Special Populations

Pregnant Women

Intrauterine or perinatally transmitted STDs can have severely debilitating effects on pregnant women, their partners, and their fetuses. All pregnant women and their sex partners should be asked about STDs, counseled about the possibility of perinatal infections, and provided access to treatment, if needed.

Recommended Screening Tests

• All pregnant women in the United States should be screened for HIV infection as early in pregnancy as possible (77). Screening should be conducted after the woman is notified that she will be screened for HIV as part of the routine panel of prenatal tests, unless she declines (i.e., opt-out screening). For women who decline HIV testing, providers should address their objections, and when appropriate, continue to encourage testing strongly. Women who decline testing because they have had a previous negative HIV test should be informed of the importance of retesting during each pregnancy. Testing pregnant women and treating those who are infected are vital not only to maintain the health of the patient, but to reduce perinatal transmission of HIV through available antiretroviral and obstetrical interventions. Retesting in the third trimester (preferably before 36 weeks' gestation) is recommended for women at high risk for acquiring HIV infection (e.g., women who use illicit drugs, have STDs during pregnancy, have multiple sex partners during pregnancy, live in areas with high HIV prevalence, or have HIV-infected partners). Rapid HIV screening should be performed on any woman in labor who has an undocumented HIV status unless she declines. If a rapid HIV test result is positive in these women, antiretroviral prophylaxis should be administered without waiting for the results of the confirmatory test (78).
• A serologic test for syphilis should be performed on all pregnant women at the first prenatal visit (79). In populations in which the amount of prenatal care delivered is not optimal, rapid plasma reagin (RPR) card test screening (and treatment, if that test is reactive) should be performed at the time that a pregnancy is confirmed. Women who are at high risk for syphilis, live in areas of high syphilis morbidity, or are previously untested should be screened again early in the third trimester (at approximately 28 weeks' gestation) and at delivery. Some states require all women to be screened at delivery. Infants should not be discharged from the hospital unless the syphilis serologic status of the mother has been determined at least one time during pregnancy and preferably again at delivery. Any woman who delivers a stillborn infant should be tested for syphilis.
• All pregnant women should be routinely tested for hepatitis B surface antigen (HBsAg) during an early prenatal visit (i.e., a visit during the first trimester), even if they have been previously vaccinated or tested (80). Women who were not screened prenatally, those who engage in behaviors that put them at high risk for infection (e.g., having had more than one sex partner in the previous 6 months, evaluation or treatment for an STD, recent or current injection-drug use, and an HBsAg-positive sex partner) and those with clinical hepatitis should be retested at the time of admission to the hospital for delivery. Pregnant women at risk for HBV infection also should be vaccinated. To avoid misinterpreting a transient positive HBsAg result during the 21 days after vaccination, HBsAg testing should be performed before vaccine administration. All laboratories that conduct HBsAg tests should use an FDA-cleared HBsAg test and perform testing according to the manufacturer's labeling, including testing of initially reactive specimens with a licensed neutralizing confirmatory test. When pregnant women are tested for HBsAg at the time of admission for delivery, shortened testing protocols can be used, and initially reactive results should prompt expedited administration of immunoprophylaxis to infants (80).
• All pregnant women should be routinely screened for Chlamydia trachomatis (see Chlamydia Infections, Diagnostic Considerations) during the first prenatal visit (81). Women aged ≤25 years and those at increased risk for chlamydia (e.g., women who have a new or more than one sex partner) also should be retested during the third trimester to prevent maternal postnatal complications and chlamydial infection in the infant. Women found to have chlamydial infection during the first trimester should be retested within approximately 3–6 months, preferably in the third trimester. Screening during the first trimester might prevent the adverse effects of chlamydia during pregnancy, but supportive evidence for such screening is lacking.
• All pregnant women at risk for gonorrhea or living in an area in which the prevalence of Neisseria gonorrhoeae is high should be screened at the first prenatal visit for N. gonorrhoeae (82). Women aged <25 years are at highest risk for gonorrhea infection. Other risk factors for gonorrhea include a previous gonorrhea infection, other STDs, new or multiple sex partners, inconsistent condom use, commercial sex work, and drug use. Pregnant women found to have gonococcal infection during the first trimester should be retested within approximately 3–6 months, preferably in the third trimester. Uninfected pregnant women who remain at high risk for gonococcal infection also should be retested during the third trimester.
• All pregnant women at high risk for hepatitis C infection should be screened for hepatitis C antibodies (see Hepatitis C, Diagnostic Considerations) at the first prenatal visit. Women at high risk include those with a history of injection-drug use and those with a history of blood transfusion or organ transplantion before 1992.
• Pregnant women should undergo a Papanicolau (Pap) test at the same frequency as nonpregnant women, although recommendations for their management differ (83,84).

Other Tests

• Evidence does not support routine testing for bacterial vaginosis (BV) in pregnancy. For asymptomatic pregnant women at high risk for preterm delivery, evidence is insufficient to assess the balance of benefits and harms of screening for BV (85). Symptomatic women should be evaluated and treated (see Bacterial Vaginosis).
• Evidence does not support routine screening for Trichomonas vaginalis in asymptomatic pregnant women. Women who report symptoms should be evaluated and treated appropriately (see Trichomonas).
• Evidence does not support routine HSV-2 serologic screening among previously undiagnosed women during pregnancy.

Other Concerns

• Pregnant women who are HBsAg positive should be reported to the local or state health department to ensure that they are entered into a case-management system and that timely and appropriate prophylaxis is provided for their infants. Information concerning the pregnant woman's HBsAg status should be provided to the hospital in which delivery is planned and to the health-care provider who will care for the newborn. In addition, household and sex contacts of women who are HBsAg positive should be vaccinated.
• Women who are HBsAg positive should be provided with, or referred for, appropriate counseling and medical management. Pregnant women who are HBsAg positive should receive information regarding hepatitis B that addresses:
  • modes of transmission;
  • perinatal concerns (e.g., breastfeeding is not contraindicated);
  • prevention of HBV transmission, including the importance of postexposure prophylaxis for the newborn infant and hepatitis B vaccination for household contacts and sex partners; and
  • evaluation for and treatment of chronic HBV infection.
• No treatment is available for pregnant women infected with hepatitis C virus (HCV). However, all women with HCV infection should receive appropriate counseling and supportive care as needed (see Hepatitis C, Prevention). No vaccine is available to prevent HCV transmission.
• In the absence of lesions during the third trimester, routine serial cultures for herpes simplex virus (HSV) are not indicated for women who have a history of recurrent genital herpes. Prophylactic cesarean delivery is not indicated for women who do not have active genital lesions at the time of delivery.
• The presence of genital warts is not an indication for cesarean delivery.

For a more detailed discussion of STD testing and treatment among pregnant women, refer to the following references: Prenatal screening for HIV: A Review of the evidence for the U.S. Preventive Services Task Force (86); Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Setting (77); Guidelines for Perinatal Care (87); Rapid HIV Antibody Testing During Labor and Delivery for Women of Unknown HIV Status: A Practical Guide and Model Protocol (88); Viral Hepatitis in Pregnancy (89); Hepatitis B Virus: A Comprehensive Strategy for Eliminating Transmission in the United States — Recommendations of the Immunization Practices Advisory Committee (ACIP) (4); Screening for Chlamydial Infection: U.S. Preventive Services Task Force Recommendation Statement (81); Canadian guidelines on sexually transmitted infections (90); USPSTF recommendations for STI screening (91); and Screening for Bacterial Vaginosis in Pregnancy to Prevent Preterm Delivery: U.S. Preventive Services Task Force Recommendation Statement (85).

Recommendations to screen pregnant women for STDs are based on disease severity and sequelae, prevalence in the population, costs, medicolegal considerations (e.g., state laws), and other factors. The screening recommendations in this report are generally broader (i.e., if followed, more women will be screened for more STDs than would by following other screening recommendations) and are also consistent with other CDC guidelines.

Adolescents

In the United States, prevalence rates of many sexually acquired infections are highest among adolescents (92,93). For example, the reported rates of chlamydia and gonorrhea are highest among females aged 15–19 years, and many persons acquire HPV infection during their adolescent years.

Persons who initiate sex early in adolescence are at higher risk for STDs, along with persons residing in detention facilities, attending STD clinics, young men having sex with men (YMSM), and youth who use injection drugs. Factors contributing to this increased risk during adolescence include having multiple sexual partners concurrently, having sequential sexual partnerships of limited duration, failing to use barrier protection consistently and correctly, having increased biologic susceptibility to infection, and experiencing multiple obstacles to accessing health care (92).

All 50 states and the District of Columbia explicitly allow minors to consent for their own health services for STDs. No state requires parental consent for STD care or requires that providers notify parents that an adolescent minor has received STD services, except in limited or unusual circumstances.

Protecting confidentiality for such care, particularly for adolescents enrolled in private health insurance plans, presents multiple problems. After a claim has been reported, many states mandate that health plans provide a written statement to a beneficiary indicating the benefits and charges covered or not covered by the health plan (i.e., explanation of benefit [EOB]). In addition, federal laws obligate notices to beneficiaries when claims are denied, including alerting consumers who need to pay for care until the allowable deductible is reached. For STD detection- and treatment-related care, an EOB or medical bill that is received by a parent might disclose services provided and list any laboratory tests performed. This type of mandated notification breeches confidentiality, and at a minimum, could prompt parents and guardians to question the costs and reasons for service provision.

Despite the high rates of infections documented in the adolescent population, providers frequently fail to inquire about sexual behaviors, assess STD risks, provide risk reduction counseling, and ultimately, fail to screen for asymptomatic infections during clinical encounters. Sexual health discussions should be appropriate for the patient's developmental level and should be aimed at identifying risk behaviors (e.g., unprotected oral, anal, or vaginal sex and drug-use behaviors). Careful, nonjudgmental, and thorough counseling is particularly vital for adolescents who might not feel comfortable acknowledging their engagement in behaviors that place them at high risk for STDs.

Screening Recommendations

Routine laboratory screening for common STDs is indicated for sexually active adolescents. The following screening recommendations summarize published federal agency and medical professional organizations' clinical guidelines for sexually active adolescents:

• Routine screening for C. trachomatis of all sexually active females aged ≤25 years is recommended annually (81).Evidence is insufficient to recommend routine screening for C. trachomatis in sexually active young men based on feasibility, efficacy, and cost-effectiveness. However, screening of sexually active young men should be considered in clinical settings associated with high prevalence of chlamydia (e.g., adolescent clinics, correctional facilities, and STD clinics) (81,94).
• Routine screening for N. gonorrhoeae in all sexually active women at risk for infection is recommended annually (82). Women aged <25 years are at highest risk for gonorrhea infection. Other risk factors that place women at increased risk include a previous gonorrhea infection, the presence of other STDs, new or multiple sex partners, inconsistent condom use, commercial sex work, and drug use.
• HIV screening should be discussed with all adolescents and encouraged for those who are sexually active and those who use injection drugs (77,95).
• The routine screening of adolescents who are asymptomatic for certain STDs (e.g., syphilis, trichomoniasis, BV, HSV, HPV, HAV, and HBV) is not recommended. However, YMSM and pregnant adolescent females might require more thorough evaluation.
• Guidelines from USPSTF and ACOG recommend that cervical cancer screening begin at age 21 years (96,97), a recommendation based on the low incidence of cervical cancer and limited utility of screening for younger adolescents (98). However, the American Cancer Society (ACS) recommends that women start cervical screening with Pap tests 3 years after initiating sexual activity, but by no later than age 21 years (99).

Primary Prevention Recommendations

Primary prevention and anticipatory guidance to recognize symptoms and behaviors associated with STDs are strategies that can be incorporated into any or all types of health-care visits. The following recommendations for primary prevention of STDs (i.e., vaccination and counseling) are based on published federal agency and medical professional organizations' clinical guidelines for sexually active adolescents:

• The HPV vaccine, either Cervarix or Gardasil, is recommended for 11 and 12 year-old females. The vaccine series can be started at 9 years of age. Catch-up vaccination is recommended for females aged 13–26 years who have not yet received or completed the vaccine series (16). The quadrivalent (Gardasil) HPV vaccine can also be used in males and females aged 9–26 years to prevent genital warts (17).
• The HBV vaccination series is recommended for all adolescents. Adolescents who have not previously received hepatitis B vaccine should be vaccinated routinely at any age with an appropriate dose and schedule (3,4).
• The HAV vaccination series for children and adolescents aged 2–18 years should be offered in areas with existing hepatitis A vaccination programs. In areas without existing hepatitis A vaccination programs, catch-up vaccination of unvaccinated children aged 2–18 years can be considered (2).
• Information regarding HIV infection, testing, transmission, and implications of infection should be regarded as an essential component of the anticipatory guidance provided to all adolescents as part of health care (77).
• Health-care providers who care for children and adolescents should integrate sexuality education into clinical practice. Providers should counsel adolescents about the sexual behaviors that are associated with risk for acquiring STDs and should educate patients using evidence-based prevention strategies, all of which include a discussion about abstinence and other risk-reduction behaviors (e.g., consistent and correct condom use). USPSTF recommends high-intensity behavioral counseling to prevent STIs* for all sexually active adolescents (6).

Children

Management of children who have STDs requires close cooperation between clinicians, laboratorians, and child-protection authorities. Official investigations, when indicated, should be initiated promptly. Certain diseases (e.g., gonorrhea, syphilis, and chlamydia), if acquired after the neonatal period, are virtually 100% indicative of sexual contact. For other diseases (e.g., HPV infections and vaginitis), the association with sexual contact is not as clear (see Sexual Assault and STDs).

Persons in Correctional Facilities

Multiple studies have demonstrated that persons entering correctional facilities have high rates of STDs (including HIV) and viral hepatitis, especially those aged ≤35 years (93). Incarcerated persons are more likely to have low socioeconomic status, live in urban areas, and be ethnic and racial minorities. Risk behaviors for contracting STDs (e.g., having unprotected sex; having multiple sexual partners; using drugs and alcohol; and engaging in commercial, survival [prostitution to earn money for food, shelter, or drugs], or coerced sex) are common among incarcerated populations. Before incarceration, many have had limited access to medical care, especially to community-based clinical prevention services.

Although no comprehensive national guidelines regarding STD care and management have been developed for correctional populations, the utility of expanded STD services in correctional settings has been reported (100). Capacity to provide STD care also varies by type of correctional facility. For example, local juvenile detention facilities and jails are short-term facilities (often housing entrants for ≤1 year) where up to half of all entrants are released back to the community within 48 hours of arrest, thereby complicating efforts to provide comprehensive STD services. These services are likely more conducive to prisons and state juvenile confinement facilities, which are long-term, secure facilities where entrants are held for a longer period of time.

Most institutions, especially those for adults, do not routinely screen for STDs. Diagnostic testing of inmates with symptoms indicative of an STD is the more common practice in juvenile detention and jail facilities. However, screening for asymptomatic infections facilitates the identification and treatment of persons with otherwise undetected infections, which not only eliminates complications for the individual, but reduces the prevalence of infection among detainees who are released back into the local community.

Females in juvenile detention facilities and young women ≤35 years of age have been reported to have high rates of chlamydia (101) and gonorrhea (93). Syphilis seroprevalence rates, which can indicate previous infection, are considerably higher among adult men and women than in adolescents, consistent with the overall national syphilis trends (102).

Chlamydia and Gonorrhea Screening

Universal screening of adolescent females for chlamydia and gonorrhea should be conducted at intake in juvenile detention or jail facilities. Universal screening of adult females should be conducted at intake among adult females up to 35 years of age (or on the basis of local institutional prevalence data).

Syphilis Screening

Universal screening should be conducted on the basis of the local area and institutional prevalence of early (primary, secondary, and early latent) infectious syphilis.

MSM

Subgroups of MSM are at high risk for HIV infection and other viral and bacterial STDs. The frequency of unsafe sexual practices and the reported rates of bacterial STDs and incident HIV infection declined substantially in MSM from the 1980s through the mid-1990s. However, since that time, increased rates of early syphilis (primary, secondary, or early latent), gonorrhea, and chlamydial infection and higher rates of unsafe sexual behaviors have been documented among MSM in the United States and virtually all industrialized countries (103,104). The effect of these behavioral changes on HIV transmission has not been ascertained, but preliminary data suggest that the incidence of HIV infection is increasing among MSM in some urban centers, particularly among MSM from racial and ethnic minority groups (105) and among those who use nonprescription drugs during sex, particularly methamphetamine and volatile nitrites (also known as "poppers"). These adverse trends likely reflect the 1) changing attitudes concerning HIV infection that have accompanied advances in HIV therapy, resulting in improved quality of life and survival for HIV-infected persons; 2) changing patterns of substance abuse; 3) demographic shifts in MSM populations; and 4) changes in sex partner networks resulting from new venues for partner acquisition (e.g., the internet). Increases in bacterial STDs are not necessarily accompanied by increases in HIV incidence; for example, oral sex may permit efficient spread of bacterial STDs but not HIV, as does serosorting (preferential selection of sex partners of the same serostatus) among HIV-infected MSM (106,107).

Clinicians should assess the STD-related risks for all male patients, including a routine inquiry about the sex of sex partners. MSM, including those with HIV infection, should routinely undergo nonjudgmental STD/HIV risk assessment and client-centered prevention counseling to reduce the likelihood of acquiring or transmitting HIV or other STDs. Clinicians should be familiar with the local community resources available to assist MSM at high risk in facilitating behavioral change and to enable the conduct of partner notification activities. Clinicians also should routinely ask sexually active MSM about symptoms consistent with common STDs, including urethral discharge, dysuria, genital and perianal ulcers, regional lymphadenopathy, skin rash, and anorectal symptoms consistent with proctitis, including discharge and pain on defecation or during anal intercourse. Clinicians should perform appropriate diagnostic testing on all symptomatic patients.

Routine laboratory screening for common STDs is indicated for all sexually active MSM. The following screening tests should be performed at least annually for sexually active MSM:

• HIV serology, if HIV negative or not tested within the previous year;
• syphilis serology, with a confirmatory testing to establish whether persons with reactive serologies have incident untreated syphilis, have partially treated syphilis, or are manifesting a slow serologic response to appropriate prior therapy;
• a test for urethral infection with N. gonorrhoeae and C. trachomatis in men who have had insertive intercourse† during the preceding year; testing of the urine using nucleic acid amplification testing (NAAT) is the preferred approach;
• a test for rectal infection§ with N. gonorrhoeae and C. trachomatis in men who have had receptive anal intercourse† during the preceding year (NAAT of a rectal swab is the preferred approach); and
• a test for pharyngeal infection§ with N. gonorrhoeae in men who have had receptive oral intercourse† during the preceding year (NAAT is the preferred approach). Testing for C. trachomatis pharyngeal infection is not recommended.

Evaluation for HSV-2 infection with type-specific serologic tests also can be considered if infection status is unknown; knowledge of HSV-2 serostatus might be helpful in identifying persons with previously undiagnosed genital tract infection.

Because of the increased incidence of anal cancer in HIV-infected MSM, screening for anal cytologic abnormalities can be considered; however, evidence is limited concerning the natural history of anal intraepithelial neoplasias, the reliability of screening methods, the safety and response to treatments, and the programmatic support needed for such a screening activity.

More frequent STD screening (i.e., at 3–6-month intervals) is indicated for MSM who have multiple or anonymous partners. In addition, MSM who have sex in conjunction with illicit drug use (particularly methamphetamine use) or whose sex partners participate in these activities should be screened more frequently.

All MSM should be tested for HBsAg to detect HBV infection. Prompt identification of chronic infection with HBV is essential to ensure necessary care and services to prevent transmission to others (108). HBsAg testing should be made available in STD treatment settings. In addition, screening among past or current drug users should include HCV and HBV testing.

Vaccination against hepatitis A and B is recommended for all MSM in whom previous infection or vaccination cannot be documented (2,3). Preimmunization serologic testing might be considered to reduce the cost of vaccinating MSM who are already immune to these infections, but this testing should not delay vaccination. Vaccinating persons who are immune to HAV or HBV infection because of previous infection or vaccination does not increase the risk for vaccine-related adverse events (see Hepatitis B, Prevaccination Antibody Screening). Sexual transmission of hepatitis C virus infection can occur, especially among HIV-infected MSM. Serologic screening for hepatitis C infection is recommended at initial evaluation of newly diagnosed HIV-infected persons. HIV-infected MSM can also acquire HCV after initial screening; therefore, men with new and unexplained increases in alanine aminotransferase (ALT) should be tested for acute HCV infection. To detect acute HCV infection among HIV-infected MSM with high-risk sexual behaviors or concomitant ulcerative STDs, routine HCV testing of HIV-infected MSM should be considered.

Women Who Have Sex with Women

Women who have sex with women (WSW) are a diverse group with variations in sexual identity, sexual behaviors, sexual practices, and risk behaviors. Recent studies indicate that some WSW, particularly adolescents, young women, and women with both male and female partners, might be at increased risk for STDs and HIV as a result of certain reported risk behaviors (109-112). WSW are at risk for acquiring bacterial, viral, and protozoal infections from current and prior partners, both male and female. WSW should not be presumed to be at low or no risk for STDs based on sexual orientation. Effective screening requires that providers and their female clients engage in a comprehensive and open discussion not only about sexual identify, but sexual and behavioral risks.

Few data are available on the risk for STDs transmitted by sex between women, but risk probably varies by the specific STD and sexual practice (e.g., oral-genital sex; vaginal or anal sex using hands, fingers, or penetrative sex items; and oral-anal sex [113,114]). Practices involving digital-vaginal or digital-anal contact, particularly with shared penetrative sex items, present a possible means for transmission of infected cervicovaginal secretions. This possibility is most directly supported by reports of metronidazole-resistant trichomoniasis (115) and genotype-concordant HIV transmitted sexually between women who reported these behaviors (116) and by the high prevalence of BV among monogamous WSW (117).

Transmission of HPV can occur with skin-to-skin or skin-to-mucosa contact, which can occur during sex between women. HPV DNA has been detected through polymerase chain reaction (PCR)-based methods from the cervix, vagina, and vulva in 13%–30% of WSW, and high- and low-grade squamous intraepithelial lesions (SIL) have been detected on Pap tests in WSW who reported no previous sex with men (118). However, most self-identified WSW (53%–99%) report having had sex with men and indicate that they might continue this practice in the future (119). Therefore, routine cervical cancer screening should be offered to all women, regardless of sexual preference or sexual practices, and women should be offered HPV vaccine in accordance with current guidelines.

Limited data demonstrate that HSV-2 genital transmission between female sex partners is probably inefficient but can occur. The relatively frequent practice of orogenital sex among WSW might place them at higher risk for genital infection with herpes simplex virus type 1 (HSV-1), a hypothesis supported by the recognized association between HSV-1 seropositivity and number of female partners among WSW (120).

Although the rate of transmission of C. trachomatis between women remains largely unknown, infection also can be acquired from past or current male partners. Recent data suggest that C. trachomatis infection among WSW might be more common than previously thought (121); transmission of syphilis between female sex partners (likely through oral sex) also has been reported. Therefore, report of same-sex behavior in women should not deter providers from screening these women for STDs, including chlamydia and syphilis, as recommended.

BV is common among women in general and even more so among women with female partners. Sexual behaviors that facilitate the transfer of vaginal fluid and/or bacteria between partners might be involved in the pathogenesis of BV. A recent study demonstrated that female sex partners frequently share identical genital Lactobacillus strains (122). Although BV is common in WSW, routine screening for BV is not recommended, nor is the treatment of partners of women with BV. Encouraging awareness of signs and symptoms of BV in women and encouraging healthy sexual practices (e.g., cleaning shared sex toys between uses) might be helpful.

*STI is the term used by USPSTF to describe the syndromes caused by various pathogens that can be acquired and transmitted through sexual activity.

† Regardless of history of condom use during exposure.

§ Commercially available NAATS are not FDA cleared for these indications, but they can be used by laboratories that have met all regulatory requirements for an off-label procedure.

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