CDC Sexually Transmitted Infections Treatment Guidelines 2021 PDF

Morbidity and Mortality Weekly Report Recommendations and Reports / Vol. 70 / No. 4 July 23, 2021 Sexually Transmitted Infections Treatment Guidelines, 2021...

Morbidity and Mortality Weekly Report Recommendations and Reports / Vol. 70 / No. 4 July 23, 2021 Sexually Transmitted Infections Treatment Guidelines, 2021 U.S. Department of Health and Human Services Centers for Disease Control and Prevention  Recommendations and Reports CONTENTS Introduction............................................................................................................1 Methods....................................................................................................................1 Clinical Prevention Guidance............................................................................2 STI Detection Among Special Populations............................................... 11 HIV Infection......................................................................................................... 24 Diseases Characterized by Genital, Anal, or Perianal Ulcers............... 27 Syphilis................................................................................................................... 39 Management of Persons Who Have a History of Penicillin Allergy.. 56 Diseases Characterized by Urethritis and Cervicitis............................... 60 Chlamydial Infections....................................................................................... 65 Gonococcal Infections...................................................................................... 71 Mycoplasma genitalium.................................................................................... 80 Diseases Characterized by Vulvovaginal Itching, Burning, Irritation, Odor, or Discharge........................................................................................... 82 Pelvic Inflammatory Disease.......................................................................... 94 Epididymitis.......................................................................................................... 98 Human Papillomavirus Infections..............................................................100 Viral Hepatitis.....................................................................................................113 Proctitis, Proctocolitis, and Enteritis..........................................................124 Ectoparasitic Infections..................................................................................126 Sexual Assault and Abuse and STIs............................................................128 References...........................................................................................................135 The MMWR series of publications is published by the Center for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services, Atlanta, GA 30329-4027. Suggested citation: [Author names; first three, then et al., if more than six.] [Title]. MMWR Recomm Rep 2021;70(No. RR-#):[inclusive page numbers]. Centers for Disease Control and Prevention Rochelle P. Walensky, MD, MPH, Director Debra Houry, MD, MPH, Acting Principal Deputy Director Daniel B. Jernigan, MD, MPH, Acting Deputy Director for Public Health Science and Surveillance Rebecca Bunnell, PhD, MEd, Director, Office of Science Jennifer Layden, MD, PhD, Deputy Director, Office of Science Michael F. Iademarco, MD, MPH, Director, Center for Surveillance, Epidemiology, and Laboratory Services MMWR Editorial and Production Staff (Serials) Charlotte K. Kent, PhD, MPH, Editor in Chief Martha F. Boyd, Lead Visual Information Specialist Ian Branam, MA, Acting Lead Christine G. Casey, MD, Editor Alexander J. Gottardy, Maureen A. Leahy, Health Communication Specialist Mary Dott, MD, MPH, Online Editor Julia C. Martinroe, Stephen R. Spriggs, Tong Yang, Shelton Bartley, MPH, Terisa F. Rutledge, Managing Editor Visual Information Specialists Lowery Johnson, Amanda Ray, David C. Johnson, Lead Technical Writer-Editor Quang M. Doan, MBA, Phyllis H. King, Jacqueline N. Sanchez, MS, Marella Meadows, Project Editor Terraye M. Starr, Moua Yang, Health Communication Specialists Information Technology Specialists Will Yang, MA, Visual Information Specialist MMWR Editorial Board Timothy F. Jones, MD, Chairman Matthew L. Boulton, MD, MPH William E. Halperin, MD, DrPH, MPH Carlos Roig, MS, MA Carolyn Brooks, ScD, MA Jewel Mullen, MD, MPH, MPA William Schaffner, MD Jay C. Butler, MD Jeff Niederdeppe, PhD Nathaniel Smith, MD, MPH Virginia A. Caine, MD Celeste Philip, MD, MPH Morgan Bobb Swanson, BS Jonathan E. Fielding, MD, MPH, MBA Patricia Quinlisk, MD, MPH Abbigail Tumpey, MPH David W. Fleming, MD Patrick L. Remington, MD, MPH  Recommendations and Reports Sexually Transmitted Infections Treatment Guidelines, 2021 Kimberly A. Workowski, MD1,2; Laura H. Bachmann, MD1; Philip A. Chan, MD1,3; Christine M. Johnston, MD1,4; Christina A. Muzny, MD1,5; Ina Park, MD1,6; Hilary Reno, MD1,7; Jonathan M. Zenilman, MD1,8; Gail A. Bolan, MD1 1Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC, Atlanta, Georgia; 2Emory University, Atlanta, Georgia; 3Brown University, Providence, Rhode Island; 4University of Washington, Seattle, Washington; 5University of Alabama at Birmingham, Birmingham, Alabama; 6University of California San Francisco, San Francisco, California; 7Washington University, St. Louis, Missouri; 8Johns Hopkins University, Baltimore, Maryland Summary These guidelines for the treatment of persons who have or are at risk for sexually transmitted infections (STIs) were updated by CDC after consultation with professionals knowledgeable in the field of STIs who met in Atlanta, Georgia, June 11–14, 2019. The information in this report updates the 2015 guidelines. These guidelines discuss 1) updated recommendations for treatment of Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis; 2) addition of metronidazole to the recommended treatment regimen for pelvic inflammatory disease; 3) alternative treatment options for bacterial vaginosis; 4) management of Mycoplasma genitalium; 5) human papillomavirus vaccine recommendations and counseling messages; 6) expanded risk factors for syphilis testing among pregnant women; 7) one-time testing for hepatitis C infection; 8) evaluation of men who have sex with men after sexual assault; and 9) two-step testing for serologic diagnosis of genital herpes simplex virus. Physicians and other health care providers can use these guidelines to assist in prevention and treatment of STIs. Introduction These STI treatment guidelines complement Recommendations for Providing Quality Sexually Transmitted Diseases Clinical The term “sexually transmitted infection” (STI) refers to Services, 2020 (2) regarding quality clinical services for STIs a pathogen that causes infection through sexual contact, in primary care and STD specialty care settings. This guidance whereas the term “sexually transmitted disease” (STD) refers specifies operational determinants of quality services in various to a recognizable disease state that has developed from an clinical settings, describes on-site treatment and partner infection. Physicians and other health care providers have a services, and indicates when STI-related conditions should be crucial role in preventing and treating STIs. These guidelines managed through consultation with or referral to a specialist. are intended to assist with that effort. Although the guidelines emphasize treatment, prevention strategies and diagnostic recommendations also are discussed. This report updates Sexually Transmitted Diseases Treatment Methods Guidelines, 2015 (1) and should be regarded as a source of These guidelines were developed by CDC staff who worked clinical guidance rather than prescriptive standards. Health care with subject matter experts with expertise in STI clinical providers should always consider the clinical circumstances of management from other federal agencies, nongovernmental each person in the context of local disease prevalence. These academic and research institutions, and professional medical guidelines are applicable to any patient care setting that serves organizations. CDC staff identified governmental and persons at risk for STIs, including family planning clinics, nongovernmental subject matter experts on the basis of their HIV care clinics, correctional health care settings, private expertise and assisted them in developing questions to guide physicians’ offices, Federally Qualified Health Centers, clinics individual literature reviews. CDC staff informed the subject for adolescent care, and other primary care facilities. These matter experts that they were being consulted to exchange guidelines are focused on treatment and counseling and do information and observations and to obtain their individual not address other community services and interventions that input. All subject matter experts disclosed potential conflicts are essential to STI and HIV prevention efforts. of interest. STI Treatment Guidelines, 2021, Work Group members are listed at the end of this report. In 2018, CDC staff identified key questions about treatment and clinical management to guide an update of the 2015 Corresponding preparer: Kimberly A. Workowski, MD, Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD treatment guidelines (1). To answer these questions STD, and TB Prevention, CDC. Telephone: 404-639-1898; Email: and synthesize new information available since publication [email protected]. of the 2015 guidelines, subject matter experts and CDC staff US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 1  Recommendations and Reports collaborated to conduct systematic literature reviews by using Management and Budget for influential scientific information. an extensive MEDLINE database evidence-based approach for A public webinar was held to provide an overview of the draft each section of the 2015 guidelines (e.g., using English-language recommendations and invite questions and comments on the published abstracts and peer reviewed journal articles). These draft recommendations. The peer review comments, webinar, systematic reviews were focused on four principal outcomes questions, and responses were considered by CDC staff in of STI therapy for each disease or infection: 1) treatment developing the final recommendations for the updated STI of infection on the basis of microbiologic eradication; treatment guidelines. Recommendations for HIV, hepatitis C, 2) alleviation of signs and symptoms; 3) prevention of sequelae; cervical cancer screening, STI screening in pregnancy, human and 4) prevention of transmission, including advantages (e.g., papillomavirus (HPV) testing, and hepatitis A virus (HAV) and cost-effectiveness, single-dose formulations, and directly hepatitis B virus (HBV) vaccination were developed after CDC observed therapy) and disadvantages (e.g., adverse effects) staff reviewed existing published recommendations. The English- of specific regimens. The outcome of the literature reviews language literature was searched periodically by CDC staff to guided development of background materials, including tables identify subsequently published articles warranting consideration. of evidence from peer-reviewed publications summarizing Throughout this report, the evidence used as the basis for the type of study (e.g., randomized controlled trial or case specific recommendations is discussed briefly. Publication series), study population and setting, treatments or other of comprehensive, annotated discussions of such evidence interventions, outcome measures assessed, reported findings, is planned in a supplemental issue of the journal Clinical and weaknesses and biases in study design and analysis. Infectious Diseases after publication of the treatment guidelines. In June 2019, the subject matter experts presented their When more than one therapeutic regimen is recommended assessments of the literature reviews at an in-person meeting and the listed regimens have similar efficacy and similar of governmental and nongovernmental participants. Each rates of intolerance or toxicity, the recommendations are key question was discussed and pertinent publications were listed alphabetically. If differences are specified, regimens are reviewed in terms of strengths, weaknesses, and relevance. prioritized on the basis of these differences. Recommended Participants evaluated the quality of evidence, provided their regimens should be used primarily; alternative regimens can be input, and discussed findings in the context of the modified considered in instances of notable drug allergy or other medical rating system used by the U.S. Preventive Services Task Force contraindications to the recommended regimens. Alternative (USPSTF). The discussions were informal and not structured regimens are considered inferior to recommended regimens on to reach consensus. CDC staff also reviewed the publications the basis of available evidence regarding the principal outcomes from other professional organizations, including the American and disadvantages of the regimens. College of Obstetricians and Gynecologists (ACOG), USPSTF, the American Cancer Society (ACS), the American Society for Colposcopy and Cervical Pathology (ASCCP), and the Clinical Prevention Guidance Advisory Committee on Immunization Practices (ACIP). Prevention and control of STIs are based on the following The discussion culminated in a list of participants’ opinions five major strategies (3): on all the key STI topic areas for consideration by CDC. 1. Accurate risk assessment and education and counseling (More detailed descriptions of the key questions, search terms, of persons at risk regarding ways to avoid STIs through systematic search, evidence tables, and review process are changes in sexual behaviors and use of recommended available at https://www.cdc.gov/std/treatment-guidelines/ prevention services default.htm). 2. Pre-exposure vaccination for vaccine-preventable STIs CDC staff then independently reviewed the tables of evidence 3. Identification of persons with an asymptomatic prepared by the subject matter experts, individual comments infection and persons with symptoms associated with from the participants and professional organizations, and existing an STI guidelines from other organizations to determine whether 4. Effective diagnosis, treatment, counseling, and follow- revisions to the 2015 STD treatment guidelines were warranted. up of persons who are infected with an STI CDC staff ranked evidence as high, medium, and low on the 5. Evaluation, treatment, and counseling of sex partners basis of each study’s strengths and weaknesses according to the of persons who are infected with an STI USPSTF ratings (https://www.uspreventiveservicestaskforce. org/uspstf/us-preventive-services-task-force-ratings). CDC staff then developed draft recommendations that were peer reviewed by public health and clinical experts as defined by the Office of 2 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention  Recommendations and Reports STI and HIV Infection Risk Assessment is it for you?”). The “Five P’s” approach to obtaining a sexual history is one strategy for eliciting information about the key Primary prevention of STIs includes assessment of behavioral areas of interest (Box 1). In addition, health care professionals risk (i.e., assessing the sexual behaviors that can place persons can consider assessing sexual history by asking patients such at risk for infection) and biologic risk (i.e., testing for risk questions as, “Do you have any questions or concerns about markers for STI and HIV acquisition or transmission). As part your sexual health?” Additional information about gaining of the clinical encounter, health care providers should routinely cultural competency when working with certain populations obtain sexual histories from their patients and address risk (e.g., gay, bisexual, or other men who have sex with men reduction as indicated in this report. Guidance for obtaining [MSM]; women who have sex with women [WSW] or with a sexual history is available at the Division of STD Prevention women and men [WSWM]; or transgender men and women resource page (https://www.cdc.gov/std/treatment/resources. or adolescents) is available in sections of these guidelines related htm) and in the curriculum provided by the National Network to these populations. of STD Clinical Prevention Training Centers (https://www. In addition to obtaining a behavioral risk assessment, a nnptc.org). Effective interviewing and counseling skills, comprehensive STI and HIV risk assessment should include characterized by respect, compassion, and a nonjudgmental STI screening as recommended in these guidelines because attitude toward all patients, are essential to obtaining a STIs are biologic markers of risk, particularly for HIV thorough sexual history and delivering effective prevention acquisition and transmission among certain MSM. In most messages. Effective techniques for facilitating rapport with clinical settings, STI screening is an essential and underused patients include using open-ended questions (e.g., “Tell me component of an STI and HIV risk assessment. Persons about any new sex partners you’ve had since your last visit” and seeking treatment or evaluation for a particular STI should be “What has your experience with using condoms been like?”); screened for HIV and other STIs as indicated by community understandable, nonjudgmental language (e.g., “What gender prevalence and individual risk factors (see Chlamydial are your sex partners?”and “Have you ever had a sore or scab Infections; Gonococcal Infections; Syphilis). Persons should on your penis?”); and normalizing language (e.g., “Some of my be informed about all the tests for STIs they are receiving and patients have difficulty using a condom with every sex act. How notified about tests for common STIs (e.g., genital herpes, BOX 1. The Five P’s approach for health care providers obtaining sexual histories: partners, practices, protection from sexually transmitted infections, past history of sexually transmitted infections, and pregnancy intention 1. Partners 4. Past history of STIs “Are you currently having sex of any kind?” “Have you ever been tested for STIs and HIV?” “What is the gender(s) of your partner(s)?” “Have you ever been diagnosed with an STI in the past?” 2. Practices “Have any of your partners had an STI?” “To understand any risks for sexually transmitted Additional questions for identifying HIV and viral infections (STIs), I need to ask more specific questions hepatitis risk: about the kind of sex you have had recently.” “Have you or any of your partner(s) ever injected drugs?” “What kind of sexual contact do you have or have you had?” “Is there anything about your sexual health that you 0 “Do you have vaginal sex, meaning ‘penis in vagina’ sex?” have questions about?” 0 “Do you have anal sex, meaning ‘penis in rectum/anus’ 5. Pregnancy intention sex?” “Do you think you would like to have (more) children 0 “Do you have oral sex, meaning ‘mouth on penis/vagina’?” in the future?” 3. Protection from STIs “How important is it to you to prevent pregnancy “Do you and your partner(s) discuss prevention of STIs (until then)?” and human immunodeficiency virus (HIV)?” “Are you or your partner using contraception or “Do you and your partner(s) discuss getting tested?” practicing any form of birth control?” For condoms: “Would you like to talk about ways to prevent 0 “What protection methods do you use? In what pregnancy?” situations do you use condoms?” US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 3  Recommendations and Reports trichomoniasis, Mycoplasma genitalium, and HPV) that are the STD National Network of Prevention Training Centers available but not being performed and reasons why they are (https://www.nnptc.org). not always indicated. Persons should be informed of their test In addition to one-on-one STI and HIV prevention results and recommendations for future testing. Efforts should counseling, videos and large group presentations can provide be made to ensure that all persons receive STI care regardless explicit information concerning STIs and reducing disease of personal circumstances (e.g., ability to pay, citizenship transmission (e.g., how to use condoms consistently and or immigration status, gender identity, language spoken, or correctly and the importance of routine screening). Group- specific sex practices). based strategies have been effective in reducing the occurrence of STIs among persons at risk, including those attending STI and HIV Infection STD clinics (9). Brief, online, electronic-learning modules for young MSM have been reported to be effective in reducing Prevention Counseling incident STIs and offer a convenient client platform for After obtaining a sexual history from their patients, all effective interventions (10). Because the incidence of certain providers should encourage risk reduction by offering STIs, most notably syphilis, is higher among persons with prevention counseling. Prevention counseling is most effective HIV infection, use of client-centered STI counseling for if provided in a nonjudgmental and empathetic manner persons with HIV continues to be encouraged by public health appropriate to the patient’s culture, language, sex and gender agencies and other health organizations (https://www.cdc.gov/ identity, sexual orientation, age, and developmental level. std/statistics/2019/default.htm). A 2014 guideline from CDC, Prevention counseling for STIs and HIV should be offered the Health Resources and Services Administration, and the to all sexually active adolescents and to all adults who have National Institutes of Health recommends that clinical and ✓ received an STI diagnosis, have had an STI during the nonclinical providers assess a person’s behavioral and biologic previous year, or ✓ have had multiple sex partners. USPSTF risks for acquiring or transmitting STIs and HIV, including recommends intensive behavioral counseling for all sexually having sex without condoms, having recent STIs, and having active adolescents and for adults at increased risk for STIs and partners recently treated for STIs (https://stacks.cdc.gov/ HIV (4). Such interactive counseling, which can be resource view/cdc/44064). That federal guideline is for clinical and intensive, is directed at a person’s risk, the situations in which nonclinical providers to offer or make referral for regular risk occurs, and the use of personalized goal-setting strategies. screening for multiple STIs, on-site STI treatment when One such approach, known as client-centered STI and HIV indicated, and risk-reduction interventions tailored to the prevention counseling, involves tailoring a discussion of risk person’s risks. Brief risk-reduction counseling delivered by reduction to the person’s situation. Although one large study in medical providers during HIV primary care visits, coupled STI clinics (Project RESPECT) demonstrated that this approach with routine STI screening, has been reported to reduce STI was associated with lower acquisition of curable STIs (e.g., incidence among persons with HIV infection (8). Other trichomoniasis, chlamydia, gonorrhea, and syphilis) (5), another specific methods have been designed for the HIV care setting study conducted 10 years later in the same settings but different (https://www.cdc.gov/hiv/effective-interventions/index.html). contexts (Project AWARE) did not replicate this result (6). With the challenges that intensive behavioral counseling poses, health care professionals might find brief prevention messages Primary Prevention Methods and those delivered through video or in a group session to be Pre-Exposure Vaccination more accessible for the client. A review of 11 studies evaluated Pre-exposure vaccination is one of the most effective methods brief prevention messages delivered by providers and health for preventing transmission of HPV, HAV, and HBV, all counselors and reported them to be feasible and to decrease of which can be sexually transmitted. HPV vaccination is subsequent STIs in STD clinic settings (7) and HIV care recommended routinely for males and females aged 11 or settings (8). Other approaches use motivational interviewing 12 years and can be administered beginning at age 9 years. to move clients toward achievable risk-reduction goals. Client- HPV vaccination is recommended through age 26 years for centered counseling and motivational interviewing can be used those not previously vaccinated (11). Sharing clinical decision- effectively by clinicians and staff trained in these approaches. making about HPV vaccination is recommended for certain CDC provides additional information on these and other adults aged 27–45 years who are not adequately vaccinated effective behavioral interventions at https://www.cdc.gov/ in accordance with existing guidance (https://www.cdc.gov/ std/program/interventions.htm. Training in client-centered vaccines/hcp/acip-recs/vacc-specific/hpv.html). counseling and motivational interviewing is available through 4 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention  Recommendations and Reports Hepatitis B vaccination is recommended for all unvaccinated, on the box or individual package. Latex condoms should not uninfected persons who are sexually active with more than be used beyond their expiration date or >5 years after the one partner or are being evaluated or treated for an STI (12). manufacturing date. Condoms made of materials other than In addition, hepatitis A and B vaccines are recommended for latex are available in the United States and can be classified MSM, persons who inject drugs, persons with chronic liver into two general categories: 1) polyurethane, polyisoprene, or disease, and persons with HIV or hepatitis C infections who other synthetic condoms and 2) natural membrane condoms. have not had hepatitis A or hepatitis B (12). HAV vaccine is Polyurethane external condoms provide protection against also recommended for persons who are homeless (13). Details STIs and HIV and pregnancy comparable to that of latex regarding HAV and HBV vaccination, including routine condoms (20,31). These can be substituted for latex condoms childhood vaccination, are available at https://www.cdc.gov/ by persons with latex sensitivity, are typically more resistant to hepatitis and at the ACIP website (https://www.cdc.gov/ deterioration, and are compatible with use of both oil-based vaccines/hcp/acip-recs/vacc-specific/index.html). and water-based lubricants. The effectiveness of other synthetic external condoms to prevent STIs has not been extensively Condoms studied, and FDA labeling restricts their recommended use External Condoms to persons who are sensitive to or allergic to latex. Natural membrane condoms (frequently called natural skin condoms When used- consistently and correctly, external latex or [incorrectly] lambskin condoms) are made from- lamb cecum condoms, also known as male condoms, are effective in and can have pores up to 1,500 nm in diameter. Although preventing the sexual transmission of HIV infection (http:// these pores do not allow the passage of sperm, they are more www.ashasexualhealth.org/pdfs/Male_and_Female_Condoms. than 10 times the diameter of HIV and more than 25 times pdf). In heterosexual HIV mixed-status relationships (i.e., those that of HBV. Moreover, laboratory studies demonstrate that involving one infected and one uninfected partner) in which sexual transmission of viruses, including HBV, herpes simplex condoms were used consistently, HIV-negative partners were virus (HSV), and HIV, can occur with natural membrane 71%–80% less likely to become infected with HIV, compared condoms (31). Therefore, natural membrane condoms are not with persons in similar relationships in which condoms were recommended for prevention of STIs and HIV. not used (14,15). Two analyses of MSM mixed-status couple Providers should advise that condoms must be used studies estimated the protective effect of condom use to be 70% consistently and correctly to be effective in preventing STIs and and 91%, respectively (16,17). Moreover, studies demonstrate HIV while noting that any condom use is better than no condom that consistent condom use reduces the risk for other STIs, use. Providing instructions about the correct use of condoms including chlamydia, gonorrhea, hepatitis B, and trichomoniasis can be useful. Communicating the following recommendations (18–21). By limiting lower genital tract infections, condoms can help ensure that patients use external condoms correctly: also might reduce the risk for pelvic inflammatory disease Use a new condom with each sex act (i.e., oral, vaginal, : (PID) among women (22). In addition, consistent and correct and anal). use of latex condoms reduces the risk for HPV infection Carefully handle the condom to avoid damaging it with and HPV-associated diseases, genital herpes, syphilis, and fingernails, teeth, or other sharp objects. chancroid when the infected area or site of potential exposure Put the condom on after the penis is erect and before any is covered (23–27). Additional information is available at genital, oral, or anal contact with the partner. https://www.cdc.gov/condomeffectiveness/index.html and Use only water-based or silicone-based lubricants (e.g., www.factsaboutcondoms.com/professional.php. Condoms K-Y Jelly, Astroglide, AquaLube, or glycerin) with latex are regulated as medical devices and are subject to random if condoms. Oil-based lubricants (e.g., petroleum jelly, sampling and testing by the Food and Drug Administration shortening, mineral oil, massage oils, body lotions, or (FDA). Each latex condom manufactured in the United States cooking oil) can weaken latex and should not be used; is tested electronically for holes before packaging. The rate of however, oil-based lubricants typically can be used with condom breakage during sexual intercourse and withdrawal in polyurethane or other synthetic condoms. the United States is approximately two broken condoms per Ensure adequate lubrication during vaginal and anal sex, 100 condoms. Rates of breakage and slippage might be slightly which might require using exogenous water-based higher during anal intercourse (28,29). The failure of condoms lubricants. to protect against STIs or unintended pregnancy usually results ✓ Hold the condom firmly against the base of the penis from inconsistent or incorrect use rather than condom breakage during withdrawal, and withdraw while the penis is still (30). Users should check the expiration or manufacture date erect to prevent the condom from slipping off. US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 5  Recommendations and Reports Additional information about external condoms is available Topical Microbicides and Spermicides at https://www.cdc.gov/condomeffectiveness. Nonspecific topical microbicides are ineffective for Internal Condoms preventing HIV infection (40–45). Tenofovir gel has been studied for prevention of herpes simplex virus 2 (HSV-2) Condoms for internal vaginal use, also known as female and HIV infections (46,47). Adherence can be low (48), and condoms, are available worldwide (e.g., the FC2 Female prevention of HIV infection, especially among women, has not Condom, Reddy condom, Cupid female condom, and Woman’s been demonstrated (47,49).Vaginal rings containing dapivirine condom) (31,32). Use of internal condoms can provide have provided some reduction in HIV infection (50,51). For protection from acquisition and transmission of STIs, although men and transgender women who have anal intercourse, data are limited. Internal condoms are more costly compared tenofovir gel appears safe when applied before and after anal with external condoms; however, they offer the advantage of sex (52). Spermicides containing nonoxynol-9 (N-9) might being controlled by the receptive partner as an STI and HIV disrupt genital or rectal epithelium and have been associated prevention method, and the newer versions might be acceptable with an increased risk for HIV infection. Condoms with N-9 to all persons. Although the internal condom also has been used are no more effective than condoms without N-9; therefore, during receptive anal intercourse, efficacy associated with this N-9 alone or in a condom is not recommended for STI and practice remains unknown (33). Additional information about HIV prevention (40). N-9 use also has been associated with the internal condom is available at http://www.ashasexualhealth. an increased risk for bacterial urinary tract infections among org/pdfs/Male_and_Female_Condoms.pdf. women (53,54). Cervical Diaphragms Nonbarrier Contraception, Female Surgical In observational studies, diaphragm use has been Sterilization, and Hysterectomy demonstrated to protect against cervical gonorrhea, chlamydia, and trichomoniasis (34). However, a trial examining the effect Contraceptive methods that are not mechanical barriers of a diaphragm plus lubricant on HIV acquisition among offer no protection against HIV or other STIs. The ECHO women in Africa reported no additional protective effect when study observed no differences in HIV incidence rates among compared with the use of male condoms alone. Likewise, no women randomly assigned to DMPA, levonorgestrel implant, difference by study arm in the rate of acquisition of chlamydia, or copper-containing IUD contraceptive methods (38). A gonorrhea, or herpes occurred (35,36). Diaphragms should systematic review of epidemiologic evidence reported that the not be relied on as the sole source of protection against HIV majority of studies demonstrated no association between use and other STIs. of oral contraceptives and HIV acquisition among women (55). Whether hormonal contraception alters a woman’s risk Multipurpose Prevention Technologies for other STIs is uncertain (56,57). Methods that combine STI and HIV prevention Sexually active women who use contraceptive methods with pregnancy prevention are known as multipurpose other than condoms should be counseled about STI and HIV infection prevention measures. These include pre-exposure - prevention technologies (MPTs) (37) (https://www.who.int/ reproductivehealth/topics/linkages/mpts/en). Internal and prophylaxis (PrEP) and postexposure prophylaxis (PEP), external condoms are both examples of MPTs because they are limiting the number of sex partners, and correct and consistent effective prevention measures when used correctly for STI and use of condoms. HIV transmission or pregnancy prevention. The multicenter Emergency Contraception Evidence for Contraception Options and HIV Outcomes (ECHO) trial observed no statistically significant differences in Unprotected intercourse exposes women to risks for STIs HIV incidence rates among women randomly assigned to one and unplanned pregnancy. Providers should offer counseling of three contraceptive methods (depot medroxyprogesterone about the option of emergency contraception if pregnancy acetate [DMPA], levonorgestrel implant, and copper- is not desired. Options for emergency contraception in the containing intrauterine device [IUD]); however, rates of HIV United States include copper-containing IUDs and emergency infection were high in all groups, indicating a need for MPTs contraceptive pills (ECPs) (58,59). More information is available (38). Development of MPTs is complex and ongoing; products at https://www.acog.org/clinical/clinical-guidance/practice- under study include microbicides with contraceptive devices bulletin/articles/2015/09/emergency-contraception?utm_ (e.g., tenofovir with a vaginal ring contraceptive delivery source=redirect&utm_medium=web&utm_campaign=otn. package) and other innovative methods (39). ECPs are available in the following formulations: ulipristal 6 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention  < 5%7 Recommendations and Reports acetate in a single dose (30 mg) available by prescription, (https://www.afro.who.int/publications/voluntary-medical-male- levonorgestrel in a single dose (1.5 mg) available over the circumcision-hiv-prevention). In the United States, the American counter or by prescription, or a combined estrogen and Academy of Pediatrics (AAP) recommends that newborn male progestin pill regimen. Insertion of a copper-containing circumcision be available to families that desire it because the IUD ≤5 days after unprotected sex can reduce pregnancy risk benefits of the procedure, including prevention of penile cancers, from a sex act by approximately 99% (60). ECPs are most urinary tract infections, GUD, and HIV infection, outweigh the efficacious when initiated as soon as possible after unprotected risks. ACOG has also endorsed AAP’s policy statement. In light sex. Ulipristal acetate is effective ≤5 days after unprotected sex, of these benefits, the American Urological Association states and levonorgestrel is most effective ≤3 days after unprotected that male circumcision should be considered an option for risk sex but has some efficacy at ≤5 days. ECPs are ineffective reduction, among other strategies (72). Additional information (but not harmful) if the woman is already pregnant (61). A for providers counseling male patients and parents regarding 2019 Cochrane review summarized the efficacy, safety, and male circumcision for preventing HIV, STIs, and other adverse convenience of different emergency contraception methods (61). health outcomes is available at https://www.cdc.gov/hiv/risk/ More information about emergency contraception is male-circumcision.html. available in Contraceptive Technology, 21st Edition (31), in the No definitive data exist to determine whether male 2016 U.S. Selected Practice Recommendations (U.S. SPR) circumcision reduces HIV acquisition among MSM, although for Contraceptive Use (emergency contraception) available one meta-analysis of 62 observational studies reported that at https://www.cdc.gov/reproductivehealth/contraception/ circumcision was protective against HIV acquisition in low- to mmwr/spr/emergency.html, and in the 2016 U.S. Medical middle-income countries but not in high-income countries Eligibility Criteria (U.S. MEC) for Contraceptive Use (copper (73). Further studies are needed to confirm any potential IUDs for emergency contraception) available at https:// benefit of male circumcision for this population. www.cdc.gov/reproductivehealth/contraception/mmwr/mec/ appendixj.html. Pre-Exposure Prophylaxis for HIV Providers should educate males and females about emergency Daily oral antiretroviral PrEP with a fixed-dose combination contraception, especially if other methods of contraception of emtricitabine (FTC) and either tenofovir disoproxil fumarate were used incorrectly or not at all and pregnancy is not desired (TDF) or tenofovir alafenamide (TAF) have demonstrated (62). An advance supply of ECPs can be provided or prescribed safety (74) and a substantial reduction in the rate of HIV so that ECPs will be available when needed (59). acquisition for MSM (75). TDF/FTC has demonstrated safety and efficacy for mixed-status heterosexual couples (76) Male Circumcision and heterosexual men and women recruited individually Male circumcision reduces the risk for HIV infection and (77); however, no evidence is yet available regarding TAF/ certain STIs among heterosexual men. Three randomized, FTC among heterosexually active women. In addition, one controlled trials performed in regions of sub-Saharan Africa, clinical trial involving persons who inject drugs (78) and one where generalized HIV epidemics involving predominantly involving heterosexual mixed-status couples (76) demonstrated heterosexual transmission were occurring, demonstrated that substantial efficacy and safety of daily oral PrEP with TDF male circumcision reduces the risk for HIV acquisition among alone. High adherence to oral PrEP was strongly associated men by 50%–60% (63–65). In those trials, circumcision with protection from HIV infection. Studies conducted with also was protective against other STIs, including high-risk MSM have demonstrated that taking PrEP at specific times genital HPV infection and genital herpes (66–68). Follow-up before and after sexual intercourse was effective in preventing studies have demonstrated sustained benefit of circumcision HIV; however, less experience exits with this regimen, it is for HIV prevention (69) and that the effect is not mediated not FDA cleared, and it has not been studied among other solely through a reduction in HSV-2 infection or genital ulcer populations (79). Tenoyovir /Emkicikbine disease (GUD) (70). Comprehensive clinical practice guidelines are available The World Health Organization (WHO) and the Joint for providers in prescribing PrEP to reduce the risk for HIV United Nations Programme on HIV/AIDS (UNAIDS) infection (80). Among HIV-negative sexually active men recommend that male circumcision efforts be scaled up as an and women, bacterial STIs are key indicators of risk for effective intervention for preventing heterosexually acquired HIV HIV acquisition. Studies have documented the risk for HIV infection (71) in countries with hyperendemic and generalized acquisition among MSM within 1 year after infection with HIV epidemics within the context of ensuring universal access rectal gonorrhea or chlamydia (one in 15 men), primary to comprehensive HIV prevention, treatment, care, and support or secondary syphilis (one in 18), and among men with no US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 7  iv monthly lakotcgranv - a Recommendations and Reports Dapirinhr ↳ vaginal ring rectal STI or syphilis infection (one in 53) (81–83). Sexually chlamydia and syphilis by 70% and 73%, respectively, but no = - - active adults and adolescents should be screened for STIs effect on gonorrhea (93). Other studies are under way or in (e.g., chlamydia, gonorrhea, and syphilis) in accordance with development regarding doxycycline prophylaxis for bacterial recommendations, and persons with infection should be STIs (91). No long-term data are available regarding the impact offered PrEP. The USPSTF recommends that persons at risk of STI PEP on antimicrobial resistance and the microbiome. for HIV acquisition be offered PrEP (84). Persons at risk for Further studies are needed to determine whether STI PEP is HIV acquisition include HIV-negative persons whose sexual an effective and beneficial strategy for STI prevention. partner or partners have HIV infection (especially if viral load is detectable or unknown), persons who have had gonorrhea HIV Treatment as Prevention: Antiretroviral or syphilis during the previous 6 months, and injecting drug Treatment of Persons with HIV to Prevent HIV users who share injection equipment (84). Clinical practice Among Partners guidelines recommend STI screening for persons taking PrEP In 2011, the randomized controlled trial HPTN 052 (80) because increased rates of STI acquisition have been demonstrated that, among HIV mixed-status heterosexual described (85–87). couples, HIV antiretroviral therapy (ART) for the infected partner decreased the risk for transmission to the uninfected Pre-Exposure Prophylaxis for STIs partner by 96% (94). Therefore, ART not only is beneficial to Providing HSV treatment to persons with HIV and HSV the health of persons with HIV infection, it also reduces the infection has not demonstrated benefit in reducing HIV risk for transmission. Additional studies of HIV mixed-status acquisition among uninfected partners. A large randomized couples, heterosexual and MSM couples (PARTNER study), controlled trial evaluated mixed-status heterosexual couples and MSM couples (Opposites Attract and PARTNERS2 among the partners with HIV infection who also were studies) reported that patients with HIV taking ART who seropositive for HSV-2 (88). Use of acyclovir had no effect maintain an undetectable viral load demonstrate no risk for on HIV transmission. These findings are consistent with a transmitting HIV to their HIV-negative sex partners (95–97). previous trial that reported no benefit of acyclovir in preventing For those reasons, ART should be offered to all persons with HIV acquisition among persons seropositive for HSV-2 (89). HIV infection to obtain viral suppression. Detailed guidance Doxycycline prophylaxis has been examined for preventing regarding ART regimens is available in the U.S. Department of bacterial STIs. In a pilot study, 30 MSM living with HIV with Health and Human Services’ HIV treatment guidelines (98). previous syphilis (two or more episodes since HIV diagnosis) were randomly assigned to doxycycline 100 mg for 48 weeks HIV Seroadaptive Strategies versus a financial incentive–based behavioral intervention (90). Seroadaptive strategies for HIV prevention have largely That study demonstrated a 73% reduction in any bacterial STI originated within communities of MSM. They are predicated at any site, without substantial differences in sexual behavior. on knowledge of self and partner HIV status. One specific - Additional studies examining doxycycline prophylaxis are seroadaptive practice is serosorting, which includes limiting under way or in development (91). anal sex without a condom to partners with the same HIV status as their own or choosing to selectively use condoms Postexposure Prophylaxis for HIV and STIs with HIV mixed-status partners. Another practice among Guidelines for using PEP aimed at preventing HIV and other mixed-status couples is - seropositioning, in which the STIs as a result of sexual exposure are available at https://www. person with HIV infection is the receptive partner for anal cdc.gov/hiv/pdf/programresources/cdc-hiv-npep-guidelines. intercourse. Observational studies have consistently reported pdf. Sexually active persons seeking HIV PEP should be that serosorting confers greater risk for HIV infection than evaluated for PrEP after completing their PEP course and consistent condom use but has lower risk compared with anal testing negative for HIV. HIV PEP is also discussed elsewhere intercourse without a condom and without serosorting (99– in this report (see Sexual Assault and Abuse and STIs). Genital 101). Serosorting practices have been associated with increased hygiene methods (e.g., vaginal washing and douching) after risk for STIs, including chlamydia and gonorrhea (102,103). I sexual exposure are ineffective in protecting against HIV and Serosorting is not recommended for the following reasons: STIs and might increase the risk for bacterial vaginosis (BV), many MSM who have HIV infection do not know they certain STIs, and HIV infection (92). have HIV because they have not been tested recently, men’s STI PEP in the form of doxycycline 200 mg taken after assumptions about the HIV status of their partners might be unprotected anal sex has been studied among MSM and wrong, and some men with HIV infection might not disclose or transgender women; results demonstrated reduction in incident might misrepresent their HIV status. All of these factors increase 8 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention  Recommendations and Reports the risk that serosorting can lead to HIV infection. Serosorting trichomoniasis, or other STIs (105). Because STI diagnoses has not been studied among heterosexually active persons. often can serve as risk markers for HIV acquisition (83), public health services might include follow-up of MSM with an STI Abstinence and Reduction of Number of to offer HIV PrEP. Public health services can also include HIV Sex Partners and STI prevention interventions including HIV and STI Abstinence from oral, vaginal, and anal sex and participating testing, linkage and relinkage of persons with HIV infection in a long-term, mutually monogamous relationship with a to HIV care clinics, and referral of partners of persons with partner known to be uninfected are prevention approaches to STIs or HIV infection to HIV PrEP, as indicated (106–109). avoid transmission of STIs. For persons who are being treated Clinicians should familiarize themselves with public health for an STI (or whose partners are undergoing treatment), practices in their area; however, in most instances, providers counseling that encourages abstinence from sexual intercourse should understand that responsibility for discussing the until completion of the entire course of medication is vital treatment of partners of persons with STIs rests with the for preventing reinfection. A trial conducted among women diagnosing provider and the patient. State laws require a good regarding the effectiveness of counseling messages when faith effort by the provider to inform partners, and providers patients have cervicitis or vaginal discharge demonstrated should familiarize themselves with public health laws. that women whose sex partners have used condoms might Clinicians who do not notify partners of patients directly benefit from a hierarchical message that includes condoms can still provide partner services by counseling infected persons but women without such experience might benefit more from and providing them with written information and medication an abstinence-only message (104). A more comprehensive to give to their partners (if recommended and allowable by discussion of abstinence and other sexual practices that can help state law), directly evaluating and treating sex partners, and persons reduce their risk for STIs is available in Contraceptive cooperating with state and local health departments. Clinicians’ Technology, 21st Edition (31). efforts to ensure treatment of patients’ sex partners can reduce the risk for reinfection and potentially diminish transmission Partner Services of STIs (110). Therefore, clinicians should encourage all persons with STIs to notify their sex partners and urge them The term “partner services” refers to a continuum of clinical to seek medical evaluation and treatment. Exceptions to this evaluation, counseling, diagnostic testing, and treatment practice include circumstances posing a risk for intimate designed to increase the number of infected persons brought to partner violence (111). Available data are limited regarding treatment and to reduce transmission among sexual networks. the rate of intimate partner violence directly attributable This continuum includes efforts of health departments, to partner notification (112,113); however, because of the medical providers, and patients themselves. The term “public reported prevalence of intimate partner violence in the general health partner services” refers to efforts by public health population (114), providers should consider the potential departments to identify the sex and needle-sharing partners risk before notifying partners of persons or encouraging of infected persons to ensure their medical evaluation and partner notification. Time spent counseling patients about the treatment. Health departments are increasingly incorporating importance of notifying partners is associated with improved referral to additional services, as indicated, into the partner services notification outcomes (115). When possible, clinicians should continuum. Aside from the general benefit to patients and partners, advise persons to bring their primary sex partner with them service referrals and linkage can mitigate the circumstances that when returning for treatment and should concurrently treat increase risk for future STI and HIV acquisition. both persons. Although this approach can be effective for a The types and comprehensiveness of public health partner main partner (116,117), it might not be a feasible approach services and the specific STIs for which they are offered vary for additional sex partners. Evidence indicates that providing by public health agency, their resources, and the geographic patients with written information to share with sex partners prevalence of STIs. In most areas of the United States, health can increase rates of partner treatment (110). departments routinely attempt to provide partner services to Certain health departments now use technology (e.g., all persons with infectious syphilis (primary or secondary) email, texting, mobile applications, and social media outlets) and persons with a new diagnosis of HIV infection. Health to facilitate partner services for locating and notifying the departments should provide partner services for persons who sex partners of persons with STIs, including HIV (118,119). might have cephalosporin-resistant gonorrhea. In contrast, Patients now have the option to use Internet sites to send relatively few U.S. health departments routinely provide anonymous email or text messages advising partners of their STI partner services to persons with gonorrhea, chlamydia, exposure to an STI (120); anonymous notification via the US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 9  Recommendations and Reports Internet is considered better than no notification at all. difference in the risk for reinfection or in the numbers of However, because the extent to which these sites affect partner partners treated between persons offered EPT and those notification and treatment is uncertain, patients should be advised to notify their sex partners (128). U.S. trials and a encouraged to notify their partners in person or by telephone, meta-analysis of EPT revealed that the magnitude of reduction email, or text message; alternatively, patients can authorize a in reinfection of index patients, compared with patient referral, medical provider or public health professional to notify their differed according to the STI and the sex of the index patient sex partners. (110,125–127). However, across trials, reductions in chlamydia prevalence at follow-up were approximately 20%, and Expedited Partner Therapy reductions in gonorrhea were approximately 50% at follow-up. Expedited partner therapy (EPT) is a harm-reduction Existing data indicate that EPT also might have a role in strategy and the clinical practice of treating the sex partners partner management for trichomoniasis; however, no partner of persons with diagnosed chlamydia or gonorrhea, who are management intervention has been reported to be more unable or unlikely to seek timely treatment, by providing effective than any other in reducing trichomoniasis reinfection medications or prescriptions to the patient as allowable by law. rates (129,130). No data support use of EPT in the routine Patients then provide partners with these therapies without management of patients with syphilis. the health care provider having examined the partner (https:// Data are limited regarding use of EPT for gonococcal www.cdc.gov/std/ept). Unless prohibited by law or other or chlamydial infections among MSM, compared with regulations, medical providers should routinely offer EPT heterosexuals (131,132). Published studies, including recent to patients with chlamydia when the provider cannot ensure data regarding extragenital testing, indicated that male partners that all of a patient’s sex partners from the previous 60 days of MSM with diagnosed gonorrhea or chlamydia might have will seek timely treatment. If the patient has not had sex other bacterial STIs (gonorrhea or syphilis) or HIV (133–135). during the 60 days before diagnosis, providers should offer Studies have reported that 5% of MSM have a new diagnosis EPT for the patient’s most recent sex partner. Because EPT of HIV when evaluated as partners of men with gonococcal must be an oral regimen and current gonorrhea treatment or chlamydial infections (133,134); however, more recent data involves an injection, EPT for gonorrhea should be offered indicate that, in certain settings, the frequency of HIV infection to partners unlikely to access timely evaluation after linkage is much lower (135). Considering limited data and potential is explored. EPT is legal in the majority of states but varies for other bacterial STIs among MSM partners, shared clinical by chlamydial or gonococcal infection. Providers should visit decision-making regarding EPT is recommended. All persons https://www.cdc.gov/std/ept to obtain updated information for who receive bacterial STI diagnoses and their sex partners, their state. Providing patients with packaged oral medication particularly MSM, should be tested for HIV, and those at risk is the preferred approach because the efficacy of EPT using for HIV infection should be offered HIV PrEP (https://www. prescriptions has not been evaluated, obstacles to EPT can exist cdc.gov/hiv/pdf/risk/prep/cdc-hiv-prep-guidelines-2017.pdf ). at the pharmacy level (121,122), and many persons (especially adolescents) do not fill the prescriptions provided to them by Reporting and Confidentiality a sex partner (123,124). Medication or prescriptions provided for EPT should be accompanied by educational materials for Accurate and timely reporting of STIs is integral to public the partner, including treatment instructions, warnings about health efforts in assessing morbidity trends, allocating limited taking medications (e.g., if the partner is pregnant or has an resources, and assisting local health authorities with partner allergy to the medication), general health counseling, and a notification and treatment. STI and HIV/AIDS cases should statement advising that partners seek medical evaluation as be reported in accordance with state and local statutory soon as possible for HIV infection and any symptoms of STIs, requirements. Syphilis (including congenital syphilis), particularly PID. gonorrhea, chlamydia, chancroid, and HIV are reportable Evidence supporting EPT is based on three U.S. clinical diseases in every state. Because the requirements for reporting trials involving heterosexual men and women with chlamydia other STIs differ by state, clinicians should be familiar with the or gonorrhea (125–127). All three trials reported that more reporting requirements applicable within their jurisdictions. partners were treated when patients were offered EPT. Two Reporting can be provider based, laboratory based, or reported statistically significant decreases in the rate of both. Clinicians who are unsure of state and local reporting reinfection, and one observed a lower risk for persistent or requirements should seek advice from state or local health recurrent infection that was statistically nonsignificant. A department STI programs. STI and HIV reports are kept fourth trial in the United Kingdom did not demonstrate a confidential. In most jurisdictions, such reports are protected 10 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention  Recommendations and Reports by statute or regulation. Before conducting a follow-up HIV through ART and obstetrical interventions. HIV testing of a person with a positive STI test result, public health should be offered as part of the routine panel of prenatal tests professionals should consult the patient’s health care provider, (i.e., opt-out testing). For women who decline HIV testing, if possible, to inform them of the purpose of the public health providers should address their concerns and, when appropriate, visit, verify the diagnosis, determine the treatments received, continue to encourage testing. Partners of pregnant patients and ascertain the best approaches to patient follow-up. should be offered HIV testing if their status is unknown (139). Retesting in the third trimester (preferably before 36 weeks’ Retesting After Treatment to Detect gestation) is recommended for women at high risk for acquiring HIV infection. Examples of women at high risk Repeat Infections include those who inject drugs, have STIs during pregnancy, Retesting 3 months after diagnosis of chlamydia, gonorrhea, have multiple sex partners during pregnancy, have a new or trichomoniasis can detect repeat infection and potentially sex partner during pregnancy, or have partners with HIV can be used to enhance population-based prevention (136,137). infection; those who are receiving care in health care facilities Any person who has a positive test for chlamydia or gonorrhea, in settings with HIV incidence ≥1 per 1,000 women per year; along with women who have a positive test for trichomonas, those who are incarcerated; those who live in areas with high should be rescreened 3 months after treatment. Any person rates of HIV infection; or those who have signs or symptoms who receives a syphilis diagnosis should undergo follow-up of acute HIV infection (e.g., fever, lymphadenopathy, skin serologic syphilis testing per current recommendations rash, myalgia, arthralgia, headache, oral ulcers, leukopenia, and follow-up testing for HIV (see Syphilis). Additional thrombocytopenia, or transaminase elevation) (140). information regarding retesting is available elsewhere in this Rapid HIV testing should be performed for any woman in labor report (see Chlamydial Infections; Gonococcal Infections; who has not been tested for HIV during pregnancy or whose HIV Syphilis; Trichomoniasis). status is unknown, unless she declines. If a rapid HIV test result is positive, ART should be administered without waiting for the results of confirmatory testing (https://clinicalinfo.hiv.gov/sites/ STI Detection Among Special default/files/inline-files/PerinatalGL.pdf). Populations Syphilis Pregnant Women During 2012–2019, congenital syphilis rates in the United States increased from 8.4 to 48.5 cases per 100,000 births, Intrauterine or perinatally transmitted STIs can have a 477.4% increase (141). At least 45 states have a prenatal debilitating effects on pregnant women, their fetuses, and their syphilis testing requirement, with high variability among those partners. All pregnant women and their sex partners should be requirements (142). In the United States, all pregnant women asked about STIs, counseled about the possibility of perinatal should be screened for syphilis at the first prenatal visit, even infections, and provided access to recommended screening and if they have been tested previously (143). Prenatal screening treatment, if needed. for syphilis has been reported to be suboptimal in the United Recommendations for screening pregnant women for States (144,145). Testing in the third trimester and at delivery STIs to detect asymptomatic infections are based on disease can prevent congenital syphilis cases (146,147). Partners of severity and sequelae, prevalence among the population, costs, pregnant women with syphilis should be evaluated, tested, medicolegal considerations (e.g., state laws), and other factors. and treated. The following screening recommendations for pregnant When access to prenatal care is not optimal, a stat rapid women summarize clinical guidelines from federal agencies plasma reagin (RPR) card test and treatment, if that test is and medical professional organizations. reactive, should be administered at the time that a pregnancy Screening Recommendations is confirmed or when the pregnancy test is performed, if follow-up is uncertain. Pregnant women should be retested HIV Infection for syphilis at 28 weeks’ gestation and at delivery if the mother All pregnant women in the United States should be tested lives in a community with high syphilis rates or is at risk for for HIV at the first prenatal visit, even if they have been syphilis acquisition during pregnancy (e.g., misuses drugs or previously tested (138). Testing pregnant women for HIV has an STI during pregnancy, having multiple sex partners, and prompt linkage to care of women with HIV infection are having a new sex partner, or having a sex partner with an STI). vital for women’s health and reducing perinatal transmission of Neonates should not be discharged from the hospital unless US Department of Health and Human Services/Centers for Disease Control and Prevention MMWR / July 23, 2021 / Vol. 70 / No. 4 11  Recommendations and Reports the syphilis serologic status of the mother has been determined diagnosed with a chlamydial infection should be rescreened at least once during pregnancy. Any woman who delivers a 3 months after treatment. stillborn infant should be tested for syphilis. Gonorrhea Hepatitis B All pregnant women aged 10 WBCs/HPF on - - Multiple factors should affect the decision to provide microscopic examination of vaginal fluid, might be a sensitive presumptive therapy for cervicitis. Presumptive treatment with = indicator of cervical inflammation with a high negative antimicrobials for C. trachomatis and N. gonorrhoeae should predictive value (i.e., cervicitis is unlikely in the absence of be provided for women at increased risk (e.g., those aged leukorrhea) (762,763). Finally, although the presence of gram- 30 years) (769). Limited data indicate that BV and frequent gonorrhea is high (see Gonococcal Infections). douching might cause cervicitis (770–772). The majority of persistent cases of cervicitis are not caused by reinfection Alternative Regimen with C. trachomatis or N. gonorrhoeae; other factors might Azithromycin 1 g orally in a single dose be involved (e.g., persistent abnormality of vaginal flora, M. genitalium, douching or exposure to other types of chemical irritants, dysplasia, or idiopathic inflammation in the zone of Other Management Considerations ectopy). Available data do not indicate an association between To minimize transmission and reinfection, women treated group B streptococcus colonization and cervicitis (773,774). for cervicitis should be instructed to abstain from sexual No specific evidence exists for a role for Ureaplasma parvum or intercourse until they and their partners have been treated Ureaplasma urealyticum in cervicitis (707,761,765,775,776). (i.e., until completion of a 7-day regimen or for 7 days after Diagnostic Considerations single-dose therapy) and symptoms have resolved. Women who receive a cervicitis diagnosis should be tested for syphilis Because cervicitis might be a sign of upper genital tract and HIV in addition to other recommended diagnostic tests. infection (e.g., endometritis), women should be assessed for signs of PID and tested for C. trachomatis and N. gonorrhoeae Follow-Up with NAAT on vaginal, cervical, or urine samples (553) (see Women receiving treatment should return to their provider Chlamydial Infections; Gonococcal Infections). Women for a follow-up visit to determine whether cervicitis has with cervicitis also should be evaluated for concomitant BV resolved. For women who are untreated, a follow-up visit gives and trichomoniasis. Because sensitivity of microscopy for providers an opportunity to communicate test results obtained detecting T. vaginalis is relatively low (approximately 50%), as part of the cervicitis evaluation. Providers should treat on symptomatic women with cervicitis and negative wet-mount the basis of any positive test results and determine whether 64 MMWR / July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human Services/Centers for Disease Control and Prevention  Recommendations and Reports cervicitis has resolved. Women with a specific diagnosis of reduces HIV shedding from the cervix and thereby might chlamydia, gonorrhea, or trichomoniasis should be offered reduce HIV transmission to susceptible sex partners (779–783). partner services and instructed to return in 3 months after Pregnancy treatment for repeat testing because of high rates of reinfection, regardless of whether their sex partners were treated (753). If Diagnosis and treatment of cervicitis for pregnant women symptoms persist or recur, women should be instructed to does not differ from that for women who are not pregnant (see return for reevaluation. Diagnostic Considerations; Treatment). Management of Sex Partners Contraceptive Management Management of sex partners of women treated for cervicitis According to U.S. Medical Eligibility Criteria for Contraceptive should be tailored for the specific infection identified or Use, 2016, leaving an IUD in place during treatment for suspected. All sex partners during the previous 60 days should cervicitis is advisable (58). However, current recommendations be referred for evaluation, testing, and presumptive treatment specify that an IUD should not be placed if active cervicitis if chlamydia, gonorrhea, or trichomoniasis was identified. EPT is diagnosed (59). and other effective partner referral strategies are alternative approaches for treating male partners of women who have chlamydial or gonococcal infection (125–127) (see Partner Chlamydial Infections Services). To avoid reinfection, sex partners should abstain from sexual intercourse until they and their partners are treated. Chlamydial Infection Among Adolescents and Adults Persistent or Recurrent Cervicitis Chlamydial infection is the most frequently reported Women with persistent or recurrent cervicitis despite bacterial infectious disease in the United States, and prevalence antimicrobial therapy should be reevaluated for possible is highest among persons aged ≤24 years (141,784). Multiple reexposure or treatment failure. If relapse or reinfection with sequelae can result from C. trachomatis infection among a specific infection has been excluded, BV is not present, and women, the most serious of which include PID, ectopic sex partners have been evaluated and treated, management pregnancy, and infertility. Certain women who receive a options for persistent cervicitis are undefined. In addition, diagnosis of uncomplicated cervical infection already have the usefulness of repeated or prolonged administration of subclinical upper genital tract infection. antimicrobial therapy for persistent symptomatic cervicitis Asymptomatic infection is common among both men and remains unknown. The etiology of persistent cervicitis, women. To detect chlamydial infection, health care providers including the potential role of M. genitalium (777), is unclear. frequently rely on screening tests. Annual screening of all M. genitalium might be considered for cases of cervicitis that sexually active women aged