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Screening for Sexually Transmitted Infections – Who, When and How Often?

SYNOPSIS:

There are an estimated 2.8 million new chlamydia infections each year in the US and 1.5 million new cases of gonorrhea diagnosed. The highest rates of both gonorrhea and chlamydia are reported in women aged 15 to 24. Symptoms are vague and sequelae can include pelvic inflammatory disease, ectopic pregnancy and infertility.  A full comprehensive sexual history may identify other risk factors to prompt more comprehensive screening for sexually transmitted infections

CLINICAL ACTIONS:

Sexually transmitted infections (STIs) are common with potential for serious long term outcomes, and remain a serious public health concern.  Here, we outline the recommendations for screening for STIs by population:

Adults

  • Annual screening for gonorrhea and chlamydia is recommended for all sexually active women < 25 years | Evidence is insufficient for routine testing of gonorrhea and chlamydia in heterosexual men | Consider screening young men in high prevalence clinical settings e.g., adolescent clinics, correctional facilities, STI/sexual health clinic
    • Re-testing is recommended 3 months after treatment due to high re-infection rates
    • Screening is recommended for adults >25 years old at increased risk for infection (new partner, multiple partners, or a partner who has an STI)
    • Consider testing for rectal chlamydia and pharyngeal gonorrhea based on sexual history practices
    • Annual testing is recommended for men who have sex with men (MSM) at sites of contact (urethra, rectum)and every 3-6 months if at higher risk e.g. MSM on PrEP, HIV infection, or if they or their sex partners have multiple partners
    • Transgender and Gender Diverse Persons screening adapted based on anatomy
  • Screening for syphilis is based on risk profile, with higher risk including history of incarceration, transactional sex work, geography, or male younger than 29 years old
    • Annual screening for sexually active MSM | 3 to 6 months if at increased risk
    • Annual screening for syphilis is recommended in transgender and gender diverse persons
  • Screening for HIV should be performed in all adults aged 13-64 and who seek evaluation and treatment for STIs | Annual HIV screening is recommended for MSM with more than one sexual partner, with consideration for more frequent 3-6 month intervals for testing
  • Consider type-specific HSV serologic testing in patients presenting for an STI evaluation | Note: USPSTF “recommends against routine serologic screening for genital HSV infection in asymptomatic adolescents and adults, including those who are pregnant”
  • Consider screening for trichomonas in high-prevalence settings or patients at higher risk for infection (multiple sex partners, transactional sex, drug misuse, or a history of STI or incarceration)
  • Screening for hepatitis B (HBV) should include all adults aged 18 years and older
    • At least once in their lifetime using a triple panel test
    • Screen pregnant people for hepatitis B surface antigen (HBsAg) during each pregnancy regardless of vaccination status and history of testing
    • Expand periodic risk-based testing to include people incarcerated, people with a history of sexually transmitted infections or multiple sex partners, and people with hepatitis C virus infection
    • Test anyone who requests HBV testing regardless of disclosure of risk
  • Screening for hepatitis C infection (HCV) should include all adults over age 18 years except in settings with HCV positivity < 0.1%
    • All persons with risk factors (eg., persons with HIV, prior recipients of blood transfusions, persons who ever injected drugs and shared needles, and persons who are born to an HCV-infected mother) should be tested for HCV, with periodic testing while risk factors persist

Persons living with HIV

  • At first HIV evaluation and annually afterwards, screen for
    • Gonorrhea
    • Chlamydia
    • Syphilis
    • Hepatitis B surface antigen and Hepatitis B immunity
    • Hepatitis C screening for all persons with HIV and subsequent annual testing for MSM
  • Specifically for women with HIV
    • Screen for trichomonas for women at first evaluation and annually afterwards
    • Women should be screened within 1 year of sexual activity with testing repeat 6 months later | 3 normal and consecutive pap tests, screening can be spaced out to every 3 years

The USPSTF 2021 update

…recommends screening for chlamydia in all sexually active women 24 years or younger and in women 25 years or older who are at increased risk for infection. (B recommendation) …recommends screening for gonorrhea in all sexually active women 24 years or younger and in women 25 years or older who are at increased risk for infection. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for chlamydia and gonorrhea in men

KEY POINTS:

  • Screen sexually active women ≥ 25 for gonorrhea and chlamydia if at increased risk
  • More comprehensive screening for STIs include evaluation for trichomonas, syphilis, HIV, Hepatitis B and Hepatitis C
  • CDC has updated guidelines to recommend universal hepatitis C and hepatitis B screening in all adults

Learn More – Primary Sources:

CDC: Sexually Transmitted Infections Treatment Guidelines 2021

CDC: A Guide to Taking a Sexual History

CDC Recommendations for Hepatitis C Screening Among Adults — United States, 2020

CDC: Screening and Testing Recommendations for Chronic Hepatitis B Virus Infection (HBV)

USPSTF: Screening for Hepatitis B Virus Infection in Adolescents and Adults

Map: Prevalence of hepatitis B virus infection

USPSTF: Screening for Chlamydia and Gonorrhea

USPSTF: Serologic Screening for Genital Herpes Infection: US Preventive Services Task Force Recommendation Statement

USPSTF Recommends Universal Screening for Hepatitis C

SUMMARY:

  • USPSTF has reviewed available evidence and has updated its hepatitis C screening guidance. HCV is the most common chronic blood-borne pathogen in the US with potential for significant morbidity and mortality if left untreated. The prevalence of chronic HCV infection in the US is approximately 1.0% (2013 to 2016), with 44,700 new HCV infections in 2017. There has been an increase in acute infections over the last decade primarily due to increased injection drug use and better surveillance.
  • The USPSTF recommends screening for HCV infection in adults aged 18 to 79 years
  • Population: All asymptomatic adults aged 18 to 79 years without known liver disease
  • B level recommendation
    • Offer or provide this service
    • There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial

The USPSTF concludes with moderate certainty that screening for HCV infection in adults aged 18 to 79 years has substantial net benefit

Risk Assessment

  • Screen all adults ages 18 to 79 years
  • Risk factors to consider
    • Injection drug use: Consider screening adolescents <18 years or >79 years
      • Young adults (ages 18 to 30): Approximately 30% are infected
      • Older adults: 70% to 90% are infected
    • Pregnancy
      • Screen pregnant adults  

Because of the increasing prevalence of HCV in women aged 15 to 44 years and in infants born to HCV-infected mothers, clinicians may want to consider screening pregnant persons younger than 18 years

Screening Test

  • Anti-HCV antibody testing followed by polymerase chain reaction testing for HCV RNA
    • HCV infection can be detected by anti-HCV screening tests (enzyme immunoassay) 4 to 10 weeks after infection
    • Delayed seroconversion may occur in immunocompromised individuals (e.g., those with HIV infection)

Screening Intervals

  • “Most adults need to be screened only once”
    • Consider more frequent screening for individuals with ongoing risk (e.g., ongoing injection drug use)
    • Data is limited to determine optimal screening interval for those at continued risk or whether pregnancy impacts need for additional screening

KEY POINTS:

Hepatitis C Overview

  • Acute Hepatitis C occurs within the first 6 months after exposure to HCV
  • Many individuals will remain asymptomatic
  • 15% of patients will spontaneously clear the virus within 6 months
  • Signs and symptoms of acute HCV infection
    • Fever | Fatigue | Dark urine | Clay-colored stool | Abdominal pain | Loss of appetite | Nausea and vomiting | Joint pain | Jaundice
    • Most individuals with newly acquired HCV infection will be asymptomatic | 20 to 30% will exhibit symptoms
    • Symptoms will usually appear within 2 to 12 weeks (range: 2–26 weeks) 
  • Signs and of chronic HCV infection
    • Most people are asymptomatic or have non-specific symptoms (e.g., chronic fatigue and depression)
    • Many eventually develop chronic liver disease, which can range from mild to severe, including cirrhosis and liver cancer
    • Chronic HCV infection is typically not recognized until asymptomatic people are identified as HCV-positive when screened for blood donation or liver function tests return an abnormal result (e.g., elevated ALT), often during routine evaluation 

Hepatitis C Treatment

Acute

  • The same regimens recommended for chronic HCV infections are recommended for acute infection

Chronic

  • Current antiviral therapies can result in sustained virologic response (SVR; absence of detectable virus 12 weeks after completion of treatment)
    • SVR is indicative of a cure of HCV infection
    • Over 90% of HCV infected persons can be cured of HCV infection regardless of HCV genotype with 8-12 weeks of oral therapy
    • CDC provides a link to currently approved FDA therapies to treat hepatitis C (see ‘Learn More – Primary Sources’ below)

Other Considerations

  • Advise abstinence from alcohol and acetaminophen during acute infection                
  • Evaluate for hepatitis B and HIV infection
  • Vaccinate against Hepatitis A and Hepatitis B
  • Evaluation for advanced hepatic fibrosis with
  • Provide education on how to prevent HCV transmission to others

Other Professional Recommendations

  • AASLD/IDSA
    • One-time, routine, opt out HCV testing is recommended for all individuals aged 18 years and older
    • One-time HCV testing should be performed for all persons less than 18 years old with behaviors, exposures, or conditions or circumstances associated with an increased risk of HCV infection
    • Periodic repeat HCV testing should be offered to all persons with behaviors, exposures, or conditions or circumstances associated with an increased risk of HCV exposure
    • Annual HCV testing is recommended for all persons who inject drugs and for HIV-infected men who have unprotected sex with men
    • As part of prenatal care, all pregnant women should be tested for HCV infection, ideally at the initial visit
  • CDC
    • All adults 18 years and older (except in settings where the prevalence is <0.1%)
    • All pregnant persons should be screened for HCV during each pregnancy (except in settings where the prevalence of HCV infection is < 0.1%)
    • All persons with risk factors (eg., persons with HIV, prior recipients of blood transfusions, persons who ever injected drugs and shared needles, and persons who are born to an HCV-infected mother) should be tested for HCV, with periodic testing while risk factors persist

Learn More – Primary Sources:

Screening for Hepatitis C Virus Infection in Adolescents and Adults – US Preventive Services Task Force Recommendation Statement

AASLD / IDSA: HCV Testing and Linkage to Care

CDC Recommendations for Hepatitis C Screening Among Adults — United States, 2020

CDC link to FDA therapies to treat hepatitis C

Hepatitis C Questions and Answers for Health Professionals

Reported Prevalence of Maternal Hepatitis C Virus Infection in the United States

SMFM Consult Series #56: Hepatitis C in pregnancy—updated guidelines