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Screening, treatment, and counseling for sexually transmitted infections (STIs) requires a thorough assessment of psychosocial, behavioral, cultural, and clinical factors. This article offers a summary of the most recent CDC data, prevention guidelines, and a guide to implementing current evidence into clinical practice.
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.
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
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
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
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.
Clinician assessment also includes considerations such as allergies, pregnancy, HIV status, and preexposure to information regarding STI treatment options. Medication should be administered on site with observation of first dose as indicated whenever possible. Emergence of resistant strains of organisms responsible for STIs necessitates judicious management of treatment regimens.
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
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.
Additional consideration regarding confidentiality among both adults and minors is partner notification. It's important for clinicians to be familiar with state mandates for partner notification and treatment. Clinicians must inquire about any potential for interpersonal violence to occur within patient relationships. Partner notification concerning STIs in the presence of interpersonal violence may heighten conflict in such relationships, thus endangering the patient.
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
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 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
STIs aren't gender, age, or ethnicity specific, although higher prevalence has been identified in certain populations. Astute assessment and counseling focused on the individual patient gives clinicians the opportunity to identify and treat those who don't fit customary at-risk groups.
* History of abuse
* Education history
* Family, cultural, and peer norms
* Access to healthcare services
* Social support for risk reduction
* Developmental level
* Beliefs (such as the value of childbearing and of relationships with sexual partners)
* Medical history (comorbidities and concurrent treatment regimens)
* Sexual self-efficacy and communication skills (negotiating condom use and ascertaining partner STI/HIV status)
* STI knowledge and skills (condom application skills, ascertaining partner symptomatology)
* Perception of severity and susceptibility, willingness, and ability to make psychological and behavioral changes
* Abuse avoidance
* Substance use (alcohol, drug, or tobacco use)
* Types and frequency of sexual encounters (group sex, same-gender sex, oral or anal sex)
* Use of condoms and other contraceptives
* Treatment completion
* Avoidance of douching
* Partner risk behavior (incarcerations, drug use, multiple partners, condom use)
* Partner beliefs and attitudes
* Partner age
* Power differentials
* Number of partners in a given period
* Number of new partners in a given time period
* Partner turnover
* Relationship context: mutual monogamy, steadiness, and satisfaction
1. Ask about partner(s): gender, number of partners in the past 2 to 12 months, and if sexual partnerships outside the main relationship exist either for the client or for the partner.
2. Ask about pregnancy prevention.
3. Ask about STI protection.
4. Ask about sexual practices: vaginal sex, anal sex, oral sex, condom use, and patterns of practice (such as substance use during sex, when the patient uses/doesn't use condoms).
5. Ask about prior STI history and risk behaviors (such as patient or partner use of I.V. drugs, exchanging money or drugs for sex).
6. Ask if the patient has additional information to offer that hasn't been asked.
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]
8. Morgenstern J, Bux DA, Jr., Parsons J, Hagman BT, Wainberg M, Irwin T. Randomized trial to reduce club drug use and HIV risk behaviors among men-who-have-sex-with-men (MSM). J Consult Clin Psychol. 2009;77(4):645-656.
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]
12. Koniak-Griffin D, Lesser J, Nyamathi A, Uman G, Stein JA, Cumberland WG. Project CHARM: an HIV prevention program for adolescent mothers. Fam Community Health. 2003;26(2):94-107.
13. Morrison-Beedy D, Nelson LE. HIV prevention interventions in adolescent girls: What is the state of the science? Worldviews Evid Based Nurs. 2004;1(3):165-175.
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]
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