STD clinical service recommendations define which services PCPs should provide

The CDC’s Recommendations for Providing Quality Sexually Transmitted Diseases Clinical Service report highlights the important role of all health care providers in reversing the increasing trend of STDs in the United States and outlines which clinical services should be available in primary care settings.

The recommendations, released shortly after the CDC announced that 2018 was the fifth straight record-breaking year for STDs in the United States, focus on eight clinical services: sexual history and physical examination; prevention; screening; partner services; assessment of STD-related conditions; laboratory services; treatment; and specialist referral.

“These new recommendations are designed to go hand-in-hand with the CDC’s 2015 STD Treatment Guidelines,” Roxanne Barrow, MD, MPH, a CDC medical epidemiologist and co-author of the new recommendations, told Healio Primary Care. “The Treatment Guidelines focus on the clinical management of patients, while the Recommendations for Providing Quality Sexually Transmitted Diseases Clinical Services can help guide clinical operations.”

Patient-centered care is an “overarching recommendation” in the guidelines, according to Melanie Thompson MD, principal investigator of the AIDS Research Consortium of Atlanta and past chair of the HIV Medicine Association. Thompson, who was not affiliated with the guidelines’ development, added that patient-centered care “is absolutely crucial for addressing the STI epidemics, especially HIV.”

 

“Increasingly, primary care clinicians are the vanguard for ending the epidemics of chlamydia, gonorrhea, syphilis and HIV. We will not end any of these epidemics unless we decrease the factors that repel people from care and bridge existing societal barriers to care,” she told Healio Primary Care.

Below are the CDC’s recommendations for providing quality STD care in primary care offices and tips from infectious disease specialists on how PCPs can discuss these services with patients.

Sexual history, physical examination

The CDC strongly recommends that the following clinical tasks should be available in a primary care setting:

• taking a patient’s sexual history and risk assessment during the patient’s first comprehensive visit or annual visit and at each visit related to reproductive, genital or urologic issues; and
• pelvic exams and physicals for patients with STD-related symptoms, STD-related concerns or those at high behavioral risk for incident STDs

The CDC offers weaker recommendations on services that could be implemented in a primary care setting:

• providing anoscopy; and
• taking sexual history and risk assessment at each visit unrelated to reproductive, genital or urologic concerns.

Prevention
The CDC strongly recommends:

• providing or referring patients to brief contraceptive counseling, HPV and hepatitis B vaccinations or referrals;
• supplying emergency contraceptive pills;
• delivering short STD/HIV prevention counseling sessions of less than 30 minutes;
• providing risk assessment, education and referral for pre-exposure prophylaxis (PrEP) for HIV prevention and nonoccupational postexposure prophylaxis of HIV; and
• offering education and referrals or links to HIV care, family planning services and behavioral health services.

The CDC offers weaker recommendations to:

• provide moderate-intensity STD behavioral counseling;
• have on-site condom provision and hepatitis A vaccination; and
• provide PrEP starter packs or prescriptions for HIV prevention and nonoccupational postexposure prophylaxis of HIV.

Screening

The CDC strongly recommends that the following screenings should be available:

• cervical cancer;
• chlamydia;
• gonorrhea;
• hepatitis B and hepatitis C; and
• HIV

There is a weaker recommendation to offer trichomoniasis screening and assessment.

Partner services

The CDC strongly recommends:

• providing guidance regarding notification and care of sex partners; and
• providing information on expedited partner therapy in local or state jurisdictions where it is legal to do so.

The agency has a weaker recommendation to provide interactive counseling for partner notification.

Evaluation of STD-related conditions

The CDC strongly recommends that the following evaluations should be available:

• ectoparasitic infections;
• epididymitis;
• genital ulcer disease;
• genital warts;
• male urethritis syndrome;
• pelvic inflammatory disease;
• pharyngitis;
• proctitis; and
• systemic or dermatologic conditions compatible with or suggestive of an STD etiology.

Laboratory services

The CDC strongly recommends that the following laboratory services should be available at the time of a patient visit:

• thermometer; and
• pH paper.

In addition, the CDC strongly recommends that the following clinical laboratory services should be available:

• extragenital (pharynx and rectum) nucleic acid amplification tests for gonorrhea and chlamydia;
• fourth-generation antigen/antibody HIV tests;
• herpes simplex virus cultures or polymerase chain reaction;
• herpes simplex virus serology tests;
• nonoccupational postexposure prophylaxis and PrEP;
• oncogenic HPV nucleic acid amplification tests with Pap smear;
• pregnancy tests;
• quantitative nontreponemal serologic tests for syphilis;
• serologic tests for hepatitis A, HBV and HCV;
• treponemal serologic tests for syphilis; and
• urogenital nucleic acid amplification test for gonorrhea and chlamydia.

Weaker recommendations for the availability of laboratory services and test results at the time of a patient visit include:

• phlebotomy;
• tests for bacterial vaginosis, HIV, pregnancy, trichomoniasis and vulvovaginal candidiasis;

• urine dipstick; and
• urinalysis with microscopy.

The CDC also offers weaker recommendations for the following clinical laboratory services:

• gonorrhea antimicrobial susceptibility testing and nucleic acid amplification test for trichomoniasis;
• gonorrhea cultures; and
• gram strain, methylene blue or gentian violet strain for urethritis.

Treatment
The CDC strongly recommends that treatment for the following conditions should be available by prescription:

• bacterial vaginosis;
• ectoparasitic infections;
• emergency contraception;
• expedited partner therapy for gonorrhea and chlamydia;
• herpes;
• nonoccupational postexposure prophylaxis and PrEP;
• patient-applied regimens for genital warts;
• trichomoniasis;
• UTI; and
• vulvovaginal candidiasis.

The CDC has a weaker recommendation that treatment for the following conditions be available onsite in primary care:

• cervicitis;
• chlamydia;
• emergency contraception;
• epididymitis;
• gonorrhea;
• nonoccupational postexposure prophylaxis and PrEP;
• nongonococcal urethritis;
• pelvic inflammatory disease; and
• proctitis; provider-applied regimens for genital warts and syphilis.

Referrals

The recommendations also provide examples of when a PCP should refer a patient to a specialist for a complex STD or STD-related condition.

Complex gonorrhea

• antimicrobial-resistant gonorrhea;
• cephalosporin or IgE-mediated penicillin allergy;
• disseminated gonococcal infection, gonococcal endocarditis or meningitis;
• gonococcal conjunctivitis;
• gonococcal ophthalmia in infants; and
• suspected cephalosporin treatment failure.

Complex chlamydial infections

• cephalosporin or IgE-mediated penicillin allergy;
• chlamydial ophthalmia in infants;
• persistent or recurrent cervicitis or epididymitis;
• pneumonia in infants; and
• suspicion of testicular torsion.

Complex syphilis

• complex vaginal discharge, trichomoniasis, and candidiasis;
• IgE-mediated penicillin allergy or allergy to nitroimidazoles;
• neurosyphilis;
• ocular (or otic) and tertiary syphilis;
• primary, secondary and latent syphilis in infants and children;
• syphilis during pregnancy with sonographic signs of fetal or placental syphilis;
• persistent or recurrent trichomoniasis;
• persistent vaginal discharge of unclear etiology; and
• recurrent vulvovaginal candidiasis in patients who remain culture-positive despite maintenance therapy or nonalbicans vulvovaginal candidiasis.

“All services must be delivered in a safe and culturally humble manner, from the front desk to the exam room if we expect people to access care,” Thompson said. “In addition, these epidemics are driven by social determinants of health: poverty and structural racism, lack of transportation, lack of housing. We must consider and address these barriers as well, including with novel methods of service delivery.”

Starting the conversation

Thompson acknowledged that “many clinicians are not comfortable” discussing sensitive information, such as sexual history. Therefore, Healio Primary Care asked her and other infectious disease experts to provide tips on getting STD-related conversations started.

Kimberly Workowski

Kimberly Workowski, MD, professor at Emory University School of Medicine and a co-author of the recommendations, said that the STD-related conversation can start before the patient enters the examination room.

“Consider having some pamphlets, having some recommendations or other written materials available as patients are waiting for you,” she said. “That might prompt a discussion.”

Thompson added that “PCPs should take a sexual history in a sex-positive, patient-centered manner emphasizing the ‘5Ps: partners, practices, prevention, past STIs and prevention of pregnancy.’ It’s not as hard as it seems and learning to do this can be quick and extremely effective.” (Editor’s note: More information about the 5Ps can be found at: https://www.cdc.gov/std/treatment/sexualhistory.pdf).

Ann Avery

Ann Avery, MD, an infectious disease specialist at MetroHealth Medical Center and associate professor of medicine at Case Western Reserve School of Medicine in Cleveland, Ohio, said the key to discussing STDs is “knowing your audience.”

“It is important to remember the community you are working in,” she said in an interview. “Patients living in, or with partners living in, larger metro areas are usually at higher risk for STDs than those living in smaller, rural areas.”

Avery added that PCPs should ask as questions like, ‘Have you ever thought that you might be at risk for an STD?’ ‘What's going on in your sex life at this moment? What do you know about your partner?’”

It is important to ask questions that require more than a “yes” or a “no” answer, Avery continued.

“Other questions you might want to ask are, ‘What do you know about your partner? Do you think your partner could have HIV or could have an STD? What other partners do you think your partner has?’”

She added that the patient may offer clues that can provide the opportunity to have these conversations.

“If a patient’s asking for a medication to help them be more sexually active, that is an opportunity to have a deeper discussion about sexual health risk and make sure that that person has all the tools they need to be safe,” Avery said. “The annual exam for women is another perfect opportunity, since it is usually when you talk about pregnancy and sexual partners.”

Thompson said PCPs may find that many patients want to discuss STDs.

“Most patients are happy to break the taboo on discussing sex and actually feel a special bond with a clinician who can do that,” she said. – by Janel Miller

Reference: Barrow RY, et al. MMWR Recomm Rep. 2020;doi:10.15585/mmwr.rr6805a1.

Disclosures: Avery, Barrow, Thompson and Workowski report no relevant financial disclosures.