Summary of Recommendation and Evidence

The USPSTF recommends intensive behavioral counseling for all sexually active adolescents and for adults who are at increased risk for sexually transmitted infections (STIs; Table 1). B recommendation.

See the Clinical Considerations section for a description of high-risk populations.

Rationale

IMPORTANCE

The Centers for Disease Control and Prevention (CDC) estimates 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. STIs 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 section 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 in adults who are at increased risk, resulting in a moderate net benefit.

Clinical Considerations

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 http://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 http://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 http://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 http://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 http://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 http://www.uspreventiveservicestaskforce.org.

This recommendation statement was first published in Ann Intern Med. 2014;161(12):894–901.

The “Other Considerations,” “Discussion,” “Update of Previous USPSTF Recommendation,” and “Recommendations of Others” sections of this recommendation statement are available at http://www.uspreventiveservicestaskforce.org/Page/Topic/recommendation-summary/sexually-transmitted-infections-behavioral-counseling1.

The USPSTF recommendations are independent of the U.S. government. They do not represent the views of the Agency for Healthcare Research and Quality, the U.S. Department of Health and Human Services, or the U.S. Public Health Service.