Notification and management of sexual partners with STDs

In almost all cases, partners of patients with STDs should be tested. If the diagnosis of a treatable STD is probable, appropriate antibiotics should be given even in the absence of clinical evidence of infection and pending laboratory test results. In many states, local or federal health departments can assist in identifying partners of patients with certain STDs, especially HIV, syphilis, gonorrhea, and chlamydia.

Healthcare workers should encourage patients with STIs to notify their sexual partners of possible infection, including those who are asymptomatic, and to encourage these partners to come to the clinic for testing. This type of partner identification is known as 'patient partner notification'. In situations where patient notification may not be effective or possible, clinical staff should notify the patient's sexual partners either by 'consensual notification' or by home visit notification. 'Consensual notification' is a method of partner identification whereby the patient agrees to notify their partners within a specified time frame. If the partners do not come forward within this time frame, then home visit notification is used, i.e. partners named by the infected patient are identified and counselled by health care staff.

Breaking the chain of transmission is critical to STD control. Onward transmission and reinfection with curable STDs can be prevented by identifying sexual partners for diagnosis, treatment, vaccination, and counseling. When physicians refer infected patients to local or state health departments, trained personnel can interview them to obtain the names and locations of all sexual partners. Each health department maintains the confidentiality of patients’ participation in partner identification. Therefore, given the confidentiality of the information they provide, many patients prefer that public health officials perform partner notification. However, public health officials may not always be able to provide appropriate prophylaxis to contacts of all patients with STDs. In situations where the number of partners whose names may not be known to patients is large, such as among individuals who trade sex for drugs, active STD screening of high-risk individuals may be more effective in interrupting onward transmission than partner identification efforts by health care providers. Recommendations for the management of sexual partners and recommendations for identifying partners for specific STIs are included in the relevant sections of this guide.

STD Registration and Confidentiality

Accurate identification and timely reporting of STD cases are part of successful disease control. Reporting is important for assessing disease trends, allocating appropriate resources, and helping local health officials identify sexual partners who may be infected. STD/HIV and AIDS cases should be reported according to local requirements.

Syphilis, gonorrhea, and AIDS are reportable diseases in every state. Chlamydial infection is reportable in most states. Other reportable STDs, including asymptomatic HIV infection, vary by state, and clinicians should be aware of local reporting requirements. Reporting may be based on clinical and/or laboratory data. Health care providers unfamiliar with local reporting regulations should consult their local health department or state STD program for guidance.

Reporting of STD and HIV cases is done under strict confidentiality and in most cases patients are protected by law from forced subpoena. Subsequently, before initiating surveillance of an STD case, program officials must consult with the patient's health care provider to verify the diagnosis and treatment of the patient.

Pregnant women

Intrauterine or perinatal transmission of STDs can result in death or severe pathology of the fetus. It is necessary to ask the pregnant woman and her sexual partners about STDs and advise them about the possibility of infection in the newborn.

Recommended screening tests

• Serologic testing for syphilis should be performed on all pregnant women at their first visit during pregnancy. In populations where adequate prenatal care is not available, rapid plasma reagin (RPR) testing and treatment of women (if positive) should be done at the time of pregnancy diagnosis. Screening should be repeated in the third trimester and before delivery for high-risk patients. Some states require screening of all women before delivery. No newborn should be discharged from the hospital unless the mother has had serologic testing for syphilis at least once during pregnancy and, preferably, again at delivery. All women who have had a stillbirth should be tested for syphilis.
• Serologic testing for hepatitis B virus (HBV) surface antigen (HBsAg) should be performed in all pregnant women at their first pregnancy visit. Women with a negative HBsAg result who are at high risk for HBV infection (e.g., HBV drug users, patients with STIs) should have repeat HBsAg testing in late pregnancy.
• Testing for Neisseria gonorrhoeae should be performed at the first visit during pregnancy for women at risk or living in areas with a high prevalence of N. gonorrhoeae. Repeat testing should be performed in the third trimester of pregnancy for women who remain at risk.
• Chlamydia trachomatis testing should be performed in the third trimester of pregnancy in women at increased risk (under 25 years of age, with a new or more than one partner) to prevent postpartum complications in the mother and chlamydial infection in the infant. Screening in the first trimester of pregnancy may prevent adverse effects of chlamydial infection during pregnancy. However, evidence of adverse effects of chlamydial infection during pregnancy is minimal. If screening is performed only in the first trimester of pregnancy, there is a long period of time before delivery during which infection may occur.
• HIV testing should be offered to all pregnant women at their first visit.
• Screening for bacterial vaginosis (BV) in the early second trimester may be considered in asymptomatic women at high risk of preterm birth (with a history of preterm birth).
• A Pap smear should be performed at the first visit unless there is a record of one in the medical history for the past year.

Other questions

Other STD-related issues to consider include:

• When managing pregnant women with primary genital herpes, hepatitis B, primary cytomegalovirus (CMV), group B streptococcal infection, and women with syphilis who are allergic to penicillin, it may be necessary to refer them to a consultant in the management of such patients.
• Pregnant women who are positive for HBsAg should be reported to local and/or state health departments to ensure that these cases are reported to the hepatitis case management system and that their infants are provided with appropriate prophylaxis. In addition, close household and sexual contacts of the HBsAg-positive woman should be vaccinated.
• In the absence of lesions during the third trimester of pregnancy, routine cultures for herpes simplex virus (HSV) are not indicated in women with a history of recurrent genital herpes. However, isolation of HSV from such women during labor may guide neonatal management. "Prophylactic" cesarean section is not indicated for women without active genital lesions at the time of labor.
• The presence of genital warts is not an indication for cesarean section.

For a more detailed discussion of these issues, as well as issues related to non-sexually transmitted infections, see the Guide to Perinatal Care [6].

NOTE: Guidelines for screening pregnant women include the Guide to Clinical Preventive Services, Guidelines for Perinatal Care, American College of Obstetricians and Gynecologists (ACOG) Technical Bulletin: Gonorrhoeae and Chlamidial Infections, Recommendations for the Prevention and Management of Chlamydia trachomatis Infections and Hepatitis B Virus: A Comprehensive Strategy for Eliminating Transmission in the United States through Universal Childhood Vaccinations: Recommendation of the Immunisation Practices Advisory Committee (ACIP). These sources do not always provide the same recommendations. The Guide to Clinical Preventive Services recommends screening at-risk patients for chlamydia, but notes that the optimal intervals for testing have not been determined. For example, the Guidelines for Perinatal Care recommends testing at first visit and repeating testing in the third trimester of pregnancy for chlamydia in high-risk women. Screening recommendations for STDs in pregnant women are based on the severity of the disease and potential for complications, prevalence in the population, cost, medical/legal considerations (including state laws), and other factors. The screening recommendations in this guideline are broader (e.g., screening more women for more STDs than in other guidelines) and are comparable to other guidelines issued by CDC. Clinicians should select a screening strategy appropriate to the population and its setting, based on their STD detection and treatment goals.

Teenagers

Health care providers caring for adolescents with STDs need to be aware of certain considerations regarding these individuals.

The incidence of most STDs is highest in the population among adolescents; for example, the incidence of gonorrhea is highest among girls aged 15–19 years. Clinical studies have shown that the prevalence of chlamydial infections and possibly human papillomavirus (HPV) infection is also highest among adolescents. In addition, surveillance data indicate that 9% of adolescents with hepatitis B either reported having sex with someone who was chronically infected, had multiple sexual partners, or had predominantly homosexual sex. As part of the national strategy to stop the spread of HBV in the United States, ACIP recommends that all adolescents be vaccinated with the hepatitis B vaccine.

Adolescents at highest risk for STDs include gay men, sexually active heterosexuals, STD clinic clients, and drug users. Younger (under 15 years of age) sexually active adolescents are particularly at risk for infection. Adolescents are at high risk for STDs because they frequently have unprotected sex, are biologically more susceptible to infection, and find many barriers to seeking medical care.

Health care providers should recognize these risk factors and the general lack of knowledge and understanding of the consequences of STDs among adolescents and offer primary prevention guidance to help young people develop healthy sexual behaviors and prevent behavior patterns that may undermine sexual health. With few exceptions, all adolescents in the United States have the right to consent to confidential testing and treatment for STDs. Treatment under these conditions may be provided without parental consent or even parental notification. Furthermore, in most states, adolescents may consent to HIV counseling and testing. The right to consent to vaccination varies by state. Some states do not require parental consent for vaccinations, as do STD treatments. Health care providers should recognize the importance of confidentiality for adolescents and make every effort to ensure it when treating STDs in adolescents.

The style and content of counseling and health education should be tailored to the adolescent. The discussion should be developmentally appropriate and should focus on identifying risky behaviors, such as drug use or promiscuity. Tactful counseling and a thorough history are especially important for adolescents, who may not be aware that their behaviors include risk factors. Care and counseling should be provided in a compassionate, nonjudgmental manner.

Children

Treatment of children with STDs requires close collaboration between clinicians, laboratories, and child protection agencies. Investigations, if needed, should be done promptly. Some infections, such as gonorrhea, syphilis, and chlamydia, when acquired after the neonatal period, are almost 100% attributable to sexual contact. For others, such as HPV infection and vaginitis, the association with sexual contact is less clear (see Sexual Abuse and STDs).

[ 1 ], [ 2 ], [ 3 ], [ 4 ], [ 5 ], [ 6 ]