What are the recommended tests and treatment regimens for a sexually active individual with a history of sexually transmitted diseases (STDs) presenting with or without symptoms such as genital discharge, pain, or lesions?

STD Testing Recommendations

For sexually active individuals with a history of STDs, screen annually for chlamydia, gonorrhea, HIV, and syphilis at minimum, with more frequent testing every 3-6 months if high-risk behaviors persist, using nucleic acid amplification tests (NAATs) for bacterial infections and fourth-generation HIV testing. 1

Core Testing Panel for All Sexually Active Individuals

The standard screening panel should include:

• Chlamydia and gonorrhea using NAATs from appropriate anatomic sites (urogenital, rectal, and oropharyngeal based on sexual practices) 1
• Syphilis using reverse algorithm screening (treponemal test followed by RPR for confirmation) 1
• HIV using fourth-generation testing (antibody plus p24 antigen) 1
• Trichomoniasis for women under 25 years using vaginal swab NAAT 1
• Hepatitis B and C for those with injection drug use or high-risk exposures 1

Risk-Stratified Screening Frequency

Standard Risk (Annual Screening)

• All sexually active women under 25 years require annual screening for chlamydia, gonorrhea, HIV, and syphilis 1
• Women 25 years and older with new or multiple partners, inconsistent condom use, or partners with high-risk behaviors 1

High Risk (Every 3-6 Months)

• HIV-infected individuals with any ongoing sexual activity 2, 1
• Men who have sex with men (MSM) with multiple or anonymous partners, methamphetamine use, or sex during drug use 1
• Persons with a new STD diagnosis (indicates ongoing unprotected sex) 2
• Individuals in communities with high STI prevalence 1

Post-Treatment (Mandatory 3-Month Retest)

• All patients treated for chlamydia or gonorrhea must be retested 3 months after treatment regardless of whether partners were treated, due to reinfection rates of 25-40% 1

Specimen Collection Sites

For Women

• Vaginal swab NAAT is preferred for chlamydia and gonorrhea (more sensitive than cervical specimens) 1
• Cervical specimens acceptable for women under 25 years 1

For Men Who Have Sex With Men

• Test all three anatomic sites: urogenital, rectal, and oropharyngeal based on reported sexual practices 1
• Rectal and pharyngeal infections are frequently asymptomatic and will be missed if only urogenital testing is performed 1

For Heterosexual Men

• First-void urine or urethral swab for NAAT 1

Special Population Considerations

Pregnant Women (First Prenatal Visit)

• Universal screening: Syphilis serology, hepatitis B surface antigen, HIV 2, 1
• Risk-based screening: Chlamydia and gonorrhea for women under 25 years or those with new/multiple partners 2
• High-risk women: Repeat syphilis testing in third trimester and at delivery 2
• No infant should be discharged without maternal syphilis status determined at least once during pregnancy 2

HIV-Infected Individuals

• Screen every 3-6 months for gonorrhea, chlamydia, syphilis, and trichomoniasis (women) 2
• Assess for genital herpes and counsel on avoiding sex during symptomatic reactivation 2

Incarcerated Individuals

• Screen for syphilis, gonorrhea, and chlamydia within first 24 hours of entry into correctional facilities 2
• Women should also be screened for trichomoniasis and bacterial vaginosis when possible 2

Adolescents in Institutional Settings

• Screen for gonorrhea and chlamydia in schools, community programs, Job Corps, and youth programs 2
• Test at every visit if prevalence ≥2% in that population 2

Critical Testing Pitfalls to Avoid

• Do not rely on wet mount microscopy for trichomoniasis—it misses 30-40% of infections; use NAAT instead 1
• Do not skip extragenital site testing in MSM—pharyngeal and rectal infections are frequently asymptomatic 1
• Do not perform routine HSV screening in asymptomatic patients—there is no evidence that treating asymptomatic HSV improves outcomes 1
• Do not skip the mandatory 3-month post-treatment retest for chlamydia/gonorrhea—this is when reinfection is detected 1
• Do not assume previous negative tests provide ongoing protection—reassess sexual risk factors at each encounter 1

Symptomatic Presentations Requiring Immediate Testing

When symptoms are present (genital discharge, pain, or lesions), testing becomes diagnostic rather than screening:

• Urethral/vaginal discharge: NAAT for chlamydia and gonorrhea from symptomatic site 1
• Genital ulcers: Syphilis serology, HSV PCR from lesion, consider chancroid testing in endemic areas 3
• Pelvic pain in women: Test for chlamydia, gonorrhea, and consider pelvic inflammatory disease evaluation 1

Partner Management

• All sex partners from the past 60 days must be notified, examined, and treated for the same STDs as the index patient 1
• Presumptive treatment should be provided to partners before test results when indicated 1
• Expedited partner therapy should be considered where legally permissible 1

Reporting Requirements

• Syphilis, gonorrhea, and AIDS are reportable in every state 2
• Chlamydia is reportable in most states 1
• Clinicians must be familiar with local reporting requirements and report in a timely manner 2