New CDC treatment guidelines for sexually transmitted infections

By Kathryn Schwarzenberger, MD, FAAD, May 1, 2022

In this month’s Clinical Applications column, Physician Editor Kathryn Schwarzenberger, MD, FAAD, talks with Kimberly A. Workowski, MD, from the Division of STD Prevention within the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention at the Centers for Disease Control and Prevention (CDC) about her Morbidity and Mortality Weekly Report, "Sexually Transmitted Infections Treatment Guidelines, 2021."

DermWorld: The updated "Sexually Transmitted Infections Treatment Guidelines, 2021" is an incredibly well done, comprehensive, and clinically useful document that anyone seeing patients should be familiar with. Are there any major changes from the previous 2015 guidelines that you would like to highlight?

It also includes information on mycoplasma genitalium diagnostic and management recommendations; expanded risk factors for repeat syphilis testing among pregnant women; two-step, type-specific serologic diagnosis for genital herpes simplex virus; harmonized recommendations for HPV vaccination with the Advisory Committee on Immunization Practices; and universal hepatitis C testing in alignment with CDC’s 2020 hepatitis C testing recommendations.

DermWorld: Dermatologists know warts. Is there anything new regarding management of HPV infection? Some dermatologists advocate therapeutic treatment with HPV vaccination. Is there data to support this at present time?

Dr. Workoski: There are no new recommendations on the management of warts, but the updated treatment guidelines include harmonized recommendations for HPV vaccination with the Advisory Committee on Immunization Practices (ACIP). According to CDC’s Epidemiology and Prevention of Vaccine-Preventable Diseases resource (also known as the “Pink Book”), ideally, the HPV vaccine should be administered before any exposure to HPV through sexual contact. However, persons in the routine and catch-up age ranges (through age 26 years) should be vaccinated, even if they might have been exposed to HPV in the past. Vaccination will provide less benefit to sexually active persons who have been already infected with one or more HPV vaccine types. However, HPV vaccination can provide protection against HPV vaccine types not already acquired. Recipients may be advised that prophylactic vaccine is not expected to have a therapeutic effect on existing HPV infection, anogenital warts, or HPV-related lesions.

DermWorld: In what setting should a dermatologist consider prescribing PrEP, and do you have any thoughts as to how can we make the dermatologic community more comfortable doing so?

Dr. Workoski: Recently updated PrEP guidelines (PDF) are the best resource for information on prescribing PrEP. The CDC recommends that all sexually active adult and adolescent patients receive information about PrEP and that it should be offered to adults and adolescents weighing ≥35 kg who are HIV negative and at substantial risk for HIV infection. Dermatologists should have patient resources on PrEP (such as flyers or brochures) on hand, and if needed, be prepared to refer patients interested in PrEP to a physician who offers ongoing medical evaluation for people taking PrEP.

DermWorld: Many of us are caring for transgender patients now. Are there any unique aspects about STIs in this population we should be aware of?

Dr. Workoski: The updated guidelines include screening recommendations for transgender and gender-diverse persons. Because of the diversity of transgender persons regarding surgical gender-affirming procedures, hormone use, and their patterns of sexual behavior, physicians should remain aware of symptoms consistent with common STIs and screen for asymptomatic infections based on the patient’s sexual practices and anatomy.

Gender-based screening recommendations should be adapted based on anatomy (e.g., routine screening for trachomatis and N. gonorrhoeae) as recommended for all sexually active females aged <25 years on an annual basis, and should be extended to transgender men and nonbinary persons with a cervix among this age group.

DermWorld: Dermatologists do see patients with genital/perianal ulcers. If I am reading your guidelines correctly, you advocate presumptive treatment of suspected syphilis (and herpes simplex) even prior to test results coming back. Can you discuss this?

Dr. Workoski: A diagnosis based only on medical history and physical examination can be inaccurate. Therefore, all persons who have genital, anal, or perianal ulcers should be evaluated. Specific evaluation of genital, anal, or perianal ulcers includes syphilis serology tests, or a nucleic acid amplification test (NAAT) if available; NAAT or culture for genital herpes type 1 or 2; and serologic testing for type-specific herpes simplex virus (HSV) antibody.

Because early syphilis treatment decreases transmission possibility, public health standards require physicians to presumptively treat any patient with a suspected case of infectious syphilis at the initial visit, even before test results are available. Presumptive treatment of a patient with a suspected first episode of genital herpes is also recommended because HSV treatment benefits depend on prompt therapy initiation.

The physician should choose the presumptive treatment based on the clinical presentation (i.e., HSV lesions begin as vesicles and primary syphilis as a papule) and epidemiologic circumstances.

DermWorld: Where are we with diagnostic testing for herpes simplex infections? Nucleic Acid Amplification Test vs. PCR? What is the present status of serologic testing?

Dr. Workoski: Currently, one of the greatest challenges in diagnosing herpes is that the lesions associated with the infection are not always present or are healing when patients see their physician — and the most accurate tests for detecting herpes infection require samples or swabs from active lesions. Random or blind genital swabs, in the absence of lesions, are not recommended to diagnose genital herpes infection, because of the risk of a false-negative test.

Type-specific serologic tests can be used to aid in herpes diagnosis when lesions are not present. However, given the limitations of the commercially available tests, screening of the general population is not recommended. Type-specific HSV-2 serologic assays for diagnosing HSV-2 are useful in persons with recurrent or atypical genital symptoms or lesions with a negative HSV PCR or culture result, for clinical diagnosis of genital herpes without laboratory confirmation, or if a patient’s partner has genital herpes.

Innovation is greatly needed for new tools to address genital herpes including more accurate diagnostic tests and vaccines. The CDC STI Treatment Guidelines reflect the most recent guidance for diagnosis and management of genital herpes.

DermWorld: Any thoughts on how to help dermatologists (and likely other physicians) become more comfortable asking questions about STI and HIV risk?

Dr. Workoski: Effective interviewing and counseling skills, characterized by respect, compassion, and a nonjudgmental attitude, are essential to obtaining a thorough sexual history and delivering effective prevention messages. Effective techniques for facilitating rapport with patients include using open-ended questions, understandable, nonjudgmental language, and normalizing language (e.g., “Some of my patients have difficulty using a condom with every sex act. How is it for you?”). I recommend that physicians refer to the STI and HIV Infection Risk Assessment section of the STI Treatment Guidelines to normalize risk assessment.

Kimberly A. Workowski, MD, is a professor of medicine in the Division of Infectious Diseases at Emory University. She also works in the Division of STD Prevention within the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention at the CDC. Her paper appeared in Morbidity and Mortality Weekly Report.

Dr. Workowski has no relevant financial or commercial conflicts of interest.

Disclaimer: The views and opinions expressed in this article do not necessarily reflect those of DermWorld.

Additional DermWorld Resources