All of the following may protect U.S. against sexually transmitted diseases except

1 . Which of the following is NOT one of the Five Ps of sexual history taking?

GENERAL STI ASSESSMENT AND PREVENTION COUNSELING

The "Five Ps" approach elicits sexual history information related to five key areas of interest: partners, practices, prevention of pregnancy, protection against STIs, and past history [1].

GENERAL STI ASSESSMENT AND PREVENTION COUNSELING

All sexually active adolescents are considered at increased risk for STIs and should be counseled. Other at-risk groups include adults with current or past-year STIs, with multiple sex partners, or who use condoms inconsistently. African Americans have the highest STI prevalence of any racial/ethnic group, and STI prevalence is higher in American Indians, Alaska Natives, and Latino/as than in white populations. Increased STI prevalence rates are also found in men who have sex with men (MSM), persons with low incomes living in urban settings, current or former inmates, military recruits, persons who exchange sex for money or drugs, persons with mental illness or a disability, current or former injecting drug users (IDUs), persons with sexual abuse history, and patients of public STI clinics [3].

BARRIER AND NONBARRIER APPROACHES TO PREVENT OR REDUCE VIRAL STI TRANSMISSION AND INFECTION

As U.S. Food and Drug Administration (FDA)-regulated medical devices, condoms are subject to quality-control testing. Each latex condom manufactured in the United States is tested electronically for holes before packaging. The rate of condom breakage during sexual intercourse and withdrawal is approximately 2 per 100 condoms used, with slightly higher rates during anal intercourse [7,8]. Condom failure to protect against STI or unintended pregnancy is usually caused by inconsistent or incorrect use, instead of condom breakage [9]. Latex condoms should not be used beyond their expiration date or more than five years after the manufacturing date, and users should check the expiration or manufacture date on the packaging before use [1]. In 2022,the FDA cleared the first natural rubber latex condom designed specifically to be used in anal intercourse [150].

External condoms made of materials other than latex fall in two general categories: synthetic and natural membrane condoms. Polyurethane and other synthetic condoms provide protection against STIs/HIV and pregnancy comparable to latex condoms and are used mainly as latex condom substitutes by persons with latex allergy. These condoms are more resistant to deterioration and are compatible with oil-based or water-based lubricants. The preventive efficacy of other synthetic external condoms is not well studied, and the FDA restricts their use to persons with latex sensitivity or allergy [6,10].

Natural membrane condoms (termed "natural skin" or "lambskin") are made from lamb cecum. The pores, no greater than 1,500 nm in diameter, block passage of sperm but are more than 10 times the diameter of HIV and more than 25 times that of HBV. Therefore, sexual transmission of hepatitis B, herpes simplex, and HIV organisms can occur with natural membrane condoms. These condoms are recommended for preventing pregnancy but not STIs/HIV [10,11,12].

BARRIER AND NONBARRIER APPROACHES TO PREVENT OR REDUCE VIRAL STI TRANSMISSION AND INFECTION

Male circumcision has been found to reduce the risk for HIV and some STIs in heterosexual men. By various means, penile foreskin is the primary biologic weak point and conduit for HIV infection during heterosexual intercourse [15]. Several controlled studies of heterosexual HIV transmission in sub-Saharan Africa found circumcision reduced the risk for HIV acquisition in men by 50% to 60% and protected against high-risk genital HPV infection and genital herpes [16,17,18]. These benefits of circumcision were sustained over time, and the effects were not solely related to reductions in herpes simplex virus type 2 (HSV-2) infection or genital ulcer disease [19,20].

SCREENING RECOMMENDATIONS

VIRAL STI SCREENING RECOMMENDATIONS

HERPES SIMPLEX VIRUS

In the United States, approximately one in eight persons 14 to 49 years of age is infected with HSV-2. The virus remains for life once infection has occurred, and prevalence rates generally increase with age due to cumulative sexual exposure [37]. Most people infected with genital herpes have not been diagnosed, and many with undiagnosed HSV-2 have minimal or no signs and symptoms, but shed virus intermittently in the anogenital area [38]. As a result, most genital herpes infections are transmitted by people who are unaware they are infected or are asymptomatic when transmitting. The risk of transmission is highest when outbreaks develop with new blisters in the anogenital area [3,36].

HERPES SIMPLEX VIRUS

HSV serologic testing is used for persons presenting for general STI evaluation (especially with multiple sex partners), those with HIV infection, and MSM at increased risk for HIV. Serologic HSV antibody testing detects the specific immune protein response to herpes infection. Several days after the primary (initial) HSV infection, immunoglobulin M (IgM) antibody is produced, remaining detectable in serum for several weeks. After HSV IgM, the body begins producing HSV IgG antibody. IgG serum levels rise for several weeks, then slowly decline, stabilize, and remain detectable forever in those with HSV exposure [42,45]. With type-common antibody testing, positive HSV IgM antibody indicates active or recent infection, while positive HSV IgG antibody indicates previous infection. A significant recent increase in HSV IgG antibodies is a sign of active or recent infection. Negative HSV antibody testing implies HSV exposure is unlikely or the body has had insufficient time to produce HSV antibodies [42,45].

HERPES SIMPLEX VIRUS

TREATMENT OF GENITAL HERPES INFECTIONS

HUMAN PAPILLOMAVIRUS

HPV is the most common STI in the United States. During 2013–2014, the prevalence of genital HPV in adults 18 to 59 years of age was 45.2% in men and 39.9% in women [75]. Around 100 HPV types have been identified, and at least 40 can infect the anogenital area in men and women. HPV types vary by propensity to cause genital warts and recurrent respiratory papillomatosis (HPV types 6 and 11), or cervical, penile, vulvar, vaginal, anal, and oropharyngeal cancers and precancers (HPV types 16 and 18) [36]. Most HPV infections are self-limited, asymptomatic, or unrecognized, and many sexually active persons will be infected with HPV at least once in their lifetime [76].

HUMAN PAPILLOMAVIRUS

Prevention of high-risk HPV is most effectively achieved through vaccination. The FDA has approved three vaccines that protect against HPV and the diseases and cancers caused by HPV. A bivalent vaccine (Cervarix) and Gardasil were previously available, but are no longer used in the United States. The currently recommended vaccine is nine-valent Gardasil 9, which protects against HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58 [80,81].

HUMAN PAPILLOMAVIRUS

All boys and girls 11 to 12 years of age are now recommended to receive HPV vaccines, as they are most effective when given at younger ages, before the onset of sexual activity and initial exposure to the virus. The earliest approved age is 9 years. The vaccine in clinical use is recommended for girls/women and boys/men. Young sexually active people should still receive the vaccination, because those already infected with one type of HPV may benefit from the protection against other types included in the vaccine. In those who have not received any or all vaccine doses, vaccination is recommended through 26 years of age for all girls/women and boys/men [80]. HPV vaccine is also recommended for those 27 to 45 years of age if desired or if a risk factor is present.

HUMAN PAPILLOMAVIRUS

Genital warts (condyloma acuminatum) are benign and mainly caused by HPV types 6 and 11. The types affecting the anogenital region are usually transmitted sexually by penetrative vaginal or anal intercourse, but digital, oral, and nonpenetrative genital contact may be involved. The development of genital warts is more common in patients who are immunocompromised. Growth rates vary, but pregnancy, immunosuppression, or maceration of the skin may accelerate the growth and spread of warts [89].

HUMAN PAPILLOMAVIRUS

RECOMMENDED TREATMENT OF GENITAL WARTS

VIRAL HEPATITIS

Hepatitis is an inflammatory state of the liver. Most cases of hepatitis are caused by viral infection; other causes include exposure to chemicals, over-the-counter or prescription drugs, heavy alcohol use, inherited diseases, autoimmune disease, and fatty buildup in the liver [104]. In all patients with symptoms that suggest acute viral hepatitis, clinicians should assess the patient and, if necessary, refer for hospital admission. Tests should be performed to assess hepatitis severity, including liver function tests, coagulation tests, and hepatitis serology (i.e., anti-HAV IgM, HBsAg, hepatitis C virus [HCV] antibodies/RNA, and hepatitis E serology/PCR) [105].

VIRAL HEPATITIS

The icteric phase is characterized by jaundice (mixed hepatic and cholestatic) and is associated with anorexia, nausea, and fatigue that usually lasts one to three weeks. This phase can persist 12 or more weeks in a minority of patients who have cholestatic symptoms (e.g., itching, deep jaundice). Fever is rare. Up to 10% of patients experience symptomatic relapse in the six months following acute illness.

VIRAL HEPATITIS

After an incubation period of 40 to 160 days, HBV concentrations are highest in the blood and present (but in lower concentrations) in wound exudates, semen, vaginal secretions, and saliva. HBV is efficiently transmitted by percutaneous or mucous membrane exposure to infected blood or body fluids. HBV is more infectious and more stable in the environment than other bloodborne pathogens, including HCV and HIV [1].

VIRAL HEPATITIS

HBV vaccination is recommended for the following unvaccinated persons [120]:

• Children and adolescents

• All adults who are IDUs, MSM, or with multiple sex partners

• All adults wanting protection from HBV

HIV/AIDS

As of 2016, an estimated 1.1 million individuals 13 years of age or older were living with HIV or acquired immune deficiency syndrome (AIDS) in the United States [129]. The CDC estimates that approximately 14% of these individuals are unaware of their infection [129].

HIV/AIDS

Posing the highest risk of infection is unprotected receptive anal intercourse, followed by unprotected receptive vaginal intercourse and unprotected insertive anal intercourse (particularly for uncircumcised men) [134,135]. Risk is reduced through the use of latex condoms. For the wearer, latex condoms provide a mechanical barrier limiting penile exposure to infectious cervical, vaginal, vulvar, or rectal secretions or lesions. Likewise, the partner is protected from infectious pre-ejaculate, semen, and penile lesions. As discussed, natural membrane condoms (made from lamb cecum) contain small pores and do not block HIV passage. It is estimated that latex condom use reduces the risk of HIV transmission by approximately 70% to 80% [136,137,138]. Although abstinence from sexual contact is the sole way to absolutely prevent sexual transmission, sexual activity in a mutually monogamous relationship in which neither partner is HIV-infected and no other risk factors are present is considered safe [139]. However, men who identify publicly as heterosexual and generally have committed relationships with women, but who also engage in sexual activity with other men, may be a transmission bridge to heterosexual women [140]. To better understand the actual extent of this behavior and its impact on HIV transmission, more research is necessary.

HIV/AIDS

In 2017, the CDC and the U.S. Department of Health and Human Services updated its clinical practice guidelines for pre-exposure prophylaxis for the prevention of HIV infection [145]. This guideline outlines indications for prophylaxis as one prevention option for HIV transmission. The most important first step in determining if an individual is a candidate for pre-exposure prophylaxis is a thorough history, including sexual and injection drug activities. All candidates will be adults without an acute or established HIV diagnosis. Pre-exposure prophylaxis is indicated for high-risk MSM, meaning those who have had any male sex partners in the past six months, are not in a monogamous partnership with a recently tested, HIV-negative man, and have one of the following [145]:

• Anal sex without condoms (receptive or insertive) in the past six months

• Any STI diagnosed or reported in the past six months

• An ongoing sexual relationship with an HIV-positive man

• High number of sex partners

• Commercial sex work

Prophylaxis is also recommended for high-risk heterosexual adults who have had sex with an opposite sex partner(s) in the past six months, are not in a monogamous partnership with a recently tested, HIV-negative partner, and one of the following [145]:

• Is a man who has sex with both women and men (behaviorally bisexual)

• Infrequently uses condoms during sex with one or more partners of unknown HIV status who are known to be at substantial risk of HIV infection (IDU or bisexual male partner)

• Is in an ongoing sexual relationship with an HIV-positive partner

• Any STI diagnosed or reported in the past six months

• Commercial sex work

• In high HIV prevalence area or network

IDUs are also considered candidates for pre-exposure prophylaxis if they meet certain criteria. The guideline states that persons who have injected drugs not prescribed by a clinician in the past six months may be candidates for prophylaxis if they also are positive for one of the following factors [145]:

• Any sharing of injection or drug preparation equipment in the past six months

• Been in a methadone, buprenorphine, or buprenorphine/naloxone treatment program in the past six months

• Increased risk of sexual acquisition (based on the previously outlined criteria)

Which of the following sexually transmitted infections STIs may be prevented with a vaccine?

What are the 20 sexually transmitted diseases?

Which of the following behaviors is likely to prevent the spread of sexually transmitted infections?

What are the common sexually transmitted infections?