STI Part 1- Canadian Guidelines

Primary care setting

can incorporate STI primary and secondary prevention in the course of routine patient care

• Assessing, discussing, helping patients recognize and minimize STI risk.
• Informing patients about signs and symptoms of STIs (and lack thereof).
• Offering patient-centred counselling and STI screening and testing.
• Offering Hep A& B immunization when indicated.
• Appropriately treating, following up and counselling infected patients and their partners.

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management of contraception and management of STI risk are closely related. When patients present for contraceptive advice, it can be an ideal time to assess and discuss STI risk.

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STI risk factors

The following STI risk factors are associated with increased incidence of STIs:

• STI Hx or Sexual contact with person(s) with a known STI
• Sexually active <25yo or A new sexual partner or >2 sexual partners in the past year.
• Serially monogamous individuals who have had a series of one-partner relationships over time.
• No contraception or sole use of non-barrier methods (i.e., OCP, Depo Provera, IUD).
• IVDU or substance use, eg. EtOH or chemicals (pot, cocaine, ecstasy, crystal meth), esp. associate with sex.
• Unsafe sexual practices (i.e., unprotected, oral, genital or anal; sex with blood exchange, including sadomasochism; sharing sex toys).
• Sex workers and their clients or “Survival sex”: exchanging sex for money, drugs, shelter or food.
• Street involvement, homelessness or Victims of sexual assault/abuse.
• Anonymous sexual partnering (i.e., Internet, bathhouse, rave party).

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History – STI

• Genital symptoms: discharge, dysuria, abdominal pain, testicular pain, rashes, lesions
• Systemic symptoms: fever, weight loss, lymphadenopathy
• Risk factors and prevention: condom use, vaccination against hepatitis B & A
• Patient’s knowledge of increased risk of STIs.
• Other pertinent Hx: relevant drug treatments, allergies and follow-up of previous problems.
• A brief risk assessment – major risk factors ↑ STIs.

• STI risk assessment script
  • “Part of my job is to assess sexual and reproductive health issues. Of course, everything we talk about is completely confidential. If it is OK with you, I would like to ask you a few questions in this area”.
    • Are you sexually active now, or have you been sexually active? This includes oral sex or anal sex, not just vaginal sex.
    • Do you have any symptoms that might make you think that you have an STI? (Do you have any sores on or around your genitals? Does it hurt or burn when you pee? Have you noticed an unusual discharge from your penis, vagina or anus? Do you have pain during sex?)
    • What are you doing to avoid pregnancy? (Do you or your partner use any type of birth control?)
    • What are you doing to avoid STIs including HIV?
    • Do you have any concerns about sexual or relationship violence or abuse?
    • Have you or your partner(s) used injection or other drugs (e.g., crystal meth)?”
  • For women also ask:
    • “When was your last menstrual period?
    • When was your last Pap test?”

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STI risk assessment questionnaire

Category and elements	Important questions to guide your assessment
Relationship
Present situation	Do you have a regular sexual partner? If yes, how long have you been with this person?
Identify concerns	Do you have any concerns about your relationship? If yes what are they? (e.g., violence, abuse, coercion)
Sexual risk behaviour
Number of partners	When was your last sexual contact? Was that contact with your regular partner or with a different partner? How many different sexual partners have you had in the past 2 months? In the past year?
Sexual preference, orientation	Are your partners, men, women or both?
Sexual activities	Do you perform oral sex (i.e., Do you kiss your partner on the genitals or anus)? Do you receive oral sex? Do you have intercourse (i.e., Do you penetrate your partners in the vagina or anus [bum]? Or do your partners penetrate your vagina or anus [bum])?
Personal risk evaluation	Have any of your sexual encounters been with people from a country other than Canada? If yes, where and when? How do you meet your sexual partners (when travelling, bathhouse, Internet)? Do you use condoms, all the time, some of the time, never? What influences your choice to use protection or not? If you had to rate your risk for STI, would you say that you are at no risk, low risk, medium risk or high risk? Why?
STI history
Previous STI screening	Have you ever been tested for STI/HIV? If yes, what was your last screening date?
Previous STI	Have you ever had an STI in the past? If yes, what and when?
Current concern	When was your sexual contact of concern? If symptomatic, how long have you had the symptoms that you are experiencing?
Reproductive health history
Contraception	Do you and/or your partner use contraception? If yes, what? Any problems? If no, is there a reason?
Known reproductive problems	Have you had any reproductive health problems? If yes, when? What?
Pap test	Have you ever had an abnormal Pap test? If yes, when? Result if known.
Pregnancy	Have you ever been pregnant? If yes, how many times? What was/were the outcome(s) (number of live births, abortions, miscarriages)?
Substance use
Share equipment for injection	Do you use alcohol? Drugs? If yes, frequency and type? If injection drug use, have you ever shared equipment? If yes, what was your last sharing date.
Sex under influence	Have you had sex while intoxicated? If yes, how often? Have you had sex while under the influence of alcohol or other substances? What were the consequences? Do you feel that you need help because of your substance use?
Percutaneous risk other than drug injection	Do you have tattoos or piercings? If yes, were they done using sterile equipment (i.e., professionally)?
Psychosocial history
Sex trade worker or client	Have you ever traded sex for money, drugs or shelter? Have you ever paid for sex? If yes, frequency, duration and last event.
Sexual Abuse	Have you ever been forced to have sex? If yes, when and by whom? Have you ever been sexually abused? Have you ever been physically or mentally abused? If yes, when and by whom?
Housing	Do you have a home? If no, where do you sleep? Do you live with anyone?

Physical Examination

Physical examination may be embarrassing for some patients. Therefore, physicians should develop a trusting environment:

• Some patients may feel more comfortable having an assistant of the same gender present.
• All patients should be assured that confidentiality will be maintained at all times.

Screening/Testing

• Select based on patient history, risk factors and findings on physical examination.
• Be aware of the “I have been tested” syndrome. There are two dimensions to this syndrome:
  • The false sense of security that individuals at risk may develop after multiple STI screenings with repeat negative results. These individuals may develop a sense that “it can never happen to me.”
  • The individual who has had some form of medical attention (i.e., a physical, been in a hospital, Pap smear, given blood) and thinks they have been tested for STIs. This is an educational opportunity.
• Simply asking a patient if he or she has been screened for STI is not enough.

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Diagnosing by Syndrome or by Organism and Post-test Counselling

• The results of microbiologic testing are not immediately available in most offices.
• When particular symptoms and signs are present, a syndromic diagnosis may be made and treatment and post-test counselling provided.
• When microbiologic results are available, treatment and counselling should be directed at specific pathogens; see appropriate chapter(s).

Post-test counselling

Post-test counselling is an integral part of management of the individual with a newly diagnosed STI or tested negative and should include, at minimum, the following:

• Organism- or syndrome-specific advice.
• Safer sex practices that can remove or reduce the risk of transmitting the STI to a partner or reduce the risk of re-infection in the patient.
• Treatment information and issues that differ as a function of whether the infection is bacterial (curable) versus viral (manageable).
• Case reporting requirements to local public health unit.
• Partner notification either via the index case, the physician or a public health official, and the implications of partners not being tested or treated.

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Syndromic Management of STI

Patients, whether symptomatic or not, should be told not to share their medications with partners and to complete the full course of their prescribed medication. Patients should also be advised that if vomiting occurs more than 1 hour post-administration, a repeat dose is not required.

Bacterial STI or trichomonal – abstain from unprotected intercourse until 7 days after treatment of both partners

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Managing Co-morbidity and Associated Risks

Many STIs are transmitted in the context of other medical and social challenges. Recurrent exposure and infection are likely unless underlying issues are dealt with. Specific management for conditions such as drug addiction and mental health conditions should be integrated into the overall multidisciplinary health care plan.

When counselling and testing for STIs, it is important to include HIV pre-test counselling and offer testing. Being infected with an STI (including syphilis, genital herpes, chlamydia, gonorrhea and trichomonas) increases the risk of transmission and acquisition of HIV. HIV-infected individuals may be less responsive to STI treatment and require special monitoring post-treatment to ensure treatment effectiveness and to prevent long-term complications arising from inadequately treated STIs.

For individuals diagnosed with chronic viral hepatitis — either HBV or hepatitis C virus (HCV) — co-infection with HIV impacts on the choice of treatment, the response to treatment and natural evolution of the disease. These patients should be referred to a specialist for treatment and management recommendations. Testing for viral hepatitis B and HIV in any patient with chronic hepatitis C is required to ensure proper management of the infection. In addition, for those infected with HCV, ensuring vaccination against HAV and HBV is essential to prevent co-infection, which can further assault the liver, complicate treatment options and compromise response to treatment and patient prognosis.^Footnote14

If lymphogranuloma venereum (LGV) is suspected and linked to a current outbreak in Canada, it is also important to test for HCV, because there is a high rate of LGV-HCV co-infection.

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Reporting to Public Health and Partner Notification

STI reporting requirements and confidentiality

Patients should be advised of the provincial/territorial public health acts and the Child Protection Act, which supersede physician/patient confidentiality and require release of personal information without patient consent for all reportable STIs and in cases where child abuse is suspected.

Those working in agencies receiving personal information are bound by ethical, legal and professional obligations to protect the confidentiality of this information. Patients need to be informed that the information will be reported to authorities only as required by law as noted above but will otherwise remain confidential. This is often a crucial concern for young people who come forward for STI care.

Confidentiality applies to all persons, including infected persons, sexual/needle-sharing partners, all youth who are competent to understand their infection and care, and people who may be involved in cases of child sexual abuse.

Partner notification

Rationale

Partner notification is a secondary prevention process through which sexual partners and other contacts exposed to an STI are identified, located, assessed, counselled, screened and treated. Partner notification not only produces a public health benefit (e.g., disease surveillance and control) but dramatically reduces the risk of re-infection for the original patient.

While partner notification is sometimes construed as an exercise in societal vs. individual rights, its aim is clearly to assist people in honouring the individual rights of their partners to know they have been put at risk and to make informed decisions regarding their health and in some instances their life.

A review of the evidence supports several recommendations related to the partner-notification process.^Footnote10 There is good evidence to show that partner notification can be an effective means of finding at-risk and infected persons and that health care provider referral generally ensures that more partners are notified and medically evaluated.^{Footnote10,Footnote11}

Who performs partner notification?

Partner notification may be done by the patient, health care providers or public health authorities. Often, more than one strategy may be used to notify different partners of the same infected person.

• Self- or patient referral: the infected person accepts full responsibility for informing partners of the possibility of exposure to an STI and for referring them to appropriate services.
• Health care provider/public health referral: with the consent of the infected person, the health care provider takes responsibility for confidentially notifying partners of the possibility of their exposure to an STI (without ever naming the index case).
• Contract referral: the health care provider negotiates a time frame with the infected person (usually 24–48 hours) to inform his or her partners of their exposure and to refer them to appropriate services.^Footnote11

Under certain circumstances (i.e., apparently monogamous relationships) the partner may deduce who the index case is by the process of elimination. The health care provider is still required to maintain confidentiality related to the index case, and no information related to the index case can be released to the partner.

If the index case does not wish to notify partners, or if partners have not come forward:

• Explore impediments/barriers to partner notification (see below).
• If needed, report to public health authorities.

Barriers to partner notification

• Actual or feared physical or emotional abuse that may result from partner notification (e.g., conjugal violence): health care provider/public health referral may be the best option in these cases so as to protect the index case. If there is a threat to patient safety, public health officials should be notified of this so that proper safety precautions are taken to protect the index case. Safety always trumps the notification process.
• Fear of losing a partner due to a STI diagnosis (blame/guilt): discuss the asymptomatic nature of STIs and the benefits of asymptomatic partner(s) knowing that they may be infected.
• Feared legal procedures: cases need to be advised that their identity is protected at all times, and unless their records are subpoenaed, no information can be released.
• Fear of re-victimization on the part of sex crime victims: health care provider/public health referral may be the best option for notification of partners in these cases.
• Anonymous partnering is a significant barrier to partner notification: wherever possible, encourage patient referral.

Note:
Actual or suspected child sexual abuse must be reported to your local child protection agency. The Child Protection Act supersedes all other acts and requires health professionals to release the names of any named contacts of a minor to the Children’s Aid Society for further investigation.

All persons named as suspects in child sexual abuse cases should be located and clinically evaluated; prophylactic treatment may or may not be offered and the decision to treat or not should be based on history, clinical findings and test results (See Sexual abuse in Peripubertal and Prepubertal Children chapter).

Novel partner-notification practices

With changing trends in STI rates and transmission, research is being conducted to look at the feasibility of alternative methods of partner notification. One such method is the use of expedited patient-initiated treatment of sex partners. The index case is given medication, together with safety information and contraindications, to give to partners for presumptive treatment without assessment to reduce gonorrhea or chlamydia reinfections and to increase the proportion of partners treated. Although still controversial, this method may be beneficial in high-risk and hard-to-reach populations.

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Patient-Centred Education and Counselling

Common counselling topics

Serial monogamy

It is important for practitioners to recognize and address the issue of serial monogamy. Serial monogamy consists of a series of faithful, monogamous relationships, one after the other. Although they may “feel safe” and “look safe,” serially monogamous relationships, with known and committed partners, do not themselves provide adequate protection from STIs. Consistent condom use and STI testing followed by mutual monogamy are far safer strategies than relying on serially monogamous partners’ apparent safety.

For youth contemplating initiation of sexual activity

Many youth will ask for contraceptive information prior to becoming sexually active. Many young women will begin using oral contraception for cycle control as opposed to contraceptive reasons. Both represent excellent opportunities to counsel on safer sex practices.

• When discussing non-barrier contraceptive options, discussion of safer sex and condom use should occur.
• Promote partner testing prior to becoming sexually active for partners who have already been sexually active.
• Let patients know the benefits of preventive behaviour.

Contraceptive advice

Oral contraceptive prescription is commonly associated with cessation of condom use. It has been documented that prescription of oral contraception is very often associated with the offset of barrier method use and increased incidence of STIs. Individuals in relationships very often move on from initial barrier protection to oral contraception without the benefit of STI testing. Clinicians need to counsel about alternatives to this risky pattern (e.g., testing before cessation of condom use), particularly when prescribing oral contraceptives.

Plan and motivate prevention and risk-reduction strategies

Acceptance of sexuality

• Individuals must accept the fact that they are or might be sexually active before they can plan for STI prevention. Primary care providers, by their actions, can show understanding of patient sexuality by initiating a non-judgmental, two-way dialogue that will help individuals examine the choices they make related to their sexuality. Examining these choices can be useful in helping patients to proactively plan for risk reduction measures appropriate to their specific situation.
• Provide easy-to-apply information:
  • Challenge patients to plan if and how they will discuss STI preventive actions with their partners, or take STI preventive actions unilaterally (e.g., put on a condom), and how they will practice safer sex consistently.
  • Assess whether patients know where they can comfortably obtain condoms in their community, if they know how to use condoms correctly, if they are aware of the signs of STIs and if they know how to seek testing and treatment if needed.

Planning prevention

• Individuals who take STI preventive action need to engage in a number of advance preparations, such as buying condoms, seeking STI/HIV testing and talking about STIs with their health care provider(s). Primary care providers can discuss setting and maintaining personal limits with their patients and identify the most “user-friendly” local STI prevention resources available.
• Health care practitioners can help patients to plan for prevention by openly discussing safer sex using a continuum approach (i.e., masturbation/mutual masturbation, low risk; oral sex, moderate risk for STIs and low risk for HIV; unprotected vaginal or anal intercourse, high risk for STIs and HIV). This can be useful in helping patients understand the risks associated with various activities, make informed choices about the initiation and maintenance of STI preventive actions and deal with possible partner resistance.
• Provide easy-to-apply information:
  • Discuss limiting alcohol or drug intake prior to sexual activity, as they decrease inhibitions and could affect decision-making and negotiation skills.
  • Reinforce that it is not possible to assess the chances that a partner has an STI on the basis of knowing the partner’s sexual history, being in a close relationship with a partner or being monogamous with a partner who has a sexual history and who has not been tested.
  • It is important to tell patients that we do not and cannot routinely test for all STIs (e.g., human papilloma virus [HPV], herpes simplex virus [HSV]), so even if they or their partner’s tests are all negative they may still have an asymptomatic STI.

Safer-sex counselling

Safer-sex counselling as a primary or secondary prevention strategy should include the following at minimum^Footnote3:

• STI modes of transmission.
• Risks of various sexual activities (oral, genital, rectal).
• Abstinence, mutual monogamy and barrier-method options and availability (male condom, female condom, dental dam).
• Harm-reduction counselling: determining which prevention measures are appropriate and realistic to implement, given the patient’s personal sexual situation(s) (e.g., if practising receptive anal intercourse, always use a condom and extra lubrication, and avoid use of spermicidal condoms).

Statements related to the fact that effective safer-sex practice requires negotiation and is something that should be discussed with partners may be approached by stating: “If you or your partner(s) have ever had another sexual partner, there are a number of options open to you for safer sex. Always using a condom, or getting tested for STI/HIV with your partner followed by mutual monogamy are a few of these options. Do you think any of these might work for you and your partner?”

Proper use of condoms

Reasons for condom failure are most often the result of improper or inconsistent use. For counselling guidelines and instructions on use, see Appendix A and AppendixB.

Efficacy of condoms in STI prevention

• Although latex and polyurethane condoms are effective in preventing the majority of STIs, including HIV, HBV, chlamydia and gonorrhea, they do not provide complete protection against HPV or HSV infection.
• Natural skin condoms may be permeable to HBV and HIV.

Discussing alternatives

• An allergy to latex may be an issue for some patients; male or female polyurethane condoms can offer needed protection in these patients.
• The female condom (a polyurethane vaginal pouch) is commercially available and represents an alternative to male condoms or in persons who have a latex allergy for both STI and pregnancy prevention. Female condoms are available in most drug stores and are more expensive than male condoms, approximately $3.00 each. For instructions on use of a female condom see Appendix B.

Female condom use for anal intercourse

Some individuals are using the female condom for anal intercourse, although the manufacturer does not provide recommendations for use in this way. What limited studies have been done on the use of female condoms for anal intercourse have found that there tends to be higher incidence of rectal bleeding and condom slippage in comparison to the male condom.^Footnote4

These studies concluded that modifications, training and research on the clinical significance of safety outcomes are needed for the use of female condoms with anal sex, and redesign of the female condom could increase acceptability and use by men who have sex with men (MSM) and address possible safety concerns.

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Following up

Ideally, follow-up should be conducted by the same health care provider to ensure resolution of symptoms, follow-up testing as indicated and follow-through on partner notification to reduce the likelihood of reinfection. Where this is not possible, patients should be directed to the appropriate community resources, counselled on when to get follow-up (especially if tests were done) and advised of indicators of treatment failure. (See infection-specificchapters for follow-up recommendations.)

For individuals identified at ongoing risk for STIs, recommend screening for gonorrhea, chlamydia, syphilis and HIV at 3-month intervals and reinforce safer sexual practices.

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References:

http://www.phac-aspc.gc.ca/std-mts/sti-its/cgsti-ldcits/section-2-eng.php