CONTROLLING THE SPREAD OF STIs

The National Strategic plan addresses the prevention of STIs and the prevention and reduction of their adverse effects. Since the majority of reported STDs are diagnosed in physician’s offices and community clinics while patients are receiving care for other conditions, clinicians in these settings must be able to identify and manage STIs/STDs (Barrow et al., 2020).

Preventative strategies to reduce the transmission of STIs include risk assessment and screening, prevention education, barrier protection through the use of condoms, preexposure vaccinations, and expedited partner therapy (HHS, 2021; Workowski et al., 2021).

STI Risk Assessment and Screening

A sexual history should routinely be included when obtaining a medical history. In non-STD specialty settings, clinicians should obtain a sexual history and conduct a risk assessment at an initial visit, annual examination, and any appointment for reproductive, genital, or urologic problems. Physical and pelvic examinations should be performed on any patient with symptoms or concerns related to STDs or in patients with high-risk behaviors for STIs, as well as anoscopy, when indicated (Barrow et al., 2020).

The interview should be conducted in a respectful and nonjudgmental manner. Many infected individuals do not develop or are not aware of symptoms, and thus they do not present themselves to the healthcare system. Other individuals avoid the healthcare system because they are hesitant about acknowledging or reporting symptoms. One method for conducting a sexual history is the use of the “Five Ps” approach (see box below). Risk assessment also includes determining biologic markers through STI and HIV screening tests.

STI Prevention Education

Preventative education should include at least one STI prevention counseling session of at least 30 minutes (Barrow et al., 2020). Education is tailored to the individual in a culturally sensitive manner. It should also consider gender identity, sexual orientation, age, and the developmental level of the individual (CDC, 2021c).

STI prevention counseling should be provided for all adolescents who are sexually active as well as adults who have an STI, were diagnosed with an STI in the past year, or have multiple sex partners (CDC, 2021c). Education can be one-on-one; in a group format; and use video, motivational interviewing, and online resources. Giving people clear and complete information about STDs/STIs and their prevention has been shown to reduce those people’s risky sexual behaviors and to slow the spread of STIs.

With limited time, money, and personnel, the strategy has been to focus resources on high-risk populations and to emphasize the first-line types of STI protection, such as barrier methods (e.g., condoms). Likewise, expensive screening tests for STIs have been aimed at high-risk populations to get the best results with limited resources.

The clinician’s best opportunity to help prevent the recurrence of an STI/STD is at the time of the patient’s diagnosis. Clinicians explain to the patient that barriers (e.g., condoms) are needed to protect against STIs/STDs and that other birth control methods will not prevent such infections. Patients are also reminded that if their partners are not monogamous, then STIs can enter the relationship between two previously uninfected people (CDC, 2021g).

Healthcare providers must also describe the long-term risks of STIs/STDs. Patients should be told that, although antibiotics will cure them, there is a high risk of reinfection. Therefore, patients are instructed to return to the clinic or office to be retested in 3–4 months.

Barriers As Protection

Condoms reduce the transmission and acquisition of STIs during sexual contact when they are used consistently and worn properly (CDC, 2021p). Patients should be instructed that there is risk of transmission if an area infected by an STI is not covered by the condom.

In theory, female condoms cover more areas of contact during sexual activity than do male condoms, but neither type of condom prevents all skin-to-skin contact. Condoms are more effective in preventing those STIs that are transmitted via fluids (e.g., chlamydia, gonorrhea, HIV) than STIs that are transmitted via direct skin contact (e.g., chancroid, genital herpes, genital warts, syphilis) (CDC, 2021p).

Oral sex is a widespread form of sexual activity. It has been found that 85% of 18- to 45-year-olds and 33% of 15- to 17-year-olds profess to having had oral sex at least once. Chlamydia, gonorrhea, syphilis, HIV, HPV, and trichomoniasis can all be spread by oral sex. Oral sex has a much lower risk for transmission of HIV, but HIV can be spread orally in the absence of protection (CDC, 2017n). Dental dams (latex or polyurethane sheets placed between the mouth and vagina or anus during oral sex) can also reduce the risk of STI transmission.

To be most protective, condoms must be used correctly and all the time. Healthcare workers should not assume that patients know how to use condoms and should demonstrate how to put a condom on a penis or in a vagina using an anatomically correct model. If lubrication is used in conjunction with condoms, patients should be instructed to use only water-based lubrication, as oil-based may cause erosion of the condom.

Preexposure Vaccinations

The major preemptive control of the spread of STIs depends on the development and the use of vaccines that can immunize people against the acquisition of STIs. Public health officials hope that preexposure vaccinations can similarly slow the spread of STIs, although only a few such vaccines are currently available, such as for hepatitis A, hepatitis B, and HPV.

(See also “HPV Vaccination” earlier in this course.)

Expedited Partner Therapy

With the cooperation of their patients, clinicians should try to find and treat sexual contacts who may have an STD/STI. Often the partner of those with STIs may be asymptomatic and unaware of having an STI or may be unwilling or unable to pursue testing and treatment. Ideally, these partners should be tested for STIs/STDs and then treated in person.

Patients should be asked to notify their sexual partners and to encourage the partners to seek medical care. Some local health departments have programs to help patients notify their partners and to arrange confidential treatment and counseling. The aim of these partner services is to provide clinical and epidemiological services to prevent transmission and reduce complications for people with STDs, partners of people with STDs, and those who are at risk for STDs (CDC, 2020d).

In many states, people who have been diagnosed with chlamydia or gonorrhea may be able to receive medication or a prescription for medication to treat their sex partners, without the partner being seen by a healthcare provider (CDC, 2021o; Jamison & Chang, 2021). This allows the partner to receive rapid treatment, reduces the risk of reinfection by the partner, and decreases the risk of passing the infection to others. According to the CDC, as of April 2021, such “expedited partner therapy” (EPT) is allowable in 46 states and the District of Columbia and potentially allowable in an additional four states and Puerto Rico (CDC, 2021q).

One issue with EPT, however, is that the partner must be treated with oral medications and current guidelines call for intramuscular antibiotic injection for syphilis and gonorrhea. As a result, providers should highly encourage the partners to come to the clinic or provider’s office for treatment (CDC, 2021c).