Sexually Transmitted Diseases Quick Guide
Screening and Diagnosis
- HIV testing is no longer included in the overseas health exam (as of January 4, 2010) and should be part of each domestic screening per age and prevalence-specific recommendations.
- Routine screening for HIV, ages 13 to 64 years, per CDC guidelines. Make sure the lab tests for both HIV type 1 and type 2.
- For refugees from areas of the world with mid-high prevalence of HIV/AIDS (e.g., Sub-Saharan Africa and Asia) universal testing (all ages) of HIV and syphilis for arrivals is recommended.
- Offer opt-out screening which involves performing HIV screening after notifying the patient that the test will be performed unless the patient specifically declines. Consent for HIV screening should be incorporated into the patient's general informed consent for medical care; a separate signed consent for HIV testing is not recommended. Information for patients should be culture and language appropriate.
- Screen other STDs if indicated by self-report or endemicity in homeland. Routine screening is not recommended.
- All patients who are diagnosed with syphilis should be tested for HIV infection.
- Technology for urine screening for both C. trachomatis and N. gonorrhoeae is available and is considered equally, if not more, sensitive than traditional laboratory methods. This non-invasive testing is preferred for the refugee population, if systems allow.
- Patients infected with N. gonorrhoeae often are co-infected with C. trachomatis.
- Most infections among men produce symptoms that cause them to seek curative treatment. However, many infections among women do not produce recognizable symptoms until complications, e.g., pelvic inflammatory disease (PID), have occurred.
- As stated in CDC's STD Treatment Guidelines, "Penicillin G, administered parenterally, is the preferred drug for treating all stages of syphilis. The preparation used (i.e., benzathine, aqueous procaine, or aqueous crystalline), the dosage, and the length of treatment depend on the stage and clinical manifestations of the disease."
- Persons who have been adequately treated in the past for syphilis may remain seropositive by nontreponomal testing and will remain seropositive by treponomal testing. A thorough medical history is essential in distinguishing untreated disease and previously treated disease.
- The differential diagnosis for a positive serology test to syphilis in a patient who is asymptomatic includes the following:
- Latent syphilis transmitted through sexual contact.
- Syphilis transmitted through nonsexual modes which include direct or indirect contact with infectious early lesions of skin and mucous membranes. This condition, also known as “endemic syphilis,” occurs in localized areas where poor socioeconomic conditions and inadequate sanitation prevail. It is caused by Treponema pallidum ssp. endemicum and is not unusual among children.
- Treponema pallidum pertenue ssp. pertenue causes yaws. Yaws predominately consists of papular skin lesions that resolve spontaneously, but latent infection occurs. Persons with latent infection may subsequently develop destructive gummatous lesions that can be quite severe.
- Cases of gonorrhea caused by N. gonorrhoeae resistant to fluoroquinolones have been reported sporadically from many parts of the world and are becoming widespread in parts of Asia.
- Because of the prevalence of quinolone-resistant N. gonorrhoeae (QRNG) in parts of Asia, treatment with a non-quinolone regimen is recommended.
- Culture and susceptibility testing should be performed on a patient who has apparent treatment failure after recommended therapy and should also be reported to MDH.
Several important sequelae can result from C. trachomatis infection in women; the most serious of these include PID, ectopic pregnancy, and infertility. Some women who have apparently uncomplicated cervical infection already have sub-clinical upper reproductive tract infection.
In populations with erratic health care-seeking behavior, poor compliance with treatment, or minimal follow-up, azithromycin may be more cost-effective because it provides single-dose, directly observed therapy.
Rationale for HIV Testing
- HIV continues to carry considerable stigma in immigrant and refugee communities, however significant health concerns justify recommendations for routine testing and follow up (i).
- Many refugees come from regions of the world where HIV/TB co-infections are prevalent. Co-infected persons experience a 5 to 10 percent annual risk of developing active tuberculosis compared to a 10 percent lifetime risk among immune competent persons.
- Immunizations are a significant component of the domestic refugee health assessment and Adjustment of Status health assessment; administering live viral vaccines (i.e. MMR, varicella) are contraindicated for HIV positive persons (ii).
- Routine and targeted universal testing for HIV allows for identification and care of individuals who may unknowingly be infected via perinatal transmission, breastfeeding, or undisclosed infection from partners.
Full Provider Guide Chapter: Sexually Transmitted Diseases
- Find more detailed information on this section of the initial refugee health assessment in the Minnesota Refugee Health Provider Guide: Sexually Transmitted Diseases chapter along with appendices and additional resources.
i. Othieno J. Understanding how contextual realities affect African born immigrants and refugees living with HIV in accessing care in the Twin Cities. J Health Care for the 2006;55(14). Poor and Underserved. 2007;18(3)170-188.
ii. Minnesota Department of Health Division of Infectious Disease Epidemiology, Prevention and Control. Comment letter on removal of HIV from the definition of communicable disease of public health significance and the changes to HIV testing from the scope of examinations to federal register, Aug. 13,2009.