Kimberly A. Workowski, M.D.
William C. Levine, M.D., M.Sc.
The material in this report was prepared for publication by the
National Center for HIV, STD, and TB Prevention, Harold W. Jaffe, M.D.,
Acting Director; and the Division of Sexually Transmitted Diseases
Prevention, Harold W. Jaffe, M.D., Acting Director.
These guidelines for the treatment of patients who have sexually
transmitted diseases (STDs) were developed by the Centers for Disease
Control and Prevention (CDC) after consultation with a group of
professionals knowledgeable in the field of STDs who met in Atlanta on
September 26--28, 2000. T
Included in these updated guidelines are
new alternative regimens for scabies, bacterial vaginosis, early
syphilis, and granuloma inguinale; an expanded section on the diagnosis
of genital herpes (including type-specific serologic tests); new
recommendations for treatment of recurrent genital herpes among persons
infected with human immunodeficiency virus (HIV); a revised approach to
the management of victims of sexual assault; expanded regimens for the
treatment of urethral meatal warts; and inclusion of hepatitis C as a
sexually transmitted infection. In addition, these guidelines emphasize
education and counseling for persons infected with human papillomavirus,
clarify the diagnostic evaluation of congenital syphilis, and present
information regarding the emergence of quinolone-resistant Neisseria
gonorrhoeae and implications for treatment. Recommendations also are
provided for vaccine-preventable STDs, including hepatitis A and
Physicians and other health-care providers play a critical role in
preventing and treating sexually transmitted diseases (STDs). These
recommendations for the treatment of STDs are intended to assist with
that effort. Although these guidelines emphasize treatment, prevention
strategies and diagnostic recommendations also are discussed.
This report was produced through a multi-stage process. Beginning in
2000, CDC personnel and professionals knowledgeable in the field of STDs
systematically reviewed literature (i.e., published abstracts and
peer-reviewed journal articles) concerning each of the major STDs,
focusing on information that had become available since publication of
the 1998 Guidelines for Treatment of Sexually Transmitted Diseases
Background papers were written and tables of evidence constructed
summarizing the type of study (e.g., randomized controlled trial or case
series), study population and setting, treatments or other
interventions, outcome measures assessed, reported findings, and
weaknesses and biases in study design and analysis. A draft document was
developed on the basis of the reviews.
In September 2000, CDC staff members and invited consultants
assembled in Atlanta for a 3-day meeting to present the key questions
regarding STD treatment that emerged from the literature reviews and the
information available to answer those questions. When relevant, the
questions focused on four principal outcomes of STD therapy for each
individual disease: a) microbiologic cure, b) alleviation of signs and
symptoms, c) prevention of sequelae, and d) prevention of transmission.
Cost-effectiveness and other advantages (e.g., single-dose formulations
and directly observed therapy [DOT]) of specific regimens also were
discussed. The consultants then assessed whether the questions
identified were relevant, ranked them in order of priority, and
attempted to arrive at answers using the available evidence. In
addition, the consultants evaluated the quality of evidence supporting
the answers on the basis of the number, type, and quality of the
In several areas, the process diverged from that previously
described. The sections concerning adolescents and hepatitis A, B, and C
infections were developed by other CDC staff members knowledgeable in
this field. The recommendations for STD screening during pregnancy were
developed after CDC staff reviewed the published recommendations from
other knowledgeable groups. The sections concerning early human
immunodeficiency virus (HIV) infection are a compilation of
recommendations developed by CDC staff members knowledgeable in the
field of HIV infection. The sections on hepatitis B virus (HBV) ()
and hepatitis A virus (HAV) ()
infections are based on previously published recommendations of the
Advisory Committee on Immunization Practices (ACIP).
Throughout this report, the evidence used as the basis for specific
recommendations is discussed briefly. More comprehensive, annotated
discussions of such evidence will appear in background papers that will
be published in a supplement issue of the journal Clinical Infectious
Diseases. When more than one therapeutic regimen is recommended, the
sequence is alphabetized unless the choices for therapy are prioritized
based on efficacy, convenience, or cost. For STDs with more than one
recommended regimen, almost all regimens have similar efficacy and
similar rates of intolerance or toxicity unless otherwise specified.
These recommendations were developed in consultation with public- and
private-sector professionals knowledgeable in the treatment of patients
with STDs. They are applicable to various patient-care settings,
including family planning clinics, private physicians' offices, managed
care organizations, and other primary-care facilities. When using these
guidelines, the disease prevalence and other characteristics of the
medical practice setting should be considered. These recommendations
should be regarded as a source of clinical guidance and not as standards
or inflexible rules. These guidelines focus on the treatment and
counseling of individual patients and do not address other community
services and interventions that are important in STD/HIV prevention.
Clinical Prevention Guidelines
The prevention and control of STDs is based on the following five
major concepts: a) education and counseling of persons at risk on ways
to adopt safer sexual behavior; b) identification of asymptomatically
infected persons and of symptomatic persons unlikely to seek diagnostic
and treatment services; c) effective diagnosis and treatment of infected
persons; d) evaluation, treatment, and counseling of sex partners of
persons who are infected with an STD; and e) preexposure vaccination of
persons at risk for vaccine-preventable STDs. Although this report
focuses mainly on the clinical aspects of STD control, primary
prevention of STDs begins with changing the sexual behaviors that place
persons at risk for infection. Moreover, because STD control activities
reduce the likelihood of transmission to sex partners, treatment of
infected persons constitutes primary prevention of spread within the
Clinicians have a unique opportunity to provide education and
counseling to their patients. As part of the clinical interview,
health-care providers can obtain sexual histories from their patients.
Guidance in obtaining a sexual history is available in Contraceptive
Technology, 17th edition (4).
Prevention messages should be tailored to the patient, with
consideration given to the patient's specific risk factors for STDs.
Messages should include a description of specific actions that the
patient can take to avoid acquiring or transmitting STDs (e.g.,
abstinence from sexual activity if STD-related symptoms develop).
If risk factors are identified, providers should encourage patients
to adopt safer sexual behaviors. Counseling skills (e.g., respect,
compassion, and a nonjudgmental attitude) are essential to the effective
delivery of prevention messages. Techniques that can be effective in
facilitating rapport with the patient include using open-ended
questions, using understandable language, and reassuring the patient
that treatment will be provided regardless of circumstances unique to
individual patients (including ability to pay, citizenship or
immigration status, language spoken, or lifestyle).
Many patients seeking treatment or screening for STDs expect
evaluation for all common STDs; all patients should be specifically
informed if testing for a common STD (e.g., genital herpes and human
papillomavirus [HPV]) is not performed.
The most reliable way to avoid transmission of STDs is to abstain
from sexual intercourse (i.e., oral, vaginal, or anal sex) or to be in a
long-term, mutually monogamous relationship with an uninfected partner.
Counseling that encourages abstinence from sexual intercourse is crucial
for persons who are being treated for an STD or whose partners are
undergoing treatment and for persons who wish to avoid the possible
consequences of sexual intercourse (e.g., STD/HIV and unintended
pregnancy). A more comprehensive discussion of abstinence and the range
of sexual expression is available in Contraceptive Technology, 17th
Both partners should get tested for STDs, including HIV, before
initiating sexual intercourse.
If a person chooses to have sexual intercourse with a partner
whose infection status is unknown or who is infected with HIV or
another STD, a new condom should be used for each act of insertive
Preexposure vaccination is one of the most effective methods for
preventing transmission of certain STDs. For example, because hepatitis
B virus infection frequently is sexually transmitted, hepatitis B
vaccination is recommended for all unvaccinated persons being evaluated
for an STD. In addition, hepatitis A vaccine is currently licensed and
is recommended for men who have sex with men (MSM) and illegal drug
users (both injection and non-injection). Vaccine trials for other STDs
are being conducted, and additional vaccines may become available in the
next several years.
When used consistently and correctly, male latex condoms are
effective in preventing the sexual transmission of HIV infection and can
reduce the risk for other STDs (i.e., gonorrhea, chlamydia, and
trichomonas). However, because condoms do not cover all exposed areas,
they are likely to be more effective in preventing infections
transmitted by fluids from mucosal surfaces (e.g., gonorrhea, chlamydia,
trichomoniasis, and HIV) than in preventing those transmitted by
skin-to-skin contact (e.g., herpes simplex virus [HSV], HPV, syphilis,
and chancroid). Condoms are regulated as medical devices and are subject
to random sampling and testing by the Food and Drug Administration
(FDA). Each latex condom manufactured in the United States is tested
electronically for holes before packaging. Rates of condom breakage
during sexual intercourse and withdrawal are low in the United States
(i.e., approximately two broken condoms per 100 condoms used). Condom
failure usually results from inconsistent or incorrect use rather than
Male condoms made of materials other than latex are available in the
United States. Although they have had higher breakage and slippage rates
when compared with latex condoms, the pregnancy rates among women whose
partners use these condoms are similar. Non-latex condoms (i.e., those
made of polyurethane or other synthetic material) can be substituted for
persons with latex allergy.
Patients should be advised that condoms must be used consistently and
correctly to be highly effective in preventing STDs. Patients should be
instructed in the correct use of condoms. The following recommendations
ensure the proper use of male condoms.
Use a new condom with each act of sexual intercourse (e.g., oral,
vaginal, and anal).
Carefully handle the condom to avoid damaging it with fingernails,
teeth, or other sharp objects.
Put the condom on after the penis is erect and before any genital
contact with the partner.
Use only water-based lubricants (e.g., K-Y Jelly™,
Astroglide™, AquaLube™, and glycerin) with latex
condoms. Oil-based lubricants (e.g., petroleum jelly, shortening,
mineral oil, massage oils, body lotions, and cooking oil) can weaken
Ensure adequate lubrication during intercourse, possibly requiring
the use of exogenous lubricants.
Hold the condom firmly against the base of the penis during
withdrawal, and withdraw while the penis is still erect to prevent
Laboratory studies indicate that the female condom (Reality™),
which consists of a lubricated polyurethane sheath with a ring on each
end that is inserted into the vagina, is an effective mechanical barrier
to viruses, including HIV (5). With the exception of one
investigation of recurrent trichomoniasis, no clinical studies have been
completed to evaluate the efficacy of female condoms in providing
protection from STDs, including HIV. If used consistently and correctly,
the female condom may substantially reduce the risk for STDs. When a
male condom cannot be used properly, sex partners should consider using
a female condom.
Vaginal Spermicides, Sponges, and Diaphragms
Recent evidence has indicated that vaginal spermicides containing
nonoxynol-9 (N-9) are not effective in preventing cervical gonorrhea,
chlamydia, or HIV infection (6). Thus, spermicides alone are not
recommended for STD/HIV prevention. Frequent use of spermicides
containing N-9 has been associated with genital lesions, which may be
associated with an increased risk of HIV transmission. The vaginal
contraceptive sponge appears to protect against cervical gonorrhea and
chlamydia, but its use increases the risk for candidiasis. In
case-control and cross-sectional studies, diaphragm use has been
demonstrated to protect against cervical gonorrhea, chlamydia, and
trichomoniasis; however, no cohort studies have been conducted (7).
Neither vaginal sponges nor diaphragms should be relied on to protect
women against HIV infection. The role of spermicides, sponges, and
diaphragms for preventing transmission of HIV to men has not been
evaluated. Diaphragm and spermicide use has been associated with an
increased risk of bacterial urinary tract infection in women.
Condoms and N-9 Vaginal Spermicides
Condoms lubricated with spermicides are no more effective than other
lubricated condoms in protecting against the transmission of HIV and
other STDs. Distribution of previously purchased condoms lubricated with
N-9 spermicide should continue provided the condoms have not passed
their expiration date. However, purchase of any additional condoms
lubricated with the spermicide N-9 is not recommended because spermicide-coated
condoms cost more, have a shorter shelf-life than other lubricated
condoms, and have been associated with urinary tract infection in young
Rectal Use of N-9 Spermicides
Recent data indicate that N-9 may increase the risk for HIV
transmission during vaginal intercourse (6). Although similar
studies have not been conducted among men who use N-9 spermicide during
anal intercourse with other men, N-9 can damage the cells lining the
rectum, thus providing a portal of entry for HIV and other sexually
transmissible agents. Therefore, N-9 should not be used as a microbicide
or lubricant during anal intercourse.
Nonbarrier Contraception, Surgical Sterilization, and Hysterectomy
Women who are not at risk for pregnancy might incorrectly perceive
themselves to be at no risk for STDs, including HIV infection.
Contraceptive methods that are not mechanical or chemical barriers offer
no protection against HIV or other STDs. Women who use hormonal
contraception (e.g., oral contraceptives, Norplant™, and
Depo-Provera™), have intrauterine devices (IUDs), have been
surgically sterilized, or have had hysterectomies should be counseled
regarding the use of condoms and the risk for STDs, including HIV
STD/HIV Prevention Counseling
Interactive counseling approaches directed at a patient's personal
risk, the situations in which risk occurs, and use of goal-setting
strategies are effective in STD prevention .
One such approach --- "client-centered" HIV prevention counseling ---
involves two sessions, each lasting 15--20 minutes, and has been
recommended for STD clinic patients who receive HIV testing. In addition
to prevention counseling, certain videos and large group presentations
that provide explicit information about how to use condoms correctly
have been effective in reducing the occurrence of additional STDs among
persons at high risk, including STD clinic patients and adolescents.
Results from randomized controlled trials demonstrate that compared with
traditional approaches to providing information, certain brief risk
reduction counseling approaches can reduce the occurrence of new
sexually transmitted infections by 25%--40% among STD clinic patients (9).
Interactive counseling strategies can be effectively used by most
health-care providers, regardless of educational background or
demographic profile. High-quality counseling is best ensured when
clinicians are provided basic training in prevention counseling methods
and skills building approaches, periodic supervisor observation of
counseling with immediate feedback to counselors, periodic counselor
and/or patient satisfaction evaluations, and regularly scheduled
meetings of counselors and supervisors to discuss difficult situations.
Prevention counseling is believed to be more effective if provided in a
non-judgmental manner appropriate to the patient's culture, language,
sex, sexual orientation, age, and developmental level.
Partner notification, once referred to as "contact tracing" but more
recently included in the broader category of partner services, is the
process of learning from persons with STDs about their sexual partners
and helping to arrange for evaluation and treatment of those partners.
Providers can furnish this service directly or with assistance from
state and local health departments. The intensity of services and the
specific conditions for which such services are offered by health
agencies vary from area to area. Such services usually are accompanied
by health counseling and may include referral of patients and their
partners for other services.
Many persons benefit from partner notification; thus, providers
should encourage their patients to make partners aware of potential STD
risk and urge them to seek diagnosis and treatment, regardless of
assistance from local health agencies. However, whether the process of
partner notification effectively decreases exposure to STDs from a
person's sexual environment or whether it changes the incidence and
prevalence of disease is uncertain. The paucity of supporting evidence
regarding the consequences of partner notification has spurred the
exploration of alternative approaches. One such approach is to place
partner notification in the larger context of the sexual and social
networks in which people are exposed to STDs. The underlying hypotheses
are that networks have an influence on disease transmission that is
independent of personal behaviors, that network structure is related
directly to prevalence and to underlying disease transmission dynamics,
and that network approaches provide a more powerful tool for identifying
exposed persons and other persons at risk. A second such approach for
which supporting data are being collected is the use of patient
delivered therapy for treatment of contacts and others at risk, a
technique that can considerably expand the role of practitioners in the
control of STDs. The combination of these approaches has the potential
to provide both an intervention and its evaluative tool.
These approaches have not yet been sufficiently assessed to warrant
definitive recommendations. However, practitioners and public health
professionals should be aware of the current potential use of these
nontraditional modalities in the prevention and control of STDs.
Reporting and Confidentiality
The accurate identification and timely reporting of STDs are integral
components of successful disease control efforts. Timely reporting is
important for assessing morbidity trends, targeting limited resources,
and assisting local health authorities in identifying sex partners who
may be infected. STD/HIV and acquired immunodeficiency syndrome (AIDS)
cases should be reported in accordance with local statutory
Syphilis, gonorrhea, chlamydia, and AIDS are reportable diseases in
every state. HIV infection and chancroid are reportable in many states.
The requirements for reporting other STDs differ by state, and
clinicians should be familiar with local reporting requirements.
Reporting can be provider- and/or laboratory-based. Clinicians who are
unsure of local reporting requirements should seek advice from local
health departments or state STD programs.
STD and HIV reports are kept strictly confidential. In most
jurisdictions, such reports are protected by statute from subpoena.
Before public health representatives conduct a follow-up of a positive
STD-test result, they should consult the patient's health-care provider
to verify the diagnosis and treatment.
Intrauterine or perinatally transmitted STDs can have severely
debilitating effects on pregnant women, their partners, and their
fetuses. All pregnant women and their sex partners should be asked about
STDs, counseled about the possibility of perinatal infections, and
ensured access to treatment, if needed.
Recommended Screening Tests
All pregnant women should be offered voluntary HIV testing at the
first prenatal visit. Reasons for refusal of testing should be
explored, and testing should be reoffered to pregnant women who
initially declined testing. Retesting in the third trimester
(preferably before 36 weeks' gestation) is recommended for women at
high risk for acquiring HIV infection (i.e., women who use illicit
drugs, have STDs during pregnancy, have multiple sex partners during
pregnancy, or have HIV-infected partners). In addition, women who have
not received prenatal counseling should be encouraged to be tested for
HIV infection at delivery.
A serologic test for syphilis should be performed on all pregnant
women at the first prenatal visit. In populations in which use of
prenatal care is not optimal, rapid plasma reagin (RPR)-card test
screening (and treatment, if that test is reactive) should be
performed at the time a pregnancy is confirmed. Patients who are at
high risk for syphilis, are living in areas of excess syphilis
morbidity, are previously untested, or have positive serology in the
first trimester should be screened again early in the third trimester
(28 weeks' gestation) and at delivery. Some states require all women
to be screened at delivery. Infants should not be discharged from the
hospital unless the syphilis serologic status of the mother has been
determined at least one time during pregnancy and preferably again at
delivery. Any woman who delivers a stillborn infant should be tested
A serologic test for hepatitis B surface antigen (HBsAg) should be
performed on all pregnant women at the first prenatal visit. HBsAg
testing should be repeated late in pregnancy for women who are HBsAg
negative but who are at high risk for HBV infection (e.g.,
injection-drug users and women who have concomitant STDs).
A test for Chlamydia trachomatis should be performed at the
first prenatal visit. Women aged <25 years and those at increased risk
for chlamydia (i.e., women who have a new or more than one sex
partner) also should be tested during the third trimester to prevent
maternal postnatal complications and chlamydial infection in the
infant. Screening during the first trimester might enable prevention
of adverse effects of chlamydia during pregnancy. However, evidence
for preventing adverse effects during pregnancy is lacking. If
screening is performed only during the first trimester, a longer
period exists for acquiring infection before delivery.
A test for Neisseria gonorrhoeae should be performed at the
first prenatal visit for women at risk or for women living in an area
in which the prevalence of N. gonorrhoeae is high. A repeat
test should be performed during the third trimester for those at
A test for hepatitis C antibodies (anti-Hepatitis C Virus) should be performed
at the first prenatal visit for pregnant women at high risk for
exposure. Women at high risk include those with a history of
injection-drug use, repeated exposure to blood products, prior blood
transfusion, or organ transplants.
Evaluation for bacterial vaginosis (BV) may be conducted at the
first prenatal visit for asymptomatic patients who are at high risk
for preterm labor (e.g., those who have a history of a previous
preterm delivery). Current evidence does not support routine testing
A Papanicolaou (Pap) smear should be obtained at the first
prenatal visit if none has been documented during the preceding year.
Other STD-related concerns are as follows.
HBsAg-positive women should be reported to the local and/or state
health department to ensure that they are entered into a
case-management system and that appropriate prophylaxis is provided
for their infants. In addition, household and sex contacts of HBsAg-positive
women should be vaccinated.
No treatment is available for anti-Hepatitis C Virus-positive pregnant women.
However, all women found to be anti-Hepatitis C Virus-positive should receive
appropriate counseling. No vaccine is available to prevent Hepatitis C Virus
In the absence of lesions during the third trimester, routine
serial cultures for HSV are not indicated for women who have a history
of recurrent genital herpes. Prophylactic cesarean section is not
indicated for women who do not have active genital lesions at the time
The presence of genital warts is not an indication for cesarean
Not enough evidence exists to recommend routine screening for
Trichomonas vaginalis in asymptomatic pregnant women.
For a more detailed discussion of these guidelines, as well as
infections not transmitted sexually, refer to the following references:
Guide to Clinical Preventive Services (10), Guidelines
for Perinatal Care (11), American College of Obstetricians
and Gynecologists (ACOG) Educational Bulletin: Antimicrobial Therapy for
Obstetric Patients (12), ACOG Committee Opinion: Primary
and Preventive Care: Periodic Assessments (13),
Recommendations for the Prevention and Management of Chlamydia
trachomatis Infections (),
Hepatitis B Virus: A Comprehensive Strategy for Eliminating Transmission
in the United States through Universal Childhood Vaccination ---
Recommendations of the Immunization Practices Advisory Committee (ACIP)
Mother-to-infant transmission of hepatitis C virus (15),
Hepatitis C: Screening in pregnancy (16), American College
of Obstetricians and Gynecologists (ACOG) Educational Bulletin: Viral
hepatitis in pregnancy (17), Human Immunodeficiency Virus
Screening: Joint statement of the AAP and ACOG (18),
Preventing Perinatal Transmission of HIV (19), and the
Revised Public Health Service Recommendations for HIV Screening of
These sources are not entirely consistent in their recommendations