What is the recommended treatment for a patient with a sexually transmitted disease (STD), including those with underlying medical conditions such as human immunodeficiency virus (HIV)?

STD Treatment Recommendations

For patients with confirmed or suspected STDs, treatment should be initiated immediately with pathogen-specific antimicrobial therapy based on clinical presentation and diagnostic testing, with special attention to partner management and prevention counseling. 1, 2

Treatment Approach Based on Clinical Presentation

Urethritis and Cervicitis (Chlamydia/Gonorrhea)

For chlamydial infections:

• Doxycycline 100 mg orally twice daily for 7 days is the preferred treatment 3, 2
• Alternative: Azithromycin 1 g orally as a single dose 4
• Doxycycline is now preferred over azithromycin due to superior efficacy and concerns about azithromycin resistance 2

For gonococcal infections:

• Ceftriaxone monotherapy intramuscularly is the recommended treatment, with dosing based on body weight 2
• Standard dose: 500 mg IM for patients weighing <150 kg 2
• Test-of-cure is mandatory for all pharyngeal gonorrhea cases 2

For non-gonococcal urethritis:

• Doxycycline 100 mg orally twice daily for 7 days 3

Syphilis Treatment

For early syphilis (less than one year's duration):

• Penicillin G benzathine 2.4 million units IM as a single dose 2
• For penicillin-allergic patients: Doxycycline 100 mg orally twice daily for 2 weeks 3

For late syphilis (more than one year's or unknown duration):

• Penicillin G benzathine 2.4 million units IM weekly for three consecutive weeks 2
• For penicillin-allergic patients: Doxycycline 100 mg orally twice daily for 4 weeks 3

Critical evaluation required:

• Thorough assessment for otic, ophthalmic, and neurologic symptoms is essential at any stage, as these complications require 10-14 days of intravenous aqueous crystalline penicillin G 2

Trichomoniasis

For vaginal trichomoniasis:

• Metronidazole 500 mg orally twice daily for 7 days is the preferred regimen 2
• Alternative single-dose regimen: Metronidazole 2 g orally as a single dose 1

Pelvic Inflammatory Disease

Treatment regimen includes:

• Doxycycline 100 mg orally twice daily 2
• Ceftriaxone at increased dosage 2
• Metronidazole should be routinely included 2

Special Considerations for HIV-Infected Patients

Screening and management:

• HIV-infected patients should be screened at least yearly for gonorrhea, chlamydia, syphilis, and trichomoniasis 5
• Screening frequency should increase if any incident STDs are detected 5
• Assessment for genital herpes is essential, with counseling to avoid sex during symptomatic reactivation periods due to higher HIV viral shedding 5

Counseling requirements:

• Determine type and frequency of sexual behaviors and HIV status of partners 5
• Counsel on eliminating unprotected sex, especially with HIV-negative or unknown-status partners 5
• Emphasize the role of STDs in facilitating HIV transmission 5
• Ensure complete abstinence from sex for the appropriate period following treatment 5

Presumptive Treatment Guidelines

When to treat presumptively (without waiting for test results):

• Men with urethral discharge when follow-up is uncertain 5
• Sexually active females with mucopurulent cervical discharge when follow-up is uncertain 5
• Persons with new-onset genital ulcers from communities with high syphilis rates 5
• HIV-infected persons with genital ulcers or urethritis to decrease viral load quickly 5

Empiric treatment considerations:

• Administer immediately without waiting for test results when follow-up compliance is poor 1
• Laboratory testing should still be performed whenever possible to confirm infection 5

Partner Management (Critical Component)

All sexual partners within the preceding 60 days must be:

• Evaluated and tested for STDs 1
• Treated presumptively with the same regimen as the index patient, even if asymptomatic 5, 1
• Counseled to abstain from sexual activity until treatment is completed 1

Treatment completion defined as:

• 7 days after single-dose regimen 1
• After completion of multi-day regimen 1

Expedited partner therapy:

• May be appropriate depending on local regulations 1
• Partners should receive the same empiric prophylactic regimen 1

Prevention Counseling (Essential for All Patients)

Barrier methods:

• Consistent and correct use of male latex condoms provides strong protection against STDs, including HIV 5, 6
• New condom must be used for each act of sexual intercourse 5
• Only water-based lubricants (K-Y Jelly, Astroglide, AquaLube) should be used with latex condoms 6
• Oil-based lubricants weaken latex and increase failure risk 6

Female condoms:

• Should be considered when male condoms cannot be used appropriately 6
• Provide theoretical mechanical barrier protection but have limited clinical data 6
• Higher pregnancy failure rates (26% at 12 months) compared to male condoms 6

Critical counseling points:

• Hormonal contraception, surgical sterilization, and hysterectomy offer no protection against STDs 6
• Both partners should be tested before initiating sexual intercourse with new partners 1
• Abstinence from sexual activity is crucial during treatment and if STD symptoms develop 5

Vaccination (Primary Prevention)

Hepatitis B vaccination:

• Recommended for all unvaccinated patients being evaluated for STDs 5, 1, 6
• Should be initiated immediately if unvaccinated 1
• Complete 3-dose series at 0,1-2 months, and 6 months 1

Hepatitis A vaccination:

• Recommended for men who have sex with men 1
• Recommended for persons who use illegal drugs 5

Follow-Up Testing Protocol

Test-of-cure requirements:

• Mandatory for all pharyngeal gonorrhea cases 2
• Required for rectal chlamydia if treated with azithromycin 2

Reinfection screening:

• Repeat testing at 3 months is mandatory for any positive chlamydia or gonorrhea result, even if partner was treated 1, 2
• High reinfection rates occur within 3.6 months for chlamydia and 6 months for gonorrhea 1

Syphilis follow-up:

• Repeat serologic testing at 6-12 weeks if initial test was negative 1

HIV follow-up:

• Repeat testing at 12 weeks to detect seroconversion 1

Common Pitfalls to Avoid

Testing errors:

• Testing too early and not following up is the most critical error 1
• A negative test at 1 week does not rule out infection 1
• Bacterial STIs need repeat testing at 2 weeks if initially negative 1

Treatment errors:

• Failing to treat sex partners leads to rapid reinfection of the index patient 5
• Not counseling patients that hormonal contraception provides no STD protection 6
• Assuming consistent condom use based on patient self-report without verification 1

Screening errors:

• Failing to test at exposure-specific sites (pharynx, rectum) misses substantial infections, particularly in men who have sex with men 1
• Not screening HIV-infected patients at least yearly for common STDs 5