What STD tests should be ordered for a patient presenting for STD testing?

Standard STD Testing Panel

For a patient requesting STD testing, order nucleic acid amplification tests (NAATs) for chlamydia and gonorrhea, syphilis serology (treponemal test with reflex to RPR), and HIV testing as the core panel, with additional tests based on sex, age, anatomic exposure sites, and risk factors. 1, 2

Core Tests for All Patients

• Chlamydia and gonorrhea NAAT - This is the preferred diagnostic method due to superior sensitivity and specificity compared to culture 1, 3
• Syphilis screening - Use the reverse algorithm approach: treponemal-specific test (EIA/chemiluminescence immunoassay) first, with reflex to nontreponemal test (RPR) if positive 1
• HIV testing - Fourth-generation HIV antigen/antibody test with reflex to confirmatory testing if positive 1, 2

Specimen Collection Based on Anatomic Sites

For Women

• Vaginal swab NAAT for chlamydia and gonorrhea (preferred over cervical specimens) 1
• Trichomoniasis NAAT if under 25 years, multiple partners, history of STIs, or high-risk behaviors 1, 2
• Cervical specimens are acceptable but vaginal swabs have equivalent sensitivity and are less invasive 1

For Men Who Have Sex With Men (MSM)

• Test all three anatomic sites based on reported sexual practices 1
  • Urogenital (urine or urethral swab)
  • Rectal swab for chlamydia and gonorrhea NAAT
  • Oropharyngeal swab for gonorrhea NAAT
• This is critical because rectal and pharyngeal infections are frequently asymptomatic and will be missed if only urogenital testing is performed 1, 4
• Oropharyngeal chlamydia testing is not recommended as it has limited clinical significance 1

For Heterosexual Men

• Urine NAAT for chlamydia and gonorrhea 1
• Consider pharyngeal gonorrhea testing if history of receptive oral sex 1

Age and Risk-Based Additional Testing

All Women Under 25 Years

• Annual screening for chlamydia and gonorrhea is mandatory regardless of reported risk factors 1, 2
• This age group has higher infection rates due to cervical immaturity and more frequent partner changes 2

High-Risk Populations Requiring Intensive Screening

• HIV-infected individuals - Screen every 3-6 months for all bacterial STIs (chlamydia, gonorrhea, syphilis, trichomoniasis) due to increased transmission risk when co-infected 1, 2
• MSM with high-risk behaviors - Screen every 3-6 months if multiple/anonymous partners, methamphetamine use, or sex in conjunction with drug use 1, 2

Pregnant Women

• First prenatal visit: Hepatitis B surface antigen, HIV, and syphilis (universal screening) 1
• Chlamydia and gonorrhea if under 25 years or at increased risk 1
• Repeat syphilis testing in third trimester and at delivery for high-risk women 1, 2
• No infant should be discharged without maternal syphilis status determined at least once during pregnancy 1, 2

Additional Considerations Based on Exposure History

Hepatitis Testing

• Hepatitis B surface antigen for all pregnant women and those at risk 1
• Hepatitis C screening for persons who inject drugs, even if only once 2
• Consider acute hepatitis panel if recent high-risk exposure 2

When NOT to Test

• Do NOT screen for HSV in asymptomatic patients - there is no evidence that treating asymptomatic herpes improves outcomes 2
• No HPV blood test exists - HPV is only detected via cervical/anal cytology or direct visualization of lesions 2

Post-Testing Management Requirements

Mandatory Retesting

• All patients treated for chlamydia or gonorrhea must be retested at 3 months after treatment, regardless of whether partners were treated, due to reinfection rates of 25-40% 1, 2

Partner Management

• All sexual partners from the past 60 days must be notified and treated presumptively 2
• Consider expedited partner therapy where legally permissible 2

Reporting Requirements

• Syphilis, gonorrhea, chlamydia, and HIV are reportable in all states 1, 2
• Consult local health department for specific reporting requirements 1

Common Pitfalls to Avoid

• Do not rely on wet mount microscopy for trichomoniasis - it misses 30-40% of infections; use NAAT instead 2
• Do not skip extragenital site testing in MSM - pharyngeal and rectal infections are frequently the only sites of infection 1, 4
• Do not assume previous negative tests provide ongoing protection - retesting is based on new risk factors, not time elapsed 2
• Do not use culture for routine screening - NAATs have superior sensitivity and allow non-invasive specimen collection 1, 3