almost entirely preventable through early screening, detection, and treatment. Evidence to support high-risk HPV DNA testing is based on federal practice policy from the DOD. Peer-reviewed studies demonstrate that improved testing technologies, particularly combined screening using both conventional cytology and high-risk HPV DNA screening, may significantly improve the rate of detection of cervical cancer precursors and facilitate the safe lengthening of the interval for screening.

Recommendation 5.2: The committee recommends for consideration as a preventive service for women: the addition of high-risk HPV DNA testing to cytology testing in women with normal cytology results. Screening should begin at 30 years of age and should occur no more frequently than every 3 years.

SEXUALLY TRANSMITTED INFECTIONS

Sexually transmitted infections (STIs), or sexually transmitted diseases (STDs), are diseases transmitted primarily by sexual activity. In 1997, the Institute of Medicine (IOM) labeled STDs a hidden epidemic, reflecting the knowledge that this largely unrecognized public health threat had considerable scope (IOM, 1997). The discussion that follows focuses primarily on chlamydia, gonorrhea, and syphilis.

Prevalence/Burden

For all STIs generally and for chlamydia, gonorrhea, and syphilis more specifically, the prevalence and number of reported cases are high among certain age groups, racial and ethnic groups and in certain geographic areas. Nevertheless, many STIs are asymptomatic and go undiagnosed; thus, current surveillance systems tend to underestimate the actual burden of disease. Significant short- and long-term morbidities are associated with these conditions, as is the risk for perinatal transmission, with its disease-specific attendant consequences. The services under consideration here include screening and counseling.

Women who contract STIs suffer from adverse reproductive health outcomes (Friedel and Lavoie, 2008). Infections in women, which are usually asymptomatic, can result in pelvic inflammatory disease, a major cause of infertility, ectopic pregnancy, and chronic pelvic pain. As with human immunodeficiency virus (HIV), women at risk for STIs often do not appreciate that they are at risk if they consider themselves in a monogamous relationship (Hodder et al., 2010).

In 2009, the overall rate of reported chlamydia infection among women (592 cases per 100,000 women) was almost three times higher than the



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