SPECIAL DNP SECTION Illustration by Dougal Waters/Getty Images Reducing STIs Screening, treatment, and counseling Abstract: Screening, treatment, and counseling for sexually transmitted infections requires a thorough assessment of psychosocial, behavioral, cultural, and clinical factors. This article offers a summary of the most recent CDC data, prevention guidelines, and steps to implementing current evidence into clinical practice. By Jane Dimmitt Champion, PhD, DNP, RN, FNP, AH-PMH-CNS, FAAN and Jennifer L. Collins, PhD, RN T he revised 2010 CDC guidelines 1 offer the most recent evidence for prevention, diagnosis, and treatment of sexually transmitted infections (STIs), formally known as sexually transmitted diseases (STDs). These guidelines include information about HIV-positive diagnoses and assessment of various populations with STIs including the incarcerated, infants, children, adolescents, and pregnant women. Screening, assessment, and treatment for STIs are important for both adolescent and adult populations in the United States. Syphilis rates are two times higher in adults ages 20 to 44 years than in 15- to 19-year-olds. 2 Factors associated with disproportionate STI prevalence include poverty, stigma of diagnosis, barriers to healthcare resources, and being a minority. 2 Adolescents of an ethnic minority are diagnosed with STIs more often and female minorities are at highest risk. Key words: counseling for sexually transmitted infections, guidelines for sexually transmitted infections, sexually transmitted infections 40 The Nurse Practitioner Vol. 37, No. 4 www.tnpj.com
Hispanic or Black females ages 15 to 19 years are 5 to 19 times more likely to be living with HIV/AIDS than non-hispanic White females. 3 Gonorrhea and chlamydia rates for Hispanic and Black females ages 15 to 19 years are 6 to 14 times higher respectively than rates for non- Hispanic White females. 3 Individual, social, and economic implications of STIs require healthcare providers to carefully assess, diagnose, and treat these infections. Assessment Diagnosis, treatment, and counseling for STIs includes an assessment of multiple interrelated factors. The AIDS Risk Reduction Model used with modifications has identified psychosocial, situational, and behavioral risk factors associated with STI. 4 (See Influences on sexual behavior ). Conducting a thorough assessment is important, and enables clinicians to evaluate the patient s personal history and knowledge regarding STI/HIV transmission. A medical and sexual history should include sexual risk behaviors and history of physical, sexual or emotional abuse. This assessment allows clinicians to ascertain appropriate testing and psychosocial or situational needs concerning counseling and social services. Behaviors inferring risk of acquisition, relationship commitments, and beliefs or social stigmas influencing behavior must also be assessed. 4 Clinicians are responsible for providing patients with knowledge about contraceptive methods and how to access them. An assessment protocol can be useful while conducting initial assessments, such as the Five P s: Partners, Pregnancy Prevention, Protection, Practices, and Past History (see The Five P s). 1 A pelvic exam may be indicated following clinical assessment, and allows for the discrete evaluation of pelvic pain, cervicitis, urethritis, discharge, polyps, warts, vesicles, and bleeding. Clinicians must carefully assess female clients for abdominal symptomatology including cervical, uterine, or adnexal tenderness to rule out the potential of pelvic inflammatory disease (PID). 1 Pain or bleeding during, or after intercourse may also indicate presence of infection and/or PID. Unfortunately, these complications have vague symptomatology and may result in delayed diagnosis, treatment, and sequelae to include infertility and ectopic pregnancy. An exam of male genitalia for symptomatology including warts, vesicles, discharge, dysuria, genital and perianal ulcers, lymphadenopathy, and skin rash should be conducted as indicated following the clinical assessment. 1 Pain or discharge with defecation or anal intercourse may also indicate presence of an infection. 1 Screening guidelines Medical and sexual history, age, gender, type of sexual partnership, number of sexual partners in a given time period, risk behavior, pregnancy status, and clinical assessment determine appropriate STI screening (see STI Testing and Treatment). 1,5 Due to the potential risk for STI coinfection, clinicians testing clients for one organism are encouraged to test for additional or related sexually transmitted organisms. 1 Clinicians are also encouraged to test for the fullest suspected range of infection for patients who report multiple risk behaviors or who are unlikely to return for additional STI assessment and testing. 1 Females The CDC recommends annual screening for chlamydia with all sexually active females age 25 years or younger. 1 Annual screening for gonorrhea is recommended for all sexually active women reporting risk behavior including prior STI history, new or multiple sex partners, less than 100% condom use, commercial sex work, drug use, and residence Thorough assessments allow clinicians to ascertain psychosocial or situational needs for counseling and social services. in high disease level communities. 1 Screening for STIs is recommended for all female patients who present with vaginal discharge, cervicitis, unusual bleeding, or urethritis. These symptoms commonly appear when chlamydia or gonorrhea is present. 1 Screening for STIs for all female clients who report a same-gender sexual relationship is also indicated, as women who report seeking same-sex sexual relations cannot be assumed to be at a lower or nonexistent risk level. 1 HIV screening is indicated for patients who are seeking STI screening, who are sexually active, use I.V. drugs, or have a sexual partner who uses I.V. drugs. 1 Pregnant women Pregnant women are at risk for STI/HIV acquisition. Careful assessment, screening, and treatment at initial and ongoing visits per CDC guidelines are indicated throughout the pregnancy. Males Routine screening for chlamydia in young sexually active men is not recommended due to insufficient evidence; however, clinicians may consider screening young men in areas of higher STI prevalence such as jails and STI clinics, www.tnpj.com The Nurse Practitioner April 2012 41
and clinics that provide services to adolescent populations. 1 Screening for STIs is recommended for all sexually active males younger than 35 years of age with epididymitis as the most frequent cause of infection is chlamydia or gonorrhea. 1 Testing for syphilis and herpes simplex virus (HSV) is recommended if a patient presents with perianal, genital, or anal ulcers. HIV screening is indicated for patients Influences on sexual behavior Psychosocial and situational factors 11-14 History of abuse Education history Age Language Gender Ethnicity Poverty Family, cultural, and peer norms Access to healthcare services Homelessness Social support for risk reduction Developmental level Beliefs (such as the value of childbearing and of relationships with sexual partners) Medical history (comorbidities and concurrent treatment regimens) Behavior and related factors 11-14 Substance use (alcohol, drug, or tobacco use) Types and frequency of sexual encounters (group sex, same-gender sex, oral or anal sex) Use of condoms and other contraceptives Treatment completion Avoidance of douching Partner risk behavior (incarcerations, drug use, multiple partners, condom use) Partner beliefs and attitudes Partner age Power differentials Number of new partners in a given time period Number of partners in a given period Partner turnover Relationship context: mutual monogamy, steadiness, and satisfaction AIDS Risk Reduction Model factors 10 Sexual self-efficacy and communication skills (negotiating condom use and ascertaining partner STI/HIV status) STI knowledge and skills (condom application skills, ascertaining partner symptomatology) Perception of severity and susceptibility, willingness, and ability to make psychological and behavioral changes Abuse avoidance requesting STI screening who are sexually active and have used I.V. drugs or have a sexual partner who has used I.V. drugs. 1 Annual testing for HIV, hepatitis B, syphilis, gonorrhea, and chlamydia is recommended for all male clients reporting same-gender sexual relationships. 1 Testing for gonorrhea and chlamydia using a urine specimen and rectal swab is indicated for all male clients reporting insertive or receptive intercourse within the previous year. 1 Testing for pharyngeal gonorrhea using a pharyngeal swab is also indicated for all male clients who report insertive oral intercourse within the prior year. 1 STI testing is recommended for male patients who have sexual relationships with men, report illicit drug use during sex, or have multiple or anonymous partners at least every 3 to 6 months. 1 Asymptomatic adolescents There are no recommendations for routine STI screening among asymptomatic adolescents. 1 However, clinicians are encouraged to screen asymptomatic adolescents for risky behaviors (such as unprotected sexual intercourse, multiple partners, and I.V. drug use). Risk behavior based and HIV screening It is recommended that clinicians conduct a STI screening for all patients reporting a history of STIs, new or multiple sexual partners, less than 100% condom use during sex, group sex, commercial sex work, I.V. drug use, or residence within a community with high disease prevalence. 1 HIV screening is indicated for patients seeking STI screening who are sexually active or have engaged in high-risk behavior. 1 Voluntary routine HIV screening is recommended for patients ages 13 to 64 years in all healthcare settings. 5 Clinicians are advised to include routine screening for STI/HIV among patients initiating The five P s: 1 1. Ask about partner(s): gender, number of partners in the past 2 and 12 months, and if sexual partnerships outside the main relationship exist either for the patient or for the partner 2. Ask about pregnancy prevention 3. Ask about STI protection 4. Ask about sexual practices: vaginal sex, anal sex, oral sex, condom use, and patterns of practice (such as substance use during sex, when the patient uses/ does not use condoms) 5. Ask about prior STI history and risky behaviors (such as patient or partner use of I.V. drugs, exchanging money or drugs for sex; ask if the patient has additional information to offer that has not been asked). 42 The Nurse Practitioner Vol. 37, No. 4 www.tnpj.com
treatment for tuberculosis as well. 5 All patients seeking services at STI clinics or STI evaluation or treatment require HIV testing at each visit for a new complaint. 5 Subsequent to initial testing, annual testing is recommended at minimum for patients reporting high-risk behavior such as I.V. drug use, partner(s) who use I.V. drugs, partners testing positive for HIV, and those with more than one sexual partner or partners who have had more than one sexual partner since the last HIV testing. 5 Treatment Individualized treatment plans designed to meet the client s specific psychosocial, behavioral, cultural, and clinical situation are essential. It is important to notify patients of all testing and treatment as initiated. 1 Clinicians are instructed to consult the CDC guidelines directly for specific dosing of medications used to treat STIs (see STI testing and treatment). Assessment of eligibility and client preference for preexposure vaccination for Human papillomavirus (HPV) and hepatitis A and B is useful during treatment planning. 1 Vaccination guidelines and client characteristics including prior exposure to infection, age, gender, and risk status must inform the clinician recommendations concerning administration. Clinician assessment also includes considerations such as allergies, pregnancy, HIV status, and preexposure to information regarding STI treatment options. Medication should be administered on site with observation of first dose as indicated whenever possible. Emergence of resistant strains of organisms responsible for STIs necessitates judicious management of treatment regimens. For example, clinicians suspecting cephalosporin treatment failure or resistance (mentioned in the CDC document with regards to gonoccocal infections) are encouraged to consult an infectious disease specialist. 1 Partner treatment Current recommendations encourage clinicians to treat all individuals with partners who have had sexual contact with the infected patient within 60 days of the onset of symptoms or of diagnosis. 1 Clinicians may use expedited partner therapy consistent with state mandates. Expedited partner therapy is indicated when a patient states that the partner is unlikely to self-initiate evaluation or treatment. 1 The clinician must label all treatments with instructions when dispensing partner therapy. Therapy indications and contraindications (such as an allergy to specific medication) must be included and the partner should be encouraged to follow-up for testing to ascertain cure. 1 Patient delivered partner therapy is a form of expedited partner therapy. No evidence exists regarding efficacy for use of patient delivered partner therapy including diagnoses of syphilis, gonorrhea, or chlamydia among males involved in same-gender sexual relationships. 1 Counseling It is extremely important to provide the patient with detailed information concerning the type of STI testing that will be conducted. CDC guidelines recommend providers review pertinent state regulations regarding consent and patient affirmation or decline of HIV testing. 1 Patients must be given the option to decline or defer HIV testing. Maintaining confidentiality of results requires vigilance. Confidentiality is of great concern for patients, particularly minors seeking services such as STI evaluation Providers should review pertinent state regulations regarding consent and patient affimation or decline of HIV testing. and treatment. Minors may self-consent for STI assessment and treatment without parental consent or notification in all 50 states and the District of Columbia. 1 Individual states however may require health insurance plans to notify beneficiaries of health services claims. 1 Therefore, minors covered by their parents or guardians insurance plans may need counseling regarding STI/HIV services when legal requirements pre-empt maintenance of confidentiality. Additional consideration regarding confidentiality among both adults and minors is partner notification. It is important for clinicians to be familiar with state mandates for partner notification and treatment. Clinicians must inquire about any potential for interpersonal violence to occur within patient relationships. Partner notification concerning STIs in the presence of interpersonal violence may heighten conflict in such relationships, thus endangering the patient. Clinicians also have a responsibility to stay informed of the mandates regarding state agency notifications of reportable diseases including syphilis, gonorrhea, chlamydia, and HIV/AIDS. These mandates vary by state and require informed reporting by the clinician. 1 Child abuse must also be considered in the provision of STI interventions. Child abuse is a reportable occurrence within the United States and mandates for reporting vary www.tnpj.com The Nurse Practitioner April 2012 43
STI testing and treatment 1,5 STI Clinical manifestations Testing Treatment Chlamydia Frequently asymptomatic May present as mucopurulent discharge, endocervical bleeding, or dysuria in women May present as discharge or dysuria in men Urine Endocervical, vaginal, rectal, urethral (men), or oropharyngeal swab Review the guidelines for clinical indications and information regarding specificity and sensitivity of each test Azithromycin Doxycycline (contraindicated if pregnant,alternative regimens are also available) Gonorrhea May present as mucopurulent discharge, endocervical bleeding, or dysuria in women May be asymptomatic in women until complications such as PID present May present as dysuria or discharge in men Disseminated gonococcal infection presents as diffuse skin lesions, arthralgia, arthritis, or tenosynovitis Urine Endocervical and vaginal swabs Urethral swab (men only) Review the guidelines for clinical indications for and information regarding specificity and sensitivity of each test Single-dose ceftriaxone or cefixime Single-dose cephalosporin plus azithromycin or doxycycline (contraindicated with pregnancy) HIV Clinical manifestations of early infection (acute retroviral syndrome) may include: fever, malaise, lymphadenopathy skin rash HIV testing and HIV plasma RNA testing if acute retroviral syndrome is a possibility Refer to an HIV specialist provider if HIV tests are positive HPV May present as genital warts or precancerous lesions on cervix Many individuals are asymptomatic HPV testing is recommended for triage of abnormal pap smear results in women 21 years of age and older and screening of cervical cancer in women 30 years of age and older Review recommendations for biopsy as indicated Patient-applied: Podofilox, Imiquimod, or Sinecatechins Provider-applied: Cryotherapy, podophyllin, Trichloroacetic acid, Bichloroacetic acid, or surgical removal HSV Often presents as vesicular or ulcerative lesions (these lesions are often absent in many who are infected) Virologic and type-specific serologic testing Acyclovir Famciclovir Valacyclovir Syphilis Clinical manifestations may include: Primary infection: perianal, genital, or anal ulcers Secondary infection: rash, mucocutaneous lesions, lymph-adenopathy, or neurologic infection Tertiary infection: cardiac or gummatous lesions Two types of serology testing are available and both must be done to confirm a diagnosis: treponemal and nontreponemal Parental Penicillin G benzathine (alternative regimen is available) Trichomoniasis May present as diffuse, malodorous, yellow-green vaginal discharge with vulvar irritation in women May present as nongonococcal urethritis in men Many women are asymptomatic Point of care testing is available for women only (no POC testing for men available): OSOM trichomonas rapid test Capillary flow dipstick technology Affirm VP III Culture (vaginal, endocervical, and urine) for women Culture (urethral, urine, or semen) for men Metronidazole Tinidazole 44 The Nurse Practitioner Vol. 37, No. 4 www.tnpj.com
Special considerations Partner treatment Follow-up Assess for PID, trichomoniasis, and bacterial vaginosis Review the guidelines for treatment of infants, children, and pregnant women Assess for allergies to regimen Treat or refer for treatment Retest 3 months after treatment (false-negatives and false-positives are common within 3 weeks after treatment) Also test for chlamydia, syphilis, HIV Assess for allergies to regimen Coinfection with chlamydia is common Review the guidelines for treatment of infants, children, and pregnant women Infections of the pharynx are often asymptomatic and require treatment Consult guidelines for treatment of disseminated gonococcal infection Treat or refer for treatment Retest : if symptoms persist in 3 months if this is a repeat infection Review the guidelines for screening and treatment of infants, children, adolescents, and pregnant women Review treatment options for pregnant women, HIV-positive individuals, and individuals with squamous cell carcinoma in situ Review pap smear guidelines for all women Encourage the patient to inform partners. Instruct the patient that he/she may allow the local health department to disclose infection anonymously if needed Encourage the patient to inform partners and abstain from sex while warts are present Use of condoms when warts are present may not prevent transmission Review guidelines for follow-up Review treatment options for first clinical episode and suppressive therapy for prevention of outbreaks and reduction of transmission Severe HSV disease or complications from HSV (such as disseminated infection, pneumonitis, hepatitis or central nervous system involvement) require hospitalization Evaluate for allergies to regimen Review special considerations for HIV- positive individuals and pregnant women Assess for allergies to penicillin Review guidelines for treatment of infants, children, pregnant women, and HIV- positive individuals If neurologic or ophthalmic symptoms are present, a cerebrospinal fluid assessment is indicated Encourage the patient to inform partners and abstain from sexual activity when lesions or symptoms are present or to use condoms Discuss possible serologic testing of asymptomatic partners Assess clinically, test serology, and treat or refer for evaluation and treatment Review guidelines for follow-up 6 and 12 months after treatment at minimum Assess for allergies to regimen Consult guidelines for treatment of pregnant women and HIVpositive individuals Treat or refer for treatment Rescreen women 3 months after treatment www.tnpj.com The Nurse Practitioner April 2012 45
by state. Providers must obtain comprehensive knowledge of state agency reporting requirements concerning STI including HIV and child abuse within their practice domain. 1 Clinicians may also employ motivational interviewing techniques to develop treatment plans and assist patients toward commitment to behavioral change. These techniques prevent the imposition of mandates for change upon individuals and allow clinicians to assess patient readiness to change throughout the process. 6 Data gathered may be used to discuss specific sexual risk factors identified during the assessment with the patient. Motivational interviewing strategies can be used to reduce sexual risk behavior and prevent intimate partner violence. 7-9 Allowing the patient to identify sexual risk factors and barriers to changing beliefs and behaviors can be an effective intervention strategy. Using reflective listening to allow the patient to identify personal challenges and strengths may also be helpful. Clinicians may provide the patient with resources for counseling, and social or medical services as needed. The patient should also be directed to abstain from any sexual contact until 7 days after treatment is completed when both the patient and their partner are asymptomatic. 1 Clinicians may instruct the patient to use condoms or abstain from sexual contact if they or their partner has open lesions. Counseling may also include instructions for the client to return for follow-up per CDC guidelines 1. Recommended considerations for follow-up include the potential for falsepositive and false-negative results within short time frames after treatment, and special considerations such as pregnancy and HIV status, type of infection, and continuation of symptoms. Prevention Clinicians should discuss prevention strategies with patients, including limiting the number of sexual partners, communicating with partners about sexual risk reduction, ascertaining partner s STI and HIV status prior to engaging in any sexual activity, using condoms and other contraceptive methods; preexposure vaccinations may be appropriate for preventing HPV and hepatitis A and B. Indications for these vaccines be found on the CDC website (http://www.cdc.gov/vaccines/). Decades of descriptive research have demonstrated that risk behavior and STI/HIV prevention, acquisition, and resolution represent a combination of interrelated psychosocial and situational factors associated with behavior change. 10-14 STIs are not gender, age, or ethnicity specific, although higher prevalence has been identified in subgroups. At-risk subgroups provide foci for clinicians regarding STI assessment and intervention. Astute assessment and counseling focused on the individual patient gives clinicians the opportunity to identify and treat those who do not fit customary at-risk foci. REFERENCES 1. Centers for Disease Control and Prevention. Sexually transmitted diseases guidelines. Morbidity and Mortality Weekly Report. 2010;59 (RR12):1-110. 2. Centers for Disease Control and Prevention. Trends in sexually transmitted diseases in the United States: 2009 National data for Gonorrhea, Chlamydia and Syphilis. 2010. http://www.cdc.gov/std/stats09/trends2009.pdf. 3. Centers for Disease Control and Prevention. Sexual and Reproductive Health of Persons Aged 10-24 Years-United States, 2002-2007. Morbidity and Mortality Weekly Report. 2009;58 (SS6):1-58. 4. Champion JD, Collins JL. The path to intervention: community partnerships and development of a cognitive behavioral intervention for ethnic minority adolescent females. Issues Ment Health Nurs. 2010;31(11):739-747. 5. Centers for Disease Control and Prevention. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. Morbidity and Mortality Weekly Report. 2006;55 (RR14):1-17. 6. Rollnick S, Allison J. Motivational interviewing. Heather N, Stockwell T, eds. The Essential Handbook of Treatment and Prevention of Alcohol Problem. 2004. http://bib.tiera.ru/dvd58/heather%20n.,%20stockwell%20t.%20-%20the%20 Essential%20Handbook%20of%20Treatment%20and%20Prevention%20 of%20alcohol%20problems(2003)(392).pdf#page=119. 7. Kiene SM, Barta WD. A brief individualized computer-delivered sexual risk reduction intervention increases HIV/AIDS preventive behavior. J Adolesc Health. 2006;39(3):404-410. 8. Morgenstern J, Bux DA Jr, Parsons J, Hagman BT, Wainberg M, Irwin T. Randomized trial to reduce club drug use and HIV risk behaviors among men-who-have-sex-with-men (MSM). J Consult Clin Psychol. 2009;77(4):645-656. 9. Weir BW, O Brien K, Bard RS, et al. Reducing HIV and partner violence risk among women with criminal justice system involvement: a randomized controlled trial of two motivational interviewing-based interventions. AIDS Behav. 2009;13(3):509-522. 10. Champion JD. Behavioural interventions and abuse: secondary analysis of reinfection in minority women. Int J STD AIDS. 2007;18(11):748-753. 11. Champion JD, Piper JM, Holden AE, Shain RN, Perdue S, Korte JE. Relationship of abuse and pelvic inflammatory disease risk behavior in minority adolescents. J Am Acad Nurse Pract. 2005;17(6):234-241. 12. Koniak-Griffin D, Lesser J, Nyamathi A, Uman G, Stein JA, Cumberland WG. Project CHARM: an HIV prevention program for adolescent mothers. Fam Community Health. 2003;26(2):94-107. 13. Morrison-Beedy D, Nelson LE. HIV prevention interventions in adolescent girls: What is the state of the science? Worldviews Evid Based Nurs. 2004;1(3):165-175. 14. Roye C, Perlmutter Silverman P, Krauss B. A brief, low-cost, theorybased intervention to promote dual method use by Black and Latina female adolescents A randomized clinical trial. Health Educ Behav. 2007;34(4): 608-621. Jane Dimmitt Champion is a professor at Texas Tech University Health Sciences Center in Lubbock, TX. Jennifer L. Collins is a post-doctoral research fellow at Texas Tech University Health Sciences Center in Lubbock, TX. The authors have disclosed that they have no financial relationships related to this article. DOI-10.1097/01.NPR.0000412894.04686.d0 46 The Nurse Practitioner Vol. 37, No. 4 www.tnpj.com