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US Public Health Service. Office of Disease Prevention and Health Promotion. Clinician's Handbook of Preventive Services. 2nd edition. Washington (DC): Department of Health and Human Services (US); 1999.

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

Cover of Clinician's Handbook of Preventive Services

Clinician's Handbook of Preventive Services. 2nd edition.

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59Sexually Transmitted Diseases and HIV Infection

Almost 12 million cases of sexually transmitted diseases (STDs) occur annually in the United States. Eighty-six percent of such cases occur in persons aged 15 through 29 years. In addition to syphilis and gonorrhea, the list of STDs now includes human immunodeficiency virus (HIV) infection, Chlamydia trachomatis infection, genital herpes virus infection, human papilloma virus (HPV) infection, chancroid, genital mycoplasmas, cytomegalovirus infection, hepatitis B infection, vaginitis, enteric infections, and ectoparasitic diseases. Chlamydial infection is the most common STD, causing an estimated 4 million acute cases annually. Although the incidence of gonorrhea and syphilis decreased in the early 1990s, these diseases remain a persistent public health problem.

Acquired immunodeficiency syndrome (AIDS) is the eighth leading cause of death in the United States. It is now the leading cause of death among men aged 25 to 44 years and the third leading cause of death among women of the same age group. AIDS is the sixth leading cause of years of potential life lost in the United States. The Centers for Disease Control and Prevention estimate that 650,000 to 900,000 people in the United States are infected with HIV. No cure for AIDS currently exists, although treatment can delay onset of symptoms.

The consequences of STDs are particularly troublesome for women and children. Apart from AIDS, the most serious complications of STDs for women are pelvic inflammatory disease (PID), an increased risk of cervical cancer, ectopic pregnancy, congenital infection and malformations, delivery of premature and low-birth-weight infants, and fetal death. Persons who are poor or medically underserved and racial and ethnic minorities also contract a disproportionate number of STDs and the disabilities associated with them.

Individuals who are at increased risk for STDs and HIV infection include: (1) those who are or were recently sexually active, especially persons with multiple sexual partners; (2) those who use alcohol or illicit drugs; (3) gay or bisexual men who have sex with other men; (4) persons with a previous history of a documented STD/HIV infection and their close contacts; (5) persons involved in the exchange of sex for drugs or money; and (6) persons living in areas where the prevalence of HIV infection and STDs is high.

Many sexually transmitted diseases (AIDS, chancroid; Chlamydia trachomatis [genital infections only]; gonorrhea; hepatitis B; hepatitis C/non-A, non-B; HIV infection [pediatric cases only]; and syphilis) are currently designated as infectious diseases notifiable at the national level. Refer to Appendix C for further information on nationally notifiable diseases.

See chapter 40 for information on screening for STDs and HIV infection, chapter 23 for information on counseling children and adolescents about STDs and HIV infection, and chapters 25 and 61 for information about counseling to prevent unintended pregnancy among adolescents and adults, respectively.

Recommendations of Major Authorities

  • American Academy of Family Physicians --
  • Adolescents and adults should be counseled about the risks for sexually transmitted diseases and how to prevent them.
  • American College of Obstetricians and Gynecologists (ACOG) and American College of Physicians --
  • Patients should be counseled on measures to prevent STDs and HIV infection. ACOG recommends offering HIV counseling and testing to all pregnant women and strongly encourages it for high-risk women. HIV and STD counseling should be included for all women as a part of their routine preventive services whether pregnant or not.
  • The Canadian Task Force on the Periodic Health Examination --
  • There is insufficient evidence to recommend for or against the inclusion or exclusion of the following from the periodic health examination of asymptomatic individuals: obtaining a history of sexual practices and injection drug use or counseling on high-risk sexual practices and condom use. There is fair evidence to include counseling to prevent the spread of gonorrhea.
  • Centers for Disease Control and Prevention --
  • Latex condoms should be made more widely available by health care providers in STD, family planning, and drug treatment clinics. HIV seronegative pregnant women and women of childbearing age who are at increased risk of becoming infected with HIV should receive additional counseling regarding the maternal and fetal risks associated with pregnancy should they become infected. STD and HIV screening should be offered to high-risk individuals; counselors should take advantage of all available opportunities to provide patients with HIV-prevention messages. HIV pretest counseling must include a personalized patient-risk assessment and should result in a personalized plan for the patient to reduce the risk of HIV infection.
  • US Preventive Services Task Force (USPSTF) --
  • All adolescent and adult patients should be advised about risk factors for sexually transmitted diseases and HIV infection and counseled appropriately about effective measures to reduce risk of infection. This recommendation is based on the proven efficacy of risk reduction, although the effectiveness of clinician counseling in the primary care setting is uncertain. Counseling should be tailored to the individual risk factors, needs, and abilities of each patient. Assessment of risk should be based on a careful sexual and drug use history and consideration of the local epidemiology of STDs and HIV infection. Patients at risk of STDs and HIV infection should receive information on their risk and be advised about measures to reduce their risk. Effective measures include abstaining from sex, maintaining a mutually faithful monogamous sexual relationship with a partner known to be uninfected, regular use of latex condoms, and avoiding sexual contact with high-risk individuals (eg, injection drug users, commercial sex workers, and persons with numerous sex partners). Women at risk of STDs should be advised of options to reduce their risk in situations when their male partner does not use a condom, including the female condom. Warnings should be provided that using alcohol and drugs can increase high-risk sexual behavior. Persons who inject drugs should be referred to available drug treatment facilities, warned against sharing drug equipment and, where possible, referred to sources for uncontaminated injection equipment and condoms. All patients at risk for STDs should be offered testing in accordance with USPSTF recommendations for screening for syphilis, gonorrhea, chlamydia, genital herpes, hepatitis B, and HIV infection (chapter 40).

Basics of STD/HIV Counseling

1.

Determine every patient's risk for STDs (Table 59.1), including HIV infection. Tailor counseling to the behaviors, circumstances, and special needs of the person being served. Risk-reduction messages must be personalized and realistic. Counseling should be culturally appropriate, sensitive to issues of sexual identity, developmentally appropriate, and linguistically specific. HIV counseling is not a lecture; an important aspect of HIV counseling is the clinician's ability to listen to the patient.

2.

Provide patients with materials about HIV transmission and prevention that are appropriate for their culture and educational level.

3.

Advise all patients that any unprotected sexual behavior poses a risk for STDs and HIV infection. A person who is infected can infect others during sexual intercourse, even if no symptoms are present. Caution patients to avoid sexual intercourse with persons who may be infected with HIV, such as those who have injected drugs, individuals with multiple or anonymous sex partners, or those who have had any STD within the past 10 years, even if they have no symptoms. Advise patients not to make decisions about sexual intercourse while they are under the influence of alcohol or other drugs that cloud judgment and permit risk-taking behavior.

4.

Provide patients with educational materials and information that explain that STDs and HIV infection are best prevented by the following measures:

  • Abstinence
  • Limiting sexual relationships to those between mutually monogamous partners known to be HIV-negative
  • Avoiding sex with high-risk partners
  • Avoiding anal intercourse
  • Using latex condoms if having sex with anyone other than a single, mutually monogamous partner known to be HIV-negative.

5.

Provide patients with educational materials and information indicating that partners can transmit infection even if males withdraw before ejaculating. Infection can be transmitted during all forms of sexual intercourse, including oral sex.

6.

Provide educational information indicating that the risk of HIV infection is increased through co-infection with other STDs, such as syphilis, genital herpes, and gonorrhea.

7.

Instruct all sexually active patients about the effective use and limitations of condoms, stressing that they are not foolproof, must be used properly, and may break during intercourse. The best preventive measure against transmission of HIV and other STDs, after abstinence, is use of latex condoms (not "lambskin" or natural-membrane condoms). Scientific research has demonstrated that latex condoms, when used consistently and correctly, are highly effective in stopping HIV transmission. Condom failure (slip, break, or leak) usually is caused by user error. See Table 23.1 for guidelines regarding condom use.

8.

Dispel myths about HIV transmission by informing patients that they cannot become infected from mosquito bites; contact with toilet seats or other everyday objects, such as doorknobs, telephones, or drinking fountains; or casual contact with someone who is infected with HIV or has AIDS, such as shaking hands, hugging, or a kiss on the cheek.

9.

Use patient-centered counseling to assess, inform, and advise about STDs and HIV prevention. In patient-centered counseling, the provider asks the patient what they know about HIV transmission and provides the correct information in response to any misconceptions the patient expresses.

  • Establish a trusting, caring relationship with the patient to enhance the efficacy of counseling on safe sex practices and risks for STD and HIV infection.
  • Listen carefully to the patient to identify any specific barriers to preventing STD and HIV infection that the patient has and to assist the patient in identifying a personal, workable preventive plan without lecturing the patient.
  • Provide counseling that is culturally appropriate. Present information and services in a manner that is sensitive to the culture, values, and traditions of the patient.
  • Counseling should be sensitive to issues of sexual orientation.
  • Provide information and services at a level of comprehension that is consistent with the age and learning skills of the patient, using a dialect and terminology consistent with the patient's language and communication style.

10.

Advise all patients of the adverse health consequences of injection drug use. Refer patients with evidence of drug dependence to appropriate drug-treatment providers and community programs specializing in treatment of drug dependencies. Providers should actively assist the patient in obtaining assessment for drug treatment.

11.

Persons who continue to inject drugs should have periodic screening for HIV and hepatitis B. Hepatitis B vaccination should be considered for individuals lacking immunity who are negative for hepatitis B surface antigen (chapter 48). Measures to reduce the risk of infection caused by drug use should also be discussed: use a new, sterile syringe for each injection; never share or reuse injection equipment; use clean (if possible, sterile) water to prepare drugs; clean the injection site with alcohol before injection; and safely dispose of syringes after use. Patients should also be informed of available resources for obtaining sterile supplies.

12.

Contact the state or local health agency responsible for communicable disease reporting to determine the local prevalence of HIV infection and other STDs. This agency also can provide information regarding state and local laws regulating patient testing and confidentiality. Requirements regarding which infections to report, when, and to whom may vary from state to state (Appendix C). Chapter 40 discusses the types of HIV tests available.

Table 59.1. Examples of Questions for Taking Clinical Histories About Sexual Behavior.

Table

Table 59.1. Examples of Questions for Taking Clinical Histories About Sexual Behavior.

Patient Resources

  • How to Prevent Sexually Transmitted Diseases, Genital Herpes, Gonorrhea and Chlamydia, Pelvic Inflammatory Disease. American College of Obstetricians and Gynecologists, 409 12th St, SW, Washington, DC 20024; (800)762-2264. Internet address: http://www.acog.com
  • HIV Infection and Women. ACOG Patient Education Pamphlet AP082. American College of Obstetricians and Gynecologists, 409 12th St, SW, Washington, DC 20024; (800)762-2264. Internet address: http://www.acog.com
  • Giving and Receiving Blood (#329 546); Testing for HIV Infection (#329 547); Women, Sex, and HIV (#329 537); HIV Infections and AIDS (#329 560). Available through your local chapter of the American Red Cross.
  • Surgeon General's Report to the American Public on HIV Infection and AIDS; Condoms and Sexually Transmitted Diseases ... Especially AIDS. To order these and many other materials, contact the CDC National AIDS Information Hot Line: (800)342-AIDS (English speaking); (800)344-SIDA (Spanish speaking); (800)AIDS-TTY (hearing impaired). All phone calls are confidential.
  • HIV in America: A Profile of the Challenges Facing Americans Living With HIV. National Association of People Living with AIDS, 1413 K St, NW, Washington, DC 20005; (202)898-0435.
  • National STD Hot Line: (800)227-8922; (809)765-1010 (Spanish; call collect).
  • Information on hemophilia and HIV: Hemophilia and AIDS Network for the Dissemination of Information, 110 Green St, New York, NY 10012; (800)424-2634.
  • Women, AIDS, and Drug Use Annotated Client Education Directory. NOVA Research Co, 4600 East-West Hwy, Suite 700, Bethesda, MD 20814; (301)986-1891.
  • National AIDS Information Hotline, Centers for Disease Control and Prevention, (800)342-AIDS.

Provider Resources

  • HIV Infection and AIDS (monograph); HIV Infection in the Family Physician's Office (brochure); Clinical and Psychosocial Aspects of Caring for HIV Patients (audiotape); HIV Infection and Physician Emotions (videotape and discussion guide). American Academy of Family Physicians, 8880 Ward Pkwy, Kansas City, MO 64114-2797; (800)944-0000. Internet address: http://www.aafp.org
  • Gynecologic Herpes Simplex Virus Infection (technical bulletin 119). American College of Obstetricians and Gynecologists, 409 12th St SW, Washington, DC 20024; (800)762-2264. Internet address: http://www.acog.com
  • National AIDS Information Clearinghouse. PO Box 6003, Rockville, MD 20850; (800)458-5231. General information (in both English and Spanish) on STDS, HIV, AIDS and AIDS-related diseases (seven brochures) and fact sheet packet (10 brochures).
  • National HIV Telephone Consultation Service is a clinical consultation service of health care providers: (800)933-3413.
  • National AIDS Information Hotline, Centers for Disease Control and Prevention, (800)342-AIDS.

Selected References

  1. American Academy of Family Physicians. Summary of Policy Recommendations for Periodic Health Examination . Kansas City, Mo: American Academy of Family Physicians; 1997.
  2. American College of Obstetricians and Gynecologists. Guidelines for Women's Health Care . Washington, DC: American College of Obstetricians and Gynecologists; 1996.
  3. American College of Obstetricians and Gynecologists and American Academy of Pediatrics. Guidelines for Perinatal Care.4th ed. Washington, DC and Elk Grove Village, Ill: American College of Obstetricians and Gynecologists and American Academy of Pediatrics; 1997.
  4. American College of Physicians. Acquired immunodeficiency syndrome. Ann Intern Med . 1986; 104:575–581. [PubMed: 3006572]
  5. American Medical Association. Prevention and control of acquired immunodeficiency syndrome: an interim report. JAMA . 1987; 258:2097–2103. [PubMed: 3477655]
  6. Canadian Task Force on the Periodic Health Examination. Prevention of gonorrhea. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 59.
  7. Canadian Task Force on the Periodic Health Examination. Screening for HIV antibody. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 58.
  8. Centers for Disease Control and Prevention. Technical guidance on HIV counseling. MMWR. . 1993; 42(RR-2):8–17.
  9. Centers for Disease Control. Sexually transmitted diseases treatment guidelines. MMWR . 1989; 38(S-8):1–43. [PubMed: 2770678]
  10. Centers for Disease Control. Estimates of HIV prevalence and projected AIDS cases: summary of a workshop, October 31-November 1, 1989. MMWR . 1990; 39:110–112, 117-119. [PubMed: 2105449]
  11. Gerber AR, Valdiserri RO, Holtgrave DR, et al. Preventive services guidelines for primary care clinicians caring for HIV-infected adults and adolescents. Arch Fam Med . 1993; 2:969–979. [PubMed: 8111528]
  12. Higgins DL, Galavotti C, O'Reilly KR, et al. Evidence for the effects of HIV antibody counseling and testing on risk behaviors. JAMA . 1991; 266:2419–2429. [PubMed: 1920748]
  13. Janssen RS, Satten GA, Critchley SE. HIV infection among patients in US acute care hospitals: strategies for the counseling and testing of hospital patients. N Engl J Med . 1992; 327:445–452. [PubMed: 1625734]
  14. US Department of Health and Human Services. Sexually transmitted diseases. In: Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington, DC: US Department of Health and Human Services, Public Health Service; 1991: chap 19. USDHHS publication PHS 91-50212.
  15. US Preventive Services Task Force. Counseling to prevent human immunodeficiency virus infection and other sexually transmitted diseases.In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services; 1996: chap 62.
  16. US Preventive Services Task Force. Screening for drug abuse.In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services; 1996: chap 53.

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