Madison Clinic
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Procedures for STD Screening/Testing

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STD Screening: Gonorrhea and Chlamydia

The Aptima Combo 2 test for the detection of Chlamydia (CT) and Gonorrhea (GC) nucleic acid (NA) has recently been validated (internally) and found to perform well on both rectal and pharyngeal specimens.  NAAT is more sensitive than culture of these organisms at all anatomic sites.  Previous studies have demonstrated the superiority of CT/GC NA testing over culture on cervical/vaginal, rectal, pharyngeal, urethral and urine specimens.  Therefore, Madison Clinic providers should use NA based tests for the detection of CT/GC.
The following points provide guidance for CT/GC testing at the clinic:
Preferred Specimens

  1. Regarding NA testing of the female genital tract, please know that the preferred specimen for GC/CT screening is a vaginal swab since this is the most sensitive, followed by cervical swabs and urine (but all are pretty good).
  2. The lab will perform the combination NA tests for both CT and GC no matter what specimen you send but will only report what you ask for.  In almost all cases you will want both CT and GC results but if you want only CT OR GC then order only the one test.  Although screening for pharyngeal CT is not recommended, if you detect a case of pharyngeal CT infection, the treatment is the same as that for genital CT infection.
  3. The NAAT kits with the orange colored swab are designed for collection of vaginal fluid, but while the kits are labeled for vaginal use, they are also suitable for specimen collection from the pharynx and rectum.  When collecting the specimen unscrew the cap with covering foil, place the blue swab in the tube, snap off the swab at the scored site, screw on the cap, label the tube and submit it to the lab.

STI Self-Testing Program

What:  Sexually transmitted infections (STI) self-testing program for men who have sex with men (MSM)

Why:  HIV+ MSM are disproportionately affected by the bacterial STIs, yet STI screening in HIV care remains suboptimal.  Patients want more frequent and more convenient screening, and providers feel they don’t have time to include STI screening into a routine clinic visit.  What is more, CDC recommends STI screening every 3-6 month for high-risk MSM (High-risk MSM are defined as having more than 10 sexual partners in one year, or more than 4 in the prior 2 months; using meth or poppers; having had a bacterial STD in the prior year or any report of unprotected anal intercourse), and routine clinic visits now occur every 6 months which prevents more frequent screening.  The STI Self-testing program at Madison clinic allows patients to screen more frequently and conveniently, and gives providers an alternative mechanism to ensure their patients are screened.

Where:  Madison Clinic, in a designated self-testing room (Restroom near Exam Room 10).

When:  The self-testing program is available during normal business hours beginning March, 1, 2013.

How:  Patients can either request STI self-testing at the front desk, or providers may refer for self-testing at the end of a clinic visit.

For provider-initiated self-testing, please explain to the patient that he is being referred for self-testing.  Then, locate the STI self-testing forms available in each exam room:

1) Check the Self-testing referral box on the main order form,

2) Sign the “Sexually Transmitted Infection Patient Self-testing Orders” 

3) Provide the patient with the “Self-Testing for STIs Patient Assessment” form.

Treatment and Provider Notification:  All patient-initiated STI self-testing will be ordered under Shireesha Dhanireddy’s name.  Dr. Dhanireddy will ensure timely and appropriate treatment of all patients with positive test results and will notified the primary provider via ORCA.  Treatment of patients who underwent STI Self-testing because the provider referred them at the end of the clinic visit is the responsibility of the primary provider.

STI Reporting:  Bacterial STI are reportable infections.  Providers who diagnose gonorrhea, chlamydia or syphilis are required to fill out the Public Health Seattle & King County STD Case Report Form. The STD Case Report form should be faxed to Public Health, which the front desk staff is happy to help you with.  Harborview also mandates that you must submit a HIPAA exception form for mandatory reporting of STD/AIDS (this form can be found in the second drawer of the forms cabinet in the provider room). This form needs to be scanned into the patient’s medical record.

Questions?  Contact Lindley Barbee or Shireesha Dhanireddy.


Screening Frequency

  1.  STD screening for “high risk” MSM should be every 3 months at all exposed anatomic sites.  High risk is defined as follows
    1. Diagnosis of a bacterial STD in the prior year (gonorrhea, chlamydial infection or early syphilis**)
    2. Methamphetamine or popper use in the prior year
    3. >10 sex partners (anal or oral) in the prior year
    4. Unprotected anal intercourse 
  2. STD screening for sexually active MSM who do not meet the high risk criteria, women and heterosexual men should be performed annually.  Those at increased risk for STDs (e.g. see #6) should be screened more frequently at the discretion of the provider.
  3. Asymptomatic CT infection of the cervix and rectum is common and asymptomatic GC infection of the cervix, rectum and pharynx is also common. Asymptomatic male urehtritis due to CT and GC is uncommon but should still be included in regular screening tests (urine NAAT).  The sites screened for asymptomatic CT and GC infection should be dictated by sexual practices (e.g. receptive anal intercourse would require anal testing for CT and GC, vaginal intercourse would require vaginal/cervix testing for CT/GC, oral sex requires pharyngeal testing for GC (not CT). 

Culture for surveillance of reduced susceptibility GC

  • Individuals who test positive for GC by NA testing should be advised to return to clinic for treatment (ceftriaxone) and should be cultured immediately prior to treatment to help monitor for drug resistant GC.
  • Individuals who present with symptoms consistent with GC should be screened at the time of presentation with both NA testing and GC culture immediately prior to treatment. 

Screening for STDs in MSM

The following guidelines are adapted from King County Department of Health website. [Link]

HIV TESTING and STD SCREENING* RECOMMENDATIONS
for MEN WHO HAVE SEX WITH MEN (MSM)

Clinicians should ask all men if they've been sexually active with men, women, or both.

  1. HIV testing and STD screening should be performed on all sexually active MSM annually except those in long-term (> 1 year), mutually monogamous, HIV concordant relationships. Sexually active MSM include all MSM engaging in any anal, or oral sex. Screening should include the following tests:
    1. HIV (if patient is not previously known to be HIV infected)
    2. Serological testing for syphilis (i.e. RPR or other syphilis screening test)
    3. Rectal cultures or nucleic acid amplification tests for gonorrhea and chlamydial infection (men who report receptive anal sex only)+
    4. Pharyngeal culture or NAAT for gonorrhea+
  2. Repeat HIV and STD testing (as above) should be performed every 3 months in MSM with any one or more of the following risks:
    1. Diagnosis of a bacterial STD in the prior year (gonorrhea, chlamydial infection or early syphilis**)
    2. Methamphetamine or popper use in the prior year
    3. >10 sex partners (anal or oral) in the prior year
    4. Unprotected anal intercourse with a partner of unknown or discordant HIV status in the prior year

* Screening refers to testing in the absence of signs, symptoms or known exposure to an STD.

+ Existing data suggest that the Aptima Combo 2 test performs well on rectal and pharyngeal specimens and is more sensitive than culture. Laboratories performing the test must first perform an internal validation study. Clinicians should use caution in interpreting results of the Roche PCR (Roche Diagnostics) assay for gonorrhea, which is not specific, and the Becton Dickenson strand displacement assay, which has not been well studied and may be insensitive.

** Persons with early syphilis should be retested at 1, 3, 6, 9 and 12 months. Persons rescreening following an episode of urethral gonorrhea or chlamydial infection should be retested for urethral gonorrhea and chlamydia

Screening for STDs in Women

Chlamydia

  • In 2001 in their most recent statement on screening for Chlamydia, the United States Preventive Services Task Force (USPSTF) strongly recommends screening for Chlamydia in all sexually active women 25 years and younger, and other asymptomatic women at increased risk for infection.
  • Besides age, other patient characteristics associated with a higher prevalence of infection include being unmarried, African-American race, having a prior history of sexually transmitted disease (STD), having new or multiple sexual partners, having cervical ectopy, and using barrier contraceptives inconsistently.
  • According to the USPSTF: “The optimal interval for screening is uncertain. For women with a previous negative screening test, the interval for re-screening should take into account changes in sexual partners. If there is evidence that a woman is at low risk for infection (e.g., in a mutually monogamous relationship with a previous history of negative screening tests for chlamydial infection), it may not be necessary to screen frequently...”
  • Except in pregnant women, test-of-cure (repeat testing 3–4 weeks after completing therapy) is not recommended for persons treated with the recommended or alterative regimens, unless therapeutic compliance is in question, symptoms persist, or reinfection is suspected.
  • Recognizing that testing for reinfection is distinct from test of cure, clinicians should consider advising all women with chlamydial infection to be retested approximately 3 months after treatment. Providers also are strongly encouraged to retest all women treated for chlamydial infection whenever they next seek medical care within the following 3–12 months, regardless of whether the patient believes that her sex partners were treated.

Gonorrhea

  • The USPSTF recommends routine screening for gonorrhea in high-risk women.
  • As with chlamydia, there is no optimal interval defined for screening

HSV1+HSV2:

Unroof lesion and use Dacron swab located in side drawer of exam table; place swab in transport media (tube containing pink fluid), label and send to the lab

Syphilis:

For Testing: Algorithm

Persons presenting as contacts to syphilis or who have signs or symptoms concerning for syphilis should have stat qualitative RPR testing and, if a possible chancre is present, testing by darkfield microscopy. Stat serological RPR testing can be performed at the PHSKC STD clinic on the 11th floor of the Ninth and Jefferson building [NJB].

The STD clinic can also perform darkfield testing; patients should go to the clinic for darkfield testing to assure that the best specimen is obtained. Persons with a history of syphilis usually remain positive on treponemal specific tests for life, therefore when evaluating such patients for signs or symptoms concerning for syphilis, clinicians should order a quantitative RPR as part of the intial laboratory evalaution and not order an EIA alone.

Serologic Testing for syphilis - Letter from Matt Golden, MD. Director of PHSKC STD Control Program [12/09] - UW Net ID required

Haemophilus ducreyi (chancroid):

This disease is very rare in the United States. To diagnose chancroid one can do a culture in chocolate agar or PCR technology may be available. If a concern arises, would recommend a call to the STD Clinic at 744-3590 for further information.

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