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This document is being maintained for historical purposes, but is now out of date.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

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1993 Sexually Transmitted Diseases Treatment Guidelines

09/24/1993

SUGGESTED CITATION
Centers for Disease Control and Prevention. 1993 Sexually
transmitted diseases treatment guidelines. MMWR 1993;42(No. RR-14):
{inclusive page numbers}.

CIO Responsible for this publication:
National Center for Prevention Services,
Division of Sexually Transmitted Diseases and HIV Prevention

STD/HIV PREVENTION GUIDELINES
     
     Prevention and control of STDs is based on four major
concepts: first, education of those at risk on the means for
reducing the risk for transmission; second, detection of
asymptomatically infected individuals and of persons who are
symptomatic but unlikely to seek diagnostic and treatment services;
third, effective diagnosis and treatment of those who are infected;
fourth, evaluation, treatment, and counseling of sex partners of
persons who have an STD. Although this document deals largely with
secondary prevention, namely clinical aspects of STD control,
primary prevention of STDs is based on changing the sexual
behaviors that place patients at risk.

     Physicians and other health-care providers have an important
role in the prevention of STDs. In addition to interrupting
transmission by treating persons who have bacterial and parasitic
STDs, clinicians have the opportunity to provide patient education
and counseling and to participate in identifying and treating
infected sex partners.

Prevention Methods

Condoms
     When used consistently and correctly, condoms are very
effective in preventing a variety of STDs, including HIV infection.
Multiple cohort studies, including those of serodiscordant couples,
have demonstrated a strong protective effect of condom use against
HIV infection. Condoms are regulated as medical devices and 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. Condom breakage
rates during use are low in the United States ( less than or equal
to 2 per 100 condoms tested). 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 effective in preventing STDs.
Patients should also be instructed in the correct use of condoms.
The following recommendations ensure the proper use of condoms:

--   Use a new condom with each act of 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 any
     genital contact with the partner.

--   Ensure that no air is trapped in the tip of the condom.

--   Ensure that there is adequate lubrication during intercourse,
     possibly requiring the use of exogenous lubricants.

--   Use only water-based lubricants (e.g., K-Y JellyTM or
     glycerine) with latex condoms (oil-based lubricants {e.g.,
     petroleum jelly, shortening, mineral oil, massage oils, body
     lotions, or cooking oil} that can weaken latex should never be
     used).

--   Hold the condom firmly against the base of the penis during
     withdrawal, and withdraw while the penis is still erect to prevent
     slippage.

Condoms and Spermicides
     The effectiveness of spermicides in preventing HIV
transmission is unknown. No data exist to indicate that condoms
lubricated with spermicides are more effective than other
lubricated condoms in protecting against the transmission of HIV
infection and other STDs. Therefore, latex condoms with or without
spermicides are recommended.

Female Condoms
     Laboratory studies indicate that the female condom
(RealityTM) -- 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. Aside from a small study of
trichomoniasis, no clinical studies have been completed to evaluate
protection from HIV infection or other STDs. However, an evaluation
of the female condom's effectiveness in pregnancy prevention was
conducted during a 6-month period for 147 women in the United
States. The estimated 12-month failure rate for pregnancy
prevention among the 147 women was 26%.

Vaginal Spermicides, Sponges, Diaphragms
     As demonstrated in several cohort studies, vaginal spermicides
(i.e., film, gel, suppositories; contraceptive foam has not been
studied) used alone without condoms reduce the risk for cervical
gonorrhea and chlamydia, but protection against HIV infection has
not been established in human studies. The vaginal contraceptive
sponge protects against cervical gonorrhea and chlamydia, but
increases the risk for candidiasis as evidenced by cohort studies.
Diaphragm use has been demonstrated to protect against cervical
gonorrhea, chlamydia, and trichomoniasis, but only in case-control
and cross-sectional studies; no cohort studies have been performed.
Gonorrhea and chlamydia among women usually involve the cervix as
a portal of entry, whereas other STD pathogens (including HIV) may
infect women through the vagina or vulva, as well as the cervix.
Protection of women against HIV infection should not be assumed
from the use of vaginal spermicides, vaginal sponges, or
diaphragms. The role of spermicides, sponges, and diaphragms for
preventing STDs among men has not been studied.

Nonbarrier Contraception, Surgical Sterilization, Hysterectomy
     Women who are not at risk for pregnancy may incorrectly
perceive themselves to be at no risk for STDs, including HIV
infection. Nonbarrier contraceptive methods offer no protection
against HIV or other STDs. Women using hormonal contraception (oral
contraceptives, NorplantTM, Depo-ProveraTM), who have been
surgically sterilized or who have had hysterectomies should be
counseled regarding the use of condoms and the risk for STDs,
including HIV infection.

Prevention Messages

     Preventing the spread of STDs requires that persons at risk
for transmitting or acquiring infections change their behaviors.
When risks have been identified, the health-care provider has an
opportunity to deliver prevention messages. Counseling skills are
essential to the effective delivery of prevention messages (i.e.,
respect, compassion, and a nonjudgmental attitude). Techniques that
can be effective in developing rapport with the patient include
using open-ended questions, using language that the patient
understands, 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 his or her specific risks. Messages should
include a description of measures, such as the following, that the
person can take to avoid acquiring or transmitting STDs:

--   The most effective way to prevent sexual transmission of HIV
     infection and other STDs is to avoid sexual intercourse with an
     infected partner.

--   If a person chooses to have sexual intercourse with a partner
     whose infection status is unknown or who is infected with HIV or
     other STDs, men should use a new latex condom with each act of
     intercourse.

--   When a male condom cannot be used, couples should consider
     using a female condom.

Injection Drug Users
     Prevention messages appropriate for injection drug users are
     the following:

--   Enroll or continue in a drug treatment program.

--   Do not, under any circumstances, use injection equipment
     (needles, syringes) that has been used by another person.

--   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,
     thoroughly and consistently cleaning injection equipment with
     bleach should reduce the rate of HIV transmission when equipment is
     shared.)


HIV Prevention Counseling
     
     Knowledge of one's HIV status and appropriate counseling are
thought to play an important role in initiating behavior change.
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 person to 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 is HIV positive,
posttest counseling should include referral for follow-up medical
services and for social and psychological services, if needed. HIV-
seronegative persons at continuing risk for HIV infection also may
benefit from referral for additional counseling and prevention
services.

     HIV counseling is considered to be an important HIV-prevention
strategy, although its efficacy in reducing risk behavior is still
under evaluation. By ensuring that counseling is empathic and
"client-centered," clinicians will be able to develop a realistic
appraisal of the person's risk and help him or her to develop a
specific and realistic HIV-prevention plan (2).

Partner Notification and Management of Sex Partners
     
     Patients with STDs should ensure that their sex partners,
including those without symptoms, are referred for evaluation.
Providers should be prepared to assist in that effort. In most
circumstances, partners of patients with STDs should be examined.
When a diagnosis of a treatable STD is considered likely,
appropriate antibiotics should be administered even though there
may be no clinical signs of infection and before laboratory test
results are available. In most states, the local or state health
department can assist in notifying the partners of patients with
selected STDs, especially HIV, syphilis, gonorrhea, and chlamydia.

     Breaking the chain of transmission is crucial to STD control.
For treatable STDs, further transmission and reinfection can be
prevented by referral of sex partners for diagnosis, treatment, and
counseling. The following two strategies are used for partner
notification: a) patient referral (index patients notify their
partners), and b) provider referral (partners named by infected
patients are notified and counseled by health department staff).
When a physician refers an infected person to a local or state
health department, trained professionals may interview the patient
to obtain names and locating information about all of his or her
sex partners. 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.

     If a patient with HIV infection refuses to notify partners
while continuing to place them at risk, the physician has an
ethical and legal responsibility to inform persons that they are at
risk of HIV infection. This duty-to-warn may be most applicable to
primary care physicians, who often have knowledge about a patient's
social and familial relationships. The decision to invoke the
duty-to-warn measure should be a last resort -- applicable only in
cases in which all efforts to persuade the patient to disclose
positive test results to those who need to know have failed.

     Although compelling ethical, theoretical, and public health
reasons exist to undertake partner notification, the efficacy of
partner notification as an STD prevention strategy is under
evaluation, and its effectiveness may be disease-specific.

     Clinical guidelines for sex partner management 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 form
an integral part of successful disease control. Reporting assists
local health authorities in identifying sex partners who may be
infected. Reporting also is important for assessing morbidity
trends. STD/HIV and acquired immunodeficiency syndrome (AIDS) cases
should be reported in accordance with local statutory requirements
and in a timely manner.

     Syphilis, gonorrhea, and AIDS are reportable diseases in every
state. The requirements for reporting other STDs and asymptomatic
HIV infection differ from state to 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 held in strictest confidence and in
many jurisdictions are protected by statute from subpoena. Further,
before any follow-up of a positive STD test is conducted by program
representatives, these persons consult with the patient's
health-care provider to verify the diagnosis and treatment.

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