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Warning:
This document is being maintained for historical purposes, but is now out of date. To view current guidelines please visit:
- STD Treatment Guidelines at http://www.cdc.gov/STD/treatment
1998 Guidelines for Treatment of Sexually Transmitted Disease
Date: 01/23/98
Source: 47(RR-1);1-118
SUGGESTED CITATION: Centers for Disease Control and Prevention. 1998 Guidelines for Treatment of Sexually Transmitted Diseases. MMWR 1998;47(No. RR-1): {inclusive page numbers}.
The material in this report was prepared for publication by: National Center for HIV, STD and TB Prevention, Division of Sexually Transmitted Diseases Prevention
CLINICAL PREVENTION GUIDELINES
The prevention and control of STDs is based on five major concepts: first, education of those at risk on ways to reduce the risk for STDs; second, detection of asymptomatically infected persons and of symptomatic persons unlikely to seek diagnostic and treatment services; third, effective diagnosis and treatment of infected persons; fourth, evaluation, treatment, and counseling of sex partners of persons who are infected with an STD; and fifth, preexposure vaccination of persons at risk for vaccine-preventable STDs. Although this report focuses primarily on the clinical aspects of STD control, prevention of STDs is based on changing the sexual behaviors that place persons at risk for infection. Moreover, because STD control activities reduce the likelihood of transmission to sex partners, prevention for individuals constitutes prevention for the community.
Clinicians have the opportunity to provide client education and counseling and to participate in identifying and treating infected sex partners in addition to interrupting transmission by treating persons who have the curable bacterial and parasitic STDs. The ability of the health-care provider to obtain an accurate sexual history is crucial in prevention and control efforts. Guidance in obtaining a sexual history is available in the chapter "Sexuality and Reproductive Health" in Contraceptive Technology, 16th edition (4). The accurate diagnosis and timely reporting of STDs by the clinician is the basis for effective public health surveillance.
Prevention Messages
Preventing the spread of STDs requires that persons at risk for transmitting or acquiring infections change their behaviors. The essential first step is for the health-care provider to proactively include questions regarding the patient's sexual history as part of the clinical interview. When risk factors have been identified, the provider has an opportunity to deliver prevention messages. Counseling skills (i.e., respect, compassion, and a nonjudgmental attitude) are essential to the effective delivery of prevention messages. Techniques that can be effective in facilitating a rapport with the patient include using open-ended questions, using understandable language, and reassuring the patient that treatment will be provided regardless of considerations such as ability to pay, citizenship or immigration status, language spoken, or lifestyle.
Prevention messages should be tailored to the patient, with consideration given to the patient's specific risk factors for STDs. Messages should include a description of specific actions that the patient can take to avoid acquiring or transmitting STDs (e.g., abstinence from sexual activity if STD-related symptoms develop).
Sexual Transmission
The most effective way to prevent sexual transmission of HIV infection and other STDs is to avoid sexual intercourse with an infected partner. Counseling that provides information concerning abstinence from penetrative sexual intercourse is crucial for a) persons who are being treated for an STD or whose partners are undergoing treatment and b) persons who wish to avoid the possible consequences of sexual intercourse (e.g., STD/HIV and pregnancy). A more comprehensive discussion of abstinence is available in Contraceptive Technology, 16th edition (4).
Both partners should get tested for STDs, including HIV, before initiating sexual intercourse.
If a person chooses to have sexual intercourse with a partner whose infection status is unknown or who is infected with HIV or another STD, a new condom should be used for each act of intercourse.
Injecting-Drug Users
The following prevention messages are appropriate for injecting-drug users:
Enroll or continue in a drug-treatment program.
Do not, under any circumstances, use injection equipment (e.g., needles and syringes) that has been used by another person.
If needles can be obtained legally in the community, obtain clean needles.
Persons who continue to use injection equipment that has been used by other persons should first clean the equipment with bleach and water. (Disinfecting with bleach does not sterilize the equipment and does not guarantee that HIV is inactivated. However, for injecting-drug users, thoroughly and consistently cleaning injection equipment with bleach should reduce the rate of HIV transmission when equipment is shared.)
Preexposure Vaccination
Preexposure vaccination is one of the most effective methods used to prevent transmission of certain STDs. HBV infection frequently is sexually transmitted, and hepatitis B vaccination is recommended for all unvaccinated patients being evaluated for an STD. In the United States, hepatitis A vaccines from two manufacturers were licensed recently. Hepatitis A vaccination is recommended for several groups of patients who might seek treatment in STD clinics; such patients include homosexual or bisexual men and persons who use illegal drugs. Vaccine trials for other STDs are being conducted, and vaccines for these STDs may become available within the next several years.
Prevention Methods
Male Condoms
When used consistently and correctly, condoms are effective in preventing many STDs, including HIV infection. Multiple cohort studies, including those of serodiscordant sex partners, have demonstrated a strong protective effect of condom use against HIV infection. Because condoms do not cover all exposed areas, they may be more effective in preventing infections transmitted between mucosal surfaces than those transmitted by skin-to-skin contact. Condoms are regulated as medical devices and are subject to random sampling and testing by the Food and Drug Administration (FDA). Each latex condom manufactured in the United States is tested electronically for holes before packaging. Rates of condom breakage during sexual intercourse and withdrawal are low in the United States (i.e., usually two broken condoms per 100 condoms used). Condom failure usually results from inconsistent or incorrect use rather than condom breakage.
Patients should be advised that condoms must be used consistently and correctly to be highly effective in preventing STDs. Patients also should be instructed in the correct use of condoms. The following recommendations ensure the proper use of male condoms:
Use a new condom with each act of sexual intercourse.
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 genital contact with the partner.
Ensure that no air is trapped in the tip of the condom.
Ensure that adequate lubrication exists during intercourse, possibly requiring the use of exogenous lubricants.
Use only water-based lubricants (e.g., K-Y Jelly (TM), Astroglide (TM), AquaLube (TM), and glycerin) with latex condoms. Oil-based lubricants (e.g., petroleum jelly, shortening, mineral oil, massage oils, body lotions, and cooking oil) can weaken latex.
Hold the condom firmly against the base of the penis during withdrawal, and withdraw while the penis is still erect to prevent slippage.
Female Condoms
Laboratory studies indicate that the female condom (Reality (TM)) -- a lubricated polyurethane sheath with a ring on each end that is inserted into the vagina -- is an effective mechanical barrier to viruses, including HIV. Other than one investigation of recurrent trichomoniasis, no clinical studies have been completed to evaluate the efficacy of female condoms in providing protection from STDs, including HIV. If used consistently and correctly, the female condom should substantially reduce the risk for STDs. When a male condom cannot be used appropriately, sex partners should consider using a female condom.
Condoms and Spermicides
Whether condoms lubricated with spermicides are more effective than other lubricated condoms in protecting against the transmission of HIV and other STDs has not been determined. Furthermore, spermicide-coated condoms have been associated with Escherichia coli urinary tract infection in young women. Whether condoms used with vaginal application of spermicide are more effective than condoms used without vaginal spermicides also has not been determined. Therefore, the consistent use of condoms, with or without spermicidal lubricant or vaginal application of spermicide, is recommended.
Vaginal Spermicides, Sponges, and Diaphragms
As demonstrated in several randomized controlled trials, vaginal spermicides used alone without condoms reduce the risk for cervical gonorrhea and chlamydia. However, vaginal spermicides offer no protection against HIV infection, and spermicides are not recommended for HIV prevention. The vaginal contraceptive sponge, which is not available in the United States, protects against cervical gonorrhea and chlamydia, but its use increases the risk for candidiasis. In case-control and cross-sectional studies, diaphragm use has been demonstrated to protect against cervical gonorrhea, chlamydia, and trichomoniasis; however, no cohort studies have been conducted. Vaginal sponges or diaphragms should not be assumed to protect women against HIV infection. The role of spermicides, sponges, and diaphragms for preventing STDs in men has not been evaluated.
Nonbarrier Contraception, Surgical Sterilization, and Hysterectomy
Women who are not at risk for pregnancy might incorrectly perceive themselves to be at no risk for STDs, including HIV infection. Nonbarrier contraceptive methods offer no protection against HIV or other STDs. Hormonal contraception (e.g., oral contraceptives, Norplant (TM), and Depo-Provera (TM)) has been associated in some cohort studies with cervical STDs and increased acquisition of HIV; however, data concerning this latter finding are inconsistent. Women who use hormonal contraception, have been surgically sterilized, or have had hysterectomies should be counseled regarding the use of condoms and the risk for STDs, including HIV infection.
HIV Prevention Counseling
Knowledge of HIV status and appropriate counseling are important components in initiating behavior change. Therefore, HIV counseling is an important HIV prevention strategy, although its efficacy in reducing risk behaviors is still being evaluated. By ensuring that counseling is empathic and client-centered, clinicians can develop a realistic appraisal of the patient's risk and help the patient develop a specific and realistic HIV prevention plan (5).
Counseling associated with HIV testing has two main components: pretest and posttest counseling. During pretest counseling, the clinician should conduct a personalized risk assessment, explain the meaning of positive and negative test results, ask for informed consent for the HIV test, and help the patient develop a realistic, personalized risk-reduction plan. During posttest counseling, the clinician should inform the patient of the results, review the meaning of the results, and reinforce prevention messages. If the patient has a confirmed positive HIV test result, posttest counseling should include referral for follow-up medical services and, if needed, social and psychological services. HIV-negative patients at continuing risk for HIV infection also may benefit from referral for additional counseling and prevention services.
Partner Notification
For most STDs, partners of patients should be examined. When exposure to a treatable STD is considered likely, appropriate antimicrobials should be administered even though no clinical signs of infection are evident and laboratory test results are not yet available. In many states, the local or state health department can assist in notifying the partners of patients who have selected STDs (e.g., HIV infection, syphilis, gonorrhea, hepatitis B, and chlamydia).
Health-care providers should advise patients who have an STD to notify sex partners, including those without symptoms, of their exposure and encourage these partners to seek clinical evaluation. This type of partner notification is known as patient referral. In situations in which patient referral may not be effective or possible, health departments should be prepared to assist the patient either through contract referral or provider referral. Contract referral is the process by which patients agree to self-refer their partners within a defined time period. If the partners do not obtain medical evaluation and treatment within that period, then provider referral is implemented. Provider referral is the process by which partners named by infected patients are notified and counseled by health department staff.
Interrupting the transmission of infection is crucial to STD control. For treatable and vaccine-preventable STDs, further transmission and reinfection can be prevented by referral of sex partners for diagnosis, treatment, vaccination (if applicable), and counseling. When health-care providers refer infected patients to local or state health departments for provider-referral partner notification, the patients may be interviewed by trained professionals to obtain the names of their sex partners and information regarding the location of these partners for notification purposes. Every health department protects the privacy of patients in partner-notification activities. Because of the advantage of confidentiality, many patients prefer that public health officials notify partners. However, the ability of public health officials to provide appropriate prophylaxis to contacts of all patients who have STDs may be limited. In situations where the number of anonymous partners is substantial (e.g., situations among persons who exchange sex for drugs), targeted screening of persons at risk may be more effective at stopping the transmission of disease than provider-referral partner notification. Guidelines for management of sex partners and recommendations for partner notification for specific STDs are included for each STD addressed in this report.
Reporting and Confidentiality
The accurate identification and timely reporting of STDs are integral components of successful disease control efforts. Timely reporting is important for assessing morbidity trends, targeting limited resources, and assisting local health authorities in identifying sex partners who may be infected. STD/HIV and acquired immunodeficiency syndrome (AIDS) cases should be reported in accordance with local statutory requirements.
Syphilis, gonorrhea, and AIDS are reportable diseases in every state. Chlamydial infection is reportable in most states. The requirements for reporting other STDs differ by state, and clinicians should be familiar with local STD reporting requirements. Reporting may be provider- and/or laboratory-based. Clinicians who are unsure of local reporting requirements should seek advice from local health departments or state STD programs.
STD and HIV reports are maintained in strictest confidence; in most jurisdictions, such reports are protected by statute from subpoena. Before public health representatives conduct follow-up of a positive STD-test result, these persons should consult the patient's health-care provider to verify the diagnosis and treatment.
