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Screening for sexually transmitted infections

Screening for sexually transmitted infections
Literature review current through: Jan 2024.
This topic last updated: May 26, 2022.

INTRODUCTION — Sexually transmitted infections (STIs) are a major public health problem in both resource-rich and limited settings. STIs are frequently asymptomatic and can lead to various complications. The immediate goal of screening for STIs is to identify and treat infected persons before they develop complications and to identify, test, and treat their sex partners to prevent transmission and reinfections.

In this topic, we discuss screening for STIs among asymptomatic individuals. In its 2021 guidelines on the treatment of sexually transmitted infections, the United States Centers for Disease Control and Prevention (CDC) also made recommendations on screening [1]. The US Preventive Services Task Force (USPSTF) has also released guidelines on screening for various STIs [2-4]. The Infectious Diseases Society of America's HIV Medical Association has published STI screening recommendations for persons with HIV [5]. The recommendations in this topic are largely consistent with these guidelines. Other subspecialty group guidelines and national guidelines may be more pertinent in certain settings [6-9].

Information on the clinical presentation, diagnosis, and treatment of specific STIs is reviewed in detail separately, as are a number of related topics:

The approach to patients with specific genitourinary symptoms and signs:

(See "Vaginitis in adults: Initial evaluation".)

(See "Pelvic inflammatory disease: Clinical manifestations and diagnosis".)

(See "Approach to the patient with genital ulcers".)

(See "Acute simple cystitis in adult and adolescent females".)

STIs and HIV infection in adolescents:

(See "Sexually transmitted infections: Issues specific to adolescents".)

(See "The adolescent with HIV infection".)

Prevention of STIs:

(See "Prevention of sexually transmitted infections".)

Guidelines for STI screening for individuals using pre-exposure prophylaxis (PrEP) for HIV prevention

(See "HIV pre-exposure prophylaxis".)

RATIONALE — Complications of untreated sexually transmitted infections (STIs) include upper genital tract infections, infertility, chronic pelvic pain, cervical cancer, and chronic infection with hepatitis viruses and HIV. The approach to STI diagnosis and management is based upon disease or symptom-specific syndromes, including vaginal discharge, urethral discharge, ulcerative genital disease, nonulcerative genital disease, and pelvic pain. However, many patients have asymptomatic disease, which increases the risk of complications and sustained transmission in the community. Thus, screening is an important approach to identify and treat infected individuals, who would otherwise go undetected. Routine screening for all potential STIs in all patients is cost-prohibitive [10]; targeted screening of asymptomatic patients in specified risk groups is more feasible.

There is little direct evidence supporting the efficacy of screening programs. Screening for chlamydia has been the most extensively studied. The drawbacks to screening pertain largely to expense of the tests, the infrastructure required to administer them, and the psychological and relationship repercussions of false positive tests, which do occur, particularly among low prevalence populations.

Chlamydia and gonorrhea — Infections with Chlamydia trachomatis and Neisseria gonorrhoeae are very common. In the United States, they are the two most commonly reported communicable diseases. In females, the primary benefit of screening and treatment is to reduce their personal risk of reproductive sequelae. In males, who have a lower risk of long-term sequelae or more frequently have symptomatic disease, the main rationale for screening and treatment would be to reduce the likelihood of reinfection of sex partners and reduce overall transmission of these infections.

Females — Among females, most chlamydial and gonococcal infections are asymptomatic or minimally symptomatic and if left untreated, can lead to serious complications, including pelvic inflammatory disease (PID), infertility, complications of pregnancy, and chronic pelvic pain [4,11]. (See "Clinical manifestations and diagnosis of Chlamydia trachomatis infections", section on 'Clinical syndromes in females' and "Clinical manifestations and diagnosis of Neisseria gonorrhoeae infection in adults and adolescents", section on 'Infection of the female urogenital tract'.)

Because the incidence of these infections are highest among adolescents and young adults, screening efforts have focused on this age group. Some proponents have argued that school-based health centers should implement systematic screening programs in adolescents to target these high-risk populations [12]. For older females, decisions on screening are based on the presence of personal behavioral risk factors. (See 'Risk factors' below.)

Several trials have suggested that screening young females for chlamydia reduces the rate of subsequent PID, although some limitations reduce certainty about the findings [13-16]. As an example, in a trial of female college students in London, all participants provided vaginal swabs at study entry and were then randomly assigned to screening (in which the samples were tested for chlamydia and those with positive tests were treated) or control (in which the samples were stored and analyzed at the end of the study) [14,17]. Among those with chlamydia at baseline, 1 of 63 in the intervention group versus 7 of 74 in the control group developed PID (RR 0.17, 95% CI 0.03- 1.01). However, 30 of the 38 cases of PID observed in the study occurred in participants with negative baseline chlamydia, and 10 of those cases were documented to be associated with chlamydia. These findings indicate the importance of ongoing chlamydial transmission and the need for repeated screening over time in at-risk individuals.

Data on the effect of screening on prevalence of chlamydia are less clear, although studies evaluating the impact have had limitations. In one study of females and males aged 16 to 29 years in the Netherlands who were offered yearly home-based chlamydia screening tests for three years, participation was low (10 to 16 percent), and there was no evidence of reduced chlamydia rates after three rounds of screening [18]. Effects on population prevalences could not be reliably estimated because of low uptake. In a cluster-randomized trial in rural Australia, a clinic-based intervention to promote yearly chlamydia screening for sexually active females and males aged 16 to 28 years did not reduce the chlamydia prevalence in the clinic population more than standard care [19]. In both groups, rates decreased from about 5 to 3.4 percent over three years. Importantly, while screening uptake increased in both groups, only 20 and 13 percent of patients in the intervention and control groups, respectively, were tested during the last year of the study.

While nongenital infections in females (eg, rectal chlamydial infection, pharyngeal and rectal gonococcal infection) have been recognized increasingly, the adverse consequences of undetected and untreated infection at these sites are largely unknown. Screening may be considered based on reported sexual behaviors and exposures, through shared clinical decision-making between the patient and provider. (See "Epidemiology of Chlamydia trachomatis infections", section on 'Extragenital infections'.)

Males — The major rationale for chlamydia and gonorrhea screening among males is to reduce infection or reinfection of existing partners and transmission to new partners. For males who have sex with only females, it is unclear if this would be of additive benefit over screening females and treating them and their sex partners. Screening is thus more relevant among men who have sex with men (MSM), among whom there is a high burden of STIs, which would be less likely impacted by screening efforts among females.

MSM are at high risk of STIs, in part, because of individual behavioral risk, but also because of other factors, such as a higher prevalence of these infections within MSM sexual networks. In the United States in 2018, the median prevalence of chlamydia and gonorrhea among MSM seen at STI clinics throughout the country was 6 and 8 percent for urogenital infection and 16 and 15 percent for rectal infection [20]. Prevalence is even higher among MSM with HIV. Although there are few data to show that these screening tests improve outcomes, it is reasonable to perform screening on at least an annual basis given the high-prevalence rates of these STIs in MSM and the higher prevalence of antimicrobial resistance among gonococcal isolates in this population. MSM with high-risk behaviors should be screened every three months. (See "Treatment of uncomplicated gonorrhea (Neisseria gonorrhoeae infection) in adults and adolescents", section on 'Antibiotic resistance'.)

Evaluation for infection at nongenital sites (ie, rectal, pharyngeal) is also important in this population. Several studies have reported that a significant proportion of gonorrhea and chlamydia cases would be missed if genital-only screening were performed [21-24]. For example, over a seven-year period, 7333 MSM attending a STI clinic in the United States underwent culture and/or NAAT sampling of multiple sites [25]. The study demonstrated that one-third of the total number of N. gonorrhoeae cases would have been missed if only urethral or urine samples were tested. Similar findings have been reported in MSM with HIV [22]. It has also been suggested that the acquisition of drug resistance mainly takes place at extragenital sites, such as the throat, where horizontal gene transfer of resistance determinants is more likely to occur than in the urethra [26].

For males who have sex with only females, there is little rationale for routine screening for chlamydia and gonorrhea. Evidence to support routine screening of chlamydia in males is lacking. Although screening and treating asymptomatic males for STI can reduce the burden of infection and thus transmission, it is unclear if this would be of additive benefit over screening females and treating them and their sex partners. Nevertheless, it is reasonable to screen heterosexual males for chlamydia in high-prevalence settings (eg, at STI or adolescent clinics and correctional facilities) if resources allow and screening programs for males would not negatively impact those for females [1].

Among asymptomatic heterosexual males, gonorrhea prevalence is low (0 to 1.5 percent), in contrast to rates as high as 28 percent among symptomatic males in some settings [27]. Focusing on treating symptomatic males would thus likely address a significant proportion of the gonococcal burden among heterosexual males, and screening asymptomatic males may not add substantial value.

Transgender and gender-diverse persons — Gonorrhea and chlamydia screening recommendations should be adapted based on anatomy (ie, screening recommendations for cisgender females should be extended to all transgender males and gender-diverse people with a cervix). Screening at the pharyngeal and rectal site for gonorrhea and chlamydia should be considered based on reported sexual behaviors and exposure.

Trichomonas — Trichomonas vaginalis infection is often asymptomatic, has been associated with adverse pregnancy outcomes, and, among females with HIV, an increased risk of PID. Some studies have suggested that vaginal trichomoniasis is also a risk factor for HIV acquisition and transmission [28,29]. The prevalence of trichomoniasis appears to increase with age and is up to twice as high in females with HIV. Screening at entry to care and at least annually thereafter is recommended for sexually active females with HIV. Screening may be considered for females receiving care in high-prevalence settings or at increased risk [1]. (See "Trichomoniasis: Clinical manifestations and diagnosis".)

Syphilis — Syphilis can lead to serious long-term sequelae, including cardiac and neurologic manifestations, which are prevented by treatment in the early stages of disease, which can be minimally symptomatic or easily left undiagnosed. Screening and treatment can also reduce transmission of infection. Additionally, syphilis is associated with an increased risk for HIV transmission and acquisition [30,31].

Although syphilis is not as common as chlamydia or gonorrhea, the prevalence can be high among certain risk groups. As an example, in the United States, the majority of all primary and secondary syphilis cases occur among MSM, many of whom have HIV [20].

In the United States, the USPSTF recommends routine screening of asymptomatic persons who are at increased risk of syphilis, in particular MSM and individuals with HIV [2]. (See "Syphilis: Screening and diagnostic testing", section on 'Asymptomatic patients'.)

HIV and hepatitis viruses — Untreated HIV infection, chronic hepatitis B virus (HBV) infection, and chronic hepatitis C virus (HCV) infection can result in substantial excess morbidity and mortality for the infected individual and contribute to further transmission of these infections. These infections can be transmitted sexually as well as through other modes of transmission, and screening is recommended for broader populations than just those at risk of sexual acquisition. Rationale for screening for these infections is discussed elsewhere:

(See "Screening and diagnostic testing for HIV infection", section on 'Rationale for routine screening'.)

(See "Hepatitis B virus: Screening and diagnosis in adults", section on 'Approach to screening and testing'.)

(See "Screening and diagnosis of chronic hepatitis C virus infection", section on 'Rationale'.)

Sexual transmission of HCV is not particularly efficient, and the risk is very low among monogamous sexual partners. However, the risk is higher in those with multiple sexual partners, and sexual transmission among MSM has been increasingly reported, particularly among MSM with HIV [32-38]. (See "Epidemiology and transmission of hepatitis C virus infection", section on 'Sexual transmission'.)

Human papillomavirus — Persistent viral infection with specific high-risk genotypes of human papillomavirus (HPV) causes virtually all cancers of the cervix and is associated with oropharyngeal and anal cancer.

Screening currently focuses on detection of oncogenic HPV infection and/or the cytologic abnormalities that can be caused by persistent HPV infection.

The rationale for cervical cancer screening among females is discussed in detail elsewhere. In the United States, guidelines issued by various professional organizations strongly recommend screening for cervical cancer, although there are minor differences in the recommended screening parameters. Cervical cancer screening policies in other countries also differ by starting age, stopping age, and frequency. (See "Screening for cervical cancer in resource-rich settings" and "Screening for cervical cancer in patients with HIV infection and other immunocompromised states".)

The rationale of screening for AIN in individuals at increased risk for anal cancer is discussed separately. (See "Anal squamous intraepithelial lesions: Epidemiology, clinical presentation, diagnosis, screening, prevention, and treatment", section on 'Screening for anal SIL'.)

There are no screening tests for HPV-associated oropharyngeal cancers.

HPV vaccination can prevent HPV infection and its sequelae. Vaccination status does not change recommendations for screening. This is discussed in detail elsewhere. (See "Human papillomavirus vaccination".)

Mycoplasma genitalium — Routine screening for M. genitalium is not recommended [1]. It is a recognized cause of nongonococcal urethritis in males and has been associated with cervicitis and PID in females. However, the benefits of screening and treatment in asymptomatic persons are unclear. (See "Mycoplasma genitalium infection".)

Herpes simplex virus — Routine screening for genital herpes simplex virus (HSV) infections is not recommended [1]. However, performing type-specific serological testing for HSV can be useful on an individual basis to counsel couples on their risk for HSV transmission, particularly during pregnancy. (See "Genital herpes simplex virus infection and pregnancy", section on 'Screening pregnant women with no HSV history' and "Prevention of genital herpes virus infections", section on 'Determining partner susceptibility to infection'.)

Genital HSV is common and can be subclinical. The majority of infections are transmitted from individuals unaware of their infection or during asymptomatic periods between outbreaks. However, treatment is generally reserved for those with symptomatic disease, and there is no evidence that more widespread treatment will reduce the burden of genital HSV.

In the United States, the USPSTF recommends against routine screening for HSV in asymptomatic individuals (including pregnant females) [3]. The CDC also indicates that routine serologic screening in the general population is not indicated but can be considered for those presenting for an STI evaluation, individuals with HIV, and MSM at risk for HIV infection [1].

ASSESSING RISK — Risk assessment through routine sexual histories is important to appropriately target at-risk individuals for sexually transmitted infection (STI) screening. This includes assessment for risk factors that place individuals at increased risk for STI, such as current or past history of STI or a history of multiple sex partners. In addition to specific behavioral risk factors, demographic factors ("risk groups") that are associated with high prevalence of STIs or high morbidity from STIs should also be assessed [39-47].

Risk factors — Behavioral factors that increase the risk of STI acquisition include:

New sex partner in past 60 days

Multiple sex partners or sex partner with multiple concurrent sex partners

Sex with sex partners recently treated for an STI

No or inconsistent condom use outside a mutually monogamous sexual partnership

Trading sex for money or drugs

Sexual contact (oral, anal, penile, or vaginal) with sex workers

Meeting anonymous partners on the internet

Risk groups — In addition to those with behavioral risk, some individuals warrant specific considerations for STI screening because they belong to particular risk groups associated with a high prevalence of STIs or groups that would have high morbidity with STIs.

Young age (15 to 24 years old)

Men who have sex with men (MSM)

History of a prior STI

HIV-positive status

Pregnant females

Admission to correctional facility or juvenile detention center

Illicit drug use

The risk of STIs is particularly high among sexually active adolescents and young adults. As an example, in the United States, the rate of reported cases of chlamydia among females are highest among 20- to 24-year-olds, followed by 15- to 19-year-olds. In 2019, the rates of reported chlamydia in these age brackets were 4110 and 3334 cases per 100,000 persons, respectively, compared with overall incidence of 553 cases per 100,000 persons [48]. The incidences of chlamydia in males and gonorrhea in both sexes are substantially lower but follow the same general age pattern.

In the United States, there are also geographic and racial differences with regard to STI prevalence [48]. The southern states tend to have the highest rates of STIs nationally, although rates of syphilis are also relatively high in western states. Black Americans have a higher prevalence of STIs compared with other races.

Sexual history — In the assessment of sexually transmitted infection (STI) risk, it is important to obtain a thorough sexual history including:

Partners

Any new sexual partner

History of multiple sexual partners

Sexual partners with concomitant partners

Practices

History of sexual intercourse with trauma (as an example, fisting in MSM has been linked to increased risk of acquisition of hepatitis C virus infection)

Anatomic sites of exposure (this will guide decisions about which mucosal sites to test diagnostically)

Protection from STIs

Type and frequency of barrier protection use (eg, male condoms)

Past history of STIs

History of any STIs, including genital ulceration, which can increase the risk of HIV acquisition

The history should be straightforward and non-judgmental with appropriate counseling regarding risk-taking behaviors, as necessary [49]. Some medical providers do not routinely obtain a sexual history. In one study, only 70 percent reported "always" or "almost always" obtaining a sexual history in adolescent females [50]. One reason for this omission may be related to provider comfort with this part of the patient interview [1]. Suggestions for open-ended, non-judgmental questions, as suggested by the Centers for Disease Control and Prevention (CDC), are found in the following table (table 1) [1].

SCREENING RECOMMENDATIONS — Screening recommendations vary by sex, age, and sexual behavior (table 2).

General principles

We recommend screening for HIV infection in all adults and adolescents aged 13 to 75 years. All individuals who seek screening or testing for sexually transmitted infections (STIs) should receive testing and counseling for HIV infection. This provides an opportunity for risk reduction education, as well as diagnosis of HIV infection. (See "Screening and diagnostic testing for HIV infection".)

Although all sexually active individuals are at some risk of STIs, screening for all STIs in all patients is not practical. Thus, screening for STIs focuses on those who are at high risk. For some STIs, this is done by targeting specific risk groups that have a high prevalence for STIs (eg, females <25 years old, men who have sex with men [MSM], patients with HIV, and individuals entering into correctional facilities). In other cases, screening is dependent on assessment of an individual's personal risk based on behavioral factors. Clinicians should also consider the characteristics of the communities they serve when determining appropriate screening strategies for their particular patient population. Local public health authorities can be a source of valuable information regarding local patterns of infection and disease prevalence. (See 'Assessing risk' above.)

The optimal interval for screening of STIs is uncertain. For individuals with prior negative screening tests, the interval for re-evaluation will be influenced by persistence or change in risk factor profile. Positive screening tests are a marker for risk and warrant more frequent testing. (See 'Rescreening and retesting' below.).

All individuals whose sex partners had been diagnosed with an STI should undergo testing or presumptive treatment for that STI. These individuals should also be tested for other curable STIs and HIV. Issues related to the management of such sex partners are discussed in detail elsewhere. (See "Treatment of uncomplicated gonorrhea (Neisseria gonorrhoeae infection) in adults and adolescents", section on 'Management of sexual partners' and "Treatment of Chlamydia trachomatis infection", section on 'Management of sex partners' and "Trichomoniasis: Treatment", section on 'Sex partners'.)

Females — Many screening efforts around sexually transmitted infections focus on females. Most chlamydial and gonococcal infections are asymptomatic or minimally symptomatic in females, and untreated can lead to serious complications, including pelvic inflammatory disease, infertility, complications of pregnancy, and chronic pelvic pain [4,11].

Heterosexual females

Younger than 25 years — For sexually active females <25 years old, screening is recommended for the following [1,4] (table 2):

C. trachomatis genital infection, annually

N. gonorrhoeae genital infection, annually

HIV screening, one time (or with greater frequency for those at high risk of infection)

Rectal chlamydia screening and pharyngeal and rectal gonorrhea screening can be considered in females based on reported sexual behaviors and exposure, via shared clinical decision-making between the patient and the provider.

Additionally, screening for T. vaginalis may be considered for females receiving care in high-prevalence settings (eg, STI clinics and correctional facilities) and for females at high risk for infection (eg, females with multiple sex partners, transactional sex, drug misuse, or a history of STI or incarceration). Screening for cervical cancer and HPV vaccination, if not already received, is recommended in this age group. These issues are discussed elsewhere. (See "Human papillomavirus vaccination", section on 'Indications and age range' and "Screening for cervical cancer in resource-rich settings".)

Approaches to screening for syphilis and hepatitis viruses are the same as for older females, based on risk factors. (See '25 years and older' below.)

Screening recommendations for pregnant females and females with HIV are discussed elsewhere. (See 'Patients with HIV infection' below and "Prenatal care: Initial assessment", section on 'Infection'.)

25 years and older — For females 25 years and older, at least one-time screening of HIV infection is recommended, if not already performed, with more frequent screening recommended for those at risk for infection (table 2). Additionally, screening for cervical cancer continues for all females in this age group, and HPV vaccination, if not already received, is recommended up to age 26. (See "Human papillomavirus vaccination", section on 'Indications and age range' and "Screening for cervical cancer in resource-rich settings", section on 'Introduction'.)

Screening for other STIs in this age group is reserved for sexually active females with risk factors for STIs [1,2,4]. Risk factors include new or multiple sex partners, sex partners with known STI or concurrent partners, inconsistent condom use outside a monogamous partnership, previous or coexisting STI, incarceration, or exchange of sex for money or drugs. Screening for STIs may also be considered in high-prevalence settings (eg, STI clinics and correctional facilities). In such females, we screen for the following:

C. trachomatis genital infection

N. gonorrhoeae genital infection

Syphilis

Trichomonas

Hepatitis B virus infection (if not vaccinated or vaccine status is not known), once, followed by vaccination in the susceptible

Screening for nongenital infections in females (eg, rectal chlamydial infection, pharyngeal and rectal gonococcal infection) can be considered based on reported sexual behaviors and exposure, via shared clinical decision-making between the patient and the provider.

One-time hepatitis C virus (HCV) screening is recommended for all adults. Ongoing screening is warranted for sexually active MSM living with HIV or on pre-exposure prophylaxis (PrEP) to prevent HIV and those with a sex partner with chronic HCV infection. Other indications for HCV screening are discussed elsewhere. (See "Screening and diagnosis of chronic hepatitis C virus infection", section on 'Whom to test'.)

Screening recommendations for pregnant females and females with HIV are discussed elsewhere. (See 'Patients with HIV infection' below and "Prenatal care: Initial assessment", section on 'Infection'.)

Females who have sex with females — Females who have sex with females and females who have sex with females and males represent diverse groups with significant variation in risk behaviors, sexual identity, and practices. Relatively few data are available regarding STI risk conferred by sex between females. Practices involving oral-genital, digital-vaginal, or digital-anal contact, especially with shared penetrative sex items, may transmit infected oral, cervicovaginal, or anal secretions.

Direct transmission of trichomonas between female partners has been demonstrated, and transmission of HPV, HSV-1, and HSV-2 can occur. Strong epidemiologic data support sexual transmission of bacterial vaginosis (BV) among females with female partners. Moreover, many females who have sex with females have had sex with males in the past and many continue to do so, thus remaining at risk for STI transmission from male as well as female partners. Studies suggest that females who have sex with females and males may experience equivalent or higher rates of STIs than females who have sex with males. Rates in females who have sex with females may be lower but still significant [51-53]. Furthermore, females who have sex with females and females who have sex with females and males may experience barriers to care (particularly Black individuals).

In sum, females who have sex with females and females who have sex with females and males may be at risk for acquiring STIs from current and previous partners, both female and male, and should not be assumed to be at low or no risk for STIs on the basis of their sexual orientation. Screening for cervical cancer and STIs should be conducted according to guidelines for females, based on an open discussion of sexual and behavioral risk factors.

Pregnant individuals — Intrauterine or perinatally transmitted STIs can have grave effects on pregnant individuals, their partners, and their fetuses. Pregnant individuals are routinely screened at the initial prenatal visit for HIV, HBV, syphilis, and (if <25 years or with risk factors) chlamydia and gonorrhea. Indications for repeat screening later during gestation and screening for other infections is discussed elsewhere. (See "Prenatal care: Initial assessment".)

Specifics on STI screening in pregnant individuals with HIV are discussed below. (See 'Patients with HIV infection' below.)

Males — STI screening recommendations differ between males who have sex with only females and MSM.

Males who have sex with only females — We screen males who have sex with only females at least once for HIV (if not already performed), with more frequent screening for those at risk for infection (table 2). Otherwise, we do not routinely screen heterosexual males without HIV for STIs unless they have a history of STI or are seeking STI evaluation (see 'Individuals seeking STI evaluation' below). It is also reasonable to screen males who have sex with only females at increased risk (eg, history of incarceration or transactional sex work, race/ethnicity, and age younger than 29 years) and in high-prevalence settings.

Men who have sex with men — We routinely screen sexually active men who have sex with men (MSM) for the following (table 2):

HIV infection

Syphilis

C. trachomatis and N. gonorrhoeae genital infection

C. trachomatis and N. gonorrhoeae rectal infection, for those with receptive anal intercourse in the prior year

N. gonorrhoeae oropharyngeal infection, for those with receptive oral intercourse in the prior year

It is reasonable to perform screening on at least an annual basis given the high-prevalence rates of these STIs in MSM. More frequent screening at three-month intervals is warranted for MSM at particularly high risk for STIs, including those with multiple or anonymous partners [1]. This includes high-risk MSM who have multiple partners and are taking pre-exposure prophylaxis for HIV; such individuals should undergo HIV testing, syphilis screening, and gonorrhea and chlamydia screening at pharyngeal, urogenital, and rectal sites every three months [54]. (See "HIV pre-exposure prophylaxis", section on 'Patient monitoring'.)

In addition, viral hepatitides are frequent pathogens among MSM:

Hepatitis A virus (HAV) – We perform one-time screening for evidence of infection or immunity in MSM who have not been previously vaccinated. If the patient is seronegative, immunization is indicated. (See "Hepatitis A virus infection: Treatment and prevention".)

Hepatitis B virus (HBV) – We perform one-time screening for evidence of infection or immunity in MSM who have not been previously vaccinated. If the patient is seronegative, immunization is indicated. (See "Hepatitis B virus immunization in adults".)

Hepatitis C virus (HCV) – We perform at least one-time screening given the mounting evidence of sexual transmission among MSM. At least annual HCV screening is recommended among MSM with HIV [1]. More frequent screening may be warranted in specific circumstances (eg, high local HCV prevalence and incidence, high-risk sexual behaviors, and concomitant ulcerative STIs or STI-related proctitis). Ongoing HCV screening is also recommended for MSM who are taking pre-exposure prophylaxis to prevent sexually transmitted HIV. (See "Screening and diagnosis of chronic hepatitis C virus infection", section on 'Those with ongoing risk'.)

MSM are also at risk for HPV infection and its associated conditions, including squamous intraepithelial lesions. Although data on the benefits of screening are limited, some experts screen MSM for HPV-associated lesions with anal cytology. This is discussed in detail elsewhere. (See "Anal squamous intraepithelial lesions: Epidemiology, clinical presentation, diagnosis, screening, prevention, and treatment", section on 'Screening for anal SIL'.)

Transgender and gender-diverse persons — The term transgender includes individuals whose gender identity is different from the sex they were born with and/or whose gender expression does not fall within the stereotypical definitions of male and female. Thus, it refers to a diverse group of individuals, some of whom have the anatomy they were born with and some whom have had sex-reassignment therapy. In addition, certain persons might identify outside the gender binary of male or female and may describe themselves as “gender nonbinary,” “genderqueer,” or “gender fluid.” Importantly, gender identity does not dictate sexual behavior.

Thus, screening for STIs in transgender and gender-diverse individuals should take into account the individual's sexual practices and anatomy (eg, a transgender male may still have a vagina, cervix, and uterus and thus may be at risk for HPV-associated cervical cancer and the sequelae of other bacterial STIs). Screening recommendations for cisgender females regarding gonorrhea, chlamydia, and cervical cancer should be extended to all transgender males and gender-diverse people with a cervix. Screening at the pharyngeal and rectal sites for gonorrhea and chlamydia should be considered based on reported sexual behaviors and exposure. At least annual screening for syphilis should be considered based on reported sexual behaviors and exposures. HIV screening should be discussed and offered to all transgender persons with frequency of repeat screenings based on level of risk.

Patients with HIV infection — High rates of STIs have been found through screening programs of patients with HIV worldwide [20,55,56]. Routine STI screening of patients with HIV in order to reduce the spread of STIs is warranted, particularly because STIs, in turn, can increase HIV transmission. Specifically, testing for the following infections is performed (table 2) [1,5]:

N. gonorrhoeae at genital sites (and for MSM, at rectal and pharyngeal sites if exposed), at initial evaluation then annually. Screening at other sites (eg, pharynx and rectum) can be considered in females based on reported sexual behaviors and exposure through shared clinical decision-making between the patient and the provider.

C. trachomatis at genital sites (and for MSM, at rectal sites if exposed), at initial evaluation then annually. Rectal chlamydia screening can be considered in females based on reported sexual behaviors and exposure through shared clinical decision-making between the patient and the provider.

Syphilis, at initial evaluation then annually.

Trichomonas (for those having receptive vaginal sex), at initial evaluation then annually.

HAV (for MSM, those who are chronically infected with HBV and/or HCV, and injection drug users), at initial evaluation with vaccination if susceptible.

HBV, at initial evaluation with vaccination if susceptible.

HCV, at initial evaluation then at least annually, with more frequent testing depending on specific circumstances (eg, local HCV prevalence and incidence, high-risk sexual behaviors, and concomitant ulcerative STIs or STI-related proctitis).

In areas of high STI prevalence, biannual STI testing may be prudent. More frequent screening for gonorrhea, chlamydia, and syphilis is indicated in MSM with HIV who have multiple or anonymous partners, as well as in patients who exchange sex for money, drugs, or basic needs. (See 'Men who have sex with men' above.)

Pregnant females with HIV are tested for gonorrhea, chlamydia, syphilis, Trichomonas, and HBV at the initial prenatal visit. Those who have not had HCV screening or who are at risk for infection are also tested at the initial prenatal visit. Repeat testing is performed at the second or third trimester for those with ongoing risk.

HPV-associated cancers are also prevalent among patients with HIV and should be screened for. These issues are discussed elsewhere. (See "Screening for cervical cancer in patients with HIV infection and other immunocompromised states" and "Anal squamous intraepithelial lesions: Epidemiology, clinical presentation, diagnosis, screening, prevention, and treatment".)

Additional considerations

Individuals seeking STI evaluation — Individuals who are seeking an STI evaluation often do so because of a specific exposure. In such cases, we screen for the following infections:

Gonorrhea (at genital, rectal, and pharyngeal sites, according to exposure)

Chlamydia (at genital and rectal sites, according to exposure)

Syphilis

HIV

Trichomoniasis (in females)

HSV-2 type-specific serology is also reasonable in certain clinical settings, such as in patients with a history of recurrent anogenital lesions or when considering antiviral suppression.

Screening for hepatitis B and C viruses is discussed elsewhere. (See "Hepatitis B virus: Screening and diagnosis in adults", section on 'Individuals without known risk for HBV infection' and "Screening and diagnosis of chronic hepatitis C virus infection", section on 'Those with ongoing risk'.)

At this time, neither the CDC nor the USPSTF recommend routine screening of females and heterosexual males for extragenital gonorrhea and chlamydia. However, in certain situations (eg, high-prevalence settings and/or patients reporting only extragenital exposures), extragenital screening of females and heterosexual males can be a useful strategy to identify infections that would otherwise go undetected. Several studies suggest that the prevalence of extragenital infections in these populations are much lower than in MSM, but they are not negligible [57-60]. As an example, among 4402 females accessing care at an STI clinic who reported extragenital exposures, 30 percent of gonorrhea cases and nearly 14 percent of chlamydia cases would have been missed with a genital-only testing approach [57]. The numbers were similar for the 5218 males who reported only sex with females. Analysis of the numbers needed to screen to detect a single isolated extragenital gonococcal infection further highlighted that the biggest yield for extragenital screening is in MSM: 43 females and 69 heterosexual males versus 6 MSM would have to be screened to detect a single isolated extragenital gonococcal case.

Individuals in correctional facilities — Individuals entering into correctional facilities are more likely to have other risk factors for STIs, and the prevalence of STIs is high among this population. Being in a correctional facility also offers the opportunity to provide treatment and follow-up.

In the United States, the CDC recommends screening for chlamydia and gonorrhea in females ≤35 years and males ≤30 years old upon entry into a correctional facility. This recommendation is supported by surveillance studies that demonstrate high prevalence of these STIs in these populations [61-63].

Screening for syphilis depends on the community prevalence of syphilis. Local syphilis rates in the United States can be found through the CDC website or by contacting the local health department.

SCREENING METHODS — Testing for sexually transmitted infections generally involves a blood test and/or self-collection of relevant body fluid specimens.

Testing for HIV is ideally performed with a combination antigen/antibody immunoassay, which requires a blood draw. At the point-of-care, other options for testing can be performed on oral secretions or finger stick samples. (See "Screening and diagnostic testing for HIV infection", section on 'Tests'.)

Testing for the following involves a blood sample:

Syphilis – either a nontreponemal or treponemal test (see "Syphilis: Screening and diagnostic testing", section on 'Serologic tests')

Hepatitis B virus (HBV) – HBV surface antigen (HBsAg), surface antibody (HBsAb), and core antibody (HBcAb) (see "Hepatitis B virus: Screening and diagnosis in adults")

Hepatitis C virus (HCV) – HCV antibody (see "Screening and diagnosis of chronic hepatitis C virus infection", section on 'Whom to test')

Testing for other STIs can be performed on relevant non-blood specimens:

N. gonorrhoeae – nucleic acid amplification testing (NAAT) on urine (preferred for males) or vaginal swabs (preferred for females), urethral swabs, endocervical swabs, rectal and oropharyngeal swabs (see "Clinical manifestations and diagnosis of Neisseria gonorrhoeae infection in adults and adolescents", section on 'Asymptomatic patients')

C. trachomatis – NAAT on urine (preferred for males) or vaginal swabs (preferred for females), urethral swabs, endocervical swabs, and rectal swabs (see "Clinical manifestations and diagnosis of Chlamydia trachomatis infections", section on 'Nucleic acid amplification testing (test of choice)')

T. vaginalis – NAAT on vaginal swabs (preferred) or urine (see "Trichomoniasis: Clinical manifestations and diagnosis", section on 'Preferred tests')

The advent of urine-based tests and the utility of self-collected vaginal swabs has increased the acceptance of STI screening among patients and providers since it allows for routine specimen collection without a pelvic examination or swab of the urethra [56,64,65].

Screening for HPV-associated disease is performed by cytology and/or HPV testing of cervical specimens or cytology of anal specimens. (See "Cervical cancer screening tests: Techniques for cervical cytology and human papillomavirus testing", section on 'HPV testing'.)

MANAGEMENT OF POSITIVE SCREENING TESTS

Treatment of the STI — Management of sexually transmitted infections depends on the specific infection. Diagnosis of non-viral STIs generally should result in prompt treatment, since a few individuals may develop complications in the interval between screening and treatment [66]. Specific treatment regimens for these infections are discussed in the dedicated topic reviews.

Of note, while there are no formal recommendations for screening for chlamydia at the pharyngeal site, should a test be sent and should it be positive, the patient should be treated for chlamydia.

Considerations regarding treatment of HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) are found elsewhere. (See "When to initiate antiretroviral therapy in persons with HIV" and "Hepatitis B virus: Overview of management" and "Patient evaluation and selection for antiviral therapy for chronic hepatitis C virus infection".)

Health department notification — Local and state public health practices of partner notification and disease reporting are important, in addition to individual sexually transmitted disease case management. In the United States, notifiable infections include C. trachomatis, N. gonorrhoeae, acute HBV, acute HCV, HIV, and syphilis [67].

Partner notification — For gonorrhea, chlamydia, syphilis, and Trichomonas, sex partners should be notified, examined, and treated for the STI identified or suspected in the index patient [1]. In some settings, expedited partner therapy (EPT) has been used for chlamydial and gonorrheal infections. With this system, the patient directly provides their sexual contacts with medications and prescriptions to be filled. EPT does not give the sexual contact a chance to ask questions, or receive counseling or additional STI screening, but does prevent recurrent chlamydial and gonococcal infections [68]. In the United States, EPT is legal in most states. Refer to the CDC website for more details. (See "Treatment of uncomplicated gonorrhea (Neisseria gonorrhoeae infection) in adults and adolescents", section on 'Management of sexual partners' and "Treatment of Chlamydia trachomatis infection", section on 'Management of sex partners'.)

Patients with non-viral STIs and their sex partners should abstain from sexual intercourse until seven days after initiating treatment.

Rescreening and retesting — Because of high rates of reinfection, individuals who were diagnosed and treated for chlamydia, gonorrhea, and Trichomonas should be retested for the infection. Retesting is performed three months after treatment or at the first follow-up visit thereafter during the year following treatment. Finally, test of cure for all pharyngeal gonococcal infections is recommended 7 to 14 days after treatment. (See "Treatment of uncomplicated gonorrhea (Neisseria gonorrhoeae infection) in adults and adolescents", section on 'Retesting' and "Trichomoniasis: Treatment", section on 'Repeat testing after treatment' and "Treatment of Chlamydia trachomatis infection", section on 'Retesting for all patients'.)

The incidence of reinfection was examined in females and males who have sex with females who were evaluated for an STI at one of three urban STI clinics [69]. Patients had follow-up visits scheduled at 3, 6, 9, and 12 months with the following results:

Among 1236 females, 26 percent had acquired one or more new infections (including C. trachomatis, N. gonorrhea, and T. vaginalis).

Among 1183 males, 15 percent had acquired one or more new infections (including C. trachomatis and N. gonorrhea).

Of those with a new STI, 66 percent were asymptomatic.

SCREENING UPTAKE — Despite recommendations for routine and targeted screening, screening rates in the appropriate populations are suboptimal [18,70,71]. As an example, in the United States, an analysis of data provided from private and public health plans indicated that less than half of eligible females were screened for chlamydia, even with an overall increase in screening rates during the reporting period [70]. Screening rates are likely lower among those without health insurance. In a trial of the effectiveness of a registry in the Netherlands inviting individuals aged 16 to 29 to participate in collecting home-based samples for chlamydia screening, participation was low (16 percent initially, which decreased over the three-year trial period), with no impact on the overall rate of chlamydia infection [18].

Screening uptake is also problematic in persons with HIV infection. In a multicenter study conducted in North America, annual gonorrhea and chlamydia testing was compared to syphilis and lipid testing among 19,368 adults with HIV (41 percent MSM, 30 percent heterosexual males, 29 percent females) engaged in care [72]. In 2010, only 39 percent were tested for gonorrhea and chlamydia, compared with 77 and 76 percent for syphilis and lipid levels, respectively. Another study involving 4217 patients with HIV found that amongst those who were sexually active, 55 percent were tested at least once in 12 months for syphilis, but only 23 and 24 percent had a test for gonorrhea and chlamydia, respectively [73]. Among MSM with HIV who were deemed to be at high sexual risk, 26 percent received repeat syphilis testing, and only 7 percent received repeat gonorrhea and chlamydia testing.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Sexually transmitted infections" and "Society guideline links: HIV screening and diagnostic testing".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Chlamydia and gonorrhea (The Basics)" and "Patient education: Genital herpes (The Basics)" and "Patient education: Sexually transmitted infections (The Basics)")

Beyond the Basics topics (see "Patient education: Gonorrhea (Beyond the Basics)" and "Patient education: Chlamydia (Beyond the Basics)" and "Patient education: Testing for HIV (Beyond the Basics)" and "Patient education: Genital herpes (Beyond the Basics)" and "Patient education: Genital warts in women (Beyond the Basics)" and "Patient education: Hepatitis B (Beyond the Basics)" and "Patient education: Hepatitis C (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Rationale – Complications of untreated sexually transmitted infections (STIs) include upper genital tract infections, infertility, chronic pelvic pain, cervical cancer, and chronic infection with hepatitis viruses and HIV. Many patients have asymptomatic disease, and screening for infection is thus an important approach to identify and treat infected individuals who would otherwise go undetected. (See 'Rationale' above.)

Risk factors and risk groups – Although all sexually active individuals are at some risk of STIs, screening for all STIs in all patients is not practical. Thus, screening for STIs focuses on those who are at high risk. For some STIs, this is done by targeting specific risk groups that have a high prevalence for STIs (eg, females <25 years old, men who have sex with men [MSM], patients with HIV, and individuals entering into correctional facilities). In other cases, screening is dependent on assessment of an individual's personal risk based on behavioral factors (table 1) or the prevalence of infection in the local community. (See 'Assessing risk' above and 'General principles' above.)

Screening recommendations – Our screening recommendations are generally consistent with those of the United States Centers for Disease Control and Prevention. (See 'Screening recommendations' above.)

We screen all adults and adolescents without HIV at least once for HIV infection. We also screen all adults at least once for chronic hepatitis C virus (HCV) infection. These issues are discussed in detail elsewhere. (See "Screening and diagnostic testing for HIV infection", section on 'Routine screening' and "Screening and diagnosis of chronic hepatitis C virus infection", section on 'Routine one-time screening for adults'.)

Additional STI screening recommendations are presented below and in the table (table 2):

Females <25 years old – For all sexually active females <25 years old, we suggest screening for genital chlamydia and gonorrhea annually (Grade 2C). For those who have risk factors for STIs (eg, new or multiple sex partners, recent STI diagnosis, exchanging sex for money or drugs) or present in high-prevalence settings (eg, STI clinics and correctional facilities), we also suggest at least annual screening for Trichomonas and syphilis and one-time screening for hepatitis B virus (HBV; if unvaccinated or of unknown status) (Grade 2C). (See 'Younger than 25 years' above.)

Females ≥25 years old – For females ≥25 years old who have risk factors for STIs (eg, new or multiple sex partners, recent STI diagnosis, exchanging sex for money or drugs) or present in high-prevalence settings (eg, STI clinics and correctional facilities), we suggest at least annual screening for genital chlamydia, gonorrhea, syphilis, and Trichomonas and one-time screening for HBV infection (if unvaccinated or of unknown status) (Grade 2C). (See '25 years and older' above.)

Pregnant individuals – Screening for STIs is a routine part of prenatal care. This is discussed in detail elsewhere. (See "Prenatal care: Initial assessment", section on 'Laboratory tests'.)

Males who have sex with only females – We do not routinely screen for STIs in males who have sex exclusively with females unless they are being assessed in a high-prevalence clinical setting (adolescent clinic, correctional facility, STI clinic), their history suggests an increased risk (history of incarceration, commercial sex work, geography), or they have a history of STI or are seeking STI evaluation. (See 'Males who have sex with only females' above.)

MSM – For MSM, we suggest ongoing screening for HIV, syphilis, genital chlamydia and gonorrhea, rectal chlamydia and gonorrhea (in those who have had receptive anal intercourse in the prior year), and oropharyngeal gonorrhea (in those who have had receptive oral intercourse in the prior year) (Grade 2C). We perform this screening at least annually; more frequent screening (eg, every three months) is warranted for MSM at particularly high risk for STIs, including those with multiple or anonymous partners. We also perform one-time screening for hepatitis A virus (HAV) and HBV, with vaccination if susceptible, and ongoing HCV screening in MSM at particularly high risk of sexual HCV transmission. (See 'Men who have sex with men' above.)

Transgender and gender-diverse individuals – The screening recommendations for urogenital gonorrhea and chlamydia listed for females, as above, apply to all sexually active individuals with a vagina and cervix. Screening at other sites and for other pathogens depends on the specific sexual behavior, exposures, and anatomy. (See 'Transgender and gender-diverse persons' above.)

Patients with HIV – For patients with HIV, we suggest at least annual screening for chlamydia, gonorrhea, syphilis, Trichomonas (in those having receptive vaginal sex), and HCV. We perform one-time screening for HAV (in MSM, injection drug users, and patients with chronic hepatitis) and HBV, with vaccination if susceptible. (See 'Patients with HIV infection' above.)

STI testing on request – Individuals who request an STI evaluation often do so because of a specific exposure. In such cases, we test for the following infections: gonorrhea (at genital and, if exposed, rectal and pharyngeal sites), chlamydia (at genital and, if exposed, rectal sites), syphilis, HIV, and Trichomonas (in females). (See 'Individuals seeking STI evaluation' above.)

Screening methods – Testing for STIs generally involves a blood test (for HIV, syphilis, HBV, HCV) and/or specimens of relevant body fluid (for chlamydia, gonorrhea, HSV, and Trichomonas), which can be collected by the patient or clinician. (See 'Screening methods' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Myron Cohen, MD and Heidi Swygard, MD, MPH, who contributed to an earlier version of this topic review.

  1. Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021; 70:1.
  2. U.S. Preventive Services Task Force. Final recommendation statement: Syphilis infection in nonpregnant adults and adolescents: Screening. June 2016. http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/syphilis-infection-in-nonpregnant-adults-and-adolescents.
  3. US Preventive Services Task Force, Mangione CM, Barry MJ, et al. Serologic Screening for Genital Herpes Infection: US Preventive Services Task Force Reaffirmation Recommendation Statement. JAMA 2023; 329:502.
  4. US Preventive Services Task Force, Davidson KW, Barry MJ, et al. Screening for Chlamydia and Gonorrhea: US Preventive Services Task Force Recommendation Statement. JAMA 2021; 326:949.
  5. Thompson MA, Horberg MA, Agwu AL, et al. Primary Care Guidance for Persons With Human Immunodeficiency Virus: 2020 Update by the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis 2021; 73:e3572.
  6. Committee on Adolescence, Society for Adolescent Health and Medicine. Screening for nonviral sexually transmitted infections in adolescents and young adults. Pediatrics 2014; 134:e302.
  7. Australian Sexual Health Alliance. Australian STI management guidelines for use in primary care. http://www.sti.guidelines.org.au/ (Accessed on July 31, 2015).
  8. Public Health Agency of Canada. Canadian guidelines on sexually transmitted infections. http://www.phac-aspc.gc.ca/std-mts/sti-its/ (Accessed on January 06, 2020).
  9. British Association for Sexual Health and HIV. Guidelines. http://www.bashh.org/BASHH/Guidelines/Guidelines/BASHH/Guidelines/Guidelines.aspx (Accessed on January 06, 2020).
  10. Low N, Broutet N, Adu-Sarkodie Y, et al. Global control of sexually transmitted infections. Lancet 2006; 368:2001.
  11. Kohl KS, Markowitz LE, Koumans EH. Developments in the screening for Chlamydia trachomatis: a review. Obstet Gynecol Clin North Am 2003; 30:637.
  12. Nsuami M, Taylor SN, Sanders LS, Martin DH. Missed opportunities for early detection of chlamydia and gonorrhea in school-based health centers. Sex Transm Dis 2006; 33:703.
  13. Scholes D, Stergachis A, Heidrich FE, et al. Prevention of pelvic inflammatory disease by screening for cervical chlamydial infection. N Engl J Med 1996; 334:1362.
  14. Oakeshott P, Kerry S, Aghaizu A, et al. Randomised controlled trial of screening for Chlamydia trachomatis to prevent pelvic inflammatory disease: the POPI (prevention of pelvic infection) trial. BMJ 2010; 340:c1642.
  15. Ostergaard L, Andersen B, Møller JK, Olesen F. Home sampling versus conventional swab sampling for screening of Chlamydia trachomatis in women: a cluster-randomized 1-year follow-up study. Clin Infect Dis 2000; 31:951.
  16. Gottlieb SL, Berman SM, Low N. Screening and treatment to prevent sequelae in women with Chlamydia trachomatis genital infection: how much do we know? J Infect Dis 2010; 201 Suppl 2:S156.
  17. Low N, Hocking J. The POPI trial: what does it mean for chlamydia control now? Sex Transm Infect 2010; 86:158.
  18. van den Broek IV, van Bergen JE, Brouwers EE, et al. Effectiveness of yearly, register based screening for chlamydia in the Netherlands: controlled trial with randomised stepped wedge implementation. BMJ 2012; 345:e4316.
  19. Hocking JS, Temple-Smith M, Guy R, et al. Population effectiveness of opportunistic chlamydia testing in primary care in Australia: a cluster-randomised controlled trial. Lancet 2018; 392:1413.
  20. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2018. Atlanta, GA: US Department of Health and Human Services; 2019. https://www.cdc.gov/std/stats18/default.htm (Accessed on October 10, 2019).
  21. Barbee LA, Dombrowski JC, Kerani R, Golden MR. Effect of nucleic acid amplification testing on detection of extragenital gonorrhea and chlamydial infections in men who have sex with men sexually transmitted disease clinic patients. Sex Transm Dis 2014; 41:168.
  22. Rieg G, Lewis RJ, Miller LG, et al. Asymptomatic sexually transmitted infections in HIV-infected men who have sex with men: prevalence, incidence, predictors, and screening strategies. AIDS Patient Care STDS 2008; 22:947.
  23. Patton ME, Kidd S, Llata E, et al. Extragenital gonorrhea and chlamydia testing and infection among men who have sex with men--STD Surveillance Network, United States, 2010-2012. Clin Infect Dis 2014; 58:1564.
  24. Marcus JL, Bernstein KT, Kohn RP, et al. Infections missed by urethral-only screening for chlamydia or gonorrhea detection among men who have sex with men. Sex Transm Dis 2011; 38:922.
  25. Gunn RA, O'Brien CJ, Lee MA, Gilchick RA. Gonorrhea screening among men who have sex with men: value of multiple anatomic site testing, San Diego, California, 1997-2003. Sex Transm Dis 2008; 35:845.
  26. Lewis DA. Will targeting oropharyngeal gonorrhoea delay the further emergence of drug-resistant Neisseria gonorrhoeae strains? Sex Transm Infect 2015; 91:234.
  27. Gaydos CA, Kent CK, Rietmeijer CA, et al. Prevalence of Neisseria Gonorrhoeae among men screened for Chlamydia Trachomatis in four United States cities, 1999-2003. Sex Transm Dis 2006; 33:314.
  28. McClelland RS, Sangare L, Hassan WM, et al. Infection with Trichomonas vaginalis increases the risk of HIV-1 acquisition. J Infect Dis 2007; 195:698.
  29. Van Der Pol B, Kwok C, Pierre-Louis B, et al. Trichomonas vaginalis infection and human immunodeficiency virus acquisition in African women. J Infect Dis 2008; 197:548.
  30. Reynolds SJ, Risbud AR, Shepherd ME, et al. High rates of syphilis among STI patients are contributing to the spread of HIV-1 in India. Sex Transm Infect 2006; 82:121.
  31. Fleming DT, Wasserheit JN. From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sex Transm Infect 1999; 75:3.
  32. Götz HM, van Doornum G, Niesters HG, et al. A cluster of acute hepatitis C virus infection among men who have sex with men--results from contact tracing and public health implications. AIDS 2005; 19:969.
  33. van de Laar T, Pybus O, Bruisten S, et al. Evidence of a large, international network of HCV transmission in HIV-positive men who have sex with men. Gastroenterology 2009; 136:1609.
  34. van der Helm JJ, Prins M, del Amo J, et al. The hepatitis C epidemic among HIV-positive MSM: incidence estimates from 1990 to 2007. AIDS 2011; 25:1083.
  35. Centers for Disease Control and Prevention (CDC). Sexual transmission of hepatitis C virus among HIV-infected men who have sex with men--New York City, 2005-2010. MMWR Morb Mortal Wkly Rep 2011; 60:945.
  36. Taylor LE, Holubar M, Wu K, et al. Incident hepatitis C virus infection among US HIV-infected men enrolled in clinical trials. Clin Infect Dis 2011; 52:812.
  37. van de Laar TJ, van der Bij AK, Prins M, et al. Increase in HCV incidence among men who have sex with men in Amsterdam most likely caused by sexual transmission. J Infect Dis 2007; 196:230.
  38. Tohme RA, Holmberg SD. Is sexual contact a major mode of hepatitis C virus transmission? Hepatology 2010; 52:1497.
  39. Ness RB, Smith KJ, Chang CC, et al. Prediction of pelvic inflammatory disease among young, single, sexually active women. Sex Transm Dis 2006; 33:137.
  40. Lofy KH, Hofmann J, Mosure DJ, et al. Chlamydial infections among female adolescents screened in juvenile detention centers in Washington State, 1998-2002. Sex Transm Dis 2006; 33:63.
  41. Kerani RP, Handcock MS, Handsfield HH, Holmes KK. Comparative geographic concentrations of 4 sexually transmitted infections. Am J Public Health 2005; 95:324.
  42. Niccolai LM, Ethier KA, Kershaw TS, et al. New sex partner acquisition and sexually transmitted disease risk among adolescent females. J Adolesc Health 2004; 34:216.
  43. Klausner JD, Kent CK, Wong W, et al. The public health response to epidemic syphilis, San Francisco, 1999-2004. Sex Transm Dis 2005; 32:S11.
  44. Kahn RH, Voigt RF, Swint E, Weinstock H. Early syphilis in the United States identified in corrections facilities, 1999-2002. Sex Transm Dis 2004; 31:360.
  45. Beymer MR, Weiss RE, Bolan RK, et al. Sex on demand: geosocial networking phone apps and risk of sexually transmitted infections among a cross-sectional sample of men who have sex with men in Los Angeles County. Sex Transm Infect 2014; 90:567.
  46. Lewnard JA, Berrang-Ford L. Internet-based partner selection and risk for unprotected anal intercourse in sexual encounters among men who have sex with men: a meta-analysis of observational studies. Sex Transm Infect 2014; 90:290.
  47. Datta SD, Sternberg M, Johnson RE, et al. Gonorrhea and chlamydia in the United States among persons 14 to 39 years of age, 1999 to 2002. Ann Intern Med 2007; 147:89.
  48. Centers for Disease Control and Prevention. National Overview - Sexually Transmitted Disease Surveillance, 2019: Chlamydia. https://www.cdc.gov/std/statistics/2019/overview.htm#Chlamydia (Accessed on October 07, 2021).
  49. Torkko KC, Gershman K, Crane LA, et al. Testing for Chlamydia and sexual history taking in adolescent females: results from a statewide survey of Colorado primary care providers. Pediatrics 2000; 106:E32.
  50. Boekeloo BO, Marx ES, Kral AH, et al. Frequency and thoroughness of STD/HIV risk assessment by physicians in a high-risk metropolitan area. Am J Public Health 1991; 81:1645.
  51. Rahman N, Ghanem KG, Gilliams E, et al. Factors associated with sexually transmitted infection diagnosis in women who have sex with women, women who have sex with men and women who have sex with both. Sex Transm Infect 2021; 97:423.
  52. Marrazzo JM, Gorgos LM. Emerging Sexual Health Issues Among Women Who Have Sex with Women. Curr Infect Dis Rep 2012.
  53. Singh D, Fine DN, Marrazzo JM. Chlamydia trachomatis infection among women reporting sexual activity with women screened in Family Planning Clinics in the Pacific Northwest, 1997 to 2005. Am J Public Health 2011; 101:1284.
  54. Centers for Disease Control and Prevention. Prexposure prophylaxis for the prevention of HIV infection in the United States. https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2017.pdf.
  55. Phipps W, Stanley H, Kohn R, et al. Syphilis, chlamydia, and gonorrhea screening in HIV-infected patients in primary care, San Francisco, California, 2003. AIDS Patient Care STDS 2005; 19:495.
  56. Hoebe CJ, Rademaker CW, Brouwers EE, et al. Acceptability of self-taken vaginal swabs and first-catch urine samples for the diagnosis of urogenital Chlamydia trachomatis and Neisseria gonorrhoeae with an amplified DNA assay in young women attending a public health sexually transmitted disease clinic. Sex Transm Dis 2006; 33:491.
  57. Trebach JD, Chaulk CP, Page KR, et al. Neisseria gonorrhoeae and Chlamydia trachomatis among women reporting extragenital exposures. Sex Transm Dis 2015; 42:233.
  58. Drinkard LN, Huxta RA, Halbritter A, et al. The Case for Extragenital Screening of Chlamydia trachomatis and Neisseria gonorrhoeae in the College Health Setting. Sex Transm Dis 2017; 44:274.
  59. van Liere GAFS, Dukers-Muijrers NHTM, Levels L, Hoebe CJPA. High Proportion of Anorectal Chlamydia trachomatis and Neisseria gonorrhoeae After Routine Universal Urogenital and Anorectal Screening in Women Visiting the Sexually Transmitted Infection Clinic. Clin Infect Dis 2017; 64:1705.
  60. Tao G, Hoover KW, Nye MB, et al. Infrequent Testing of Women for Rectal Chlamydia and Gonorrhea in the United States. Clin Infect Dis 2018; 66:570.
  61. Joesoef MR, Weinstock HS, Kent CK, et al. Sex and age correlates of Chlamydia prevalence in adolescents and adults entering correctional facilities, 2005: implications for screening policy. Sex Transm Dis 2009; 36:S67.
  62. Pathela P, Hennessy RR, Blank S, et al. The contribution of a urine-based jail screening program to citywide male Chlamydia and gonorrhea case rates in New York City. Sex Transm Dis 2009; 36:S58.
  63. CDC. Evaluation of large jail STD screening programs, 2008 - 2009.Atlanta, GA: CDC, NCHHSTP; 2011. http://www.cdc.gov/std/publications/JailScreening2011.pdf (Accessed on August 02, 2015).
  64. Hobbs MM, van der Pol B, Totten P, et al. From the NIH: proceedings of a workshop on the importance of self-obtained vaginal specimens for detection of sexually transmitted infections. Sex Transm Dis 2008; 35:8.
  65. Lunny C, Taylor D, Hoang L, et al. Self-Collected versus Clinician-Collected Sampling for Chlamydia and Gonorrhea Screening: A Systemic Review and Meta-Analysis. PLoS One 2015; 10:e0132776.
  66. Geisler WM, Wang C, Morrison SG, et al. The natural history of untreated Chlamydia trachomatis infection in the interval between screening and returning for treatment. Sex Transm Dis 2008; 35:119.
  67. Hopkins RS, Jajosky RA, Hall PA, et al. Summary of notifiable diseases--United States, 2003. MMWR Morb Mortal Wkly Rep 2005; 52:1.
  68. Golden MR, Whittington WL, Handsfield HH, et al. Effect of expedited treatment of sex partners on recurrent or persistent gonorrhea or chlamydial infection. N Engl J Med 2005; 352:676.
  69. Peterman TA, Tian LH, Metcalf CA, et al. High incidence of new sexually transmitted infections in the year following a sexually transmitted infection: a case for rescreening. Ann Intern Med 2006; 145:564.
  70. Centers for Disease Control and Prevention (CDC). Chlamydia screening among sexually active young female enrollees of health plans--United States, 2000-2007. MMWR Morb Mortal Wkly Rep 2009; 58:362.
  71. Heijne JC, Tao G, Kent CK, Low N. Uptake of regular chlamydia testing by U.S. women: a longitudinal study. Am J Prev Med 2010; 39:243.
  72. Berry SA, Ghanem KG, Mathews WC, et al. Brief Report: Gonorrhea and Chlamydia Testing Increasing but Still Lagging in HIV Clinics in the United States. J Acquir Immune Defic Syndr 2015; 70:275.
  73. de Voux A, Bernstein KT, Bradley H, et al. Syphilis Testing Among Sexually Active Men Who Have Sex With Men and Who Are Receiving Medical Care for Human Immunodeficiency Virus in the United States: Medical Monitoring Project, 2013-2014. Clin Infect Dis 2019; 68:934.
Topic 7596 Version 59.0

References

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