What are the risks and preventive measures for unprotected sex?

Education on Unprotected Sex: Risks and Preventive Measures

Immediate Time-Sensitive Actions

If unprotected sex has already occurred, emergency contraception must be taken within 72 hours, with effectiveness declining every hour, and HIV post-exposure prophylaxis (nPEP) should be initiated within 72 hours if substantial exposure risk exists. 1, 2

Within 72 Hours Post-Exposure

• Emergency contraception (levonorgestrel 1.5 mg) should be taken as soon as possible, ideally immediately, as efficacy decreases significantly with each passing hour 3, 1, 2
• Perform a baseline urine pregnancy test before administering emergency contraception 3, 1
• Initiate HIV post-exposure prophylaxis (nPEP) within 72 hours if the exposure involved potential HIV transmission risk 1
• Collect specimens for gonorrhea, chlamydia, and syphilis testing using urine NAAT (males) or vaginal swab NAAT (females) 3, 1

Primary STI Transmission Risks

Most Common Infections

• Gonorrhea, chlamydia, and trichomoniasis are the most frequently transmitted STIs through unprotected sex 3, 1
• Syphilis transmission occurs through direct contact with syphilis sores during vaginal, anal, or oral sex 3, 1
• HIV transmission risk increases substantially when other STIs are present, as STIs promote increased HIV viral shedding and create mucosal inflammation 3, 4
• Herpes simplex virus type 2 (HSV-2) facilitates HIV transmission and is highly prevalent among sexually active populations 4

High-Risk Populations Requiring Intensive Screening

• Men who have sex with men (MSM) face disproportionate STI rates, with gonorrhea prevalence up to 16%, chlamydia 12%, and syphilis outbreaks continuing despite declining general population rates 4
• Persons with more than one sex partner per year require intensive screening and prevention interventions 4
• Injection drug users face combined risks from both sexual transmission and needle-sharing behaviors 3

Comprehensive Prevention Strategies

Most Effective Prevention Methods

The most effective way to prevent sexual transmission of HIV and other STIs is to avoid sexual intercourse with an infected partner, and both partners should be tested for STDs including HIV before initiating sexual intercourse. 3, 1

Barrier Methods

• Latex condoms, when used consistently and correctly from start to finish of intercourse, are highly effective in preventing HIV, gonorrhea, chlamydia, and other STIs 3, 1, 5
• Men should use a new latex condom with each act of intercourse when partner infection status is unknown or positive 3
• Female condoms should be considered when male condoms cannot be used 3, 5
• Condom failure typically results from inconsistent or incorrect use rather than breakage, occurring at approximately 2 per 100 condoms 5

Critical Pitfall: Unsafe Protected Sex

• Using condoms only at ejaculation, after initial unprotected penetration, or experiencing condom failure all constitute "unsafe protected sex" and carry significant STI transmission risk 6
• Surveys of sexual risk behavior likely underestimate levels of unprotected sex because participants may not report these forms of unsafe protected sex 6

Non-Barrier Contraception Warning

Women using hormonal contraception (oral contraceptives, Norplant, Depo-Provera), who have been surgically sterilized, or who have had hysterectomies must be counseled that these methods offer zero protection against STDs including HIV. 3, 5

Screening Recommendations by Population

Sexually Active Women

• All sexually active women under age 25 require annual screening for chlamydia and gonorrhea, even without symptoms 5
• Women over 25 with risk factors (new sex partner, multiple partners) require annual screening 5
• Screening should include chlamydia, gonorrhea, syphilis, and when possible, trichomoniasis and bacterial vaginosis 3, 5

Men Who Have Sex with Men

• Annual screening is the minimum for all sexually active MSM, but screening every 3-6 months is required for those with multiple or anonymous partners, drug use during sex, or partners engaging in these activities 4
• Comprehensive screening must include testing at all potential exposure sites: pharynx, rectum, and urethra for gonorrhea and chlamydia 4
• Serologic testing for syphilis and HIV is required 4
• Doxycycline post-exposure prophylaxis (doxy PEP) is now recommended for MSM who have had a bacterial STI diagnosed in the past 12 months 4

HIV-Infected Persons

• All HIV-infected persons at risk for STD acquisition should be screened at least yearly, more frequently if incident STDs are detected 3
• The presence of a new STD in an HIV-infected person strongly indicates unprotected sex and requires immediate intensive counseling 3
• HIV-infected persons should be assessed for genital herpes and counseled to avoid sex during symptomatic reactivation periods, which are associated with higher HIV viral shedding 3

Pregnant Women

• All pregnant women, including those who use drugs, must be screened for HIV, syphilis, chlamydia, and gonorrhea at the first prenatal visit 3
• High-risk women require repeat screening early in the third trimester (approximately 28 weeks) and at delivery 3

Vaccination Opportunities

Hepatitis B

• Hepatitis B vaccine should be offered to all unvaccinated or incompletely vaccinated patients after unprotected sex, as sexual transmission is well-documented 3, 1
• Pregnant women should be tested routinely for hepatitis B surface antigen during early prenatal visits 3

Human Papillomavirus (HPV)

• HPV vaccination series should be initiated at age 9 years and older, or continued/completed if all doses have not been received 3

Follow-Up Testing Schedule After Exposure

Initial and Repeat Testing Timeline

• Repeat testing for gonorrhea, chlamydia, and syphilis at 2 weeks post-exposure is required, as many STIs have incubation periods necessitating repeat testing to detect infections not present initially 1
• Baseline HIV testing should occur at the initial visit, with repeat testing at 6 weeks, 3 months, and 6 months post-exposure 1

Partner Management

Notification and Treatment

• Sexual partners must be notified, examined, and treated for identified or suspected STDs 5
• Both patient and partners must abstain from sexual intercourse until therapy is completed, typically 7 days after single-dose treatment 5
• Partner notification is essential to prevent reinfection and further transmission 5, 4

Mental Health Screening After Sexual Assault

Immediate Psychiatric Assessment

• All sexual assault victims require immediate screening for suicidal ideation, self-harm behaviors, and homicidal ideation, as these patients have significantly elevated rates of depression and suicide attempts 3, 1
• If suicidal or homicidal ideation is present, immediate referral to an experienced mental health professional is mandatory 3, 1
• Sexual assault victims demonstrate increased rates of risky behaviors including younger age at first voluntary intercourse, poor contraception use, higher pregnancy and abortion rates, and increased STI rates 3

Counseling Messages for Risk Reduction

Essential Education Points

• Persons who continue injection drug use must clean equipment with bleach and water before each use, though this does not guarantee HIV inactivation 3
• Methamphetamine and crack cocaine use are associated with unprotected sex, multiple partners, and exchange of sex for money or drugs 3
• Optimism about antiretroviral therapy effectiveness may contribute to relaxed attitudes toward safer sex practices and increased sexual risk-taking 3
• Beliefs that HIV treatments reduce transmission risks are incorrect and are associated with increases in unprotected anal intercourse among MSM 7

When Empiric Treatment Is Indicated

Sexual Assault Context

• Empiric treatment for gonorrhea, chlamydia, and trichomoniasis should be provided to sexual assault victims, as these are the most common STIs and waiting for results delays critical treatment 3, 1

General Clinical Context

• Empiric treatment should only be considered if infection prevalence is high in the patient population and the patient might be difficult to locate for treatment follow-up 5