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Managing
sexually transmitted infections:
Beyond the 2015 guidelines
1.5
CONTACT HOURS
1.0
CONTACT HOUR

Copyright (c) 2018 Wolters Kluwer Health, Inc. All rights reserved.
Abstract: Guidelines for the prevention and management of sexually transmitted infections
(STIs) are updated periodically while new science is continuously developed. Advanced
practice registered nurses implement clinical decisions based on current guidelines and
evidence. This article provides recent updates on managing STIs.
By Versie Johnson-Mallard, PhD, WHNP, FAANP, FAAN; Kim Curry, PhD, FNP, FAANP; Rasheeta Chandler,
PhD, FNP, FAANP; Ivy Alexander, PhD, ANP, FAAN; Elizabeth Kostas-Polston, PhD, WHNP, FAANP, FAAN;
Susan Orsega, MSN, FNP, FAAN; and Nancy Fugate Woods, PhD, RN, FAAN
D
espite efforts to improve access to evidence-
based reproductive healthcare services, out
comes of sexually transmitted infection (STI)
prevention efforts in the United States continue to lag
behind other developed countries.1-3 Some progress in
STI prevention and treatment services can be attributed
to the Patient Protection and Affordable Care Act,
which provides coverage for STI services for adolescent
and young adult women up to 26 years of age. However,
health disparities continue to exist regarding STI preva
lence rates. Populations most burdened by STIs include
15- to 19-year-old adolescents, 20- to 24-year-old
women, older adults, special populations (such as some
transgender individuals), those who are incarcerated,
and the homeless.1,2
Recommendations on STI prevention and manage
ment are frequently updated by the CDC, United States
Preventive Services Task Force (uspstf), and the World
Health Organization (WHO).1,2,4,5 STI guidelines are not
based on race or ethnicity, but in some cases, they are
based on age, gender, culture, and sexual preference.6,7
For example, chlamydia is the most common reportable
STI in the United States, whereas the human papilloma
virus (HPV) is the most common STI in women.1,2
Varijanta / Thinkstock
Keywords: men who have sex with men, MSM, prevention, reproductive health, sexual assault, sexually transmitted infections, STI, transgender
28 The Nurse Practitioner -  Vol. 43, No. 8
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Managing sexually transmitted infections: Beyond the 2015 guidelines
Respect and compassion are important to elicit
accurate and pertinent information during
screening and treatment of STIs.

Copyright (c) 2018 Wolters Kluwer Health, Inc. All rights reserved.
This article provides updates from the current STI
prevention and management literature published since
the 2015 CDC STI treatment guidelines were issued.
Only those infections for which information has been
updated since the most recent CDC guidelines are
included. Notable updates include:
-  treatment regimens for Neisseria gonorrhea and geni
tal warts
-  use of nucleic acid amplification (NAAT) test
-  update of HPV vaccine recommendation and coun
seling messages
-  managing the care of transgender individuals
-  hepatitis C annual testing in those with HIV infections
-  retesting to detect repeat infections
-  recognition and treatment of urethritis/cervicitis
caused by Mycoplasma genitalium (M. genitalium).
 STI prevention
Primary prevention. To prevent the onset of STIs, active
strategies of technology, behavior counseling, preven
tion education, and vaccination should be implement
ed before sexual debut.1,2,8,9 Research supports high
intensity behavioral counseling and motivational in
terviewing to augment information
provided in pamphlets, handouts,
and videos.10-12 Primary prevention
also includes anticipatory guidance
for parents of adolescents.
Secondary prevention. Screening
is an important secondary preven
tion strategy and should include the use of age- and
gender-appropriate, nonjudgmental strategies.1,13,14
During STI screening and treatment, nonjudgmental
acknowledgment of adolescent, youth, and older adult
engagement in behaviors that place them at high risk
for STIs is a critical component of communication.12-14
Respect and compassion are important to elicit ac
curate and pertinent information during screening
and treatment of STIs.1,12-14
The uspstf, CDC, and WHO provide screening
recommendations for viral and bacterial STIs.1,3-5 The
uspstf recommends a combined approach to screen
ing, which includes attention to individual's sexual
history for behaviors that indicate increased risk.4,5 The
CDC and WHO use an approach based on systematic
review of the literature for individual disease or infec
tion and population (national and global).1,2
The use of clinical prediction rules is an approach
that is growing momentum. Clinical prediction rules
combine an individualized risk assessment and popula
tion approach to STI screening,which is similar to mea
sures used to predict and manage several chronic
 diseases.6,7 Falasinnu and colleagues assessed differences
in impact of individual-based and population-based
approaches on over 35,000 individuals being screened
for gonorrhea and chlamydia.6,7 Results indicated that
this method would result in the detection of more cases
of STIs while reducing the need for screening.
 Viral STIs
HPV. It is widely accepted that high-risk HPV is a
 cancer-causing STI.15-17 The oncogenic high-risk geno
types 16 and 18 cause most of the cervical, vulvar, vagi
nal, anal, penile, and oropharyngeal cancers and cancer
precursors.1,16,17 Low-risk genotypes 6 and 11 cause
external genital warts, which are mostly benign in na
ture; however, these warts tend to cause great emotional
distress.1,2,16,17
HIV. The current recommendation for HIV pre
vention is preexposure prophylaxis (PrEP).18-20 PrEP
is an oral daily fixed-dose combination of two drugs:
tenofovir disoproxil fumarate and emtricitabine.1,18,20
The drugs are recommended for use in HIV discordant
heterosexual couples and men who have sex with men
(MSM).1,20
Randomized placebo-controlled trials have estab
lished risk for HIV transmission during sex, and I.V.
drug use is substantially lowered for becoming infected
with the HIV  virus that causes AIDS when PrEP is
used.1,20 Comprehensive guidance for use of HIV se
roadaptive strategies, such as serosorting (choosing
sex partners with similar HIV status) and strategic
positioning (avoiding insertive anal sex if HIV posi
tive) are behaviors that some MSM practice to prevent
transmission.20 Seroadaptive strategies include:
-  limiting anal sex without a condom to partners with
a similar HIV status
-  using a condom only with HIV serodiscordant
partners
-  HIV-infected partner acting as a receptive partner
for anal intercourse.20
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Copyright (c) 2018 Wolters Kluwer Health, Inc. All rights reserved.
Managing sexually transmitted infections: Beyond the 2015 guidelines
Sexual transmission of Zika virus23,25
Category
Risk
Transmission
-  Most commonly from symptomatic men to female partners
Period of
-  May exceed 1 month after onset of symptoms
contagiousness
Body fl uids affected
-  Semen, saliva, blood, urine, and vaginal and cervical secretions
Presentation of
-  May be asymptomatic or include mild symptoms such as fever, arthralgia, rashes, headaches
infection
-  Guillain-Barre syndrome is a potential sequela
Risk of infection to
-  Risks include microcephaly and other severe brain defects, miscar riage, ocular or hearing
maternal child
defects, and others
health
-  Spontaneous miscarriage or stillbirth is possible sequela
Prevention
-  Condom use if either partner has been exposed to Zika virus
-  Males should use condoms or abstain from sex for 6 months after onset of symptoms
-  Pregnant women should avoid travel to areas where Zika virus is present
-  Females should avoid sex for 8 weeks after onset of symptoms to avoid transmission to partners
Counseling for seroadaptive strategies include
sharing knowledge that home-testing HIV kits detect
antibodies, not acute HIV infection. Serosorting and
other adaptive behaviors carry greater HIV risk than
consistent condom use.19,20
Hepatitis. Sexual transmission rates of hepatitis C
are higher among individuals who engage in high-risk
sexual practices, group sex, and use of drugs during
sex.8,21 Screening for hepatitis C is recommended based
on risk and for all individuals born between the years
1945 and 1965.21,22 Annual hepatitis C screening and
diagnostic testing with assays is recommended among
MSM with HIV.9,21,22
Zika. Infection with the Zika virus can be sexually
transmitted.23-25 This mosquito-borne fl avivirus has
infected as many as 1.3 million individuals in Brazil
alone.24-27 Twenty countries or territories reported local
transmission in 2018.25-27 Most Zika virus infections
are characterized by subclinical or mild infl uenza-like
illness.23-27 However, severe neurologic manifestations
have been described, including Guillain-Barre syn
drome in adults and microcephaly in babies born to
infected mothers.25,27
Screening is not recommended to determine pres
ence of the Zika virus.25-27 The prevention strategy for
Zika includes avoidance of exposure via mosquito bites
or body fluids, especially for pregnant women and men
and women of childbearing age (see Sexual transmis
sion of Zika virus).23-25 Risks to the unborn fetus include
microcephaly, a severe brain defect, among other de
fects, such as developmental delay and vision and hear
ing problems.23-27 Viral RNA has been detected in
breast milk, but transmission via breastfeeding has not
been reported.27 Diagnosis remains suboptimal be
cause lab tests are not widely available.26
 Bacterial STIs
Gonorrhea and Chlamydia. Sexually active women
under the age of 25 years should be routinely screened
for gonorrhea and chlamydia, as prevalence is highest
among this age-group.2,6,7,15,28-30 However, current evi
dence is insuffi cient to assess the balance of benefi t
and harm of routine screening for chlamydia and
gonorrhea in sexually active men.1,28 Gonorrhea treat
ment and screening have experienced a paradigm
shift.29,31-34
Fluoroquinolones are no longer recommended,
and dual therapy is routinely recommended, prefer
ably under direct observation; in addition, emerging
resistance to oral cephalosporins has been document
ed.1,28 Treatment for chlamydia has remained stable.11
Men and women in the younger age-group (between
15 and 24 years) are less likely to use condoms than
older men and women, increasing the risk of repeated
chlamydia and/or gonorrhea infections.6,7,12,15
Syphilis. In 2016, an advisory was issued on ocular
syphilis outbreaks in San Francisco and Seattle, pri
marily among HIV-positive homosexual men.30 In
addition, if these men are diagnosed with syphilis, they
should be tested for HIV.1 For rapid diagnostic testing
of anti-HIV and anti-Treponema pallidum, a one-test
device is on the horizon according to the WHO.13,35,36
Penicillin G benzathine and penicillin G procaine were
in short supply in 2016.1
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Managing sexually transmitted infections: Beyond the 2015 guidelines
In 2016, the WHO issued new guidelines for treating
chlamydia, gonorrhea, and syphilis based on
emerging patterns of antibiotic therapy resistance.

Copyright (c) 2018 Wolters Kluwer Health, Inc. All rights reserved.
Penicillin G procaine is the recommended treat
ment for congenital syphilis and an alternative
treatment for neurosyphilis and ocular syphilis.30 Peni
cillin G benzathine remains the first-line treatment for
syphilis and is the only recommended treatment in
pregnant women.1,2 Similarly in 2016, the WHO issued
new guidelines for treating chlamydia, gonorrhea, and
syphilis based on emerging patterns of resistance to
antibiotic therapy.2,10,11 All individuals treated for syph
ilis should have follow-up serologic testing.1
Trichomoniasis vaginalis (T. vaginalis). The parasitic
protozoal infection T. vaginalis is included in this section
as it is conventionally discussed along
with bacterial infections. The CDC
guidelines recommend screening
women who seek care for vaginal dis
charge concerns and possibly for
those in high-prevalence settings.1
Routine screening for T. vaginalis in
asymptomatic women with HIV infection is also recom
mended because of the adverse reactions associated with
T. vaginalis and HIV infection.1
Use of highly sensitive and specific NAAT testing
is now recommended for detecting T. vaginalis.1 More
over, individuals with positive NAAT testing should
be retested after treatment. Retesting 3 months after
diagnosis of chlamydia, gonorrhea, or T. vaginalis is
advised to detect repeat infection.1
M. genitalium. Since being isolated in 1980, M.
genitalium has become known as a signifi cant source
of nongonococcal urethritis in men and as a signifi 
cant source of cervicitis, urethritis, and upper pelvic
infections in women.32 Major symptoms in women
include abdominal pain and dyspareunia. In men,
urethritis and penile discharge are the most common
symptoms.32 The only way of specifi cally diagnosing
M. genitalium infection is via NAAT.1
If left untreated, the disease can cause preterm
birth or spontaneous abortion and/or pelvic infl am
matory disease (PID).1,33,34,35 A history of PID appears
to be associated with subsequent development of non
invasive tumors of uncertain malignant potential.34
Rasmussen and colleagues noted that women with two
or more episodes of PID had twice the risk of develop
ing these tumors.34
 Special populations
Adolescents. With a few exceptions specific to age and
service type, all 50 states and the District of Columbia
allow minors to consent for their own health services
for STIs.1,35 No state requires parental consent for STI
care, nor is there a requirement that providers notify
parents that their adolescent minor has received STI
services.1,35 It is important to note that constraints may
exist even when the minor may consent, and parental
notification may differ by state.1
Older adults. Men and women are living longer,
healthier lives and are sexual beings well into older
adulthood, as reflected in a rise in STI and HIV rates
in the United States and internationally among this
age cohort.36,37 Screening and education during clinical
encounters should include consistent condom use as
well as biological risk factors such as decreased im
mune response, decreased estrogen, and psychosocial
changes, as these all have a role in STI prevention
among older adults.36 The CDC's routine HIV screen
ing recommendations end at age 64 years.1 Screening
is based on sexual risk assessment in older adults over
age 65 years.1
Transgender individuals. Transgender women (also
referred to as trans women) are a special population
of individuals who were born with male anatomy but
identify as women (see Summary of updates for special
populations). Approximately 27.7% of all transgender
women and 56.3% of Black transgender women in the
United States are infected with HIV.38,39
Transgender men (also referred to as trans men)
are individuals born with female anatomy but iden
tify as men.40 There is a great deal of anatomic diver
sity in this population, with many individuals who
still have a vagina and cervix, and thus, are suscep
tible to diseases of the female genital tract.41 Estab
lishing rapport with the individual and discussing
anatomical needs for screening  are both important
factors to ensuring the individual is appropriately
screened.29,39-41
 Immunizations
Currently, immunizations are available for three STIs:
hepatitis A, hepatitis B, and HPV.42 There are no re
cent changes in recommendations for the hepatitis A
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Copyright (c) 2018 Wolters Kluwer Health, Inc. All rights reserved.
Managing sexually transmitted infections: Beyond the 2015 guidelines
Summary of updates for special populations1,35-39
Special population
Key points
Adolescents
-  With a few exceptions specific to age and service type, minors may consent for their own
health services for STIs
-  No parental consent is necessary for STI treatment
-  Parental notification of treatment is not required, however, it is important to note that constraints
may exist even when the minor may consent, and parental notification may differ by state
Older adults
-  Rise in STI and HIV rates internationally in older adults
-  Providers should screen/educate on condom use, biological risk factors for STIs, hormonal
changes affecting sexual a ctivity, and psychosocial changes of aging
-  Screening for HIV in those over age 65 years is based on risk assessment
Transgender
-  Transgender women have high rates of HIV infection
individuals
-  There is much anatomic diversity in the transgender population
-  Female-to-male transgender individuals may be susceptible to female genital tract infections
depending on their anatomy
-  Establishing a rapport to determine appropriate screening is key
vaccine. In 2018, the CDC issued updated recom
mendations for the hepatitis B vaccine. These updates
include:
-  a universal recommendation for vaccination within
24 hours of birth for medically stable newborns of
normal birthweight
-  testing pregnant women for the presence of hepatitis
B DNA if they are positive for hepatitis B surface
antigen (HBsAg)
-  serologic testing of infants whose mothers' hepatitis
B status is unknown
Confidentiality requirements related to STI
treatment have been recently updated to include
requirements for individuals with HIV.
-  single-dose revaccination of infants not respond
ing to the initial vaccine series whose mothers are
 HBsAg positive
-  vaccination for those with chronic liver disease
-  removal of permissive language allowing delay of
the birth dose until after a newborn is discharged
from the hospital following birth.43
Recommendations for HPV vaccination were re
vised in 2016.44 The CDC amended the 3-dose 9-valent
HPV vaccine series to include a 2-dose series in those
under the age of 15 years.44 In December 2015, the FDA
granted approval to the manufacturer of the 9-valent
vaccine to extend the indication to include males 16
through 26 years of age. Evidence supporting the
ongoing use of the HPV vaccine is growing.45 After only
6 years of provider recommendation for HPV vaccina
tion in the United States, HPV prevalence declined by
64% in adolescent females ages 14 to 19 years and by
34% in women ages 20 to 24 years.16,45
 Confidentiality
Confidentiality requirements related to STI treatment
have been recently updated to include requirements
for individuals with HIV.46 Individuals with HIV are
protected against discrimination under provisions of
the Americans with Disabilities Act
of 1990, which assumes that indi
viduals with HIV, whether symp
tomatic or asymptomatic, "have
physical impairments that substan
tially limit one or more major life
activities."46 A number of cases of
discrimination based on HIV status have been litigated
within the past 3 years.46
 Conclusion
As noted by the CDC, WHO, and FDA, the prevention,
management, and treatment of STIs is an area of rap
idly changing evidence requiring advance practice
registered nurses (APRNs) to maintain awareness of
up-to-date guidelines. APRNs are members of the
primary prevention healthcare team responsible for
guaranteeing confidentiality and ensuring that neces
sary preventive services, immunizations, and PrEP
services are delivered according to guidelines and cur
rent evidence.
32 The Nurse Practitioner -  Vol. 43, No. 8
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Copyright (c) 2018 Wolters Kluwer Health, Inc. All rights reserved.
Managing sexually transmitted infections: Beyond the 2015 guidelines
Without APRNs having a strong fundamental un
derstanding of health consequences of missed or inap
propriately diagnosed and treated STIs, patients can
develop disease sequela. APRNs who use targeted edu
cation campaigns geared toward specifi c age-groups
and special populations, such as adolescents, are cham
pions for preventing and decreasing STIs.
During patient encounters, assessing each indi
vidual's risk of STIs (sexual exposures, practices) pro
vides the APRN an opportunity for focused patient
education. Furthermore, educating individuals about
the signs and symptoms of STIs reinforces importance
of early treatment if an infection occurs.
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36. MacDonald J, Lorimer K, Knussen C, Flowers P. Interventions to increase
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37. Johnson BK. Sexually transmitted infections and older adults. J Gerontol
Nurs. 2013;39(11):53-60.
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Managing sexually transmitted infections: Beyond the 2015 guidelines
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-  If you prefer to submit your test by mail, record your an-
swers in the test answer section of the CE enrollment form
on page 35. You may make copies of the form.
Each question has only one correct answer. There is no
minimum passing score required.
Complete the registration information and course evalua-
tion. Mail the completed form and registration fee of $17.95
to: Lippincott Professional Development CE Group, 74 Brick
Blvd., Bldg. 4, Suite 206, Brick, NJ 08723. We will mail your
certificate in 4 to 6 weeks. For faster service, include a fax
number and we will fax your certificate within 2 business
days of receiving your enrollment form. You will receive
your CE certificate of earned contact hours and an answer
key to review your results.
-  Registration deadline is June 5, 2020.
40. Scheim AI, Bauer GR, Travers R. HIV-related sexual risk among transgender
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pdfs/rr6701-H.pdf.
44. Meites E, Kempe A, Markowitz LE. Use of a 2-dose schedule for human pap
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Versie Johnson-Mallard is a department chair and associate professor at the
University of Florida, Gainesville, Fla.
Kim Curry is a clinical associate professor and associate dean, Student Affairs, at
the University of Florida, College of Nursing, Gainesville, Fla.
Rasheeta Chandler is an  at Neill Hodgson School of Nursing,
Emory University, Atlanta, Ga.
Ivy Alexander is a professor and director of Advanced Practice Programs and
director of the Adult-Gerontology Primary Care Track at the University of
Connecticut, School of Nursing, Storrs, Conn.
Elizabeth Kostas-Polston is an  at Daniel K. Inouye Graduate
School of Nursing, Bethesda, Md.
Susan Orsega is a rear admiral at the United States Public Health Service
(USPHS), Bethesda, Md.
Nancy Fugate Woods is a Professor and dean emerita at the University of
Washington, Department of Biobehavioral Nursing and Health Informatics,
Seattle, Wash.
The authors and planners have disclosed the following fi nancial relationships
related to this article:
Nancy Fugate Woods (scientific advisory board, Procter & Gamble; external ad
visory board, CTSA Duke University; external advisory board, CTSA University
of Pittsburgh; and consultancy, University of California, Davis).
Ivy Alexander (board member, Pfizer; consultancy, Pfizer and WebMD; grants,
HRSA ANA; lectures, MidlevelU, Planned Parenthood, Quinnipiac; and royal
ties, Jones & Bartlett Publishers, NPACE).
This article has been reviewed, and all potential or actual conflicts have been
resolved.
DOI-10.1097/01.NPR.0000541464.23795.5b
34 The Nurse Practitioner -  Vol. 43, No. 8
www.tnpj.com