CDC Recommendations for Quality Clinical Services for Sexually Transmitted Diseases

The Centers for Disease Control and Prevention (CDC) released recommendations for providing quality clinical services (QCS) for sexually transmitted diseases (STDs) in primary care and STD specialty care settings. These recommendations, published in the Morbidity and Mortality Weekly Report and henceforth referred to as STD QCS, are intended to complement the CDC’s STD Guidelines, 2015 by providing guidance on clinical operations and the types of services that should be available for STD care.

The focus of STD QCS is on structural-level policy recommendations about which STD-related clinical services should be available to facilitate implementation of the CDC’s STD Guidelines, 2015. STD QCS recommendations are outlined in the following 8 sections: (1) sexual history and physical examination, (2) prevention, (3) screening, (4) partner services, (5) evaluation of STD-related conditions, (6) laboratory, (7) treatment, and (8) referral to a specialist for complex STD or STD-related conditions. 

While the full report provides guidance on strong and weak recommendations for each of the 8 sections, the following list outlines the strong recommendations for primary care and STD specialty care setting. Primary care setting is defined as a place where patients are evaluated for various health conditions. An STD specialty care setting is defined as a place where the focus is on providing patients with timely, comprehensive, confidential, and culturally sensitive STD care. The report authors also note that STD care delivered in STD specialty care settings includes all care delivered in primary care settings.

Sexual History and Physical Examination

In primary care settings, a sexual history, a physical examination, and a pelvic examination are strongly recommended. In STD specialty care settings, the addition of an anoscopy and a colposcopy for women with abnormal Papanicolaou (Pap) smear tests should be available.

Prevention

The following prevention services should be available as basic STD care services: referral to or on-site hepatitis B and human papillomavirus (HPV) vaccination; brief single STD/HIV prevention counseling session (up to 30 minutes); pre-exposure prophylaxis (PrEP) for HIV prevention and nonoccupational postexposure prophylaxis (PEP) for HIV risk assessment, education, and referral or link to HIV care; emergency contraceptive pills; brief contraceptive counseling or referral; and referral or link to HIV care, family planning services, and behavioral health services, if indicated.

In addition to this list, the following prevention services should be available in STD specialty care settings: on-site condom provision; on-site hepatitis A vaccination; provision of PrEP for HIV prevention; and provision of nonoccupational PEP for HIV. 

Screening

In primary care settings, screening and assessment for the following should be available: gonorrhea, chlamydia, syphilis, hepatitis B and C viruses, HIV, and cervical cancer. Additionally, screening and assessment for trichomoniasis should be available as specialized STD care services.

Partner Services

Guidance regarding notification and care of sex partners and expedited partner therapy (EPT), where its use is not prohibited by legal and local or state jurisdictions, should be available as basic STD care services. In addition to these 2 services, specialized STD care services should make available an interactive counseling for partner notification and health department disease intervention specialist elicitation of sex partner information to identify those who might have been exposed and to identify patient follow-up needs.

Evaluation of STD-Related Conditions

Primary care and STD specialty care settings should evaluate (history and examination) for the following STD-related conditions: genital ulcer disease, male urethritis syndrome, vaginal discharge, pelvic inflammatory disease (PID), genital warts, proctitis, ectoparasitic infections, pharyngitis, epididymitis, and systemic or dermatologic conditions compatible with or suggestive of an STD etiology.

Laboratory

At the time of patient visit, the following general services, equipment, or tests should be available as basic STD care services: thermometer and pH paper. In addition to thermometer and pH paper, the following should be available in STD specialty care settings: phlebotomy; testing for trichomoniasis, bacterial vaginosis, and vulvovaginal candidiasis; urine dipstick; urinalysis with microscopy; test for pregnancy; Gram stain, methylene blue, or gentian violet stain for urethritis; and on-site qualitative nontreponemal serologic test for syphilis.

The following tests should be available through clinical laboratory as basic STD care services: urogenital nucleic acid amplification test (NAAT) for gonorrhea and chlamydia; extragenital (pharynx and rectum) NAAT for gonorrhea and chlamydia; quantitative nontreponemal serologic test for syphilis; treponemal serologic test for syphilis; herpes simplex virus (HSV) viral culture or polymerase chain reaction; HSV serology; fourth-generation antigen/antibody HIV test; oncogenic HPV NAATs with Pap smear; nonoccupational PEP and PrEP; serologic tests for hepatitis A, B, and C viruses; and test for pregnancy. In addition, the following tests should be available through a clinical laboratory in STD specialty care settings: gonorrhea culture and antimicrobial susceptibility testing and NAAT for trichomoniasis.

Treatment

As basic STD care services, all recommended medications for the following should be available by prescription: EPT for gonorrhea and chlamydia, herpes, trichomoniasis, bacterial vaginosis, vulvovaginal candidiasis, urinary tract infection, PrEP, nonoccupational PEP, emergency contraceptive pills, patient-applied regimens for genital warts, and ectoparasitic infections.

In STD specialty care settings, medications for the following should be available on site: gonorrhea, chlamydia, cervicitis, nongonococcal urethritis, proctitis, PID, epididymitis, syphilis, nonoccupational PEP, provider-applied regimens for genital warts, emergency contraceptive pills, EPT for gonorrhea and chlamydia, herpes, and trichomoniasis.

Referral to a Specialist for Complex STD or STD-Related Conditions

Referrals should be made to clinicians who have extensive specialized training or experience in diagnosing, treating, and providing follow up for complex STD cases. These providers can include adult and pediatric infectious disease clinicians, maternal-fetal medicine specialists, allergists, ophthalmologists, gastroenterologists, colorectal surgeons, urologists, oncologists, and other specialists.

These recommendations allow health care providers to build, maintain, or enhance the delivery of STD services, noted the researchers. “Health care settings might not provide every service outlined for quality STD care; however, the recommendations can provide the opportunity to assess which services are available in a facility and determine whether additional services can or should be made available or whether mechanisms for referral can or should be developed,” they added.

Reference

Barrow RY, Ahmed F, Bolan GA, Workowski KA. Recommendations for providing quality sexually transmitted diseases clinical services, 2020. MMWR Recomm Rep. 2020;68(5):1-20.