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 (http://www.cdc.gov/std/treatment/EPTFinalReport2006.pdf) 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 (http://www.who.int/std_diagnostics/news/SDI_founding_members.htm) Bibliography Agosti JM, Goldie SJ: Introducing HPV vaccine in developing countries— key challenges and issues. N Engl J Med 356:1908, 2007 [PMID: 17494923] Auvert B et al: Randomized, controlled interv ention trial of male circumcision for reduction of HIV infection risk: The ANRS 1265 Trial. PloS Med 2:e298, 2005 Baden LR et al: Human papillomavirus vaccine— opportunity and challenge. N Engl J Med 356:1990, 2007 [PMID: 17494932] Bailey RC et al: Male circumcision for HIV prevention in young men in Kisumu, Kenya: A randomized controlled trial. Lancet 369:643, 2007 [PMID: 17321310] Centers for Disease Control and Prevention: Update to CDC's sexually transmitted diseases treatment guidelines, 2006: Flu oroquinolones no longer recommended for treatment of gonococcal infections. MMWR 56:332, 2007 D'Souza G et al: Case- control study of human papillomavirus and oropharyngeal cancer. N Engl J Med 356:1944, 2007 [PMID: 17494927] Garland SM et al: Quadrival ent vaccine against human papillomavirus to prevent anogenital diseases. N Engl J Med 356:1928, 2007 [PMID: 17494926] Gray RH et al: Male circumcision for HIV prevention in men in Rakai, Uganda: A randomized trial. Lancet 369:657, 2007 [PMID: 17321311] Kamali A et al: Syndromic management of sexually transmitted infections and behaviour change interventions on transmission of HIV- 1 in rural Uganda: A community randomised trial. Lancet 361:645, 2003 [PMID: 12606175] Mao C et al: Efficacy of human papillomavirus- 16 vaccine to prevent cervical intraepithelial neoplasia: A randomized controlled trial. Obstet Gynecol 107:18, 2006 [PMID: 16394035] Morris M (ed): Network Epidemiology: A Handbook for Survey Design and Data Collection. New York, Oxford University Press, 2004 Morse SA et al: Atlas of Sexually Transmitted Diseases , 3d ed. Baltimore, Mosby, 2003 Public Health Agency of Canada: Canadian Guidelines on Sexually Transmitted Infections, 2006 ed. Ottawa, Canadian Public Health Association, 2006 (www.publichealth.gc.ca/sti) Richardson D, Golmeier D: Lymphogranuloma venereum: An emerging cause of proctitis in men who have sex with men. Int J STD A IDS 18:11, 2007 [PMID: 17326855] Tapsall JW: What management is there for gonorrhea in the postquinolone era? Sex Transm Dis 33:8, 2006 [PMID: 16385215] Wald A et al: Comparative efficacy of famciclovir and valacyclovir for suppression of recurrent gen ital herpes and viral shedding. Sex Transm Dis 33:529, 2006 [PMID: 16540883] Ward H et al: Lymphogranuloma venereum in the United Kingdom. Clin Infect Dis 44:26, 2007 [PMID: 17143811] Winer RL et al: Condom use and the risk of genital human papillomavi rus infection in young women. N Engl J Med 354:2645, 2006 [PMID: 16790697] World Health Organization: Guidelines for the management of sexually transmitted infections. Geneva, WHO, 2003 (http://www.who.int/reproductive- health/publications/rhr_01_10_mngt_stis/index.html) . Chapter 124. Sexually Transmitted Infections: Overview and Clinical Approach (Part 21) Although gonorrhea is now substantially less common. 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. prevention in men in Rakai, Uganda: A randomized trial. Lancet 369:657, 2007 [PMID: 17321311] Kamali A et al: Syndromic management of sexually transmitted infections and behaviour change interventions