April is Sexually Transmitted Infection (STI) Awareness month, a time to remind teens and adults of the dangers of STIs and ways to prevent them.
There are over two dozen different types of sexually transmitted infections, which result in nearly 20 million new diagnoses per year in the United States[i]. The cost of this is an estimated $16 billion annually[ii]. Public health departments have mandatory reporting requirements for several of these illnesses, upon diagnosis, due to the impact on short and long term health outcomes at both the individual and population health levels. Reportable STIs include:
- Hepatitis B
STIs disproportionately affect people ages 15-24. On an individual health impact level, STIs cause a range of acute symptoms such as:
- Ulcerated lesions
- Genital discharge
- Pain with urination, and
- Moderate to severe abdominal or low back pain.
Longer-term individual outcomes can include:
- Pelvic inflammatory disease (PID)
- Ectopic pregnancy
- Chronic pelvic pain in men and women
- Progression to advanced stages of illness, and
The CDC estimates STIs will cause infertility in 20,000 women every year[iii].
After many years of decreasing STI rates in the United States, numbers are now climbing. From 2014-2015, there were notable increases in new cases of chlamydia, syphilis and gonorrhea in both men and women[iv]. The rise in gonorrhea cases is concerning for several reasons, one of which is that this microbe continues to demonstrate antibiotic resistance and is now requiring dual therapy treatment.
Focus: N. gonorrhoeae
Gonorrhea is the second most common reportable STI. As a common cause of PID, this infection can potentially leading to ectopic pregnancy and chronic pelvic pain. Common signs and symptoms of infection include:
- For males: purulent discharge with painful urination (dysuria) due to urethritis
- For females: purulent discharge along with an excoriated, painful vulva in females that may or may not be accompanied by dysuria[v].
In 2015, there were over 390,000 reported cases of gonorrhea in the U.S.—the result of an overall 20% increase in cases since 2011[vi]. Western and southern states saw the greatest increase in gonorrhea incidence from 2014-2015 and the majority of age-identified cases were in people under the age of 44.
In addition to concerns over increasing incidence in gonorrhea is the growing antibiotic resistance the N. gonorrhoeae is also demonstrating. Beyond resistance to single fluoroquinolone therapy, gonorrhea infections are now showing resistance to single cephalosporin therapy[vii]. This change is now warranting dual antimicrobial therapy for successful treatment of gonorrhea infections.
With STI incidence rising across communities throughout the nation, screening, symptoms-driven testing and treatment are more important than ever. The United States Preventive Services Taskforce (USPSTF) recommends screening men and women for STIs, including gonorrhea, based on several factors: age, pregnancy status, sex (male or female); sexual activity status; and if sexually active, participation in high-risk sexual behaviors such as:
- Having multiple sex partners
- Having a new sex partner
- Using condoms inconsistently
- Engaging in sex while under the influence of one or more substances
- Exchanging sex for money or drugs[viii]
Screening recommendations vary slightly between different professional organizations including USPSTF, Centers for Disease Control and Prevention (CDC) American College of Gynecologists (ACOG) and the American Academy of Family Physicians (AAFP). Most guidelines agree screening for gonorrhea and chlamydia should begin for sexually active men and women under the age of 25. Screening for other STIs like syphilis, HIV, herpes simplex virus (HSV) and human papilloma virus (HPV) should be driven by risk status, known or suspected exposure to one or more STIs and community STI prevalence data (Table 1).
It is important to treat all sexual partners of anyone diagnosed with gonorrhea. Health care providers should stress the importance of avoiding unprotected sexual contact until both partners have completed treatment. Guidelines including treatment recommendations are available in the CDC’s 2015 Sexually Transmitted Disease Treatment Guidelines report. These guidelines cover testing and treatment recommendations, including antibiotic selection, for all prominent STIs and can be downloaded onto Apple and Android devices, making them easily accessible at the point of care. STI prevention strategies such as immunization for vaccine-preventable STIs are included in this report as well.
While the healthcare team provides crucial screening, diagnosis and treatment services along with prevention counseling, patients should be strongly encouraged to practice proactive prevention and management strategies that include:
- Attending regular health exams during which screening might be performed
- Consistently avoiding high-risk sexual behaviors
- Asking sexual partners about their sexual history and engaging in STI screening and treatment, as needed, prior to starting a new sexual relationship
- Maintaining awareness of signs and symptoms associated with STIs and discontinuing sexual contact until testing and treatment have been completed
- Requiring sexual partners are tested and treated in the event an individual is diagnosed with an STI
Elsevier Patient Education
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Table 1: Comparison of STI Screening Recommendations for Sexually Active Nonpregnant Women
Kimmelin Hull, PA, CPH, MPH is a Clinical Editor for Elsevier Interactive Patient Education. Prior to joining Elsevier, Kimmelin worked clinically as a physician assistant in surgical, emergency and urgent care medicine. She taught the undergraduate Human Sexuality course at Montana State University and as a Lamaze Certified Childbirth Educator, she ran a perinatal education program in Bozeman, Montana where she currently resides.
[i]–ii United States Department of Health and Human Services. United States Office of Disease Prevention and Health Promotion. Sexually Transmitted Diseases. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/sexually-transmitted-diseases
[iii] Centers for Disease Control and Prevention. National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention. Division of STD Prevention. (2015). Sexually Transmitted Disease Surveillance. Retrieved from https://www.cdc.gov/std/stats15/std-surveillance-2015-print.pdf
[iv] Centers for Disease Control and Prevention. National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention. Division of STD Prevention. CDC Factsheet: Reported STDs in the United States. 2015 National Data for Chlamydia, Gonorrhea and Syphilis. Retrieved from https://www.cdc.gov/nchhstp/newsroom/docs/factsheets/std-trends-508.pdf
[v] Darville, T. (2016) Nelson Textbook of Pediatrics. 20th ed. Book Chapter: Neisseria gonorrhoeae (Gonococcus). Elsevier.
[vii] Centers for Disease Control and Prevention. National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention. Division of STD Prevention. Antibiotic-Resistant Gonorrhea Basic Information. Retrieved from https://www.cdc.gov/std/gonorrhea/arg/basic.htm
[viii] United States Preventive Services Task Force. USPSTF Recommendations for STI Screening. Retrieve 3/13/17 fromhttps://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-recommendations-for-sti-screening#uspstf-recommendations