Sexually Transmitted Infections: Behavioral Counseling -- Sexually Active Adolescents and Adults


General

Grade: B The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. Offer or provide this service.

Specific Recommendations

The USPSTF recommends intensive behavioral counseling for all sexually active adolescents and for adults who are at increased risk for sexually transmitted infections (STIs).

Frequency of Service

No information available.

Risk Factor Information

All sexually active adolescents are at increased risk for STIs and should be counseled. Other risk groups that have been included in counseling studies include adults with current STIs or other infections within the past year, adults who have multiple sex partners, and adults who do not consistently use condoms. Clinicians should be aware of populations with a particularly high prevalence of STIs. African Americans have the highest STI prevalence of any racial/ethnic group, and STI prevalence is higher in American Indians, Alaska Natives, and Latinos than in white persons. Increased STI prevalence rates are also found in men who have sex with men (MSM), persons with low incomes living in urban settings, current or former inmates, military recruits, persons who exchange sex for money or drugs, persons with mental illness or a disability, current or former intravenous drug users, persons with a history of sexual abuse, and patients at public STI clinics.


Clinical

Patient Population Under Consideration

This recommendation applies to all sexually active adolescents and to adults who are at increased risk for acquiring or transmitting STIs.

Assessment of Risk

All sexually active adolescents are at increased risk for STIs and should be counseled. Other risk groups that have been included in counseling studies include adults with current STIs or other infections within the past year, adults who have multiple sex partners, and adults who do not consistently use condoms.Clinicians should be aware of populations with a particularly high prevalence of STIs. African Americans have the highest STI prevalence of any racial/ethnic group, and STI prevalence is higher in American Indians, Alaska Natives, and Latinos than in white persons. Increased STI prevalence rates are also found in men who have sex with men (MSM), persons with low incomes living in urban settings, current or former inmates, military recruits, persons who exchange sex for money or drugs, persons with mental illness or a disability, current or former intravenous drug users, persons with a history of sexual abuse, and patients at public STI clinics.

Behavioral Counseling Interventions

Behavioral counseling interventions can reduce a person's likelihood of acquiring an STI. Interventions ranging in intensity from 30 minutes to 2 or more hours of contact time are beneficial. Evidence of benefit increases with intervention intensity. High-intensity counseling interventions (defined in the review as contact time of ≥2 hours) were the most effective, moderate-intensity interventions (defined as 30 to 120 minutes) were less consistently beneficial, and low-intensity interventions (defined as <30 minutes) were the least effective. Interventions can be delivered by primary care clinicians or through referral to trained behavioral counselors.Most successful approaches provided basic information about STIs and STI transmission; assessed the person's risk for transmission; and provided training in pertinent skills, such as condom use, communication about safe sex, problem solving, and goal setting. Many successful interventions used a targeted approach to the age, sex, and ethnicity of the participants and also aimed to increase motivation or commitment to safe sex practices. Intervention methods included face-to-face counseling, videos, written materials, and telephone support. The USPSTF did not find enough evidence to determine whether the following intervention characteristics were related independently to effectiveness: degree of cultural tailoring, group versus individual format, condom negotiation or other communication as an intervention component, counselor characteristics, setting, or type of control group.

Additional Approaches to Prevention

The CDC provides information about STI prevention, testing, and resources at www.cdc.gov/std/prevention/default.htm. It recommends that health care providers inform patients on how to reduce their risk for STI transmission, including abstinence, correct and consistent condom use, and limiting the number of sex partners. The CDC also maintains an inventory of efficacious interventions in the “Compendium of Evidence-Based HIV Behavioral Interventions” (available at www.cdc.gov/hiv/prevention/research/compendium). The Community Preventive Services Task Force has issued several recommendations on the prevention of HIV/AIDS, other STIs, and teen pregnancy. The Community Guide discusses interventions that have been effective in school settings and for MSM (available at www.thecommunityguide.org/hiv/index.html). The CDC Advisory Committee on Immunization Practices has issued recommendations on the control of vaccine-preventable diseases, including hepatitis B and human papillomavirus (available at www.cdc.gov/vaccines/hcp/acip-recs/index.html). The National Coalition of Sexually Transmitted Disease Directors and the National Alliance of State and Territorial AIDS Directors developed optimal care checklists for health providers of MSM (available at www.ncsddc.org/publications/optimal-care-checklists-providers-msm-patients).

Useful Resources

The USPSTF has issued several recommendations related to screening for STIs, including screening for chlamydia and gonorrhea, hepatitis B, genital herpes, HIV, and syphilis. These recommendations can be found at www.uspreventiveservicestaskforce.org.

Implementation

Intensive behavioral counseling may be delivered in primary care settings or other sectors of the health care system. This may require referral from the primary care clinician or system. In addition, risk-reduction counseling may be offered by community organizations, schools, and health departments or their affiliated STI clinics. Despite the seriousness and prevalence of STIs, primary care clinicians often do not provide counseling about sexual activity, contraception, or STIs during routine periodic health examinations or other health care visits, and many believe that counseling is ineffective. Surveys examining STI counseling by primary care clinicians have found wide variations in practice. Stronger linkages between the primary care setting and the community may greatly improve the delivery of this service. Providers should select behavioral counseling interventions on the basis of their effectiveness, appropriateness to the patient population, and feasibility of implementation. Examples of effective behavioral counseling interventions are described in the Table.  

Table. Examples of Behavioral Counseling Interventions for STIs*

Intervention (Reference)Study Population, Setting, and GoalsIntervention CharacteristicsIntervention Package Information
HORIZONS Population: heterosexual, sexually active African American adolescent girls seeking sexual health services Setting: public community clinicGoals: reduce STIs, increase condom use, increase communication with male partners about safer sex and STIs, and increase male partners' use of STI services Duration: two 4-h group sessions on 2 consecutive Saturdays, followed by 4 (15 min) telephone contacts approximately every 10 wk over 9 mo Delivered by: African American female health educatorsMethods: Discussion, exercises, games, practice, printed materials, role play, telephone reinforcement, and vouchers for STI services An intervention package is not available at this time. For details about intervention materials, contact Dr. Ralph J. DiClemente, Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, 1518 Clifton Road Northeast, Atlanta, GA 30322; e-mail,rdiclem@sph.emory.edu.
RESPECT Population: heterosexual, HIV-negative patients Setting: public STI clinicsGoals: eliminate or reduce risky sexual behaviors and reduce STIs Duration of brief counseling: two 20-min sessions (40 min total) delivered over 7 to 10 d Duration of enhanced counseling: one 20-min and three 60-min sessions (200 min total) delivered over 3 to 4 consecutive wkDelivered by: trained HIV and STI counselorsMethods: Counseling, exercises, goal setting, printed materials, and risk-reduction supplies (condoms) An intervention package was developed with funding from the CDC Replicating Effective Programs Project.  The intervention package and training are available through the CDC Diffusion of Effective Behavioral Interventions Project (www.effectiveinterventions.org).
Sister to Sister Population: inner-city African American women Setting: inner-city women's health clinicGoals: eliminate or reduce sexual risk behaviors and prevent new STIs Duration: 1 session; 200 min for the group format and 20 min for the one-on-one forma Delivered by: African American female nurses with >10 y of nursing experience and working with the target populationMethods: demonstration, exercises, games, group discussion, lectures and teaching, practice, printed materials, role play, and video An intervention package for the individual-level format is currently being developed with funding from the CDC Replicating Effective Programs Project.  For details on intervention materials, contact Dr. Loretta Sweet Jemmott, University of Pennsylvania School of Nursing, Claire M. Fagin Hall, 418 Curie Boulevard, Philadelphia, PA 19104; e-mail,jemmott@nursing.upenn.edu.
VOICES/VOCES Population: African American and Hispanic patients Setting: inner-city public STI clinicGoals: prevent new STIs and increase condom use Duration: one 20-min video followed by one 25-min group discussion session Delivered by: gender-matched facilitatorsMethods: video, group discussion, risk-reduction supplies (condoms), and printed materials An intervention package was developed with funding from the CDC Replicating Effective Programs Project.  The intervention package and training are available through the CDC Diffusion of Effective Behavioral Interventions Project (www.effectiveinterventions.org).

Abbreviations: CDC = Centers for Disease Control and Prevention; STI = sexually transmitted infection.

* Adapted from the CDC Compendium of Evidence-Based Interventions and Best Practices for HIV Prevention (available atwww.cdc.gov/hiv/prevention/research/compendium).

Research Needs and Gaps

Most of the studies identified by the USPSTF were in high-risk populations of adults or sexually active girls. Research on interventions that reduce risk for STIs in sexually active boys, prevent STIs in younger adolescents who are not yet sexually active, and reduce risk for STIs in older adults are needed. More data are needed from trials including both sexes and other broad-based interventions that could be implemented in or linked to primary care. The effectiveness of low-intensity interventions that are more practical in the typical primary care setting is another research gap. Promising approaches have been identified that need replication.

Rationale

Importance

The Centers for Disease Control and Prevention (CDC) estimate that approximately 20 million new cases of STIs occur each year in the United States. Half of these cases occur in persons aged 15 to 24 years. Sexually transmitted infections are frequently asymptomatic, which leads persons to unknowingly transmit STIs to others. Serious sequelae of STIs include pelvic inflammatory disease, infertility, and cancer. Untreated STIs present during pregnancy or birth may cause harms to the infant, including perinatal infection, death, and serious physical and mental disabilities.

Recognition of Behavior

Primary care clinicians can identify adolescents and adults who are at increased risk for STIs. See the Clinical Considerations for more information.

Benefits of Behavioral Counseling Interventions

The USPSTF found adequate evidence that intensive behavioral counseling interventions reduce the likelihood of STIs in sexually active adolescents and in adults who are at increased risk. The USPSTF determined that this benefit is of moderate magnitude. The USPSTF also found adequate evidence that intensive interventions reduce risky sexual behaviors and increase the likelihood of condom use and other protective sexual practices.

Harms of Behavioral Counseling Interventions

The USPSTF found adequate evidence that the harms of behavioral interventions to reduce the likelihood of STIs are small at most. The primary harm is the opportunity cost associated with intensive behavioral counseling interventions.

USPSTF Assessment

The USPSTF concludes with moderate certainty that intensive behavioral counseling interventions reduce the likelihood of STIs in sexually active adolescents and adults at increased risk, resulting in a moderate net benefit.


Others

The CDC recommends that all providers routinely obtain a sexual history from their patients and encourage risk reduction using various strategies (for example, prevention counseling) . It also recommends that HIV prevention counseling be offered and encouraged in all health care facilities that serve patients who are at high risk (for example, STI clinics) and persons living with HIV. The American Congress of Obstetricians and Gynecologists recommends discussing contraception and STIs during the initial reproductive health visit for adolescent patients. It also recognizes that the annual well-woman visit provides an excellent opportunity to counsel patients about maintaining a healthy lifestyle and minimizing health risks. The visit should include screening, evaluation and counseling, and immunizations based on the patient's age and risk factors. In addition, applying principles of motivational interviewing (for example, prompting patients to use safe sex practices and more consistent contraception) to daily patient practices has proved effective in eliciting behavior change that contributes to positive health outcomes and improved patient-clinician communication. Comprehensive care, including prevention of STIs, is recommended for lesbian and bisexual patients; education about the risks for STIs and dispelling the perception that STI transmission between women is negligible will help these patients make informed decisions. All patients should be encouraged to use safe sex practices to reduce the risk for transmitting or acquiring STIs and HIV, such as using condoms on sex toys, gloves, and dental dams and avoiding sharing other sex paraphernalia . Several approaches (for example, gender-tailored and culturally appropriate interventions to reduce risk-taking behavior) can reduce the rate of HIV infection and optimize health in women of color . Practitioners should provide risk-reduction counseling to prevent STIs in women participating in noncoital activities (for example, mutual masturbation or anal sex). The Institute for Clinical Systems Improvement states that counseling on sexual behaviors to prevent STIs could be recommended beginning at age 12 years and for higher-risk adults. The National Institute for Health and Care Excellence recommends one-on-one structured discussions with patients who are identified as high risk for STIs (if the health professional is trained in sexual health) or arranging these discussions with a trained practitioner. When appropriate, practitioners should provide one-on-one sexual advice about STI prevention and information on testing to persons younger than 18 years, including pregnant women and mothers. The American Academy of Family Physicians recommends intensive behavioral counseling for all sexually active adolescents and for adults who are at increased risk for STIs.


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