STI Screening and Treatment

STI screening should be offered to all sexually active persons at the time of HIV diagnosis, annually thereafter or at any time STI symptoms are reported and during pregnancy. More frequent screening is warranted for persons at particularly high risk of STIs, including those with multiple or anonymous partners. Frequent HIV screening is also essential for those on PrEP, see Pre-exposure Prophylaxis (PrEP)

Diagnosis procedures should follow local or national guidelines. More comprehensive advice can be found at https://iusti.org/treatment-guidelines/

The following STIs should be universally considered in persons with HIV and their sexual partner(s):

	Therapy	Comment
Chlamydia infection including lymphogranuloma venereum (LGV)	Preferred treatment: Doxycycline (100 mg po bid 7-10 days, contraindicated in pregnancy) for urethritis and cervicitis⁽ⁱ⁾ Alternatives: Azithromycin 1 g po followed by 500mg once daily for two days or Erythromycin (500 mg po qid⁽ⁱⁱ⁾ for 10-14 days) or levofloxacin (500 mg po qd for 7 days) In case of extra-genital infection, a test of cure (TOC) should be performed For LGV: Preferred treatment: Doxycycline (100 mg po bid for 21 days) Alternatives: Erythromycin (500 mg po qid⁽ⁱⁱ⁾ for 21 days)	Screening recommended at genital, rectal and pharyngeal sites according to exposure Pharyngeal infections are usually asymptomatic Consider co-infection with Neisseria gonorrhoeae Avoid sexual activity for 7 days post-treatment initiation Individuals should only resume having sex after symptoms have resolved and sex partners have been treated • The same treatment for LGV is recommended for asymptomatic individuals and contacts of individuals with LGV
Gonorrhoea	Ceftriaxone (1 g im as a single dose)⁽ⁱ⁾	Can cause proctitis, prostatitis and epididymitis Screening recommended at genital, rectal and pharyngeal sites according to exposure Rectal and pharyngeal infections may be asymptomatic Often asymptomatic in women Avoid sexual activity for 7 days post treatment initiation Individuals should only resume having sex after symptoms have resolved and sex partners have been treated Fluoroquinolone resistance is highly prevalent in all regions Note ceftriaxone 1 g im as a single dose is based on BASHH recommendations, www.bashhguidelines.org/current-guidelines/ urethritis-and-cervicitis/gonorrhoea-2018/. IUSTI Guidelines recommend 1g im with azithromycin 2 g as a single dose, however these recommendations have not been updated in several years, https://iusti.org/regions/guidelines/
HAV infection HBV infection HCV infection	See detailed information on HIV/HCV or HIV/HBV co-infections.	Interruption of TDF, 3TC or FTC can lead to HBV reactivation Clusters of acute HAV and HCV infections in HIV-positive MSM across Europe have been reported See Immunisation in Persons with HIV
HPV infection	There are several treatment modalities for the management of genital warts with no evidence to suggest one approach is better than another approach. Consider operative removal by laser surgery, infrared coagulation, cryotherapy etc. if appropriate. Management of both pre-invasive cervical lesions as well as peri- and intra-anal lesions should follow local or national guidelines	Infection is mostly asymptomatic; relapse of genital warts is frequent Cervical PAP smear test recommended in all HIV-positive women Anal HPV screening and cytology should be considered in all persons with HIV practicing receptive anal sex Consider high resolution anoscopy (See Cancer: Screening Methods) Rectal palpation or external inspection is not sufficient See Immunisation in Persons with HIV
HSV infection	First episode of genital herpes: aciclovir (400 mg po tid), famciclovir (250 mg po tid) or valaciclovir (500 mg po bid) all for 5-10 days Recurrent episodes: aciclovir (400 mg po tid) or valaciclovir (500 mg po bid) for 5 days Suppressive management: Suppressive therapy is usually offered to persons who experience six or more clinical episodes per year or who experience significant anxiety or distress related to their clinical recurrences. Suppression: aciclovir (400 mg bid or tid) or famciclovir 500 mg bid or valaciclovir 500 mg po od or bid	Treatment of HSV2 alone does not prevent HIV-transmission and only modestly prevents HIV disease progression
Mpox	For information on the diagnosis and management of Mpox, see Management of Mpox in Persons with HIV section
Syphilis	Penicillin is the gold standard for the treatment of syphilis in both pregnant and non-pregnant individuals. -Primary/secondary syphilis: benzathine penicillin G (2.4 million IU im as single dose). Alternative regimen include doxycyline (100 mg po bid for 14 days) -Late latent syphilis and syphilis of unknown duration: benzathine penicillin (2.4 million IU im weekly on days 1, 8 and 15); the alternative doxycycline (100 mg po bid for 4 weeks) is considered less effective -Neurosyphilis and ocular syphilis: penicillin G (6 x 3 - 4 million IU iv for at least 2 weeks) Alternative regimen: ceftriaxone (2 g iv as a single daily dose for 10 to 14 days) if the person can be safely treated with other beta-lactam drugs. Doxycycline (200 mg po bid) for 28 days is also an alternative approach but should be reserved for exceptional circumstances. This regimen has very limited supporting data⁽ⁱ⁾ Adjunctive therapy with prednisolone: adjunctive treatment with prednisolone (20-60 mg po daily for 3 days,starting syphilis treatment 24 h after commencing prednisolone) may be considered in optic neuritis, uveitis, pregnancy, neurosyphilis or possible cardiovascular involvement	Consider cerebrospinal fluid (CSF) testing in persons with neurological symptoms (evidence for intrathecally-produced specific antibodies, pleocytosis, etc.) Successful therapy clears clinical symptoms and decreases VDRL test four-fold within 6-12 months Consider cerebrospinal fluid examination if a four-fold reduction in VDRL test is not achieved

Refer to local guidelines
Rarely used