Chapter 124. Sexually Transmitted Infections:
Overview and Clinical Approach
(Part 21)

Although gonorrhea is now substantially less common than chlamydial
infection in industrialized countries, screening tests for N. gonorrhoeae are still
appropriate for women and teenage girls attending STD clinics and for sexually
active teens and young women from areas of high gonorrhea prevalence.
Multiplex NAATs that combine screening for N. gonorrhoeae and C. trachomatis
in a single low-cost assay now facilitate the prevention and control of both
infections in populations at high risk.
All patients with newly detected STIs or at high risk for STIs according to
routine risk assessment as well as all pregnant women should be encouraged to
undergo serologic testing for syphilis and HIV infection, with appropriate HIV
counseling before and after testing. Randomized trials have shown that risk-
reduction counseling of patients with STIs significantly lowers subsequent risk of
acquiring an STI; such counseling should now be considered a standard
component of STI management. Preimmunization serologic testing for antibody to
HBV is indicated for unvaccinated persons who are known to be at high risk, such
as homosexually active men and injection drug users. In most young persons,
however, it is more cost-effective to vaccinate against HBV without serologic
screening. In 2006, the Advisory Committee on Immunization Practices (ACIP) of
the CDC recommended the following: (1) Universal hepatitis B vaccination should
be implemented for all unvaccinated adults in settings in which a high proportion
of adults have risk factors for HBV infection (e.g., STD clinics, HIV testing and
treatment facilities, drug-abuse treatment and prevention settings, health care
settings targeting services to injection drug users or men who have sex with men,
and correctional facilities). (2) In other primary care and specialty medical settings
in which adults at risk for HBV infection receive care, health care providers
should inform all patients about the health benefits of vaccination, the risk factors
for HBV infection, and the persons for whom vaccination is recommended and

should vaccinate adults who report risk factors for HBV infection as well as any
adult who requests protection from HBV infection. To promote vaccination in all
settings, health care providers should implement standing orders to identify adults
recommended for hepatitis B vaccination, should administer HBV vaccination as
part of routine clinical services, should not require acknowledgment of an HBV
infection risk factor for adult vaccination, and should use available reimbursement
mechanisms to remove financial barriers to hepatitis B vaccination.
In 2007, the ACIP recommended routine immunization of 9- to 26-year-old
girls and women with the quadrivalent HPV vaccine (against HPV types 6, 11, 16,
and 18) approved by the U.S. Food and Drug Administration; the optimal age for
recommended vaccination is 11–12 years because of the very high risk of HPV
infection after sexual debut.
Partner notification is the process of identifying and informing partners of
infected patients about possible exposure to an STI and of examining, testing, and
treating partners as appropriate. In a series of 22 reports concerning partner
notification during the 1990s, index patients with gonorrhea or chlamydial
infection named a mean of 0.75–1.6 partners, of whom one-fourth to one-third
were infected; those with syphilis named 1.8–6.3 partners, with one-third to one-
half infected; and those with HIV infection named 0.76–5.31 partners, with up to
one-fourth infected. Persons who transmit infection or who have recently been
infected and are still in the incubation period usually have no symptoms or only
mild symptoms and seek medical attention only when notified of their exposure.
Therefore, the clinician must encourage patients to participate in partner
notification, must ensure that exposed persons are notified, and must guarantee
confidentiality to all involved. In the United States, local health departments often
offer assistance in partner notification, treatment, and/or counseling. It seems both
feasible and most useful to notify those partners exposed within the patient's likely
period of infectiousness, which is often considered the preceding 1 month for
gonorrhea, 1–2 months for chlamydial infection, and up to 3 months for early
syphilis.

Persons with a new-onset STI always have a source contact who gave them
the infection; in addition, they may have a secondary (spread or exposed) contact
with whom they had sex after becoming infected. The identification and treatment
of these two types of contacts have different objectives. Treatment of the source
contact (often a casual contact) benefits the community by preventing further
transmission; treatment of the recently exposed secondary contact (typically a
spouse or another steady sexual partner) prevents both the development of serious
complications (such as PID) in the partner and reinfection of the index patient. A
survey of a random sample of U.S. physicians found that most instructed patients
to abstain from sex during treatment, to use condoms, and to inform their sex
partners after being diagnosed with gonorrhea, chlamydial infection, or syphilis;
physicians sometimes gave the patients drugs for their partners. However, follow-
up of the partners by physicians was infrequent. A randomized trial compared
patients' delivery of therapy to partners exposed to gonorrhea or chlamydial
infection with conventional notification and advice to partners to seek evaluation
for STD; patients' delivery of partners' therapy (PDPT), also known as expedited
partner therapy (EPT), significantly reduced combined rates of reinfection of the
index patient with N. gonorrhoeae or Chlamydia. State-by-state variations in
regulations governing this approach have not been well defined, but the 2006 CDC
STD treatment guidelines and the EPT final report of 2006
( describe its potential
use. Currently, EPT is commonly used by many practicing physicians; it is not
feasible in some settings and lacks clear legal sanctioning in some states.
In summary, clinicians and public health agencies share responsibility for
the prevention and control of STIs. In the managed-care era, the role of primary
care clinicians has become increasingly important in prevention as well as in
diagnosis and treatment.
Further Readings
Centers for Disease Control and Prevention: Sexually transmitted diseases
treatment guidelines, 2006. MMWR Recomm Rep 55(RR-

11):1, 2006 (Erratum in
MMWR Recomm Rep 55(36):997, 2006)
Fredricks DN et al: Molecular identification of bacteria asso
ciated with
bacterial vaginosis. N Engl J Med 353:1899, 2005 [PMID: 16267321]
FUTURE II Group: Quadrivalent vaccine against human papillomavirus to
prevent high-grade cervical lesions. N Engl J Med 356:1915, 2007
Golden MR et al: Effect of expedited tr
eatment of sex partners on recurrent
or persistent gonorrhea or chlamydial infection. N Engl J Med 352:676, 2005
[PMID: 15716561]
Holmes KK et al (eds): Sexually Transmitted Diseases
, 4th ed. New York,
McGraw-Hill, 2008
Manhart LE, Holmes KK: Randomized controlled trials of individual-
level,
population-
level, and multilevel interventions for preventing sexually transmitted
infections: What has worked? J Infect Dis 191(Suppl 1):S7, 2005
Markowitz LE
et al: Quadrivalent human papillomavirus vaccine:
Rec
ommendations of the Advisory Committee on Immunization Practices (ACIP).
MMWR Recomm Rep 56(RR-2):1, 2007
Mast EE
et al: A comprehensive immunization strategy to eliminate
transmission of hepatitis B virus infection in the United States: Recommendations
of the Advisory Committee on Immunization Practices (ACIP) Part II:
Immunization of adults. MMWR Recomm Rep 55(RR-16):1, 2006
Workowski KA: Sexually transmitted disease treatment guidelines. Clin

Infect Dis 44(Suppl 3):S1, 2007
World Health Organizatio
n: Sexually transmitted diseases diagnostics
initiative. Geneva, WHO, 2001
(
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