What is the recommended follow-up testing and treatment for a patient with a history of sexually transmitted diseases (STDs), including previous diagnoses and treatment for conditions such as chlamydia, gonorrhea, and human immunodeficiency virus (HIV)?

Follow-Up STD Testing After Previous Infections

For patients with a history of treated chlamydia, gonorrhea, or HIV, implement site-specific NAAT retesting at 3 months post-treatment for bacterial STIs, with HIV-positive patients requiring comprehensive STI screening every 3-6 months at all anatomic exposure sites. 1

Immediate Post-Treatment Follow-Up for Bacterial STIs

Test-of-cure is not routinely recommended for uncomplicated chlamydia or gonorrhea treated with recommended regimens. However, specific circumstances require verification:

• Retest all patients 3 months after treatment for chlamydia and gonorrhea at the same anatomic sites originally infected, as reinfection rates approach 20% within this timeframe 1
• If 3-month follow-up is unlikely, retest whenever the patient next presents for care within 12 months 1
• Pharyngeal gonorrhea requires test-of-cure at 7-14 days due to higher treatment failure rates with oral cephalosporins 1

HIV-Positive Patients: Enhanced Surveillance Protocol

HIV-infected patients require intensified STI screening every 3-6 months regardless of symptoms, as they face substantially higher STI prevalence and transmission risk 2, 3:

Comprehensive Testing Battery Every 3-6 Months:

• Site-specific NAATs for gonorrhea and chlamydia from pharynx, rectum, and urethra/vagina based on sexual practices 2, 1
• Syphilis serology (RPR or VDRL with treponemal confirmation if reactive) 2
• For women: Pap smear every 6-12 months due to increased cervical dysplasia risk, plus testing for gonorrhea, chlamydia, and trichomonas 2
• Hepatitis B markers if not previously immune, with vaccination offered to seronegative patients 2

Critical HIV-Specific Considerations:

• Lumbar puncture for neurosyphilis evaluation should be strongly considered when RPR titer ≥1:32 or CD4 count <350 cells/mm³, regardless of syphilis stage 2
• CD4 count and HIV viral load must be monitored to guide prophylaxis decisions and assess immunosuppression severity 2
• Tuberculin skin test (TST) with ≥5mm induration considered positive in HIV-infected persons 2

Anatomic Site-Specific Testing Strategy

Match testing sites to sexual exposure history—never rely on urine testing alone 1:

• Men: First-catch urine NAAT for urethral infections 1
• Women: Vaginal swab NAAT (superior to cervical or urine specimens) 1
• Receptive anal intercourse (any gender): Rectal NAAT for both gonorrhea and chlamydia 1, 3
• Receptive oral intercourse: Pharyngeal swab for gonorrhea only (chlamydia pharyngeal testing has minimal yield) 1

High-Risk Populations Requiring Quarterly Screening

Screen every 3 months for patients with 1, 3:

• Multiple or anonymous sexual partners
• Substance use during sex (particularly methamphetamine)
• Partners engaging in these high-risk activities
• Men who have sex with men (MSM) with any bacterial STI in past 12 months (also offer doxycycline post-exposure prophylaxis) 3
• Previous STI diagnosis within the past year

Window Period Pitfalls

Testing too early produces false-negatives—respect these critical timeframes 1:

• Gonorrhea/Chlamydia: 1-2 weeks from exposure
• Syphilis: 1-3 months for antibody development
• HIV: 4-12 weeks for antibody/antigen detection

For new exposures, repeat serologic testing at 12 weeks even if initial tests were negative 2

Special Circumstances

Sexual Assault Cases:

• Baseline testing immediately with serum preservation for comparison 2
• Repeat NAAT testing at 2 weeks for gonorrhea/chlamydia 2
• Repeat serology at 6,12, and 24 weeks for syphilis and HIV 2
• Consider empiric prophylaxis: Ceftriaxone 125mg IM + Metronidazole 2g PO + Azithromycin 1g PO (or Doxycycline 100mg BID × 7 days) 2

Documentation Requirements:

For HIV-positive patients, document 4:

• Lowest CD4 count ever recorded (determines lifetime opportunistic infection risk)
• Complete antiretroviral history with resistance testing results
• Prior opportunistic infections
• Geographic exposures (Ohio/Mississippi River valleys for histoplasmosis, Southwest for coccidioidomycosis)
• Specific sexual practices to guide anatomic site testing

Common Pitfall to Avoid

Never accept a patient's self-assessment of "low risk"—directly ask about specific sexual behaviors (receptive anal intercourse, number of partners, condom use) and base screening frequency on actual practices, not perceived risk 3, 4. Recurrent bacterial STIs in MSM indicate substantial HIV acquisition risk requiring immediate PrEP discussion 3.