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These guidelines for the treatment of persons who have or are at risk for sexually transmitted diseases (STDs) were updated by CDC after consultation with a group of professionals knowledgeable in the field of STDs who met in Atlanta on April 30–May 2, 2013.
The term sexually transmitted diseases (STDs) refers to a variety of clinical syndromes and infections caused by pathogens that can be acquired and transmitted through sexual activity. These guidelines were developed by CDC staff and an independent workgroup for which members were selected on the basis of their expertise in the clinical management of STDs. In 2012, CDC staff and workgroup members were charged with identifying key questions regarding treatment and clinical management that were not addressed in the 2010 STD Treatment Guidelines (1). In April 2013, the workgroup's research was presented at an in-person meeting of the multidisciplinary workgroup members. Throughout this report, the evidence used as the basis for specific recommendations is discussed briefly. After obtaining a sexual history from their patients, all providers should encourage risk reduction by providing prevention counseling. USPSTF recommends high-intensity behavioral counseling for all sexually active adolescents and for adults at increased risk for STDs and HIV (6,7). Because the incidence of some STDs, notably syphilis, is higher in persons with HIV infection, the use of client-centered STD counseling for persons with HIV infection continues to be strongly encouraged by public health agencies and other health organizations.
Pre-exposure vaccination is one of the most effective methods for preventing transmission of human papillomavirus (HPV), HAV, and HBV. Hepatitis B vaccination is recommended for all unvaccinated, uninfected persons being evaluated or treated for an STD (3,4). The most reliable way to avoid transmission of STDs is to abstain from oral, vaginal, and anal sex or to be in a long-term, mutually monogamous relationship with a partner known to be uninfected.
When used consistently and correctly, male latex condoms are highly effective in preventing the sexual transmission of HIV infection. Condoms are regulated as medical devices and are subject to random sampling and testing by the U.S.
Providers should advise that condoms must be used consistently and correctly to be effective in preventing STDs and HIV infection; providing instructions about the correct use of condoms can be useful. Carefully handle the condom to avoid damaging it with fingernails, teeth, or other sharp objects. Put the condom on after the penis is erect and before any genital, oral, or anal contact with the partner. Ensure adequate lubrication during vaginal and anal sex, which might require the use of exogenous water-based lubricants.
To prevent the condom from slipping off, hold the condom firmly against the base of the penis during withdrawal, and withdraw while the penis is still erect.
Several condoms for females are globally available, including the FC2 Female Condom, Reddy condom, Cupid female condom, and Woman's condom (36).
In observational studies, diaphragm use has been demonstrated to protect against cervical gonorrhea, chlamydia, and trichomoniasis (38). Contraceptive methods that are not mechanical barriers offer no protection against HIV or other STDs. Whether hormonal contraception raises a woman's risk for acquiring HIV or another STD is unclear. No definitive data exist to determine whether male circumcision reduces HIV acquisition in MSM, although one randomized trial is ongoing in China (62). Guidelines for the use of postexposure prophylaxis (PEP) aimed at preventing HIV infection and other STDs as a result of sexual exposure are discussed in another section of this report (see Sexual Assault and STDs). The randomized controlled trial HPTN 052 demonstrated that in HIV serodiscordant, heterosexual couples, HIV antiretroviral therapy in the infected partner decreases the risk for transmission to the uninfected partner by 96% (69). Providing HSV treatment to persons co-infected with HIV and HSV has not been demonstrated to be beneficial in reducing HIV acquisition in uninfected partners. Certain large, randomized, placebo-controlled trials examining daily oral antiretroviral preexposure prophylaxis (PrEP) with a fixed-dose combination of tenofovir disoproxil fumarate (TDF) and emtricitabine (FTC) have demonstrated safety (73) and a substantial reduction in the rate of HIV acquisition for MSM (74), HIV-discordant heterosexual couples (75), and heterosexual men and women recruited as individuals (76). Seroadaptive strategies for HIV prevention have largely originated within communities of MSM. Serosorting is not recommended for the following reasons: 1) too many MSM who have HIV do not know they are infected because they have not been tested for HIV recently, 2) men's assumptions about the HIV status of their partners might be wrong, and 3) some men with HIV infection might not disclose or may misrepresent their HIV status. Retesting several months after diagnosis of chlamydia, gonorrhea, or trichomoniasis can detect repeat infection and potentially can be used to enhance population-based prevention (85,86).
The term "partner services" refers to a continuum of clinical evaluation, counseling, diagnostic testing, and treatment designed to increase the number of infected persons brought to treatment and to disrupt transmission networks. Clinicians can provide partner services by counseling infected persons and providing them with written information and medication to give to their partners (if recommended and allowable by state law), directly evaluating and treating sex partners, and cooperating with state and local health departments. The types and comprehensiveness of public health partner services and the specific STDs for which they are offered vary by public health agency and the geographic burden of STDs. Expedited Partner Therapy (EPT), also termed patient-delivered partner therapy (PDPT), is the clinical practice of treating the sex partners of persons who receive chlamydia or gonorrhea diagnoses by providing medications or prescriptions to the patient. The accurate and timely reporting of STDs is integral to public health efforts to assess morbidity trends, allocate limited resources, and assist local health authorities in partner notification and treatment.
Intrauterine or perinatally transmitted STDs can have severely debilitating effects on pregnant women, their partners, and their fetuses. All pregnant women in the United States should be screened for HIV infection at the first prenatal visit, even if they have been previously tested (103,104). A serologic test for syphilis should be performed for all pregnant women at the first prenatal visit (106). All pregnant women should be routinely tested for hepatitis B surface antigen (HBsAg) at the first prenatal visit even if they have been previously vaccinated or tested (107).
All pregnant women at risk for HCV infection should be screened for hepatitis C antibodies at the first prenatal visit. Pregnant women should undergo a Papanicolau (Pap) test at the same frequency as nonpregnant women, although recommendations for management of abnormal Pap tests in pregnancy differ (110).
Evidence does not support routine screening for BV in asymptomatic pregnant women at high risk for preterm delivery (111). Evidence does not support routine screening for Trichomonas vaginalis in asymptomatic pregnant women.
Evidence does not support routine HSV-2 serologic screening among asymptomatic pregnant women. In the United States, prevalence rates of many sexually acquired infections are highest among adolescents and young adults (117,118).
Persons who initiate sex early in adolescence are at higher risk for STDs, along with adolescents residing in detention facilities, those who use injection drugs, adolescents attending STD clinics, and young men who have sex with men (YMSM). All 50 states and the District of Columbia explicitly allow minors to consent for their own health services for STDs.
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, screen for asymptomatic infections during clinical encounters. Guidelines from USPSTF, ACOG, and ACS recommend that cervical cancer screening begin at age 21 years (124–126). 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 for adolescents and young adults. The HBV vaccination series is recommended for all adolescents and young adults who have not previously received the hepatitis B vaccine (3,4).
The HAV vaccination series should be offered to adolescents and young adults who have not previously received the HAV vaccine series. 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 and young adults as part of health care (122). Health-care providers who care for adolescents and young adults should integrate sexuality education into clinical practice.
Management of children who have STDs requires close cooperation between clinicians, laboratorians, and child-protection authorities.
Although no comprehensive national guidelines regarding STD care and management have been developed for correctional populations, growing evidence demonstrates the utility of expanded STD screening and treatment services in correctional settings. Both men and women ?35 years of age in juvenile and adult detention facilities have been reported to have higher rates of chlamydia (131) and gonorrhea (118) than their nonincarcerated counterparts in the community, and across many studies, rates have been consistently higher among women than men. In short-term facilities, including jails and juvenile detention facilities that commonly house entrants for <1 year, up to half of entrants are released back in the community within 48 hours.
Universal screening for chlamydia and gonorrhea in women ?35 years entering juvenile and adult correctional facilities has been a long-standing recommendation. Whereas several studies have shown a high prevalence of trichomonas among incarcerated persons, none have demonstrated the impact of trichomonas screening in correctional facilities (135–137). Women ?35 and men <30 years in correctional facilities should be screened for chlamydia and gonorrhea. Universal screening should be conducted on the basis of the local area and institutional prevalence of early (primary, secondary, and early latent) infectious syphilis. The term "men who have sex with men" (MSM) describes a heterogeneous group of men who have varied behaviors, identities, and health-care needs (138). Approximately two thirds of the cases of primary and secondary syphilis diagnoses in the United States are in MSM, particularly those in ethnic minority groups (118,139,140).
Gonococcal infection in MSM has been associated with similar risk factors, including having multiple anonymous partners and abuse of substances, particularly crystal methamphetamine (149). MSM remain at disproportionate risk for HIV acquisition and transmission in the United States, particularly those who are black or Hispanic.
Substantial numbers of MSM remain unaware of their serostatus (up to 44% in one recent survey of young men in minority populations) (160). Clinicians should be familiar with local resources available to assist MSM with syphilis and HIV partner services as well as HIV linkage and retention in care.
The following screening tests should be performed at least annually for sexually active MSM, including those with HIV infection.
HIV serology, if HIV status is unknown or negative and the patient himself or his sex partner(s) has had more than one sex partner since most recent HIV test.
Syphilis serology to establish whether persons with reactive tests have untreated syphilis, have partially treated syphilis, are manifesting a slow serologic response to appropriate prior therapy, or are serofast. Data are insufficient to recommend routine anal-cancer screening with anal cytology in persons with HIV infection or HIV-negative MSM. Sexual transmission of HCV can occur, especially among MSM with HIV infection (see Emerging Issues, Hepatitis C). Women who have sex with women (WSW) are a diverse group with variations in sexual identity, sexual behaviors, sexual practices, and risk behaviors. HPV, which can be transmitted through skin-to-skin contact, is common among WSW, and sexual transmission of HPV likely occurs between female sex partners (197–199). A fetus that is infected during the pregnancy (congenital infection), will not show any symptoms at birth most of the time. Expression of concern regarding paper by Park et al, published on 25 June 2015: “Epidemiological investigation of MERS-CoV spread in a single hospital in South Korea, May to June 2015”, Euro Surveill. It has been brought to our attention that some of the authors may not have been informed about the content of the above paper.
Citation style for this article: Nicolay N, Gallay A, Michel A, Nicolau J, Desenclos JC, Semaille C. In France, the resurgence of syphilis infection since the beginning of the 2000s, with cases reported among women of reproductive age is a reason for concern considering the possible occurrence of congenital syphilis (CS). IntroductionBecause of the availability of cost-effective treatment and better prevention of sexually transmitted infections (STI) following the emergence of HIV in the 1980s, syphilis infection had almost disappeared in western European countries by the end of the 90s  [1-5]. Data collectionFor each diagnosis of CS identified in the PMSI database, we contacted the hospital where the patient had stayed and asked the head of the medical informatics department to collect the following information from the patient’s medical records: sex, age, date of stay, clinical symptoms, serology of syphilis and place of birth of the infant and term of the pregnancy, screening of the mother for syphilis during pregnancy, date of screening, antenatal care and treatment received for syphilis during pregnancy, and mother’s place of birth. Among the remaining six infants classified as probable cases of CS, two were adopted babies born in North Africa.
Disclaimer: The opinions expressed by authors contributing to Eurosurveillance do not necessarily reflect the opinions of the European Centre for Disease Prevention and Control (ECDC) or the editorial team or the institutions with which the authors are affiliated. The information in this report updates the Sexually Transmitted Diseases Treatment Guidelines, 2010 (MMWR Recomm Rep 2010;59 [No. Physicians and other health-care providers play a critical role in preventing and treating STDs.
These recommendations should be regarded as a source of clinical guidance rather than prescriptive standards; health-care providers should always consider the clinical circumstances of each person in the context of local disease prevalence. Each key question was discussed, and pertinent publications were reviewed in terms of strengths, weaknesses, and relevance. To ensure development of evidence-based recommendations, a second independent panel of public health and clinical experts reviewed the draft recommendations.
More comprehensive, annotated discussions of such evidence will appear in background papers that will be available in a supplement issue of the journal Clinical Infectious Diseases after publication of these treatment guidelines. As part of the clinical encounter, health-care providers should routinely obtain sexual histories from their patients and address risk reduction as indicated in this report.
Prevention counseling is most effective if provided in a nonjudgmental and empathetic manner appropriate to the patient's culture, language, gender, sexual orientation, age, and developmental level. Such interactive counseling, which can be resource intensive, is directed at a person's risk, the situations in which risk occurs, and the use of personalized goal-setting strategies. Group-based strategies have been effective in reducing the occurrence of STDs among persons at risk, including those attending STD clinics (11).
A recent federal guideline recommends that clinical and nonclinical providers assess an individual's behavioral and biologic risks for acquiring or transmitting STD and HIV, including having sex without condoms, recent STDs, and partners recently treated for STDs.
In addition, hepatitis A and B vaccines are recommended for MSM, injection-drug users (IDUs), persons with chronic liver disease (CLD), and persons with HIV infection who have not yet been infected with one or both types of hepatitis virus (3,4,17). For persons who are being treated for an STD other than HIV (or whose partners are undergoing treatment), counseling that encourages abstinence from sexual intercourse until completion of the entire course of medication is crucial.
These can be substituted for latex condoms by persons with latex allergy, are generally more resistant to deterioration, and are compatible with use of both oil-based and water-based lubricants. Use of female condoms can provide protection from acquisition and transmission of STDs, although data are limited (36). However, a trial examining the effect of a diaphragm plus lubricant on HIV acquisition among women in Africa showed no additional protective effect when compared with the use of male condoms alone.
Spermicides containing N-9 might disrupt genital or rectal epithelium and have been associated with an increased risk for HIV infection. A systematic review of epidemiologic evidence found that most studies showed no association between use of oral contraceptives and HIV acquisition among women. These organizations also recommend that countries with hyperendemic and generalized HIV epidemics and low prevalence of male circumcision expand access to safe male circumcision services within the context of ensuring universal access to comprehensive HIV prevention, treatment, care, and support.
A review found a modest protective effect among men who were the insertive partner for anal intercourse, but the evidence was rated as poor.
Providers managing such women should offer counseling about the option of emergency contraception (EC) if pregnancy is not desired.
Therefore, antiretroviral therapy not only is beneficial to the health of persons with HIV infection, but also reduces the risk for continued transmission.
A large randomized, controlled trial evaluated 3,408 serodiscordant heterosexual couples enrolled at 14 Africa sites in which the partner with HIV infection was also seropositive for HSV-2. In addition, one clinical trial involving IDUs (77) and one involving heterosexual HIV-discordant couples (75) demonstrated substantial efficacy and safety of daily oral PrEP with TDF alone when combined with repeated condom provision, sexual risk-reduction counseling, and the diagnosis and treatment of STDs. Any person who tests positive for chlamydia or gonorrhea, along with women who test positive for trichomonas, should be rescreened 3 months after treatment. This continuum includes efforts undertaken by health departments, medical providers, and patients themselves. Clinicians' efforts to ensure the treatment of a patient's sex partners can reduce the risk for reinfection and potentially diminish transmission of STDs (87). In most areas of the United States, health departments routinely attempt to provide partner services to all persons with early syphilis (primary, secondary, and early latent syphilis) and persons with a new diagnosis of HIV infection. Clinicians who are unsure of state and local reporting requirements should seek advice from state or local health department STD programs. All pregnant women and their sex partners should be asked about STDs, counseled about the possibility of perinatal infections, and provided access to screening and treatment, if needed.
When access to prenatal care 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 aged <25 years and those at increased risk for chlamydia also should be retested during the third trimester to prevent maternal postnatal complications and chlamydial infection in the neonate. The most important risk factor for HCV infection is past or current injection drug use (109).
However, type-specific serologic tests might be useful for identifying pregnant women at risk for HSV infection and guiding counseling regarding the risk for acquiring genital herpes during pregnancy. For example, the reported rates of chlamydia and gonorrhea are highest among females during their adolescent and young adult years, and many persons acquire HPV infection at this time. 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 facing multiple obstacles to accessing health care (118).
The following screening recommendations summarize published federal agency and medical professional organizations' clinical guidelines for sexually active adolescents. Frequency of repeat screenings of those who are at risk for HIV infection should be based on level of risk (122,123). This recommendation is based on the low incidence of cervical cancer and limited utility of screening for cervical cancer in adolescents (127). Vaccination is also recommended for females aged 13–26 years who have not yet received all doses or completed the vaccine series. Incarcerated persons are more likely to have low socioeconomic status, live in urban areas, and be ethnic and racial minorities. For example, in jurisdictions with comprehensive, targeted jail screening, more chlamydial infections among females (and males if screened) are detected and subsequently treated in the correctional setting than any other single reporting source (118,129) and might represent the majority of reported cases in certain jurisdictions (130). Syphilis seroprevalence rates, which can indicate previous or current infection, are considerably higher among adult men and women than in adolescents, consistent with the overall national syphilis trends (132).


As a result, treatment completion rates for those screened for STDs and who receive STD diagnoses in short-term facilities might not be optimal. However, no such recommendation existed for men until 2006, when CDC convened a consultation on male chlamydia screening (121) that resulted in recommendations to screen men <30 years for chlamydia at intake into jails.
Correctional facilities should stay apprised of syphilis prevalence as it changes over time.
Some MSM are at high risk for HIV infection and other viral and bacterial STDs because MSM may practice anal sex, and the rectal mucosa is uniquely susceptible to certain STD pathogens.
Factors that increase the risk for HIV infection in MSM include either receptive or insertive anal sex without a condom, having another STD, having sex with anonymous partners without a condom, and using methamphetamines or drugs that enhance sexual performance (159). Unfortunately, many men are not asked about STD-related risks, including the gender of sex partners. More evidence is needed concerning the natural history of anal intraepithelial neoplasia, the best screening methods and target populations, safety of and response to treatments, and other programmatic considerations before screening can be routinely recommended. Prompt identification of chronic infection with HBV is essential to ensure necessary care and services to prevent transmission to others (169).
Serologic screening for HCV is recommended at initial evaluation of persons with newly diagnosed HIV infection. Recent studies indicate that some WSW, particularly adolescents and young women as well as women with both male and female partners, might be at increased risk for STDs and HIV based on reported risk behaviors (179–183). Practices involving digital-vaginal or digital-anal contact, particularly with shared penetrative sex items, present a possible means for transmission of infected cervicovaginal or anal secretions. The test measure the amount of immunoglobulin G the signifies whether a person is infected with T. Those with a compromised immune system are treated with a combination of prescribed drugs such as pyrimethamine(Daraprim) and sulfadiazine, together with folinic acid.
Jones, Deanna Kruszon-Moran, Marianna Wilson, Geraldine McQuillan, Thomas Navin, and James B. Using the French national private and public hospital database, we investigated the number of children with a diagnosis of CS born in France in 2004. However, since 2000, France as well as other western European countries has been facing an increasing number of syphilis cases especially among men who have sex with men (MSM), although heterosexual transmissions affecting an increasing number of women are reported too [6,7].
This database includes information on all the diagnoses made for all the patients admitted to French hospitals.
The remaining four cases were born in France, two of them prematurely, including one with foetal hepatomegaly (Table 2).
Probable cases of congenital syphilis (CS) less than one year of age born in France identified in the PMSI database in 2004, FranceDiscussionThis original study is the first documentation of CS occurrence in France. Neither ECDC nor any person acting on behalf of ECDC is responsible for the use that might be made of the information in this journal. These guidelines are applicable to any patient-care setting that serves persons at risk for STDs, including family-planning clinics, HIV-care clinics, correctional health-care settings, private physicians' offices, Federally Qualified Health Centers (FQHCs), and other primary-care facilities.
All workgroup members disclosed potential conflicts of interest; several members of the workgroup acknowledged receiving financial support for clinical research from commercial companies. The recommendations for STD screening during pregnancy, cervical cancer screening, and HPV vaccination were developed after CDC staff reviewed the published recommendations from other professional organizations, including the American College of Obstetricians and Gynecologists (ACOG), USPSTF, American Cancer Society (ACS), American Society for Colposcopy and Cervical Pathology (ASCCP), and the Advisory Committee on Immunization Practices (ACIP) as part of the initial review process. When more than one therapeutic regimen is recommended, the recommendations are listed alphabetically unless prioritized based on efficacy, tolerance, or costs. Persons seeking treatment or evaluation for a particular STD should be screened for HIV and other STDs as indicated by community prevalence and individual risk factors (see prevention section and sections on chlamydia, gonorrhea, and syphilis). This guideline also recommends that clinical and nonclinical providers offer or make referral for 1) regular screening for several STDs, 2) onsite STD treatment when indicated, and 3) risk-reduction interventions tailored to the individual's risks (12). A recent trial conducted among women on the effectiveness of counseling messages demonstrated that women whose sexual partners have used condoms may benefit from a hierarchical message that includes condoms, whereas women without such experience might benefit more from an abstinence-only message (18). Moreover, studies demonstrate that consistent condom use reduces the risk for other STDs, including chlamydia, gonorrhea, and trichomoniasis (22–24). Each latex condom manufactured in the United States is tested electronically for holes before packaging. The effectiveness of other synthetic male condoms to prevent sexually transmitted infections has not been extensively studied, and FDA-labeling restricts their recommended use to latex-sensitive or allergic persons. Likewise, no difference by study arm in the rate of acquisition of chlamydia, gonorrhea, or herpes occurred (39,40). Condoms with N-9 are no more effective than condoms without N-9; therefore, N-9 alone or in a condom is not recommended for STD or HIV prevention (41). Women who take oral contraceptives and are prescribed certain antimicrobials should be counseled about potential interactions (19). Studies examining the association between progestin-only injectables and HIV acquisition have had mixed results; some studies show a higher risk of acquisition among women using depo-medroxyprogesterone acetate (DMPA), while other studies do not (48).
In these trials, circumcision was also protective against other STDs, including high-risk genital HPV infection and genital herpes (54–56). In the United States, the American Academy of Pediatrics (AAP) recommends that newborn male circumcision be available to families that desire it, as the benefits of the procedure, including prevention of penile cancers, urinary tract infections, genital ulcer disease, and HIV outweigh the risks (60). Further higher quality studies are needed to confirm any potential benefit of male circumcision for this population (62). The options for EC in the United States include the copper IUD and emergency contraceptive pills (ECPs) (63). The co-infected partner was randomized to receive either placebo or acyclovir 400-mg twice per day, and the primary outcome was HIV transmission to the uninfected partner. High adherence to oral PrEP with TDF alone or in a fixed-dose combination with FTC was strongly associated with protection from infection. USPHS recommends that clinicians evaluate HIV-negative men and women who are sexually active or injecting illicit drugs and consider PrEP as a prevention option for persons whose sexual or injection behaviors and epidemiologic context place them at substantial risk for acquiring HIV infection. One specific seroadaptive practice is serosorting, which includes limiting anal sex without a condom to partners with the same HIV status as their own, or choosing to selectively use condoms only with HIV serodiscordant partners.
Any person who receives a syphilis diagnosis should undergo follow-up serologic syphilis testing per current recommendations (see Syphilis). The term "public health partner services" refers to efforts by public health departments to identify the sex- and needle-sharing partners of infected persons to assure their medical evaluation and treatment.
Therefore, clinicians should encourage all persons with STDs to notify their sex partners and urge them to seek medical evaluation and treatment. It is also recommended that health departments provide partner services for persons who might have cephalosporin-resistant gonorrhea. Internet sites allowing patients to send anonymous e-mail or text messages advising partners of their exposure to an STD are operational in some areas; anonymous notification via the internet is considered better than no notification at all and might be an option in some instances. Unless prohibited by law or other regulations, medical providers should routinely offer EPT to heterosexual patients with chlamydia or gonorrhea infection when the provider cannot confidently ensure that all of a patient's sex partners from the prior 60 days will be treated. All three trials reported that more partners were treated when patients were offered PDPT: two reported statistically significant declines in the rate of reinfection and one observed a lower risk of persistent or recurrent infection that was statistically nonsignificant. Syphilis (including congenital syphilis), gonorrhea, chlamydia, chancroid, HIV infection, and AIDS are reportable diseases in every state.
For women who decline HIV testing, providers should address their objections, and when appropriate, continue to encourage testing. Women who are at high risk for syphilis or live in areas of high syphilis morbidity should be screened again early in the third trimester (at approximately 28 weeks' gestation) and at delivery. Pregnant women found to have chlamydial infection should have a test-of-cure to document chlamydial eradication (preferably by nucleic acid amplification testing [NAAT]) 3–4 weeks after treatment and then retested within 3 months.
Additional risk factors for gonorrhea include inconsistent condom use among persons not in mutually monogamous relationships, previous or coexisting sexually transmitted infection, and exchanging sex for money or drugs. Additional risk factors include having had a blood transfusion before July 1992, receipt of an unregulated tattoo, having been on long-term hemodialysis, intranasal drug use, and other percutaneous exposures. In the absence of lesions during the third trimester, routine serial cultures for HSV are not indicated for women in the third trimester who have a history of recurrent genital herpes.
No state requires that providers notify parents that an adolescent minor has received STD services, except in limited or unusual circumstances.
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. Persons who test positive for HIV should receive prevention counseling and referral to care before leaving the testing site.
The quadrivalent or 9-valent HPV vaccine is recommended routinely for males aged 11 and 12 years and also can be administered beginning at 9 years of age (16).
Detection and treatment of early syphilis in correctional facilities might impact rates of transmission (133). However, because of the mobility of incarcerated populations in and out of the community, the impact of screening in correctional facilities on the prevalence of infections among detainees and subsequent transmission in the community after release might be considerable (134). In addition, multiple sex partners, substance use, and sexual network dynamics of MSM increase risk for HIV and STDs in this population. Acute HIV infection has been associated with a recent or concurrent STD, including syphilis, among men at a municipal STD clinic (142) and in the multisite iPrex study (143), and several studies have demonstrated that early syphilis is associated with HIV infection among MSM (144,145). Even if gender of sex partners is ascertained, many MSM, including those with HIV infection, are neither asked about risky sexual behaviors nor provided with routine STD testing (especially at anatomic sites of exposure for gonorrhea or chlamydia), often because of the discomfort associated with these discussions (161–163). Because of accumulating evidence of acute HCV infection acquisition among persons with HIV infection (especially MSM with HIV infection [170–175]) and because regular screening for HCV infection is cost effective (176,177), MSM with HIV infection should be regularly screened for HCV.
This possibility is most directly supported by reports of shared trichomonas infections (190,191) and by concordant drug resistance genotype testing and phylogenetic linkage analysis identifying HIV transmitted sexually between women (192,193).
One consists of a sexual cycle that happens only in cats, the definitive host, and the other is a asexual cycle that occurs in warm-blooded animals called the intermediate hosts. This is due to the fact that most of the peoples immune system refrains the parasite from causing a disease. Some cases of infected newly-borns, show apparent symptoms of damage to the brain and eyes. Another form of treatment can be through administering medication such as antimalarial drugs and antibiotics.
Medical doctors register all hospital stays with a principal and associated diagnosis coded according to the 10th edition of the International Classification of Diseases (ICD-10) [10]. In 113 of these CS appeared among the diagnoses coded, but only 19 hospital stays had the principal or associated diagnosis of CS. The mothers of these four cases were screened positive for syphilis during their third trimester of pregnancy two of them at the premature delivery.
We identified six probable early CS cases less than one year of age according to the CDC definition. Although these guidelines emphasize treatment, prevention strategies and diagnostic recommendations also are discussed. The discussion culminated in a proposal of recommendations to be adopted for consideration by CDC. The sections on hepatitis B virus (HBV) and hepatitis A virus (HAV) infections are based on previously published recommendations (2–4). For infections with more than one recommended regimen, listed regimens have similar efficacy and similar rates of intolerance or toxicity unless otherwise specified.
Effective interviewing and counseling skills characterized by respect, compassion, and a nonjudgmental attitude toward all patients are essential to obtaining a thorough sexual history and delivering effective prevention messages. Brief risk-reduction counseling delivered by medical providers during HIV primary-care visits coupled with routine STD screening has been shown to reduce STD incidence in persons with HIV infection (10). A more comprehensive discussion of abstinence and other sexual practices than can help persons reduce their risk for STDs is available in Contraceptive Technology, 20th Edition (19). By limiting lower genital tract infections, condoms also might reduce the risk of developing pelvic inflammatory disease (PID) in women (25).
Rate of condom breakage during sexual intercourse and withdrawal is approximately two broken condoms per 100 condoms used in the United States. Natural membrane condoms (frequently called "natural skin" condoms or [incorrectly] "lambskin" condoms) are made from lamb cecum and can have pores up to 1,500 nm in diameter. Although the female condom also has been used during receptive anal intercourse, efficacy associated with this practice remains unknown (37).
Diaphragms should not be relied on as the sole source of protection against HIV or other STDs. N-9 use has also been associated with an increased risk for bacterial urinary tract infections in women (46,47).
The World Health Organization (WHO) and CDC reviewed the evidence on hormonal contraception and HIV acquisition and concluded that data are insufficient to recommend that women modify their hormonal contraceptive practices, but that women using progestin-only injectables should be strongly advised to also use condoms as an HIV prevention strategy (49,50). Follow up studies have demonstrated sustained benefit of circumcision for HIV prevention (57) and that the effect is not mediated solely through a reduction in herpes simplex virus type 2 (HSV-2) infection or genital ulcer disease (58).
Data suggest that when administered orally, levels of TDF are lower in vaginal tissue than rectal tissue, potentially explaining why high levels of adherence were needed to yield benefits among women in these trials (78). Another practice among serodiscordant couples is seropositioning, in which the person with HIV infection is the receptive partner for anal intercourse. Further details on retesting can be found in the specific sections on chlamydia, gonorrhea, syphilis, and trichomonas within this report. Timespent counseling patients on the importance of notifying partners is associated with improved notification outcomes (88).
However, because the extent to which these sites affect partner notification and treatment is uncertain, patients should be encouraged either to notify their partners in person or by telephone, personal e-mail, or text message; alternatively, patients can authorize a medical provider or public health professional to do so. If the patient has not had sex in the 60 days before diagnosis, providers should attempt to treat a patient's most recent sex partner.
A fourth trial in the United Kingdom did not demonstrate a difference in the risk of reinfection or in the numbers of partners treated between persons offered PDPT and those advised to notify their sex partners (96). Existing data suggest that PDPT also might have a role in partner management for trichomoniasis; however, no single partner management intervention has been shown to be more effective than any other in reducing trichomoniasis reinfection rates (97,98). Because the requirements for reporting other STDs differ by state, clinicians should be familiar with the reporting requirements applicable within their jurisdictions. Women who decline testing because they have had a previous negative HIV test should be informed of the importance of retesting during each pregnancy. To avoid misinterpreting a transient positive HBsAg result during the 21 days after vaccination, HBsAg testing should be performed before vaccine administration.
Screening during the first trimester might prevent the adverse effects of chlamydia during pregnancy, but evidence for such screening is lacking.
Clinicians should consider the communities they serve and might choose to consult local public health authorities for guidance on identifying groups that are at increased risk. 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. Electronic media is also an important tool for disseminating and collecting information to and from MSM. Vaccination against hepatitis A and B is recommended for all MSM in whom previous infection or vaccination cannot be documented (2,3).
Use of barrier protection with female partners (gloves during digital-genital sex, condoms with sex toys, and latex or plastic barriers [also known as dental dams for oral-genital sex]) was infrequent in all studies. People with infection experience symptoms similar to a flu and lymph glands that are swollen. The possibility of miscarriage and the birth of a still born can also result through congenital infection. Other tests consist of obtaining tissue from the cerebral spinal fluid (CSF), but this procedure is rarely done due to the difficulty of obtaining this kind of specimen. Patients with a compromised immune system have to undergo lifelong treatment to keep the parasite from becoming reactivated. Two of these cases were adopted children from outside Europe, whereas the other four were born in France. The surveillance of syphilis is based on voluntary notifications by clinicians working in STI health centres, and the burden of the disease in the general population is by consequence underestimated. All data contained in the database are anonymous and protected by professional confidentiality. These 19 stays corresponded to 16 infants, as four stays were linked to the same patient (Figure). They had not received proper treatment for syphilis infection: two were not treated at all, one received only two doses of extencillin (benzathine benzyl penicillin), and the last one received three doses but starting less than 30 days before delivery. None of them were confirmed CS that would have required laboratory confirmation with evidence of Treponema pallidum [11]. Mother-to-child (congenital)Generally if a woman has been infected before becoming pregnant, the unborn child will be protected because the mother has developed immunity. Physicians and other health-care providers can use these guidelines to assist in the prevention and treatment of STDs.
Recommended regimens should be used primarily; alternative regimens can be considered in instances of notable drug allergy or other medical contraindications to the recommended regimens.
Briefer provider-delivered prevention messages have been shown to be feasible and to decrease subsequent STDs in HIV primary-care settings (10). In addition, consistent and correct use of latex condoms reduces the risk for HPV infection and HPV-associated diseases, genital herpes, hepatitis B, syphilis, and chancroid when the infected area or site of potential exposure is covered (26–32). Although these pores do not allow the passage of sperm, they are more than 10 times the diameter of HIV and more than 25 times that of HBV.
No proven topical antiretroviral agents exist for the prevention of HIV, though trials are underway to evaluate several candidates for vaginal and rectal microbicides using tenofovir and other antiretroviral drugs. In light of these benefits, the American Urological Association states that male circumcision should be considered an option for risk reduction, among other strategies (61). Some ECPs can be obtained over the counter; ECPs can also be provided through advance prescription or supply from providers (64,65). These findings are consistent with those from a previous trial that found no benefit of acyclovir in preventing HIV-1 acquisition in persons who were seropositive for HSV-2 (72). Observational studies have consistently found that serosorting confers greater risk of HIV infection than consistent condom use, but is lower risk compared with anal intercourse without a condom and without serosorting (80–82).


When possible, clinicians should advise persons to bring their primary sex partner along with them when returning for treatment and should concurrently treat both persons.
Before conducting a follow-up of a positive STD-test result, public health professionals should consult the patient's health-care provider if possible to verify the diagnosis and determine the treatments being received.
Testing pregnant women and treating those who are infected are vital not only to maintain the health of the woman, but to reduce perinatal transmission of HIV through available antiretroviral and obstetrical interventions. Neonates 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 if at risk.
All laboratories that conduct HBsAg tests should test initially reactive specimens with a licensed neutralizing confirmatory test. Gonococcal infection, in particular, is concentrated in specific geographic locations and communities.
However, all women with HCV infection should receive appropriate counseling and supportive care as needed (see Hepatitis C, Prevention). Protecting confidentiality for such care, particularly for adolescents enrolled in private health insurance plans, presents multiple problems. However, since that time, increased rates of early syphilis (primary, secondary, or early latent), gonorrhea, and chlamydial infection and higher rates of sexual risk behaviors have been documented among MSM in the United States and virtually all industrialized countries.
Rectal gonorrhea and chlamydia infections, especially those that are recurrent, have been associated with increased risk for HIV seroconversion among MSM (155,156).
In addition, providers should offer evidence-based counseling on safer sex using interventions that have been demonstrated to decrease STD incidence in clinical-care settings (10).
Because many MSM meet partners online and seek health information from websites, increased use of the internet for STD prevention might be warranted. All MSM with HIV infection entering care should be screened for gonorrhea and chlamydia at appropriate anatomic sites of exposure, as well as for syphilis (17).
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. Screening should be performed using HCV antibody assays followed by HCV RNA testing for those with a positive antibody result (178). Despite this, few comprehensive and reliable resources of sexual health information for WSW are available (187).
It is strictly an intracellular parasite that relies on the host for reproduction and resources. Handling food with unwashed hands or using utensils that are contaminated on food can also result in the ingestion of the parasite and acquiring the infection. Other symptoms in children from the result of congenital infection are sporadic spasms of the muscles, cerebral palsy, mental retardation, impairment to hearing and vision, and experiencing convulsions. In other third world countries, reports showed that the percent of population infected reaches as high as 95%. Parasite from blood results can also be isolated, though like before, it is difficult to obtain and is time consuming. Pregnant women who are infected are treated with spiramycin (Rovamycine) and leucovorin (Wellcovorin)along with pyrimethamine and sulfadiazine.
The mothers of these last four infants tested positive for syphilis during the third trimester of pregnancy, two of them during premature delivery. In our study, information on hospital stays in 2004 of patients less than one year old with a principal or associated diagnosis of CS (Table 1) were extracted from the PMSI database.
No information on syphilis screening during the first trimester of pregnancy was available for any of these four women.
Among these six probable cases, two adopted infants were born outside Europe, in North Africa. Except where otherwise stated, all manuscripts published after 1 January 2016 will be published under the Creative Commons Attribution (CC BY) licence.
If a woman is pregnant and becomes newly infected with Toxoplasma during or just before pregnancy, she can pass the infection to her unborn baby (congenital transmission). Following the April meeting, the literature was searched periodically by CDC staff to identify subsequently published articles warranting consideration by the workgroup either through e-mail or conference calls. Other approaches use motivational interviewing to move clients toward achievable risk-reduction goals. The failure of condoms to protect against STD or unintended pregnancy usually results from inconsistent or incorrect use rather than condom breakage (35). Moreover, laboratory studies demonstrate that sexual transmission of viruses, including hepatitis B, herpes simplex, and HIV, can occur with natural membrane condoms (19). Emergency insertion of a copper IUD up to 5 days after sex can reduce pregnancy risk by more than 99% (66). Serosorting practices have been associated with increased risk of STDs including chlamydia and gonorrhea (83,84). Although this approach can be effective for a main partner (89,90), it might not be feasible approach for additional sex partners.
Clinicians should familiarize themselves with public health practices in their area, but in most instances, providers should understand that responsibility for ensuring the treatment of partners of persons with STDs other than syphilis and HIV rests with the diagnosing provider and the patient.
Data on the use of PDPT for gonorrhea or chlamydial infection among MSM are limited (99,100).
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 neonates (107). Women found to have gonococcal infection should be treated immediately and retested within 3 months. HPV vaccination has not been associated with a change in perceptions about risks posed by sexual behavior (128).
Because of this risk for repeat infection, these data suggest that prevention efforts should include follow up serologic testing.
MSM are amenable to receiving HIV and STD risk-reduction messages online (165) and willing to respond to requests for partner identification from public health authorities through the internet (166).
The frequency of follow-up testing might be dictated by subsequent behavior; screening is recommended annually, at a minimum, to include syphilis serologic testing and chlamydia and gonorrhea screening at exposed anatomic sites (138). 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 A and Hepatitis B). The condition may cause an increased pressure in the head that may cause the infant's head to increase abnormally, called hydrocephalus, or decrease in size, called microcephaly. Evidence shows that regions that have a climate which is humid, hot and a altitude that is low, have the highest percent of infection. A test to check a fetus involves obtaining a sample of the amniotic fluid that, through molecular techniques, can detect the DNA of the parasite if fetus is infected.
Other drugs are sometimes used which consist of clindamycin (Cleocin), azithromycin (Zithromax), or atovaquone (Mepron). In France, syphilis screening is mandatory and free of charge during the first trimester of pregnancy. In three cases coding error occurred; the principal diagnosis coded was different than the principal diagnosis mentioned in the medical records. Additional information on social integration difficulties and undesired pregnancy was mentioned in the medical documentation of two mothers. You are free to share and adapt the material, but you must give appropriate credit, provide a link to the licence, and indicate if changes were made. The damage to the unborn child is often more severe the earlier in pregnancy the transmission occurs.
The "Five P's" approach to obtaining a sexual history is one strategy for eliciting information concerning five key areas of interest (Box 1).
Client-centered counseling and motivational interviewing can be used effectively by clinicians and staff trained in these approaches. While natural membrane condoms are recommended for pregnancy prevention, they are not recommended for prevention of STDs and HIV.
ECPs are most efficacious when initiated as soon as possible after unprotected sex but have some efficacy up to 5 days later. Some evidence suggests that providing patients with written information to share with sex partners can increase rates of partner treatment (87).
Providing patients with appropriately packaged medication is the preferred approach to PDPT because data on the efficacy of PDPT using prescriptions is limited and many persons do not fill the prescriptions given to them by a sex partner. Rapid HIV screening should be performed on any woman in labor who has not been screened for HIV during pregnancy unless she declines.
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 to their infants.
Pregnant women who remain at high risk for gonococcal infection also should be retested during the third trimester to prevent maternal postnatal complications and gonococcal infection in the neonate.
In addition, federal laws obligate notices to beneficiaries when claims are denied, including alerting beneficiaries who need to pay for care until the allowable deductible is reached. Thus, rectal gonorrhea and chlamydia screening in MSM might be a cost-effective intervention in certain urban settings (158). The parasite has the ability to survive its way through the stomach and progress to infect the epithelial cells of the small intestine.
The most common zoonotic way of infection is through a cat, which is a definitive host for the parasite.
The parasite still remains in the body but exist in a dormant form that can be reactivated if the immune system becomes compromised.
Latex condoms should not be used beyond their expiration date or more than 5 years after the manufacturing date. Medication or prescriptions provided for PDPT should be accompanied by treatment instructions, appropriate warnings about taking medications (if the partner is pregnant or has an allergy to the medication), general health counseling, and a statement advising that partners seek medical evaluation for any symptoms of STD, particularly PID. 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 (105).
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.
For STD detection- and treatment-related care, an EOB or medical bill that is received by a parent might disclose services provided and list STD laboratory tests performed or treatment given. People that have a compromised immune system, such as HIV or ADS, risk a higher chance of showing symptoms that are most severe.
Persons with ocular diseaseEye disease (most frequently retinochoroiditis) from Toxoplasma infection can result from congenital infection or infection after birth by any of the modes of transmission discussed on the epidemiology and risk factors page.
Male condoms made of materials other than latex are available in the United States and can be classified in two general categories: 1) polyurethane and other synthetic and 2) natural membrane. A 2012 Cochrane review summarized the efficacy, safety, and convenience of various methods of emergency contraception (67). All persons who receive bacterial STD diagnoses and their sex partners, particularly MSM, should be tested for HIV infection.
In addition, household and sex contacts of women who are HBsAg positive should be vaccinated. A person can also get infected when handling soil that has been contaminated by feces containing parasite. The symptoms of a infected person with a compromised immune system are a headache, feeling nauseous, inability to coordinate well, seizures, feeling confused, and a fever.
Indeed, CS can occur with non-specific symptoms, or the infection can be asymptomatic at birth and the diagnosis is by consequence delayed. Eye lesions from congenital infection are often not identified at birth but occur in 20-80% of infected persons by adulthood. Women who are HBsAg positive should be provided with, or referred for, appropriate counseling and medical management. Those that have been infected earlier in life and whose infection has been reactivated, result in a severe case of Toxoplasmosis. Among the nine children with CS reported between 1994 and 1997 in the United Kingdom [12], only three had clinical abnormalities. Evaluation for HSV-2 infection with type-specific serologic tests also can be considered if infection status is unknown in persons with previously undiagnosed genital tract infection. Such a case can cause brain damage, affect the eyes and cause damage to other organs in the body.
Our study focused on early CS in children less than one year of age but the diagnosis of CS can be made in older children (“early” CS defined as affecting children less than two years old and “late” CS diagnosed in children older than two years). Eye infection leads to an acute inflammatory lesion of the retina, which resolves leaving retinochoroidal scarring. Though a few cases have shown that a even a healthy person with a good immune system can acquire damage to the eyes, if infected with the parasite.
In the PMSI database, a two-year-old child and eight children aged between two and 15 years were reported with a principal or associated diagnosis of CS in 2004.
Symptoms of acute disease includeeye painsensitivity to light (photophobia)tearing of the eyesblurred visionThe eye disease can reactivate months or years later, each time causing more damage to the retina. Symptoms of Ocular Toxoplasmosis my result in sensitivity to bright light, eye redness, blurry vision, and a decrease in vision.
If the central structures of the retina are involved there will be a progressive loss of vision that can lead to blindness.
Finally, coding errors may have occurred, and cases who had never been hospitalised were missed. Persons with compromised immune systemsPersons with compromised immune systems may experience severe symptoms if they are infected with Toxoplasma while immune suppressed. For example, a person who is HIV-infected and who has reactivated Toxoplasma infection can have symptoms that include fever, confusion, headache, seizures, nausea, and poor coordination. Previous studies showed that CS occurs more frequently in absence of or inappropriate antenatal care [13,14].
The consequence is a late or no syphilis screening and inappropriate treatment of the mothers which fail to prevent foetal contamination [15,16]. In France, a pregnant woman should attend seven antenatal consultations, and syphilis screening must be performed during the first trimester (Decret n°92-143) [17]. However, despite this regulation, different factors such as language and cultural barriers or an illegal administrative status can hinder pregnant women from getting appropriate medical care [8,9]. In our study, specific socio-cultural conditions may have been responsible for the lack of antenatal care: three mothers were migrants and “social integration difficulties” (but no details) were reported for the fourth one. The fact that one mother refused the treatment and one had an undesired pregnancy may be indicative of further psychosocial problems [18]. In France, like in the other western European countries, the re-emergence of syphilis especially affects MSM [6]. However, the number of infected women also increased from 11 (of the total of 207 cases of syphilis reported) in 2001 to 30 (total of 455 cases) in 2006 [6].
The contagiousness of syphilis as well as the high percentage of heterosexuals who engage in high risk sexual behaviours, such as not using condoms for oral sex (92% heterosexuals in France), may be responsible for an increasing number of syphilis cases among women. Immigrant women were identified to be at a higher risk of syphilis infection during pregnancy [19].
In France, among the 19 women with a diagnosis of syphilis notified in 2004, 13 were born in foreign countries and four were born in France (information unavailable for the remaining two women). In this context, health care practitioners should consider the option of syphilis screening at each pregnancy consultation [20,21], especially in the presence of risk factors identified above.
Indeed, the French National Authority for Health (Haute Autorite de Sante - HAS) recommends another syphilis screening performed before 28 weeks of gestation when the woman or her partner has high risk sexual behaviour. Finally, a lack of syphilis screening during pregnancy should result in performing serology at birth to avoid late diagnosis of CS [21]. Evidence for increased transmission of syphilis among homosexual men and heterosexual men and women in Europe.
Despite their limits, data from PMSI can be used to describe the annual trend of CS cases, but not to perform a prospective follow up as the data are available with a minimum delay of three years.
In France, the very low number of CS cases suggests that the antenatal care system is efficient.
However, because of the overall increasing incidence of syphilis infection the French gynaecologists, obstetricians and paediatricians should be aware of the risk of CS, especially among women belonging to specific under-privileged groups, and should double check at delivery whether and how the screening was performed during pregnancy. A prospective notification of CS cases by maternity or paediatric wards with an investigation of each case should allow to better characterise the circumstances of syphilis infection before or during pregnancy and the performance or the absence of syphilis screening.
These information may improve the prevention and the treatment of CS in the population at risk.
International Statistical Classification of Diseases and Related Health Problems 10th Revision.
Syphilis in pregnant women and their children in the United Kingdom: results from national clinician reporting surveys 1994-7. Inadequate syphilis screening among women with prenatal care in a community with a high syphilis incidence.
Congenital syphilis: identification of two distinct profiles of maternal characteristics associated with risk. Decret n°92-143 du 14 fevrier 1992 relatif aux examens obligatoires prenuptial, pre et postnatal [Decree nr 92-143 of 14 February 1992 regarding mandatory pre-nuptial, antenatal and postnatal medical examinations]. Prenatal syphilis infection is a possible cause of preterm delivery among immigrant women from eastern Europe. Evaluation a priori du depistage de la syphilis en France – recommandation en sante publique [Assessment of syphilis screening in France – Public Health recommendation].



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