What is the recommended approach for a patient requesting a blood test for all sexually transmitted diseases (STDs), including Human Immunodeficiency Virus (HIV), syphilis, gonorrhea, chlamydia, hepatitis B and C, herpes simplex virus (HSV), and human papillomavirus (HPV)?

Recommended Approach for Comprehensive STD Testing

The approach to STD testing should be risk-stratified and anatomically comprehensive, not a simple "test for everything" blood panel, because many STDs require non-blood specimens and testing all anatomic sites of exposure is essential to avoid missing infections. 1

Initial Risk Assessment and Sexual History

Before ordering any tests, obtain a focused sexual history to determine:

• Number and type of sexual partners in the past 60 days (new partners, multiple partners, anonymous partners) 1
• Specific sexual practices (vaginal, anal receptive/insertive, oral receptive/insertive) to guide anatomic site testing 1
• Condom use consistency and substance use during sexual activity 1
• Previous STD history and partner STD status 1
• Pregnancy status for women, as this changes screening requirements 2

This history determines which tests to order and from which anatomic sites, as blood tests alone will miss the majority of bacterial STDs that require genital, rectal, or pharyngeal specimens. 1

Core Testing Panel Based on Risk Profile

For All Sexually Active Patients Requesting Comprehensive Screening:

Blood-based tests:

• HIV testing using fourth-generation antigen/antibody test (detects infection 2-4 weeks post-exposure) 1
• Syphilis screening using reverse algorithm: treponemal test first (T. pallidum antibody), followed by RPR for confirmation 1
• Hepatitis B surface antigen if not previously vaccinated 1, 3
• Hepatitis C antibody if risk factors present (injection drug use, multiple partners) 1

Specimen-based tests (NOT blood):

• Chlamydia and gonorrhea via nucleic acid amplification test (NAAT) from:
  • Urine specimen for men OR vaginal swab (preferred) for women 1
  • Rectal swab if receptive anal intercourse reported 1
  • Pharyngeal swab if receptive oral sex reported (gonorrhea only; pharyngeal chlamydia testing not recommended) 1
• Trichomonas via vaginal NAAT for women (not wet mount, which misses 30-40% of infections) 1

Common Pitfall to Avoid:

Do not rely solely on urogenital testing in men who have sex with men or anyone reporting receptive anal/oral sex, as extragenital infections are frequently asymptomatic and will be completely missed. 1 Testing all exposure sites based on reported sexual practices is mandatory. 1

Tests That Cannot Be Done or Are Not Recommended:

• HPV blood test does not exist - HPV testing is only done via cervical/anal cytology or direct visualization of lesions 2
• Herpes simplex virus (HSV) screening is explicitly NOT recommended for asymptomatic patients, as there is no evidence that treating asymptomatic HSV improves outcomes 2
• Hepatitis A testing is not part of routine STD screening unless specific exposure or symptoms present 1

Population-Specific Modifications:

For Women Under 25 Years:

• Annual screening mandatory for chlamydia, gonorrhea, HIV, and syphilis regardless of perceived risk 1
• Add trichomonas testing via vaginal NAAT 1

For Men Who Have Sex with Men (MSM):

• Screen every 3-6 months if multiple/anonymous partners, substance use during sex, or methamphetamine use 1
• Must test all three anatomic sites: urogenital, rectal, and pharyngeal for gonorrhea and chlamydia 1
• Annual syphilis screening minimum, more frequently if high-risk behaviors 1

For Pregnant Women:

• Universal screening at first prenatal visit for hepatitis B, HIV, and syphilis 2, 1
• Screen for chlamydia and gonorrhea if under 25 years or at increased risk 2, 1
• Repeat syphilis testing in third trimester and at delivery for high-risk women 1

For HIV-Positive Patients:

• Screen every 3-6 months for all bacterial STDs (chlamydia, gonorrhea, syphilis, trichomonas) due to increased transmission risk when co-infected 2, 1
• Annual minimum if lower risk behaviors 1

Follow-Up Testing Requirements:

• Mandatory 3-month retest for anyone who tests positive for chlamydia or gonorrhea, regardless of whether partners were treated, due to 25-40% reinfection rates 1
• Repeat HIV testing at 3 months if initial test negative but exposure within window period 3
• Repeat syphilis serology at 6-12 weeks if initial test negative but recent exposure 3

What to Tell the Patient:

Explain that "testing for all STDs" requires multiple specimen types collected from different body sites based on sexual practices, not just a blood draw. 1 Blood tests only detect HIV, syphilis, and hepatitis - they completely miss chlamydia, gonorrhea, and trichomonas, which are the most common bacterial STDs. 1

Emphasize that some infections have window periods where testing too early yields false negatives, requiring follow-up testing at 3 months for definitive results. 3

For patients with ongoing risk behaviors (multiple partners, inconsistent condom use), recommend establishing a regular screening schedule every 3-6 months rather than one-time testing. 1