STI and HIV Infection Risk Assessment
Primary prevention of STIs includes assessment of behavioral risk (i.e., assessing the sexual behaviors that can place persons at risk for infection) and biologic risk (i.e., testing for risk markers for STI and HIV acquisition or transmission). As part of the clinical encounter, health care providers should routinely obtain sexual histories from their patients and address risk reduction as indicated in this report. Guidance for obtaining a sexual history is available at the Division of STD Prevention resource page (https://www.cdc.gov/std/treatment/resources.htm) and in the curriculum provided by the National Network of STD Clinical Prevention Training Centers (https://www.nnptc.org). Effective interviewing and counseling skills, characterized by respect, compassion, and a nonjudgmental attitude toward all patients, are essential to obtaining a thorough sexual history and delivering effective prevention messages. Effective techniques for facilitating rapport with patients include using open-ended questions (e.g., “Tell me about any new sex partners you’ve had since your last visit” and “What has your experience with using condoms been like?”); understandable, nonjudgmental language (e.g., “What gender are your sex partners?”and “Have you ever had a sore or scab on your penis?”); and normalizing language (e.g., “Some of my patients have difficulty using a condom with every sex act. How is it for you?”). The “Five P’s” approach to obtaining a sexual history is one strategy for eliciting information about the key areas of interest (Box 1). In addition, health care professionals can consider assessing sexual history by asking patients such questions as, “Do you have any questions or concerns about your sexual health?” Additional information about gaining cultural competency when working with certain populations (e.g., gay, bisexual, or other men who have sex with men [MSM]; women who have sex with women [WSW] or with women and men [WSWM]; or transgender men and women or adolescents) is available in sections of these guidelines related to these populations.
In addition to obtaining a behavioral risk assessment, a comprehensive STI and HIV risk assessment should include STI screening as recommended in these guidelines because STIs are biologic markers of risk, particularly for HIV acquisition and transmission among certain MSM. In most clinical settings, STI screening is an essential and underused component of an STI and HIV risk assessment. Persons seeking treatment or evaluation for a particular STI should be screened for HIV and other STIs as indicated by community prevalence and individual risk factors (see Chlamydial Infections; Gonococcal Infections; Syphilis). Persons should be informed about all the tests for STIs they are receiving and notified about tests for common STIs (e.g., genital herpes, trichomoniasis, Mycoplasma genitalium, and HPV) that are available but not being performed and reasons why they are not always indicated. Persons should be informed of their test results and recommendations for future testing. Efforts should be made to ensure that all persons receive STI care regardless of personal circumstances (e.g., ability to pay, citizenship or immigration status, gender identity, language spoken, or specific sex practices).
- “Are you currently having sex of any kind?”
- “What is the gender(s) of your partner(s)?”
- “To understand any risks for sexually transmitted infections (STIs), I need to ask more specific questions about the kind of sex you have had recently.”
- “What kind of sexual contact do you have or have you had?”
- “Do you have vaginal sex, meaning ‘penis in vagina’ sex?”
- “Do you have anal sex, meaning ‘penis in rectum/anus’ sex?”
- “Do you have oral sex, meaning ‘mouth on penis/vagina’?”
- Protection from STIs
- “Do you and your partner(s) discuss prevention of STIs and human immunodeficiency virus (HIV)?”
- “Do you and your partner(s) discuss getting tested?”
- For condoms:
- “What protection methods do you use? In what situations do you use condoms?”
- Past history of STIs
- “Have you ever been tested for STIs and HIV?”
- “Have you ever been diagnosed with an STI in the past?”
- “Have any of your partners had an STI?”
Additional questions for identifying HIV and viral hepatitis risk:
- “Have you or any of your partner(s) ever injected drugs?”
- “Is there anything about your sexual health that you have questions about?”
- Pregnancy intention
- “Do you think you would like to have (more) children in the future?”
- “How important is it to you to prevent pregnancy (until then)?”
- “Are you or your partner using contraception or practicing any form of birth control?”
- “Would you like to talk about ways to prevent pregnancy?”
After obtaining a sexual history from their patients, all providers should encourage risk reduction by offering prevention counseling. Prevention counseling is most effective if provided in a nonjudgmental and empathetic manner appropriate to the patient’s culture, language, sex and gender identity, sexual orientation, age, and developmental level. Prevention counseling for STIs and HIV should be offered to all sexually active adolescents and to all adults who have received an STI diagnosis, have had an STI during the previous year, or have had multiple sex partners. USPSTF recommends intensive behavioral counseling for all sexually active adolescents and for adults at increased risk for STIs and HIV (4). Such interactive counseling, which can be resource intensive, is directed at a person’s risk, the situations in which risk occurs, and the use of personalized goal-setting strategies. One such approach, known as client-centered STI and HIV prevention counseling, involves tailoring a discussion of risk reduction to the person’s situation. Although one large study in STI clinics (Project RESPECT) demonstrated that this approach was associated with lower acquisition of curable STIs (e.g., trichomoniasis, chlamydia, gonorrhea, and syphilis) (5), another study conducted 10 years later in the same settings but different contexts (Project AWARE) did not replicate this result (6).
With the challenges that intensive behavioral counseling poses, health care professionals might find brief prevention messages and those delivered through video or in a group session to be more accessible for the client. A review of 11 studies evaluated brief prevention messages delivered by providers and health counselors and reported them to be feasible and to decrease subsequent STIs in STD clinic settings (7) and HIV care settings (8). Other approaches use motivational interviewing to move clients toward achievable risk-reduction goals. Client-centered counseling and motivational interviewing can be used effectively by clinicians and staff trained in these approaches. CDC provides additional information on these and other effective behavioral interventions at https://www.cdc.gov/std/program/interventions.htm. Training in client-centered counseling and motivational interviewing is available through the STD National Network of Prevention Training Centers (https://www.nnptc.org).
In addition to one-on-one STI and HIV prevention counseling, videos and large group presentations can provide explicit information concerning STIs and reducing disease transmission (e.g., how to use condoms consistently and correctly and the importance of routine screening). Group-based strategies have been effective in reducing the occurrence of STIs among persons at risk, including those attending STD clinics (9). Brief, online, electronic-learning modules for young MSM have been reported to be effective in reducing incident STIs and offer a convenient client platform for effective interventions (10). Because the incidence of certain STIs, most notably syphilis, is higher among persons with HIV infection, use of client-centered STI counseling for persons with HIV continues to be encouraged by public health agencies and other health organizations (https://www.cdc.gov/std/statistics/). A 2014 guideline from CDC, the Health Resources and Services Administration, and the National Institutes of Health recommends that clinical and nonclinical providers assess a person’s behavioral and biologic risks for acquiring or transmitting STIs and HIV, including having sex without condoms, having recent STIs, and having partners recently treated for STIs (https://stacks.cdc.gov/view/cdc/44064). That federal guideline is for clinical and nonclinical providers to offer or make referral for regular screening for multiple STIs, on-site STI treatment when indicated, and risk-reduction interventions tailored to the person’s risks. Brief risk-reduction counseling delivered by medical providers during HIV primary care visits, coupled with routine STI screening, has been reported to reduce STI incidence among persons with HIV infection (8). Other specific methods have been designed for the HIV care setting specific methods have been designed for the HIV care setting (https://www.cdc.gov/hiv/effective-interventions/index.html).