What is the recommended screening protocol for a patient requesting a sexually transmitted disease (STD) panel, considering their age, sex, medical history, and high-risk behaviors?

Recommended STD Panel for Sexually Active Patients

All sexually active patients requesting STD testing should receive a comprehensive panel including chlamydia, gonorrhea, syphilis, and HIV, with specific anatomic site testing and screening intervals determined by age, sex, sexual practices, and ongoing risk behaviors. 1

Core Testing Components for All Patients

The standard STD panel should include:

• Chlamydia and gonorrhea using nucleic acid amplification tests (NAATs), which are strongly preferred over culture due to superior sensitivity 1, 2
• Syphilis screening using the reverse algorithm approach (treponemal-specific test followed by RPR for confirmation) 1
• HIV testing using fourth-generation Ag/Ab combination testing for all sexually active persons aged 13-64 years 1, 2
• Hepatitis B serologic testing if the patient has not been previously vaccinated 1, 3

Anatomic Site Selection Based on Sexual Practices

Testing must be performed at all sites of sexual exposure, not just urogenital sites:

• For women: Vaginal swab NAAT is the preferred specimen (can be self-collected) for chlamydia and gonorrhea 1, 2
• For men who have sex with men (MSM): Test all three anatomic sites—urogenital, rectal, and oropharyngeal—based on reported sexual practices 1, 2
• For receptive anal intercourse: Rectal specimens for chlamydia and gonorrhea 1, 3
• For receptive oral sex: Pharyngeal specimens for gonorrhea only (pharyngeal chlamydia testing is not recommended) 1, 3

Critical pitfall: Failing to test extragenital sites in MSM misses a substantial proportion of infections, as rectal and pharyngeal infections are frequently asymptomatic 1

Age and Sex-Specific Screening Recommendations

Women Under 25 Years

• Annual screening for chlamydia and gonorrhea regardless of reported risk factors 1, 2
• Trichomoniasis testing using vaginal swab NAAT should be considered 1
• HIV and syphilis screening annually 1

Women 25 Years and Older

• Screen for chlamydia and gonorrhea only if high-risk behaviors are present 2
• High-risk behaviors include: new or multiple partners, inconsistent condom use, sex while using drugs/alcohol, partner with STI, history of previous STI, or living in high-prevalence communities 1, 2

Men Who Have Sex with Men

• Comprehensive screening every 3-6 months for those with multiple or anonymous partners, methamphetamine use, or sex in conjunction with drug use 1, 2
• Annual screening at minimum for all sexually active MSM 1
• Must include urogenital, rectal, and pharyngeal testing based on sexual practices 1, 2

HIV-Infected Individuals

• Screening every 3-6 months for all bacterial STIs (chlamydia, gonorrhea, syphilis, trichomoniasis) due to increased HIV transmission risk when co-infected 1
• Syphilis screening at least annually, with more frequent testing (every 3-6 months) for those with high-risk behaviors 4, 1

Pregnant Women

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

Screening Frequency Based on Risk Behaviors

Annual Screening Indicated For:

• All sexually active women under 25 years 1, 2
• All sexually active MSM (minimum frequency) 1, 2
• Anyone with ongoing sexual activity and previous risk factors 1

Every 3-6 Month Screening Indicated For:

• Multiple or anonymous sexual partners 1, 2
• Sex in conjunction with illicit drug use 1, 2
• Methamphetamine use 1
• Partners who engage in high-risk behaviors 1, 2
• Recent STI diagnosis 2
• Sex work or transactional sex 1, 2
• HIV-infected individuals with high-risk behaviors 4, 1

Post-Treatment Mandatory Retesting

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

This is not optional—it is a mandatory component of STI management to detect reinfection, which occurs rapidly (within 3.6 months for chlamydia, 6 months for gonorrhea) 3

Additional Testing Considerations

Tests NOT Routinely Recommended:

• Herpes simplex virus (HSV) screening is explicitly not recommended for asymptomatic patients, as there is no evidence that treating asymptomatic HSV improves outcomes 1
• HPV blood testing does not exist; HPV is only detected via cervical/anal cytology or direct visualization of lesions 1
• Pharyngeal chlamydia testing is not generally recommended 1, 3

Hepatitis C Screening:

• Screen all persons who inject drugs, even if only once 1
• Consider for those with multiple partners or other risk factors 1

Partner Management and Reporting

• All sexual partners from the past 60 days must be notified, examined, and treated presumptively 1, 3
• Expedited partner therapy should be considered where legally permissible 1, 3
• Syphilis, gonorrhea, chlamydia, and HIV are reportable in all states 1

Common Pitfalls to Avoid

• Don't rely on wet mount microscopy for trichomoniasis—it misses 30-40% of infections; use NAAT instead 1
• Don't assume low risk based on age alone—persons as young as 12 may be sexually active and require screening 2
• Don't skip extragenital testing in MSM—this misses the majority of rectal and pharyngeal infections 1, 2
• Don't accept patient self-report of "always using condoms" as sufficient reassurance—condoms provide incomplete protection and screening remains essential 3
• Don't forget the mandatory 3-month retest after positive chlamydia or gonorrhea results 1, 2