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SCREENING, DIAGNOSIS, AND TREATMENT OF SEXUALLY TRANSMITTED DISEASES IN PRIMARY CARE SETTINGS (14HC03)

Bonnie Richards, DO, BSN, Patricia Mason, BS, PHA and Sindy M. Paul, MD, MPH, FACPM

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Introduction

Sexually transmitted diseases (STDs) cause significant morbidity and mortality each year in the United States. The Centers for Disease Control and Prevention (CDC) has estimated that approximately 19 million STDs occur in the United States annually.1 This is a major public health concern as the potential complications of untreated infections include pelvic inflammatory disease, infertility, cervical cancer, and increased transmission of the human immunodeficiency virus (HIV).2

Primary care physicians (PCPs) are often the first to see patients with STD symptoms and, as such, play an important role in preventing, diagnosing, and treating STDs by screening for those at-risk and counseling to prevent high-risk behaviors that may lead to STDs and their sequelae. This paper focuses on information useful for PCPs in diagnosing, treating, and preventing sexually transmitted diseases. It is based primarily on the CDC Sexually Transmitted Disease Treatment Guidelines, 2010. 2

HISTORY-TAKING AND PREVENTION COUNSELING

The prevention and control of STDs are based on the following five major strategies:2
  1. Education and counseling of persons at risk on ways to avoid STDs through changes in sexual behaviors and use of recommended prevention services;
  2. Identification of asymptomatic infected persons and of symptomatic persons unlikely to seek diagnostic and treatment services;
  3. Effective diagnosis, treatment, and counseling for all infected persons;
  4. Evaluation, treatment, and counseling for all sex partners of persons who are infected with an STD; and
  5. Pre-exposure vaccination of persons at risk for vaccine-preventable STDs.

Primary prevention of STDs begins with changing the sexual behaviors that place persons at risk for infection. As part of the clinical interview, you, as the healthcare provider, should routinely obtain sexual histories from all patients and provide tailored risk reduction messages as suggested by the sexual history.

Sexual history taking

A sexual history needs to be taken during:3

  • A client’s initial visit
  • Routine preventive exams
  • When you see signs and/or symptoms of an STD

A sexual history allows you to identify those at risk for STDs, including HIV and hepatitis, and to identify appropriate sites for STD testing. The dialogue lends itself to the opportunity for risk-reduction counseling.

Few patients feel comfortable talking about their sexual history, sex partners, or sexual practices. Try to put patients at ease and let them know that taking a sexual history is an important part of a regular medical exam or physical history. You may want to say something such as:

“I am going to ask you a few questions about your sexual health and sexual practices. I understand that these questions are very personal, but they are important for your overall health. Just so you know, I ask these questions to all of my adult patients, regardless of age, gender, or marital status. These questions are as important as the questions about other areas of your physical and mental health. Like the rest of our visits, this information is kept in strict confidence. Do you have any questions before we get started?”5

Interviewing skills

Effective interviewing and counseling skills, characterized by respect, compassion, and a nonjudgmental attitude toward all patients, are essential to obtaining a thorough sexual history and to delivering prevention messages effectively. Key techniques that can be effective in facilitating rapport with patients include the use of:

  • Open-ended questions (e.g., “Tell me about any new sex partners you’ve had since your last visit,” and “What’s your experience with using condoms been like?”)
  • Understandable language (“Have you ever had a sore or scab on your penis?”)
  • Normalizing language, i.e. wording that suggests that you ask everyone this question or that it is common to have this problem (“Some of my patients have difficulty using a condom with every sex act. How is it for you?”).
The “Five P’s” approach provides guidance on obtaining a sexual history.
PARTNERS
  • Do you have sex with men, women, or both?
  • In the past 2 months, how many partners have you had sex with?
  • In the past 12 months, how many partners have you had sex with?
  • Is it possible that any of your sex partners in the past 12 months had sex with someone else while they were still in a sexual relationship with you?

PREVENTION OF PREGNANCY

  • What are you doing to prevent pregnancy?

PROTECTION FROM STDS

  • What do you do to protect yourself from STDs and HIV?
PRACTICES
  • To understand your risks for STDs, I need to understand the kind of sex you have had recently.
  • Have you had vaginal sex, meaning “penis in vagina sex”?
    If yes, do you use condoms: never, sometimes, or always?
  • Have you had anal sex, meaning “penis in rectum/anus sex”?
    If yes, do you use condoms: never, sometimes, or always?
  • Have you had oral sex, meaning “mouth on penis/vagina”?

For condom answers:

  • If never: Why don’t you use condoms?
    If sometimes: In what situations (or with
    whom) do you not use condoms?

PAST HISTORY OF STDS

  • Have you ever had an STD?
  • Have any of your partners had an STD?

Additional questions to identify HIV and viral hepatitis risk include:

  • Have you or any of your partners ever injected drugs?
  • Have any of your partners exchanged money or drugs for sex?
  • Is there anything else about your sexual practices that I need to know about?

Adapted from: Centers for Disease Control and Prevention (CDC) Sexually Transmitted Diseases Treatment Guidelines, 2010. MMWR 2010:59 (No.RR-12). Page 3.

STDs and HIV prevention counseling

The United States Preventive Services Task Force (USPSTF) recommends high-intensity behavioral counseling for all sexually active adolescents and for adults at increased risk for STDs and HIV.2 In addition to routinely obtaining a sexual history from your patients, provide clients with appropriate, tailored prevention messages that provide them with information and support to reduce risk for STDs, including HIV and hepatitis (e.g., abstinence, condom use, limiting the number of sex partners, modifying sexual practices, and vaccination). Key prevention messages include the following:

  • A reliable way to avoid transmission of STDs is to abstain from oral, vaginal, and anal sex or to be in a long-term, mutually monogamous relationship with an uninfected partner.
  • Pre-exposure vaccination is highly effective. Vaccination is currently available against human papilloma virus (HPV), Hepatitis A and Hepatitis B.
  • Anyone at risk of an STD is also at risk of HIV. Routinely provide clients-at-risk with information about HIV, HIV testing, HIV transmission and HIV prevention. Provide routine screening for HIV or refer to an HIV counseling and testing site
  • When used consistently and correctly, male and female condoms are highly effective in preventing the sexual transmission of HIV infection and other STDs.
  • Contraceptive methods that are not mechanical barriers (e.g., intrauterine devices, oral contraceptives, levonorgestrel implant, surgical sterilization, etc) offer no protection against HIV or other STDs. These methods can be combined with condoms to reduce risk of STDs, including HIV and hepatitis.
  • Women who might have been exposed to an STD during a recent act of unprotected intercourse are at risk for pregnancy. Provide these women with counseling on emergency contraception (EC) if pregnancy is not desired. EC is available over-the-counter to women aged ≥17 years and by prescription to younger women. All oral EC regimens are efficacious when initiated as soon as possible after unprotected sex, but have some efficacy as long as 5 days later.

A more comprehensive discussion on the provision of risk reduction information and support to clients can be found:

  • In the CDC Sexually Transmitted Disease Treatment Guidelines,2010, (which can be downloaded free-of-charge at http://www.cdc.gov/std/treatment/2010/)
  • In Contraceptive Technology, 19th Edition (Hatcher RA, Trussell J, Nelson AL, et al.NewYork:Ardent Media; 2007). Available wherever books are sold.
  • At the website entitled “Effective Interventions, HIV Prevention that Works”; see http://effectiveinterventions.org/en/Home.aspx
Primary prevention of STDs begins with changing the sexual behaviors that place persons at risk for infection.


 
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