand your risks for STDs, I need to understand the kind of sex you have had recently.)
  • Past history of STDs (eg, Have you ever had an STD?).8

The USPSTF and the US Centers for Disease Control and Prevention (CDC) recommend certain populations be screened for STDs.7,8

Everyone age 13 through 64 should be tested for HIV at least once, per CDC recommendation.8

Sexually active females up to age 24 should routinely be screened for chlamydia every year.7,8

Nonpregnant women at higher risk of infection should be screened for gonorrhea and syphilis.

Pregnant women, regardless of risk, should be screened for chlamydia, hepatitis B, HIV, and syphilis; pregnant women at higher risk of infection should also be screened for gonorrhea and hepatitis C.7,9

Men should be screened for HIV, and men at higher risk should also be screened for syphilis.8

Men who have sex with men should be screened at least annually for HIV and syphilis and undergo a test for urethral chlamydia and gonorrhea infection. Men who participate in receptive anal intercourse should be tested for rectal chlamydia and gonorrhea and, in those who participate in oral intercourse, for pharyngeal gonorrhea.8


Vaccination against HPV, hepatitis A and B

Preexposure vaccination is one of the most effective ways to prevent human papillomavirus (HPV), hepatitis A, and hepatitis B infection.10

HPV vaccination. The Advisory Committee on Immunization Practices recommends routine HPV vaccination of female patients at age 11 or 12, or through age 26 if not previously vaccinated.11,12 Routine vaccination is also recommended for males at age 11 or 12 and through age 21, if not previously vaccinated.12 The upper age is extended through age 26 for men who have sex with men and for immunocompromised patients.12

Two HPV vaccines are available for females; one is quadrivalent and the other is bivalent. Both protect against two HPV types that cause cervical and other HPV-associated cancers.11 The quadrivalent vaccine also protects against the two types that cause 90% of genital warts.13 Only the quadrivalent vaccine is licensed for use in males.12

Hepatitis A and B vaccination. Hepatitis B vaccination is recommended for all unvaccinated, uninfected patients being evaluated for an STD.8,14

Vaccinating for hepatitis A and hepatitis B is important for men who have sex with men, who have a higher risk of acquiring and transmitting these infections.15

Other preventive practices

Male circumcision has been shown to reduce the risk of HIV infection, high-risk genital HPV infection, and genital herpes in heterosexual men.10,16,17

Male condoms, when used consistently and correctly, can reduce the risk of chlamydia, gonorrhea, and trichomoniasis.8 The risk of transmission of syphilis, genital HPV, and genital herpes can also be reduced by correctly and consistently using condoms when the infected area of exposure is covered.8

Microbiocides not recommended. Topical microbiocides do not have not enough evidence to recommend them for STD prevention. However, limited data suggest that tenofovir 1% vaginal gel may reduce the risk of acquiring genital herpes simplex virus type 2 (HSV-2) infection in women.18,19


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