What is the recommended STD testing and treatment for a 40-year-old female with a history of Trichomonas (Trich), recurrent Herpes Simplex Virus 2 (HSV-2) infections, and previous Gonorrhea (GC) and Chlamydia (CT) infections, who is asymptomatic but concerned about STD possibility after a recent condom break with a male partner of unknown history?

Recommended STD Testing and Management Following Condom Failure

This patient requires immediate comprehensive STD testing including nucleic acid amplification tests (NAATs) for gonorrhea and chlamydia from all exposure sites, syphilis serology, HIV testing, and consideration for trichomonas testing, with follow-up testing at 2 weeks and 3 months for syphilis and HIV, given her high-risk history of multiple prior STIs including recurrent HSV-2. 1, 2

Immediate Testing Panel (Within 72 Hours)

Initial laboratory workup should include:

• Gonorrhea and Chlamydia NAATs from cervical/vaginal specimens (or urine if preferred), as these tests have sensitivities of 86.1%-100% and specificities of 97.1%-100% 3, 4
• Syphilis serology using sequential treponemal and nontreponemal antibody testing 4
• HIV antibody testing with baseline serology 1
• Trichomonas vaginalis NAAT from urine or vaginal specimen, particularly given her history of prior trichomoniasis infection 1, 3
• Hepatitis B surface antigen and antibody if vaccination status is unknown 1

The CDC specifically recommends that all patients tested for gonorrhea should be tested for other STDs including chlamydia, syphilis, and HIV due to high coinfection rates 5. This is especially critical in your patient given her history of recurrent HSV-2, which is associated with altered vaginal flora and increased susceptibility to multiple STIs 6.

Risk Stratification Justifying Comprehensive Testing

Your patient meets multiple high-risk criteria warranting aggressive screening:

• History of previous gonorrhea, chlamydia, and trichomonas infections 1
• Recurrent HSV-2 infections, which independently increase risk for acquiring other STIs (incidence rate ratios of 4.3 for gonorrhea, 2.3 for trichomonas, and 4.7 for syphilis) 6
• New sexual partner with unknown STI history 1, 2
• Condom failure representing barrier contraception breakdown 1, 2

The American Congress of Obstetricians and Gynecologists specifically recommends screening for gonorrhea in asymptomatic women at high risk, including those with previous STIs, new or multiple sex partners, and inconsistent condom use 1.

Follow-Up Testing Schedule

Repeat testing is essential because infectious agents may not produce sufficient concentrations for positive results at initial examination:

• 2-week follow-up: Repeat NAATs for gonorrhea, chlamydia, and trichomonas if initial tests were negative and no presumptive treatment was given 1
• 6-week follow-up: HIV and syphilis serology 1
• 3-month follow-up: HIV and syphilis serology (final testing) 1, 2

The CDC emphasizes that examination for STDs should be repeated 2 weeks after exposure because infectious agents may not have produced sufficient concentrations of organisms to result in positive test results at the initial examination 1.

Presumptive Treatment Considerations

Given her high-risk profile, consider presumptive treatment while awaiting results:

The CDC recommends presumptive antibiotic treatment in settings where the likelihood of STD infection is high or prompt follow-up is uncertain 1. However, the 2021 CDC guidelines now recommend awaiting test results before treating for chlamydia or gonorrhea unless the patient is high-risk or unlikely to return for follow-up 5, 2.

If you elect presumptive treatment based on her risk factors:

• Ceftriaxone 500 mg IM (single dose) for gonorrhea 7
• Doxycycline 100 mg orally twice daily for 7 days for chlamydia 3, 7
• Metronidazole 2 g orally (single dose) for trichomonas 1, 7

Azithromycin 1 g orally as a single dose is FDA-approved for chlamydia and gonorrhea 8, but doxycycline is now preferred for chlamydia per 2021 CDC guidelines 7.

HIV Post-Exposure Prophylaxis (PEP) Consideration

Evaluate need for HIV PEP within 72 hours of exposure:

If the sexual partner's HIV status is unknown or positive, consider offering HIV PEP with bictegravir/emtricitabine/tenofovir alafenamide or dolutegravir plus tenofovir alafenamide plus emtricitabine for 28 days 1. The window for initiating PEP is 72 hours post-exposure, with earlier initiation being more effective.

Hepatitis B Prophylaxis

If patient is not vaccinated or immunity is uncertain:

Initiate hepatitis B vaccination series at the initial visit, with follow-up doses at 1-2 months and 4-6 months 1. Post-exposure hepatitis B vaccination without HBIG adequately protects against HBV infection 1.

Critical Management Pitfalls to Avoid

Common errors in this scenario include:

• Failing to test all exposure sites: NAATs should be performed from all sites of penetration or attempted penetration 3
• Inadequate follow-up testing: Many clinicians only perform initial testing and miss infections that develop later 1
• Ignoring the HSV-2 connection: Her recurrent HSV-2 significantly increases her risk for other STIs and should lower your threshold for presumptive treatment 6
• Not addressing reinfection risk: The CDC recommends retesting all patients diagnosed with chlamydial or gonococcal infections 3 months after treatment due to high likelihood of reinfection 1, 2

Partner Management

If any tests return positive, the sexual partner must be notified and treated:

All sex partners from the past 60 days should be notified, examined, and treated presumptively for the same STDs 3, 2. Both patient and partner must abstain from sexual intercourse for 7 days after single-dose therapy or until completion of 7-day regimen 2.

Counseling Points

Provide clear guidance on:

• Symptoms of STDs requiring immediate re-evaluation 1
• Abstinence from sexual intercourse until test results return or treatment is completed 1
• The increased risk conferred by her HSV-2 infection for acquiring other STIs 6
• Importance of follow-up testing even if asymptomatic 1, 2