With the challenges that intensive behavioral counseling poses, health care professionals might find brief prevention messages and those delivered through video or in a group session to be more accessible for the client. A review of 11 studies evaluated brief prevention messages delivered by providers and health counselors and reported them to be feasible and to decrease subsequent STIs in STD clinic settings (7) and HIV care settings (8). Other approaches use motivational interviewing to move clients toward achievable risk-reduction goals. Client-centered counseling and motivational interviewing can be used effectively by clinicians and staff trained in these approaches. CDC provides additional information on these and other effective behavioral interventions at Training in client-centered counseling and motivational interviewing is available through the STD National Network of Prevention Training Centers ( ).
Methods that combine STI and HIV prevention with pregnancy prevention are known as multipurpose prevention technologies (MPTs) (37) ( ). Internal and external condoms are both examples of MPTs because they are effective prevention measures when used correctly for STI and HIV transmission or pregnancy prevention. The multicenter Evidence for Contraception Options and HIV Outcomes (ECHO) trial observed no statistically significant differences in HIV incidence rates among women randomly assigned to one of three contraceptive methods (depot medroxyprogesterone acetate [DMPA], levonorgestrel implant, and copper-containing intrauterine device [IUD]); however, rates of HIV infection were high in all groups, indicating a need for MPTs (38). Development of MPTs is complex and ongoing; products under study include microbicides with contraceptive devices (e.g., tenofovir with a vaginal ring contraceptive delivery package) and other innovative methods (39).
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A detailed sexual history should be taken for all MSM to identify anatomic locations exposed to infection for screening. Clinics that provide services for MSM at high risk should consider implementing routine extragenital screening for N. gonorrhoeae and C. trachomatis infections, and screening is likely to be cost-effective (220).
Other enteric organisms might also cause disease among MSM through sexual activities leading to oral-anal contact, including bacteria such as Escherichia coli (264) and Campylobacter jejuni or Campylobacter coli (265,266); viruses such as HAV (267); and parasites such as Giardia lamblia or Entamoeba histolytica (268,269). Behavioral characteristics associated with the sexual transmission of enteric infections are broadly similar to those associated with other STIs (e.g., gonorrhea, syphilis, and lymphogranuloma venereum [LGV]). This includes multiple sex partners and online hookup sites that increase opportunities for sexual mixing, which might create dense sexual networks that facilitate STI transmission among MSM (270). Specific behaviors associated with sexually transmitted enteric infections among MSM involve attendance at sex parties and recreational drug use including chem sex (i.e., using crystal methamphetamine, gamma-butyrolactone, or mephedrone before or during sex), which might facilitate condomless sex, group sex, fisting, use of sex toys, and scat play (253,271). The growing number of sexually transmitted enteric infections might be attributable in part to the emergence of antimicrobial resistance. This is well reported regarding Shigella species, for which rapid intercontinental dissemination of a S. flexneri 3a lineage with high-level resistance to azithromycin through sexual transmission among MSM (272) and clusters of multidrug resistant shigella cases among MSM have recently been reported (273). Multidrug-resistant Campylobacter species have also been documented (266,274). For MSM patients with diarrhea, clinicians should request laboratory examinations, including stool culture; provide counseling about the risk for infection with enteric pathogens during sexual activity (oral-anal, oral-genital, anal-genital, and digital-anal contact) that could expose them to enteric pathogens; and choose treatment, when needed, according to antimicrobial drug susceptibility.
Partner notification is a key component in the evaluation of persons with HIV infection. Early diagnosis and treatment of HIV among all potentially exposed sexual and injecting drug sharing partners can improve their health and reduce new infections. For those partners without HIV infection, partner services also provide an opportunity for offering HIV prevention services, including PrEP or PEP (if exposure was
Health care providers should inform persons with diagnosed HIV infection about any legal obligations of providers to report cases of HIV to public health; the local confidential processes for managing partner services, including that a public health department still might be in contact to follow up in their care and partner services; and the benefits and risks of partner notification and services. Health care providers should also encourage persons with a new HIV diagnosis to notify their partners and provide them with referral information for their partners about HIV testing. Partner notification for exposure to HIV should be confidential. Health care providers can assist in the partner notification process, either directly or by referral to health department partner notification programs. Health department staff are trained to use public health investigation strategies for confidentially locating persons who can benefit from HIV treatment, care, or prevention services. Guidance regarding spousal notification varies by jurisdiction. Detailed recommendations for notification, evaluation, and treatment of exposed partners are available in Recommendations for Partner Services Programs for HIV Infection, Syphilis, Gonorrhea, and Chlamydial Infections (111).
Randomized clinical trials have demonstrated that PrEP with daily oral TDF/FTC decreases the risk for HSV-2 acquisition by 30% in heterosexual partnerships (492). Pericoital intravaginal tenofovir 1% gel also decreases the risk for HSV-2 acquisition among heterosexual women (493). Among MSM and transgender women, daily oral TDF/FTC decreases the risk for severe ulcers with symptomatic genital HSV-2 infection but not for HSV-2 acquisition (494). Insufficient evidence exists that TDF/FTC use among those who are not at risk for HIV acquisition will prevent HSV-2 infection, and it should not be used for that sole purpose. Oral TDF does not prevent HSV-2 acquisition among persons with HIV infection who are taking TDF as part of their ART regimen (495). No data indicate that antivirals (acyclovir, valacyclovir, or famciclovir) can be taken as PrEP by persons without HSV-2 to prevent its acquisition.
Newborn infants exposed to HSV during birth, as documented by virologic testing of maternal lesions at delivery or presumed by observation of maternal lesions, should be followed clinically in consultation with a pediatric infectious disease specialist. Detailed guidance is available regarding management of neonates who are delivered vaginally in the presence of maternal genital herpes lesions and is beyond the scope of these guidelines; more information is available from the AAP ( ). Surveillance cultures or PCR of mucosal surfaces of the neonate to detect HSV infection might be considered before the development of clinical signs of neonatal herpes to guide treatment initiation. In addition, administration of acyclovir might be considered for neonates born to women who acquired HSV near term because the risk for neonatal herpes is high for these newborn infants. All newborn infants who have neonatal herpes should be promptly evaluated and treated with systemic acyclovir. The recommended regimen for infants treated for known or suspected neonatal herpes is acyclovir 20 mg/kg body weight IV every 8 hours for 14 days if disease is limited to the skin and mucous membranes, or for 21 days for disseminated disease and disease involving the CNS.
Sexual transmission of T. pallidum is thought to occur only when mucocutaneous syphilitic lesions are present. Such manifestations are uncommon after the first year of infection. Persons exposed through sexual contact with a person who has primary, secondary, or early latent syphilis should be evaluated clinically and serologically and treated according to the following recommendations:
The initial step in recurrent urethritis is assessing compliance with treatment or potential reexposure to an untreated sex partner (697,743). If the patient did not comply with the treatment regimen or was reexposed to an untreated partner, retreatment with the initial regimen can be considered. If therapy was appropriately completed and no reexposure occurred, therapy is dependent on the initial treatment regimen. Ideally, diagnostic testing among men with recurrent or persistent symptoms, including those with gonorrhea, chlamydia, M. genitalium, and trichomoniasis, can be used to guide further management decisions.
Neonatal ocular prophylaxis with erythromycin, the only agent available in the United States for this purpose, is ineffective against chlamydial ophthalmia neonatorum (or pneumonia) (833). As an alternative, prevention efforts should focus on prenatal screening for C. trachomatis, including
Neonates born to mothers who have untreated gonorrhea are at high risk for infection. Neonates should be tested for gonorrhea at exposed sites (e.g., conjunctiva, vagina, rectum, and oropharynx) and treated presumptively for gonorrhea.
Oral therapy has not been reported to be superior to topical therapy for treating symptomatic BV in effecting cure or preventing adverse outcomes of pregnancy. Pregnant women can be treated with any of the recommended regimens for nonpregnant women, in addition to the alternative regimens of oral clindamycin and clindamycin ovules. 2ff7e9595c
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