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From the CDC...

The revised 2010 CDC guidelines provide the most recent evidence for prevention, diagnosis, and treatment of STIs, formally known as sexually transmitted diseases (STDs).1 The guidelines include information about HIV-positive diagnoses and the assessment of various populations with STIs, including the incarcerated, infants, children, adolescents, and pregnant women. Screening, assessment, and treatment for STIs are important for both adolescent and adult populations in the United States. Syphilis rates are two times higher for adults ages 20 to 44 years than for ages 15 to 19.2 Factors associated with disproportionate STI prevalence include poverty, stigma of diagnosis, barriers to healthcare resources, and being a minority.2 Adolescents of an ethnic minority are diagnosed with STIs more often, and females have the highest risk. Hispanic or Black females ages 15 to 19 are 5 to 19 times more likely to be living with HIV/AIDS than non-Hispanic White females.3 Gonorrhea and chlamydia rates for Hispanic and Black females ages 15 to 19 are 6 to 14 times higher, respectively, than rates for non-Hispanic White females.3 Individual, social, and economic implications of STIs require healthcare providers to carefully assess, diagnose, and treat these infections.

Assessment

Diagnosis, treatment, and counseling for STIs include an assessment of multiple interrelated factors. Use of the AIDS Risk Reduction Model with modifications in prior studies has identified psychosocial, situational, and behavioral risk factors associated with STI.4 (See Influences on sexual behavior.)

Assessment involves completion of a medical and sexual history, including sexual risk behaviors and history of abuse. This assessment allows clinicians to ascertain appropriate testing and psychosocial or situational needs concerning counseling and social services. Conducting a thorough assessment is important, and enables clinicians to evaluate the patients' personal history and knowledge regarding STI/HIV transmission. Behaviors inferring risk of acquisition, relationship commitments, and type and beliefs or norms influencing behavior must also be assessed.4 Clinicians are responsible for providing patients with knowledge about the use of or access to contraceptive methods. An assessment protocol can be useful while conducting initial assessments. (See The Five P's: Partners, prevention of pregnancy, protection from STIs, practices, and past history of STI.)1

Screening guidelines

Medical and sexual history, age, gender, type of sexual partnership, number of sexual partners in a given time period, risk behavior, pregnancy status, and clinical assessment determine appropriate STI screening. (See STI testing and treatment.)1,5 Due to the potential risk of STI coinfection, clinicians testing clients for one organism are encouraged to test for additional or related sexually transmitted orgaisms.1 Clinicians are also encouraged to test for the fullest suspected range of infection for patients who report multiple risk behaviors or who are unlikely to return for additional STI assessment and testing.1

Risk behavior and HIV screening

It's recommended that clinicians conduct a STI screening for all patients reporting a history of STIs, new or multiple sexual partners, less than 100% condom use during sex, group sex, commercial sex work, I.V. drug use, or residence within a community with high disease prevalence.1

HIV screening is indicated for patients seeking STI screening who are sexually active or have engaged in high-risk behavior.1 Voluntary routine HIV screening is recommended for patients ages 13 to 64 years in all healthcare settings.5 Clinicians are advised to include routine screening for STI/HIV among patients initiating treatment for tuberculosis as well.5 All patients seeking services at STI clinics or STI evaluation or treatment require HIV testing at each visit for a new complaint.5 Subsequent to initial testing, annual testing is recommended at minimum for patients reporting high-risk behavior such as I.V. drug use, partner(s) who use I.V. drugs, partners testing positive for HIV, and those with more than one sexual partner or partners who have had more than one sexual partner since the last HIV testing.5

Treatment

Individualized treatment plans designed to meet the client's specific psychosocial, behavioral, cultural, and clinical situation are essential. Be sure to notify patients of all testing and treatment as initiated.1STD testing and treatment describes medications used to treat specific STDs; however, clinicians are instructed to consult the CDC guidelines directly for specific dosing. Assessment of eligibility and client preference for preexposure vaccination for human papillomavirus (HPV) and hepatitis A and B is useful during treatment planning.1 Vaccination guidelines and client characteristics, including prior exposure to infection, age, gender, and risk status, must inform the clinician recommendations concerning administration.

Current recommendations encourage clinicians to treat all individuals with partners who have had sexual contact with the infected patient within 60 days of the onset of symptoms or of diagnosis.1 Clinicians may use expedited partner therapy consistent with state mandates. Expedited partner therapy is indicated when a patient states that the partner is unlikely to self-initiate evaluation or treatment.1 The clinician must label all treatments with instructions when dispensing partner therapy. Therapy indications and contraindications (such as an allergy to specific medication) must be included and the partner should be encouraged to follow-up for testing to ascertain cure.1 Patient-delivered partner therapy is a form of expedited partner therapy. No evidence exists regarding efficacy for use of client-delivered partner therapy, including diagnoses of syphilis, gonorrhea, or chlamydia among males involved in same-gender sexual relationships.1

Counseling

It's extremely important that patients receive detailed information concerning the type of STI testing that will be conducted. CDC guidelines recommend providers review pertinent regulations in each state regarding consent and designation of client affirmation or decline of HIV testing.1 Patients must be given the option to decline or defer HIV testing.

Maintaining confidentiality of results requires vigilance. Confidentiality is of great concern for patients, particularly minors seeking services such as STI evaluation and treatment. Minors may self-consent for STI assessment and treatment without parental consent or notification in all 50 states and the District of Columbia.1 Individual states, however, may require health insurance plans to notify beneficiaries of health services claims.1 Therefore, minors covered by their parents or guardians' insurance plans may need counseling regarding STI/HIV services when legal requirements preempt maintenance of confidentiality.

Clinicians also have a responsibility to stay informed of the mandates regarding state agency notification of reportable diseases, including syphilis, gonorrhea, chlamydia, and HIV/AIDS. These mandates vary by state and require informed reporting by the clinician.1

Table STI testing and treatment

Child abuse must also be considered in the provision of STI interventions. Child abuse is a reportable occurrence within the United States and mandates for reporting vary by state. Providers must obtain comprehensive knowledge of state agency reporting requirements concerning STI, including HIV and child abuse within their practice domain.1

Clinicians may also employ motivational interviewing techniques to develop treatment plans and assist patients toward commitment to behavioral change. These techniques prevent the imposition of mandates for change upon individuals and allow clinicians to assess patient readiness to change throughout the process.6

Data gathered may be used to discuss specific sexual risk factors identified during the assessment with the patient. Motivational interviewing strategies can be used to reduce sexual risk behavior and prevent intimate partner violence.7-9 Allowing the patient to identify sexual risk factors and barriers to changing beliefs and behaviors can be an effective intervention strategy. Using reflective listening to allow the patient to identify personal challenges and strengths may also be helpful.

Clinicians may provide the patient with resources for counseling, and social or medical services, as needed. The patient should also be directed to abstain from any sexual contact until 7 days after treatment is completed when both the patient and their partner are asymptomatic.1 Clinicians may instruct the patient to use condoms or abstain from sexual contact if they or their partner has open lesions. Counseling may also include instructions for the client to return for follow-up per CDC guidelines.1 Recommended considerations for follow-up include the potential for false-positive and false-negative results within short time frames after treatment, and special considerations such as pregnancy and HIV status, type of infection, and continuation of symptoms.

Prevention

Prevention strategies discussed with patients include limiting the number of sexual partners, communicating with partners about sexual risk reduction, ascertaining partner's STI3 and HIV status prior to engaging in any sexual activity, and using condoms and other contraceptive methods; preexposure vaccinations may be appropriate for prevention of HPV and hepatitis A and B. Indications for these vaccination series can be found on the CDC website (http://www.cdc.gov/vaccines/).

Decades of descriptive research has demonstrated that risk behavior and STI/HIV prevention, acquisition, and resolution represent a combination of interrelated psychosocial and situational factors associated with behavior change.10-14

1. Centers for Disease Control and Prevention. Sexually transmitted diseases guidelines. MMWR Recomm Rep. 2010;59(RR12):1-110. [Context Link]

2. Centers for Disease Control and Prevention. Trends in sexually transmitted diseases in the United States: 2009 National data for Gonorrhea, Chlamydia and Syphilis. 2010. [Context Link]

3. Centers for Disease Control and Prevention. Sexual and reproductive health of persons aged 10-24 years-United States, 2002-2007. MMWR Surveill Summ. 2009;58(6):1-58. [Context Link]

4. Champion JD, Collins JL. The path to intervention: community partnerships and development of a cognitive behavioral intervention for ethnic minority adolescent females. Issues Ment Health Nurs. 2010;31(11):739-747. [Context Link]

5. Centers for Disease Control and Prevention. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55(RR14):1-17; quiz CE1-CE4. [Context Link]

6. Rollnick S, Allison J. Motivational interviewing. In: Heather N, Stockwell T, eds. The Essential Handbook of Treatment and Prevention of Alcohol Problem. http://bib.tiera.ru/dvd58/Heather%20N.,%20Stockwell%20T.%20-%20The%20Essential%2. [Context Link]

7. Kiene SM, Barta WD. A brief individualized computer-delivered sexual risk reduction intervention increases HIV/AIDS preventive behavior. J Adolesc Health. 2006;39(3):404-410. [Context Link]

9. Weir BW, O'Brien K, Bard RS, et al. Reducing HIV and partner violence risk among women with criminal justice system involvement: a randomized controlled trial of two motivational interviewing-based interventions. AIDS Behav. 2009;13(3):509-522. [Context Link]

10. Champion JD. Behavioural interventions and abuse: secondary analysis of reinfection in minority women. Int J STD AIDS. 2007;18(11):748-753. [Context Link]

11. Champion JD, Piper JM, Holden AE, Shain RN, Perdue S, Korte JE. Relationship of abuse and pelvic inflammatory disease risk behavior in minority adolescents. J Am Acad Nurse Pract. 2005;17(6):234-241. [Context Link]

14. Roye C, Perlmutter Silverman P, Krauss B. A brief, low-cost, theory-based intervention to promote dual method use by Black and Latina female adolescents A randomized clinical trial. Health Educ Behav. 2007;34(4):608-621. [Context Link]