What are the guidelines for screening sexually active individuals for sexually transmitted diseases (STDs), including which tests to use and how often to screen based on risk factors and demographics?

STI Screening Guidelines: Who to Screen and What to Ask

Screen all sexually active women under 25 years annually for chlamydia and gonorrhea, and screen women over 25 years plus all men based on specific high-risk behaviors and demographics. 1, 2

Key Questions to Ask During Sexual History

When assessing STI risk, directly inquire about:

• Number and gender of sexual partners in the past 60 days and past year (multiple or new partners increase risk) 2
• Condom use consistency during vaginal, anal, and oral sex 2
• Substance use during sex (alcohol or drugs impair judgment and increase risk) 2
• Transactional sex (exchanging sex for money, drugs, housing, or other needs) 2, 1
• Specific sexual practices (receptive anal intercourse, receptive oral sex) to determine anatomic sites for testing 1, 3
• Partner's risk behaviors (partners with multiple partners, partners who inject drugs, partners with known STIs) 1
• History of prior STIs (increases reinfection risk substantially) 1
• Partner notification status if previously diagnosed (to assess reinfection risk) 2

Population-Specific Screening Recommendations

Sexually Active Women

Women ≤24-25 years:

• Screen annually for chlamydia and gonorrhea regardless of reported risk factors 2, 1
• Screen for HIV and syphilis if any high-risk behaviors present 2
• Younger women have higher infection rates due to more partner turnover and cervical ectopy making them biologically more susceptible 2

Women >25 years:

• Screen for chlamydia and gonorrhea only if high-risk behaviors present: multiple partners, new partner, inconsistent condom use, substance use during sex, sex work, or partner with these risk factors 2, 1
• Screen for HIV and syphilis if high-risk behaviors present 2
• Consider stopping routine screening at menopause or age 55 if only demographic risk factors (not behavioral) 2

Sexually Active Men

Men who have sex with men (MSM):

• Screen annually at minimum for urethral, rectal, and pharyngeal gonorrhea and chlamydia based on sexual practices 2, 1
• Screen annually for syphilis 1
• Increase screening frequency to every 3-6 months if multiple/anonymous partners, substance use during sex, or recent STI 2, 1, 3
• Test all anatomic sites of exposure: pharyngeal swabs for receptive oral sex, rectal swabs for receptive anal sex, urethral/urine for insertive sex 2, 1, 3

Heterosexual men:

• Routine universal screening is not recommended 2
• Screen annually in high-prevalence settings (≥2% prevalence): correctional facilities, STD clinics, adolescent clinics, job training programs 2
• Screen if high-risk behaviors: multiple partners, inconsistent condom use, substance use during sex, sex work 1

Pregnant Women

All pregnant women:

• Screen for hepatitis B, HIV, and syphilis at first prenatal visit 2
• Screen for chlamydia and gonorrhea if ≤24 years or if high-risk behaviors present 2
• Retest in third trimester if initial test positive or continued risk factors 2

Bisexual Individuals

• Apply screening based on actual sexual practices, not identity label alone 3
• Test all anatomic sites of exposure: urogenital, rectal (if receptive anal intercourse), pharyngeal (if receptive oral sex) 3
• Screen every 3-6 months if high-risk behaviors present 3

HIV-Infected Individuals

• Screen at least annually for syphilis, chlamydia, and gonorrhea regardless of symptoms 4
• Screen at all sites of sexual exposure 4
• Despite guidelines, only 36% of sexually active HIV-infected patients received all three STI tests in 2013, indicating substantial gaps in implementation 4

Demographic and Community Risk Factors

Beyond individual behaviors, consider:

• Race/ethnicity as surrogate for social determinants: Black and Hispanic individuals may have higher STI prevalence due to community-level factors (poverty, incarceration rates, partner availability, discrimination) independent of individual behaviors 2
• Geographic location: Southern states and urban centers have higher STI rates 2
• Consult local epidemiologic data from public health departments to tailor screening to your specific community prevalence 2

Screening Frequency and Timing

Standard frequency:

• Annual screening for most sexually active individuals meeting age/risk criteria 1

Increased frequency (every 3-6 months) indicated for:

• Multiple or anonymous sexual partners 1, 3
• Sex in conjunction with illicit drug use 1, 3
• Partners who engage in high-risk behaviors 1, 3
• Recent STI diagnosis 1, 3
• Sex work or transactional sex 1, 3

Post-treatment rescreening:

• Retest all patients 3 months after treatment for chlamydia or gonorrhea, regardless of whether partners were treated (reinfection rates 25-40%) 2, 1, 5
• If 3-month rescreening not feasible, retest at next visit within 12 months 1

Testing Methods and Anatomic Sites

Preferred testing method:

• Nucleic acid amplification tests (NAATs) are strongly preferred over culture or other methods due to superior sensitivity 1, 3, 5

Specimen collection by site:

• Urogenital: First-catch urine for men; vaginal swab (can be self-collected) or urine for women 5
• Rectal: Rectal swab using NAAT (if laboratory validated) 3
• Pharyngeal: Pharyngeal swab using NAAT or culture (if laboratory validated) 3
• Collect specimens from all sites of sexual exposure, not just urogenital 1, 3

Critical Pitfalls to Avoid

• Don't assume low risk based on age alone: Persons as young as 12 may be sexually active and at risk 2
• Don't rely solely on urogenital testing in MSM or bisexual individuals: Extragenital infections (pharyngeal, rectal) are frequently asymptomatic and account for 6-10% of infections 3
• Don't skip screening in young women with urinary symptoms: Test for STIs regardless of urinalysis findings, as UTI and STI symptoms overlap 5
• Don't assume sexual orientation identity predicts sexual practices: Ask about actual behaviors and anatomic sites of exposure 3
• Don't forget community prevalence: In high-prevalence populations, screen more broadly than individual risk factors alone would suggest 2
• Don't rely on patients for partner notification alone: Only 25-34% of physicians notify health departments, and case reporting remains suboptimal 6

Tests NOT Recommended

• Do not screen for herpes simplex virus (HSV) in asymptomatic individuals 7
• Do not routinely screen for trichomoniasis in asymptomatic adolescents (consider only in high-risk women) 1
• Do not screen for hepatitis B or C in general population (screen only based on specific risk factors or vaccination status) 2, 3