Preventing and Detecting STIs
According to the CDC, about 20 million cases of sexually transmitted infections (STIs) occur each year in the United States, with half of those cases diagnosed in people ages 15-24. If untreated, STIs such as gonorrhea and chlamydial infection can lead to serious complications, including pelvic inflammatory disease (PID), ectopic pregnancy, chronic pelvic pain, infertility, cancer and even death.
"We can do a lot to prevent STIs and their serious complications through effective prevention, screening and treatment," said family physician and USPSTF Chair Michael LeFevre, M.D., M.S.P.H., of Columbia, Mo., in the release. "Evidence shows that intensive behavioral counseling for sexually active teens and for adults at increased risk can help to prevent STIs, reduce high-risk behaviors and increase protective behaviors. Primary care providers can make a difference by offering or referring patients to intensive behavioral counseling."
Behavioral Counseling Recommendation Overview
The first USPSTF recommendation calls for using intensive behavioral counseling for all sexually active adolescents and for adults who are at increased risk for STIs. This is a B recommendation that updates the task force's 2008 recommendation on STIs, replacing the term "high-intensity" (counseling) with "intensive."
"(The USPSTF) changed the language in order to recognize that there is some benefit from less-intensive behavioral counseling, although high-intensity counseling provides the most consistent benefit," said Jennifer Frost, M.D., medical director for the AAFP Health of the Public and Science Division. "More than two hours of counseling is considered high-intensity. Unfortunately, it is challenging for most family physicians to provide effective counseling as they are generally allowed no more than 15 minutes for a visit." So referral to an outside counselor is another option.
The AAFP issued a parallel recommendation calling for intensive behavioral counseling for sexually active adolescents and adults at increased risk for STIs.
According to the USPSTF evidence report, investigators reassessed studies from the 2008 recommendation, as well as reviewing another 16 published since that earlier report, for a total of 31 studies.
Counseling interventions reviewed included one to 13 sessions, with multiple-session interventions typically lasting only three months or less. Sixteen studies involved high-intensity interventions, 10 involved moderate-intensity interventions, and nine involved low intensity interventions.
Most of the high-intensity interventions involved group sessions with extensive educational and behavior-changing components, according to the evidence report. Most moderate-intensity interventions involved one or two individual meetings of 45-60 minutes, although some involved group meetings. Most low-intensity interventions involved brief individual meetings with a counselor or primary care health professional or were limited to delivery by print, computer or video.
No matter how the counseling is delivered, however, certain elements need to be included, said Frost. "The content of the counseling should include teaching the basics of STIs and transmission, assessing the patient's individual risk of transmission, and providing training in specific skills such as condom use and how to communicate with a partner about safe sex," she said.
Screening Recommendation Overview
The second USPSTF recommendation combined two previous recommendations regarding screening for chlamydial infection and gonorrhea from 2007 and 2005, respectively, recommending screening for both types of infection in sexually active women age 24 or younger and in older women who are at increased risk.
Frost noted that the 2005 gonorrhea recommendation was aimed at "sexually active women at increased risk for infection," with young age being a risk factor. Changing the recommendation to read "sexually active women age 24 and younger" makes it much clearer, she said.
In addition, both the USPSTF and AAFP concluded that evidence is insufficient to assess the balance of benefits and harms of screening for chlamydial infection and gonorrhea in men.
"There aren't any studies of the effect of screening on complications in males -- likely because serious complications in males are rare," Frost said.
According to the evidence report for this screening recommendation, investigators focused on 14 FDA-cleared tests in randomized controlled trials and controlled observational studies published since the two previous recommendations, but uncontrolled observational studies were also included to determine adverse effects.
Researchers concluded that:
· screening for chlamydial infection may reduce the incidence of PID in young women,
· risk prediction tools may be useful in identifying patients with infections but require validation in the populations of intended use, and
· nucleic acid amplification tests are accurate for diagnosing gonorrhea and chlamydial infection in asymptomatic persons, regardless of specimen, site or test.
The greatest risk factor for STIs is age, according to Frost, with patients younger than age 25 having the highest risk. Older women at increased risk include those with multiple sexual partners and those whose partners do not use condoms. African Americans also have higher rates of STIs, she said. And there are certain parts of the country that have higher rates of gonorrhea than others; chlamydia is more widespread.
"STIs are prevalent and can result in serious complications, especially for infants born to women with active sexually transmitted infection," Frost said. "Screening for STIs and providing counseling are important tools to help reduce this burden."