Sexual Health Information for Physicians

Testing recommendations

Nucleic Acid Amplification Test (NAAT)

• Test anytime following exposure.
• NAATs are preferred to culture tests due to the increased sensitivity and specificity of the method
• Urine Sample (male/female): collect 20-30 mL initial stream, first-void sample.
• Endocervical and self-collected or clinician collected vaginal swab (female). Use woven swab from NAAT kit.
• Pharyngeal swabs and self-collected or clinician collected rectal swabs (male/female). Use woven swab from NAAT kit. Use for unprotected rectal and pharyngeal exposure.

If male rectal site is positive for CT, Public Health Ontario laboratory (PHOL) automatically forwards in-house samples for lymphogranuloma venereum (LGV) testing.

Other sites are tested for LGV only if testing is specifically requested by the ordering provider.

Recommended treatment

• Azithromycin 1g PO in a single dose OR Doxycycline 100mg PO BID x 7 days
• LGV treatment: Doxycycline 100mg PO BID x 21 days OR Azithromycin 1 g PO once weekly x 3 weeks
• During pregnancy and breastfeeding: Azithromycin 1g PO in a single dose OR Amoxicillin 500mg PO TID x 7 days OR Erythromycin 2g/day PO in divided doses x 7 days OR Erythromycin 1g/day orally in divided doses x 14 days
• Cephalosporin or severy penicillin allergy: Same as recommended treatment regimen.

Follow-up

See Get PrEP in Ontario - One Pill a Day to Prevent HIV - Ontario PrEP Clinics (external link) for guidance.

Testing recommendations

See Public Health Ontario: Gonorrhea (external link)

Recommended treatment

• First line treatment: Ceftriaxone 500mg IM in a single dose (monotherapy)
• Alternative treatment options if access to IM injection is not available / client refuses IM: Cefixime 800mg PO PLUS Doxycycline 100mg PO BID x 7 days (anogenital) OR Cefixime 800mg PO PLUS Azithromycin 1g PO in a single dose (pharyngeal)
• During pregnancy and breastfeeding:
  • First line treatment for pregnant patients: Ceftriaxone 500mg IM in a single dose (monotherapy).
  • Alternative GC treatment regimens are not recommended in pregnancy. In cases of cephalosporin allergy or other contraindications, consult with an infectious disease specialist.
• Cephalosporin or severy penicillin allergy: Azithromycin 2g PO in a single dose PLUS Gentamicin 240mg IM in a single dose OR Gentamicin 240 mg IM in a single dose PLUS Doxycycline 100 mg PO twice daily for 7 days

Gentamicin is available from your local public health unit. Please visit Gonorrhea guide: Treatment and follow-up (external link) for recommended treatment options.

Follow-up

Test of cure (TOC):

• Recommended for ALL positive cases, from ALL positive sites. Particularly when first line treatment is not used. TOC Culture (preferred) – at least3-7 days, but can be collected up to 4 weeks after treatment completion
• NAAT- collect 2-4 weeks after treatment completion for asymptomatic cases
• Obtain both NAAT and Culture if treatment failure suspected more than 3 weeks after treatment completion
• Repeat testing in all individuals with gonorrhea infection is recommended 6 months post-treatment as re-infection is high.
• Rectal GC infections have been associated with increased risk of HIV infection in gay, bisexual, and other men who have sex with men, and transgender women. Screening for HIV is highly recommended in these individuals.

Consider PrEP initiation for HIV negative individuals. See Get PrEP in Ontario - One Pill a Day to Prevent HIV - Ontario PrEP Clinics (external link) for guidance.

Testing recommendations

Syphilis Screen (Serology)

• Screen all sexually active persons with a new or multiple partners, and/or upon request of the individual.
• Screening every 3 to 6 months is recommended for individuals with multiple partners.
• Window period can range from 4-12 weeks
• When a test is performed within the window period, a negative test result does not rule out syphilis infection. A syphilis test should be repeated outside of the window period to completely rule out infection.
• Test detects both IgG and IgM antibodies. If screen is reactive, RPR will automatically be completed. TPPA is completed on non-reactive RPR when there is no previous TPPA result.
• Repeat blood work in 2-4 weeks to best stage diagnosis if patient is asymptomatic, or if uncertain of diagnosis.

Recommended treatment

• Stage: Primary, Secondary or Early latent (less than 1 year duration) treatment: Benzathine penicillin G 2.4 million units IM in a single dose.*
• Stage: Late latent (more than 1 year or of indeterminate duration) treatment:Benzathine penicillin G 2.4 million units IM once a week for 3 successive weeks (total dose 7.2 million units)*
• During pregnancy and breastfeeding: Same as recommended treatment regimen. If a pregnant woman diagnosed with infectious syphilis is treated with anything other than Benzathine penicillin G or is treated in the last month of pregnancy, the baby must be treated after birth and referred to an ID (Infectious Disease) specialist for follow up.
• Cephalosporin or severy penicillin allergy: Desensitization and use of penicillin is preferred.
  • Stage: Primary, Secondary, or Early latent treatment: Doxycycline 100mg orally BID x 14 days
  • Stage: Late latent: Doxycycline 100mg orally BID x 28 days OR Refer to STBBI Syphilis Guide (external link)

Refer to: STBBI Syphilis Guide (external link) or Syphilis- Serology PHO (external link)

*Additional doses have not been shown to be more effective for HIV+ individuals

Follow-up

Testing recommendations

HIV 1/2 Ag/Ab Combo Screen (Serology)

• Window period is 6 weeks for laboratory-based serology tests.
• Window period is 12 weeks for Rapid/Point of Care (POC) tests.
• When a test is performed within the window period, a negative result does not rule out HIV infection. The HIV test should be repeated outside of the window period to completely rule out infection.

See Ontario HIV Testing Guidelines for Providers (external PDF).

Follow-up