Sexually Transmitted Infections: Updates From the 2021 CDC Guidelines.

Sexually transmitted infection (STI) rates are increasing for most nationally notifiable disease categories in the United States. The 2021 Centers for Disease Control and Prevention STI guidelines provide several updated, evidence-based testing and treatment recommendations. The recommended treatment for gonorrhea is ceftriaxone monotherapy given intramuscularly, with dosing based on the patient's body weight. For chlamydia, doxycycline is the preferred treatment. A test-of-cure is recommended for all cases of pharyngeal gonorrhea and for rectal chlamydia if treated with azithromycin. Vaginal trichomoniasis should be treated with a seven-day regimen of metronidazole. Treatment of pelvic inflammatory disease routinely includes metronidazole with doxycycline and an increased dosage of ceftriaxone. Syphilis of less than one year's duration should be treated with a single dose of intramuscular penicillin G benzathine, 2.4 million units. Syphilis of more than one year's or unknown duration should be treated with three consecutive weekly doses of intramuscular penicillin G benzathine, 2.4 million units each. A thorough evaluation for otic, ophthalmic, and neurologic symptoms is essential for anyone with syphilis because these complications can occur at any stage and require 10 to 14 days of treatment with intravenous aqueous crystalline penicillin G. Family physicians can reduce STI rates by taking a thorough sexual history, especially in teens and young adults, ordering screening tests and treatment based on the updated Centers for Disease Control and Prevention STI guidelines, and collaborating with public health departments for disease reporting and partner services.

The Emerging Intersection Between Injection Drug Use and Early Syphilis in Nonurban Areas of Missouri, 2012-2018.

BACKGROUND: The national rate of syphilis has increased among persons who inject drugs (PWID). Missouri is no exception, with increases in early syphilis (ES), congenital syphilis, and PWID, especially in nonurban counties. METHODS: Disease intervention specialist records for ES cases in Missouri (2012-2018) were examined. Drug use was classified as injection drug use (IDU) (opioid or methamphetamine) or non-IDU (opioid, methamphetamine, or cocaine). Rates were compared based on residence, sex of sex partner, and drug use. RESULTS: Rates of ES in Missouri increased 365%, particularly in small metropolitan and rural areas (1170%). Nonurban areas reported a higher percentage of persons with ES who used injection drugs (12%-15%) compared with urban regions (2%-5%). From 2012 to 2018, women comprised an increasing number of ES cases (8.3%-21%); 93% of women were of childbearing age. Increasingly more women in rural areas with ES also reported IDU during this time (8.4%-21.1%). CONCLUSIONS: As syphilis increases in small metropolitan and rural regions, access to high-quality and outreach-based sexual health services is imperative. Healthcare policy to equip health departments with harm reduction services and drug treatment resources offers an opportunity to impact both syphilis increases as well as health outcomes associated with IDU.

Single and Repeated Use of the Emergency Department for Chlamydia and Gonorrhea Care.

OBJECTIVE: Chlamydia and gonorrhea infection rates are rising in the United States, and the emergency department (ED) is increasingly a site where individuals seek care for these infections, sometimes more than once. This article investigates how individuals who use the ED more than once and receive chlamydia and gonorrhea care differ from individuals who are single users of the ED, as well as characteristics associated with being a repeat user of the ED. METHODS: We analyzed 46,964 visits made by individuals who attended 1 of 4 EDs from January 1, 2010, to May 31, 2016, and received a test for chlamydia and gonorrhea infection. We used negative binomial regression to test the ability of age, sex, race, infection status, and insurance status to predict number of visits. RESULTS: Individuals who used the ED more than once and received chlamydia and gonorrhea care were at their first visit more likely to be younger (incident rate ratio [IRR], 0.98; 95% confidence interval [CI], 0.97-0.98 per year) nonpregnant female (IRR, 1.23; 95% CI, 1.06-1.42), black (IRR, 1.27; 95% CI, 1.04-1.57), and have no or public insurance compared with single users of the ED. DISCUSSIONS: Individuals likely to make multiple visits to the ED and receive chlamydia and gonorrhea care may be identifiable on their first visit and potentially directed elsewhere during subsequent visits for more comprehensive and potentially less expensive sexually transmitted disease care.

The influence of race and sex on gonorrhea and chlamydia treatment in the emergency department.

BACKGROUND: Emergency Departments (EDs) are a care source for patients with sexually transmitted diseases (STDs). St. Louis, MO reports among the highest rates of gonorrhea and chlamydia infection. We examined STD treatment in a high-volume urban ED, in St. Louis MO, to identify factors that may influence treatment. METHODS: A retrospective chart review and analysis was conducted on visits to a high volume, academic ED in St. Louis, MO where patients received a gonorrhea/chlamydia nucleic acid amplification test (NAAT) with a valid matching test result over two years. Using multiple logistic regression, we examined available predictors for under and overtreatment. RESULTS: NAATs were performed on 3.3% of all ED patients during the study period. Overall prevalence was 6.9% for gonorrhea (95% CI: 6.2, 7.7) and 11.6% for chlamydia (95% CI: 10.6, 12.5). Race was not a statistically significant predictor for undertreatment but Black patients were significantly more likely to be overtreated compared to White patients. (OR 1.83, 95% CI: 1.5, 2.2). Females were more likely to be undertreated when positive for infection compared to males (OR 7.34, 95% CI: 4.8, 11.2) and less likely to be overtreated when negative for infection (OR 0.27, 95% CI: 0.2, 0.3). CONCLUSION: The burden of STDs in a high-volume academic ED was significant and treatment varied across groups. Attention should be paid to particular groups, specifically women and patients reporting Black as their race, to ensure appropriate treatment is administered. Patients would benefit from targeted STD management protocols and training in the ED.

Presenting to the Emergency Department Versus Clinic-Based Sexually Transmitted Disease Care Locations for Testing for Chlamydia and Gonorrhea: A Spatial Exploration.

BACKGROUND: Rates of sexually transmitted diseases (STDs) including chlamydia and gonorrhea are increasing in the United States while public health funding for STD services is decreasing. Individuals seek care in various locations including the emergency department (ED). The objective of this study is to investigate whether there are more physically proximal clinic-based STD care locations available to individuals who present to the ED in a major metropolitan area. METHODS: Addresses of EDs, clinics, and patients 13 years or older in St. Louis City or County given a nucleic acid amplification test and assigned an STD diagnosis (n = 6100) were geocoded. R was used to analyze clinics within 5 radii from the patients' home address and assess missed clinic opportunities (open, no charge, with walk-in availability) for those living in an urban versus suburban area. RESULTS: In urban areas, 99.1% of individuals lived closer to a clinic than the ED where they sought STD services; in suburban areas, 82.2% lived closer to a clinic than the ED where they presented. In the region, 50.6% lived closer to the health department-based STD care location than the hospital where they presented. Up to a third of ED patient visits for STD care could have occurred at a clinic that was closer to the patient's home address, open, no charge, and available for walk-in appointments. CONCLUSIONS: Clinic availability is present for most of the individuals in our study. Clinics providing STD services can increase advertising efforts to increase public awareness of the services which they provide.

The National Network of Sexually Transmitted Disease Clinical Prevention Training Centers Turns 40-A Look Back, a Look Ahead.

Since 1979, the National Network of Sexually Transmitted Disease (STD) Clinical Prevention Training Centers (NNPTC) has provided state-of-the-art clinical and laboratory training for STD prevention across the United States. This article provides an overview of the history and activities of the NNPTC from its inception to present day, and emphasizes the important role the network continues to play in maintaining a high-quality STD clinical workforce. Over time, the NNPTC has responded to changing STD epidemiological patterns, technological advances, and increasing private-sector care-seeking for STDs. Its current structure of integrated regional and national training centers allows NNPTC members to provide dynamic, tailored responses to STD training needs across the country.

Lymphogranuloma Venereum 2015: Clinical Presentation, Diagnosis, and Treatment.

Lymphogranuloma venereum (LGV) has emerged as an important cause of proctitis and proctocolitis in men who have sex with men; classical inguinal presentation is now increasingly uncommon. We report summary findings of an extensive literature review on LGV clinical presentation, diagnosis, and treatment that form the evidence base for the 2015 Centers for Disease Control and Prevention treatment guidelines for sexually transmitted diseases. Proctitis and proctocolitis are now the most commonly reported clinical manifestations of LGV, with symptoms resembling those of inflammatory bowel disease. Newer molecular tests to confirm LGV infection are sensitive and specific, but are generally restricted to research laboratory or public health settings. Doxycycline (100 mg twice daily for 21 days) remains the treatment of choice for LGV. Patients with rectal chlamydial infection and signs or symptoms of proctitis should be tested for LGV, or if confirmatory testing is not available, should be treated empirically with a recommended regimen to cover LGV infection.

"Testing-only" visits: an assessment of missed diagnoses in clients attending sexually transmitted disease clinics.

BACKGROUND: At sexually transmitted disease (STD) clinics, advances in testing technology coupled with increasing demands and diminishing resources have promoted the use of testing-only visits (clinic visits with testing for STDs but no full examination) to meet increasing demands for STD services. OBJECTIVES: The aims of the present study were to estimate the prevalence of STD diagnoses that could become "missed diagnoses" if patients would use testing-only visits and to examine patient characteristics associated with these potential missed diagnoses. METHODS: We conducted a self-administered survey of STD-related symptoms and sexual risk behaviors in patients seeking routine clinical care at 3 STD clinics. Medical charts were abstracted to estimate the prevalence of viral STDs, trichomoniasis, and other diagnoses from standard clinical services that could become missed diagnoses. RESULTS: Of 2582 patients included, the median age was 24 years and 50% were women. In women, overall, 3.2% were diagnosed as having a viral STD; 9.6%, trichomoniasis; and 41.0%, vulvovaginal candidiasis or symptomatic bacterial vaginosis. The prevalence of these potential missed diagnoses varied by patient characteristics, but in women who reported no symptoms, the prevalence of trichomoniasis was still 6.3%. In men, 19.3% received a diagnosis of urethritis but tested negative for both gonorrhea and chlamydia; this prevalence varied from 15.7% in those who reported no symptoms to 32.6% in those who reported malodor. CONCLUSIONS: A high proportion of STD clients received diagnoses from standard care visits that would be missed by testing-only visits. When patients, even those asymptomatic, use testing-only visits, missed diagnoses of STDs or related genital tract conditions can be substantial. The potential disadvantages of testing-only visits should be weighed against the advantages of such visits.

Determinants of COVID-19 knowledge and self-action among African women: Evidence from Burkina Faso, the Democratic Republic of Congo, Kenya, and Nigeria.

Knowledge of infectious diseases and self-action are vital to disease control and prevention. Yet, little is known about the factors associated with knowledge of and self-action to prevent the coronavirus disease (COVID-19). This study accomplishes two objectives. Firstly, we examine the determinants of COVID-19 knowledge and preventive knowledge among women in four sub-Saharan African countries (Kenya, Nigeria, the Democratic Republic of Congo, and Burkina Faso). Secondly, we explore the factors associated with self-action to prevent COVID-19 infections among these women. Data for the study are from the Performance for Monitoring Action COVID-19 Survey, conducted in June and July 2020 among women aged 15-49. Data were analysed using linear regression technique. The study found high COVID-19 knowledge, preventive knowledge, and self-action among women in these four countries. Additionally, we found that age, marital status, education, location, level of COVID-19 information, knowledge of COVID-19 call centre, receipt of COVID-19 information from authorities, trust in authorities, and trust in social media influence COVID-19 knowledge, preventive knowledge, and self-action. We discuss the policy implications of our findings.

Screening methods for Chlamydia trachomatis and Neisseria gonorrhoeae infections in sexually transmitted infection clinics: what do patients prefer?

OBJECTIVES: To meet the need for services at sexually transmitted infection (STI) clinics, self-obtained vaginal (SOV) swabs or first-catch urine (FCU) samples collected at a clinic visit have been proposed as an alternative approach for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) screening. The purpose of this clinic-based survey was to determine if non-invasive clinic-based SOV swabs and FCU samples for CT and GC screening are acceptable replacements for a traditional provider visit. METHODS: Patients seen at STI clinics in three US cities completed a self-administered survey of preferences for methods of CT and GC screening under hypothetical circumstances. RESULTS: A total of 2887 participants completed a self-administered questionnaire that contained multiple-choice questions about their preference. If there was a hypothetical long clinic wait, 58% of the survey participants preferred to wait to see a doctor. If the clinic had to turn patients away, 41% of patients preferred to come back the next business day and 46% preferred to self-collect a sample. The percentages were similar across site, demographic and clinical groups. CONCLUSIONS: Clinic-based self-collected specimens for CT and GC screening were not preferred by most patients who participated in this survey. The findings indicate that more detailed information about self-collection practices must be provided for patients to adopt this new approach.

A prospective study of the psychosocial impact of a positive Chlamydia trachomatis laboratory test.

BACKGROUND: Few data exist on potential harms of chlamydia screening. We assessed the psychosocial impact of receiving a positive Chlamydia trachomatis test result. METHODS: We prospectively studied women ≥16 years of age undergoing chlamydia testing in 2 Midwestern family planning clinics. We surveyed women at baseline and about 1 month after receiving test results, using 9 validated psychosocial scales/subscales and chlamydia-specific questions. Changes in scale scores were calculated for each woman. Mean percent changes in scores for chlamydia-positive and -negative women were compared using a t test. RESULTS: We enrolled 1807 women (response rate, 84%). Of the 1688 women with test results, 149 (8.8%) tested positive. At follow-up, chlamydia-positive women (n = 71) had a 75% increase in anxiety about sexual aspects of their life on the Multidimensional Sexual Self-Concept Questionnaire (P < 0.001), significantly greater than the 26% increase among 280 randomly selected chlamydia-negative women (P = 0.02). There were no differences for the other 8 scales/subscales, including general measures of anxiety, depression, and self-esteem. Chlamydia-positive women were more likely than chlamydia-negative women to be "concerned about chlamydia" (80% vs. 40%, P < 0.001) and to report breaking up with a main partner (33% vs. 11%, P < 0.001) at follow-up. Women testing positive reported a range of chlamydia-specific concerns. CONCLUSIONS: Chlamydia-positive women had significant increases in anxiety about sex and concern about chlamydia, but did not have marked changes in more general measures of psychosocial well-being about 1 month after diagnosis. Chlamydia diagnoses were associated with some disruption of relationships with main partners. Chlamydia-specific concerns may guide counseling messages to minimize psychosocial impact.

Anal intercourse among young heterosexuals in three sexually transmitted disease clinics in the United States.

OBJECTIVE: To examine factors associated with heterosexual anal intercourse (AI). METHODS: Between 2001 and 2004, 1084 heterosexual adults aged 18 to 26 attending public sexually transmitted disease clinics in Seattle, New Orleans, and St Louis were interviewed using computer-assisted self interview and tested for STIs; Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium, Trichomonas vaginalis, and genital herpes (HSV-2). Characteristics associated with AI were identified using logistic regression. RESULTS: Overall 400 (37%) reported ever having had AI, 266 (28.9%) reported AI with at least 1 of their last 3 partners, and 19% reported AI with their last partner. Fewer women than men reported condom use at last AI (26% vs. 45%, P <0.001). Ever having AI was associated with sex on the same day as meeting a partner [AOR 3.9 (95% CI, 2.46-6.21)], receiving money for sex [AOR 2.8 (1.40-5.45)], and >3 lifetime sex partners [AOR 2.8 (1.56-5.07)] among women, and sex on the same day as meeting a partner [AOR 2.0 (1.33-3.06]) among men. AI with the last partner was associated with sex toy use [AOR 5.6 (2.63-12.0)] and having concurrent partners [AOR 2.2 (1.21-4.11)] among men, and with sex within a week of meeting [AOR 2.4 (1.28-4.37)], believing the partner was concurrent (AOR 1.9 [1.12-3.22]), and sex toy use [AOR 5.7 (2.31-14.0)] among women. Prevalent vaginal and urethral sexually transmitted infections were not associated with AI. CONCLUSIONS: Many young heterosexuals attending sexually transmitted disease clinics reported AI, which was associated with other sexual risk behaviors, suggesting a confluence of risks for HIV infection.

Existence, Distribution, and Characteristics of STD Clinics in the United States, 2017.

OBJECTIVES: Studies of sexually transmitted disease (STD) clinics have been limited by the lack of a national list for representative sampling. We sought to establish the number, type, and distribution of STD clinics and describe selected community characteristics associated with them. METHODS: We conducted a 2-phased, multilevel, online search from September 2014 through March 2015 and from May through October 2017 to identify STD clinics in all 50 US states and the District of Columbia. We obtained data on clinic name, address, contact information, and 340B funding status (which requires manufacturers to provide outpatient drugs at reduced prices). We classified clinics by type. We also obtained secondary county-level data to compare rates of chlamydia and HIV, teen births, uninsurance and unemployment, and high school graduation; ratios of primary care physician to population; health care costs; median household income; and percentage of population living in rural areas vs nonrural areas. We used t tests to examine mean differences in characteristics between counties with and without STD clinics. RESULTS: We found 4079 STD clinics and classified them into 10 types; 2530 (62.0%) clinics were affiliated with a local health department. Of 3129 counties, 1098 (35.1%) did not have an STD clinic. Twelve states had an STD clinic in every county, and 34 states had ≥1 clinic per 100 000 population. Most STD clinics were located in areas of high chlamydia morbidity and where other surrogate needs were greatest; rural areas were underserved by STD clinics. CONCLUSIONS: This list may aid in more comprehensive national studies of clinic services, STD clinic adaptation to external policy changes (eg, in public financing or patient access policy), and long-term clinic survival, with special attention to clinic coverage in rural areas.

Current controversies in the management of adult syphilis.

Clinical management of patients with syphilis is controversial. This article summarizes recent research on syphilis treatment efficacy and outcomes and is based on a comprehensive systematic review of published literature, relevant abstracts, conference proceedings, technical reports, and guidelines. Penicillin remains the drug of choice for the treatment of syphilis. Although several studies have suggested that azithromycin may have clinical efficacy, macrolide resistance has been widely documented among strains of Treponema pallidum, and treatment failures have been reported. Ceftriaxone is effective for the treatment of syphilis when used in multiple-dose regimens. Lumbar puncture should be performed for human immunodeficiency virus-infected patients with syphilis of >1 year's duration and a serum nontreponemal test titer > or =1 : 32, as well for other patients for whom the clinical suspicion of neurosyphilis is high. Newer laboratory tests for syphilis are undergoing extensive evaluation and may prove to be useful for future clinical care. American and European approaches to syphilis treatment are similar, but they vary across several parameters.

Treatment of lymphogranuloma venereum.

BACKGROUND: Lymphogranuloma venereum (LGV) classically presents with 1 or more genital ulcers or papules, as well as inguinal lymphadenopathy (buboes). Recently reported cases of LGV proctitis in men who have sex with men, many of whom are coinfected with human immunodeficiency virus (HIV), have highlighted the importance of optimal clinical treatment of LGV. METHODS: A review was conducted of the literature on LGV published between 1998 and 2004, as part of the development of the 2006 sexually transmitted disease treatment guidelines of the Centers for Disease Control and Prevention (CDC). RESULTS: Doxycycline (100 mg orally twice daily for 21 days) remains the treatment of choice for LGV. No controlled trials support the use of azithromycin or the use of alternative treatment regimens for persons with HIV infection. CONCLUSIONS: On the basis of the present literature review, the CDC's treatment recommendations for LGV remain unchanged. LGV clinical care, surveillance, and research are severely hindered by the lack of widely available, rapid, standardized tests for the diagnosis of LGV; therefore, patients with symptoms suggestive of LGV, including LGV proctitis, should be presumptively treated with antibacterial therapy for 3 weeks.

Sexual networks of pregnant women with and without HIV infection.

OBJECTIVES: To determine the relationship of HIV infection in pregnant women to sexual network size and other risk factors. DESIGN: Case-control study of women attending the public maternity hospital in Lima, Peru. METHODS: We interviewed 75 HIV-seropositive women, 41 of their most recent male partners, and two control groups totaling 137 uninfected pregnant women and 70 of their most recent male partners. Each woman's sexual network size was estimated through second and third-generation partnerships over the past year, 5 years and lifetime. RESULTS: Few HIV-seropositive women reported behavioral risk factors for HIV infection, but 79% of male partners were HIV seropositive. Risk factors in male partners included sex with a female sex worker (FSW) or with another man (MSM). The mean 5-year sexual network sizes through the second generation (8.4 persons for HIV-seropositive women, and 2.5 and 1.9 for women in the two control groups) predicted HIV in the women, independently of her own number of partners. These differences were largely attributable to the number of partners reported by male partners. Using data from concurrent studies of FSW and MSM, estimates of 5-year sexual network sizes through the third-generation, excluding contacts with FSW which were protected by consistent condom use, were 672 persons for HIV-seropositive women, and 160 and 224 for women in the two control groups. CONCLUSIONS: HIV infection risk among pregnant women in Lima depends largely on their male partners' risk behaviors. Even monogamous women had very large sexual networks.