What are the recommended tests and treatments for sexually transmitted diseases (STDs), including chlamydia, gonorrhea, syphilis, Human Immunodeficiency Virus (HIV), and hepatitis B and C?

STD Screening Test Recommendations

All sexually active women under 25 years should receive annual screening for chlamydia, gonorrhea, HIV, and syphilis, while screening for men and older women should be based on specific risk factors including multiple partners, inconsistent condom use, or sex in conjunction with drug use. 1

Core Screening Panel Components

The comprehensive STD screening panel should include:

• Chlamydia trachomatis testing via nucleic acid amplification test (NAAT) using urine, cervical, or urethral swabs 2
• Neisseria gonorrhoeae testing via NAAT using urine, cervical, or urethral swabs 2
• Syphilis serologic testing (RPR or equivalent) 2
• HIV testing 2
• Hepatitis B surface antigen (HBsAg) testing 2

Population-Specific Screening Algorithms

Sexually Active Women Under 25 Years

• Screen annually for chlamydia, gonorrhea, HIV, and syphilis regardless of symptoms 1
• Higher infection rates in this population result from more frequent partner changes and cervical immaturity 1
• Use cervical specimens for testing 1

Women with High-Risk Behaviors

Screen annually for chlamydia, gonorrhea, HIV, and syphilis if any of the following apply 1:

• New or multiple sex partners
• Inconsistent condom use
• Sex while using drugs or alcohol
• Partner with these risk behaviors

Men Who Have Sex with Men (MSM)

• Comprehensive screening every 3-6 months for those with multiple or anonymous partners, methamphetamine use, or sex in conjunction with drug use 1
• Test at all exposed anatomical sites (urethral, rectal, pharyngeal) for gonorrhea and chlamydia 3
• Annual syphilis screening at minimum, with testing every 3-6 months for high-risk behaviors 1

Sexually Active Men at Increased Risk

Screen for HIV and syphilis if risk factors present 1

Pregnant Women

All pregnant women require the following screening at first prenatal visit 4, 2:

• Syphilis serology
• Hepatitis B surface antigen
• HIV testing
• Gonorrhea testing (for at-risk women or those in high-prevalence areas)

Additional pregnancy-specific screening 4:

• Chlamydia testing in third trimester for women under 25 or with risk factors
• Repeat syphilis testing in third trimester and at delivery for high-risk women
• No infant should be discharged without determination of mother's syphilis status at least once during pregnancy 1

Special Populations

Persons entering correctional facilities should be screened for syphilis, gonorrhea, and chlamydia within the first 24 hours, with females also screened for trichomoniasis and bacterial vaginosis when possible 5, 1

Adolescents in institutional settings (schools, Job Corps, community programs) should be screened for gonorrhea and chlamydia, with testing at every visit if prevalence ≥2% 5, 1

High-risk persons in street settings should be screened for gonorrhea, chlamydia, and syphilis during community outreach programs, targeting populations with prevalence ≥2% 5, 1

HIV-Infected Persons

• Annual syphilis screening at minimum 1
• Screening every 3-6 months for those with ongoing high-risk behaviors 1
• Routine screening for all common STIs including chlamydia, gonorrhea, syphilis, and trichomoniasis 1

Persons Who Use Drugs

• Routine screening for all common STIs including chlamydia, gonorrhea, syphilis, and trichomoniasis 1
• Hepatitis C screening for all who inject drugs, even if only once 1

Testing Frequency and Follow-Up

Retesting after treatment is critical to detect reinfection 1:

• Rescreen patients diagnosed with chlamydia or gonorrhea 3 months after treatment 1
• Test-of-cure is recommended for all cases of pharyngeal gonorrhea and rectal chlamydia if treated with azithromycin 6

Ongoing screening intervals 1:

• Every 3-6 months for those with ongoing high-risk behaviors (multiple partners, inconsistent condom use, drug use)
• Annual screening if any potential risk exists for STD acquisition

Treatment Recommendations

Chlamydia

• Doxycycline is the preferred treatment 6
• Azithromycin 1 gram orally as single dose is an alternative and preferred in pregnancy 4, 7

Gonorrhea

• Ceftriaxone monotherapy given intramuscularly, with dosing based on body weight 6
• Ceftriaxone 125-250 mg IM plus azithromycin 1 gram orally addresses frequent chlamydial co-infection 4

Syphilis

• Syphilis <1 year duration: Single dose of intramuscular penicillin G benzathine 2.4 million units 6
• Syphilis >1 year or unknown duration: Three consecutive weekly doses of intramuscular penicillin G benzathine 2.4 million units each 6
• In pregnancy, parenteral penicillin G is the only proven effective treatment and must be given at least 1 month before delivery 4

Trichomoniasis

• Seven-day regimen of metronidazole for vaginal trichomoniasis 6
• Metronidazole is safe in pregnancy 4

Pelvic Inflammatory Disease

• Treatment includes metronidazole with doxycycline and increased dosage of ceftriaxone 6
• Pregnant women with suspected PID must be hospitalized and treated with parenteral antibiotics 4

Presumptive Treatment Considerations

When follow-up is uncertain or patient adherence is questionable 5:

• Men with urethral discharge should receive presumptive treatment for gonorrhea and chlamydia
• Sexually active females with mucopurulent cervical discharge should receive presumptive treatment for gonorrhea and chlamydia
• Persons with new onset genital ulcers from communities with high syphilis rates should receive presumptive treatment for primary syphilis
• HIV-infected persons with genital ulcers or urethritis should receive empiric treatment to decrease viral load quickly

Partner Management

• Sex partners of persons with STIs should be evaluated and treated 1
• Consider presumptive treatment for partners of persons with curable STIs 1
• Partner notification can be performed by the patient, healthcare provider, or public health officials 1

Reporting Requirements

Mandatory reporting 1, 2:

• Syphilis, gonorrhea, and AIDS are reportable in every state
• Chlamydial infection is reportable in most states
• All positive cases must be reported to local health departments
• Clinicians should be familiar with local STD reporting requirements

Critical Pitfalls to Avoid

Pregnancy-specific contraindications 4:

• Never use doxycycline, tetracyclines, or fluoroquinolones in pregnant women
• Penicillin-allergic pregnant women with syphilis require desensitization—alternative antibiotics are inadequate for fetal infection

Testing gaps 1:

• Ensure all recommended tests are performed at appropriate intervals for pregnant women
• Do not rely on symptom-based testing alone—the majority of chlamydia (77%) and gonorrhea (45%) cases are asymptomatic 8
• Screen extragenital sites in MSM, as 53-100% of extragenital infections are asymptomatic 9

Treatment considerations 6:

• Antimicrobial resistance limits oral treatment options for gonorrhea and Mycoplasma genitalium
• Azithromycin should not be relied upon to treat syphilis 7
• Evaluate for otic, ophthalmic, and neurologic symptoms in anyone with syphilis, as these complications require 10-14 days of IV penicillin 6