Decreasing availability of sexually transmitted disease (STD) clinics in the US over time has pushed many patients toward non-specialty providers such as primary care, emergency departments, and family planning clinics. In fact, primary care clinicians play an important role in sexual health care as may patients are asymptomatic, and infections are diagnosed during a primary care visit scheduled for other reasons.Given the potential wide variation between the sexual health services now provided in both STD and non-STD settings, the Centers for Disease Control and Prevention (CDC) this month released a new report that specifies operational determinants of quality services delivered in primary and specialty care settings. (Continued below)
The recommendations are broken into 8 sections, categorized as either “strong” or “weak” with strong recommendations worded as "should" and weak recommendations worded as "could. In the slides above we focus on the CDC’s recommendations that “should" be available as part of basic STD care in primary care.
1. Sexual History and Physical Examination. A complete sexual history includes inquiring about the 5 Ps, that is, partners, practices, protection, past STD history, and pregnancy prevention. In addition to the strong recommendations stated above, a sexual history and risk assessment could be available at each visit unrelated to reproductive, genital, or urologic concerns and an anoscopy could be available as well.
2. Prevention. Along with the prevention services that are strongly recommended (as stated in the slide above), on-site condom provision, on-site hepatitis A (HAV) vaccination, provision of PrEP for HIV prevention, provision of nPEP of HIV, and moderate-intensity STD behavioral counseling (≥30 mins) could all be available as basic STD care services.
3. Screening and Assessment. Screening patients for asymptomatic STDs is crucial for early disease detection and prevention. Also, because patients often do not present with symptoms, testing is the sole method for diagnosis. In addition to the STDs that should be screened/assessed as listed above, PCPs could screen and assess for trichomoniasis.
4. Partner Services. Treating the sexual partner of a patient with an STD is important in preventing reinfection and interrupting STD transmission. Partner services include guidance regarding notification and care of sex partners (strong recommendation), EPT (strong recommendation), and interactive counseling for partner notification (weak recommendation). Interactive counseling for partner notification allows both PCPs and patients to actively participate in an individualized plan to notify the patient's sexual partner(s).
5. Evaluation of STD-related conditions. Evaluation for the following STD-related conditions should be available:
•Genital ulcer disease •Male urethritis syndrome •Vaginal discharge •PID •Genital warts •Proctitis
•Ectoparasitic infections •Pharyngitis •Epididymitis •Systemic or dermatologic conditions compatible with or suggestive of STD etiology
6. Laboratory. At the time of the patient visit, the general services, equipment, or tests that should be available are thermometers and pH paper. Phlebotomy, trichomoniasis testing, bacterial vaginosis testing, vulvovaginal candidiasis testing, urine dipstick, urinalysis with microscopy, pregnancy testing, and HIV testing could be available as basic STD services with test results available during the patient visit. In addition to the above mentioned tests that should be available through a clinical laboratory, ones that could be available include gram stain, methylene blue, or gentian violet stain for urethritis, gonorrhea culture, gonorrhea antimicrobial susceptibility testing, and NAAT for trichomoniasis.
7. Treatment. For quality STD care in primary care clinics, medications for the following STDs could be available on site vs by prescription:
•Gonorrhea •Chlamydia •Cervicitis •Nongonococcal urethritis •Proctitis •PID •Epididymitis •Syphilis •PrEP •nPEP •Provider-applied regimens for genital warts •Emergency contraceptive pills
8. Referral. PCPs should make referrals to physicians who have extensive specialized training or experience in diagnosing, treating, and providing follow-up for complex STD cases. Services can be provided in different sites within a multispecialty practice or hospital system.
