Alida Maria Gertz, MD, MPH, MSc, DTM&H
Core Faculty, Wellstar Atlanta Medical Center Family Medicine Residency Program
Georgia has high rates of STDs. In 2018, by rate per 100,000 population, Georgia ranked #7 in chlamydia cases, #15 in gonorrhea, #4 in primary and secondary syphilis, and #10 in congenital syphilis UU. In 2015, Georgia ranked #5 in number of HIV diagnoses . From 2014-2018, adolescents and youth (15-24 years old) made up 58-64% of all STD cases in Georgia. African American youth make up 35% of these cases. From 2014-2018, females made up 72% of chlamydia cases in the 15-24 years old age group and over 53% of gonorrhea cases. It is thus important for family physicians in Georgia to be aware of updated guidelines for STD prevention, screening, and treatment, and to remember to focus on at risk populations including importantly, adolescents and young adults when seeing patients in the primary care setting.
The most recent CDC treatment guidelines for STDs came out in 2015 . The CDC created PDFs summarizing these guidelines, which are easily and freely downloadable as a pocket guide , a wall chart , and even apps for iPhones or Androids . More recently, in January 2020, the CDC created a companion guideline to the 2015 STD treatment guidelines, which outlines additional services that primary care clinics should be offering, to ensure quality comprehensive clinical services are provided for STD prevention, screening, and treatment . Eight sections, summarized below, are included in this new guideline: 1) sexual history and physical examination, 2) prevention, 3) screening, 4) partner services, 5) evaluation of STD-related conditions, 6) laboratory, 7) treatment, and 8) referral to a specialist for complex STD or STD-related conditions.
Sexual History and Physical Examination
Taking a good sexual history is key. The five Ps of a thorough sexual history should include questions about: 1) partners, 2) practices, 3) protection, 4) past STDs, and 5) pregnancy prevention (contraception). It is notable that in Georgia, contraception can be prescribed to minors without parental consent. A freely downloadable pocket guide with example questions and step by step instructions on sexual history taking can be found 24There24T 24T24T. The STD physical exam should include inspection of skin, throat, lymph nodes, anogenital area, and a neurologic exam. Notably, the CDC estimates that about half of all new STD infections each year are in people aged 15-24 years old, and Georgia is no exception as noted above 24T24T. For this reason, it is particularly important for providers to ensure they speak to adolescents alone when taking a sexual history 24T24T. Another important group to consider is LGBTQ patients. Men who have sex with men are at increased risk of STDs particularly HIV, and practices should make an effort to include LGBTQ friendly signage in clinics, and staff and providers should have specific training on LGBTQ terminology and how to provide culturally competent care for this vulnerable population 24T24T.
Services that should be offered in the primary care setting include: 1) providing condoms, 2) offering hepatitis A, B, and HPV vaccinations, 3) providing emergency contraception pills, 4) offering STD counseling services, and 5) HIV pre-exposure prophylaxis (PrEP) and nonoccupational postexposure prophylaxis (nPEP) services. PrEP usually consists of a single daily dose of tenofovir disoproxil fumarate (TDF) 300 mg and emtricitabine (FTC) 200 mg, however, a full guideline for PrEP prescribing can be found here , with a summary on page 11. A supplement with additional information on PrEP for patients who inject drugs, primary care practice protocols for prescribing PrEP, and other special situations also exists . Providers should take note that unlike STD treatment, PrEP and nPEP are NOT allowed to be prescribed to minors without parental consent in Georgia .
Screening and assessment should be available in the primary care setting for: gonorrhea, chlamydia, syphilis, hepatitis B, hepatitis C, HIV, cervical cancer, and trichomoniasis. Screening for STIs is notably allowed in minors without parental consent in Georgia .
Strategies should be employed by clinics to identify, test, and treat exposed partners, and should consist of: 1) guidance to patients on notification and treatment of partners, 2) counseling of patients on partner notification, 3) expedited partner treatment (EPT) , which is permissible in Georgia (a link to the full Georgia prescribing rules and regulations can be found here ), and 4) information on gathering of partner information by health department specialists (disease intervention specialist [DIS]). It is notable that cefixime is no longer recommended for treatment of gonorrhea and therefore also not for EPT; however, it can be used in certain situations .
Evaluation of STD-Related Conditions
Clinicians should know to evaluate the following clinical diagnoses for STD etiologies: genital ulcer disease (etiologies include: syphilis, HSV, chancroid, granuloma inguinale, and lymphogranuloma venereum), urethritis (etiologies include: gonorrhea, chlamydia, mycoplasma, trichomoniasis, and HSV), vaginal discharge (etiologies include: bacterial vaginosis, trichomoniasis, and candidiasis), PID (gonorrhea and chlamydia), epididymitis, pharyngitis, genital warts (HPV), proctitis (etiologies include: gonorrhea, LGV serovars of Chlamydia trachomatis, syphilis, and HSV), ectoparasitic infections (etiologies include: pediculosis pubis and scabies), and certain systemic or dermatologic conditions (which can be caused by: disseminated gonorrhea, neurosyphilis, ocular syphilis, condylomata lata, or palmar plantar syphilitic rash). Empiric treatment should be provided when appropriate if clinical suspicion is high.
The following diagnostic tools should be available in the primary care setting: thermometers, pH paper, and phlebotomy. If able, clinics should also consider offering testing with same day results for trichomoniasis, bacterial vaginosis, vulvovaginal candidiasis, urine dipstick, urinalysis with microscopy, pregnancy test, and rapid HIV tests. The following tests should be available via a local laboratory: urogenital NAAT for gonorrhea and chlamydia, extragenital (pharynx and rectum) NAAT for gonorrhea and chlamydia, quantitative nontreponemal serologic test for syphilis, treponemal serologic test for syphilis, HSV viral culture or PCR, HSV serology, fourth-generation antigen/antibody HIV test, oncogenic HPV NAATs with Pap smear, serologic tests for hepatitis A, B, and C, and blood test for pregnancy. Having gram stain, methylene blue, or gentian violet stain for urethritis, gonorrhea culture, gonorrhea antimicrobial susceptibility testing, and NAAT for trichomoniasis in the primary care setting, is optional.
First line therapies for STDs and STD related conditions should be available on site or by prescription. A tracking system to ensure patients with confirmed infections fill prescriptions is also recommended. As per the 2015 treatment guideline, metronidazole (oral or vaginal), and vaginal clindamycin are first line recommended treatments for bacterial vaginosis. Azithromycin or doxycycline are first line treatment for cervicitis, chlamydia, and nongonococcal urethritis. For epididymitis, ceftriaxone plus doxycycline is recommended. Acyclovir, valacyclovir, or famciclovir can all be used for genital HSV. Patient-applied imiquimod, podofilox, or sinecatechins, or provider-applied cryotherapy, surgical excision, trichloroacetic acid, or bichloroacetic acid, can all be used for genital warts. Ceftriaxone plus azithromycin is still recommended for gonococcal infections. Permethrin cream can be used for pediculosis pubis and scabies. Penicillin is still recommended for syphilis. Oral metronidazole or tinidazole is advised for trichomoniasis. Finally doxycycline alone is recommended for lymphogranuloma venereum [5-7]. Treatment of STD is allowable for minors without parental consent in Georgia .
Specialist referral should be considered in the situations listed in the table below.
|Table 1: Situations involving STDs that should prompt specialist referrals|
|Complex gonorrhea||● Resistant gonorrhea
● Cephalosporin or IgE-mediated penicillin allergy
● Suspected cephalosporin treatment failure
● Gonococcal conjunctivitis
● Disseminated gonococcal infection
● Gonococcal endocarditis or meningitis
● Gonococcal ophthalmia in infants
|Complex chlamydial infections||● Chlamydial ophthalmia in infants
● Pneumonia in infants
● Persistent or recurrent epididymitis
● Persistent or recurrent cervicitis
● Cephalosporin or IgE-mediated penicillin allergy
● Suspicion of testicular torsion
|Complex syphilis||● Primary, secondary, and latent syphilis in infants and children
● IgE-mediated penicillin allergy
● Tertiary syphilis
● Ocular or otic syphilis
● Syphilis during pregnancy
|Complex vaginal discharge, trichomoniasis, and candidiasis||● Persistent vaginal discharge of unclear etiology
● Persistent or recurrent trichomoniasis
● IgE-mediated allergy to nitroimidazoles
● Recurrent vulvovaginal candidiasis in patients who remain culture-positive despite maintenance therapy
● Recurrent non albicans vulvovaginal candidiasis
|Complex PID||● Cephalosporin or IgE-mediated penicillin allergy
● PID surgical complications (e.g., tubo-ovarian abscess)
|Complex herpes||● Antiviral-resistant herpes infection
● Genital herpes contracted during third trimester of pregnancy
● Neonatal herpes
|Viral hepatitis||● HBV
|Complex warts||● Cervical or intra-anal warts
● Atypical anogenital warts with high-grade squamous intraepithelial lesion on biopsy
|Cervical intraepithelial neoplasia or cervical cancer||● High- or low-grade squamous intraepithelial lesions on Pap smear|
|Complex ectoparasitic infections||● Crusted scabies in persons with HIV infection|
|Sexual assault||● When HIV nPEP is being considered
● STDs in children (if suspected possibility of sexual abuse)
|HIV infection||● For a new diagnosis or to establish a link to care|
Family physicians are on the frontlines of STD prevention, screening, and treatment. Along with our public health colleagues, it is up to us to decrease the number of STDs in Georgia. Focusing on prevention, screening and treatment, in high risk groups, including adolescents, will help us to do this. Primary care physicians should also work with their local Georgia public health department branches to ensure all notifiable STDs are properly reported . By following the strategies outlined above, we can ensure that best practice for STD prevention, screening and treatment are followed in primary care settings across the state.
References and links to CDC STD resources
- 2018 STD Surveillance Report: State Ranking Tables – CDC
- Georgia 2015 Health Profile – CDC
- STD Tx Guidelines 2015 – Full: https://www.cdc.gov/std/tg2015/tg-2015-print.pdf
- STD Tx Guidelines 2015 – Pocket Guide: https://www.cdc.gov/std/tg2015/2015-pocket-guide.pdf
- STD Tx Guidelines 2015 – Wall Chart: https://www.cdc.gov/std/tg2015/2015-wall-chart.pdf
- STD Tx Guidelines 2015 – App Links: https://www.cdc.gov/std/tg2015/default.htm
- STD Clinical Services 2020: https://www.cdc.gov/mmwr/volumes/68/rr/pdfs/rr6805a1-H.pdf
- Taking a Sexual History – https://www.cdc.gov/std/treatment/sexualhistory.pdf
- 2017 MMWR on confidentiality issues and use of STD services among Adolescents
- CDC Page on LGBTQ Health – https://www.cdc.gov/healthyyouth/disparities/health-considerations-lgbtq-youth.htm
- PrEP Guideline 2017 – https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2017.pdf
- PrEP Guideline 2017 Supplement – https://www.cdc.gov/mmwr/volumes/66/wr/mm6609a1.htm https://www.cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-provider-supplement-2017.pdf
- Minors’ Consent Laws for HIV and STD Services – https://www.cdc.gov/hiv/policies/law/states/minors.html
- Expedited Partner Treatment – https://www.cdc.gov/std/ept/default.htm
- Georgia STD Screening and Treatment – https://dph.georgia.gov/STDs/screening-and-treatment
- EPT for Gonorrhea – https://www.cdc.gov/std/ept/gc-guidance.htm
- Georgia DPH reportable disease list – https://dph.georgia.gov/sites/dph.georgia.gov/files/DPH%20ND%20Reporting%20Poster_0324126.96.36.1996.pdf