What is the recommended approach for managing high-risk sexually transmitted infection (STI) behavior?

Management of High-Risk STI Behavior

All sexually active adolescents and adults with high-risk STI behaviors should receive intensive behavioral counseling (≥2 hours of contact time), routine sexual history assessment, and comprehensive STI screening at 3-6 month intervals. 1, 2

Identifying High-Risk Populations

High-risk individuals requiring intervention include: 1, 2

• All sexually active adolescents (regardless of other risk factors) 1
• Adults with current STIs or infections within the past year 1
• Individuals with multiple or new sexual partners 1, 2
• Those who do not consistently use condoms 1
• Men who have sex with men (MSM) 1
• Persons exchanging sex for money or drugs 1
• Current or former intravenous drug users 1
• Individuals with substance use, especially methamphetamine 1
• African Americans, American Indians, Alaska Natives, and Latinos (higher prevalence populations) 1
• Persons in urban settings with low incomes 1

Behavioral Counseling Interventions

Intensity and Content

High-intensity behavioral counseling (≥2 hours total contact time) demonstrates the strongest evidence for reducing STI acquisition, with moderate-intensity interventions (30-120 minutes) showing less consistent benefit. 1

Effective interventions must include: 1

• Basic information about STI transmission 1
• Individual risk assessment 1
• Skills training in condom use, communication about safe sex, problem-solving, and goal setting 1
• Motivational interviewing techniques to prompt safe sex practices 1
• Age-appropriate, gender-tailored, and culturally appropriate content 1

Delivery Methods

Counseling can be provided through: 1

• Face-to-face individual or group sessions 1
• Primary care clinicians or trained behavioral counselors 1
• Video materials, written resources, and telephone support 1

Comprehensive STI Screening Protocol

Screening Frequency

For individuals with ongoing high-risk behaviors or new partners, screen every 3-6 months rather than annually. 1, 2

Required Screening Components

All high-risk patients require site-specific testing at each anatomic site of reported sexual contact: 2

For All Patients: 1, 2

• Syphilis: Both nontreponemal (RPR or VDRL) and treponemal tests (EIA or CIA) 1, 2
• Gonorrhea and Chlamydia:
  • Men: Urine NAAT 1
  • Women: Vaginal swab (preferred), cervical swab, or urine NAAT 1, 2
• HSV-2: Type-specific glycoprotein G-based serology (consider) 1

For Women: 1

• Trichomoniasis: Vaginal swab NAAT (preferred), culture, or rapid antigen test 1

For Patients Reporting Receptive Anal Sex: 1, 2

• Rectal NAAT for gonorrhea and chlamydia 1, 2

For Patients Reporting Receptive Oral Sex: 1, 2

• Pharyngeal NAAT for gonorrhea 1, 2

Critical Screening Pitfall

Failing to screen all anatomic sites of exposure leads to missed infections, as many STIs are asymptomatic and anatomically isolated. 2 Testing only one site when multiple sites are at risk represents inadequate care. 2

Risk Reduction Counseling Specifics

Essential Counseling Messages

Patients must understand: 1

• Condom use: Correct and consistent use with all partners, including on sex toys 1
• Partner selection: Importance of knowing partners' risk behaviors and avoiding high-risk partners 1
• Risk hierarchy: Mutual masturbation carries lower risk than receptive anal/vaginal intercourse 1
• Barrier methods: Use of gloves and dental dams for non-penetrative activities 1
• Partner notification: Ensuring sex partners receive evaluation and treatment 1

Special Population Considerations

For lesbian and bisexual women: Dispel the misconception that STI transmission between women is negligible; recommend barrier methods for all sexual activities 1

For women of color: Implement gender-tailored and culturally appropriate interventions to reduce HIV and STI risk 1

For adolescents: Begin counseling at age 12 years using developmentally appropriate strategies 1

Partner Management

Sex partners of patients with chlamydial or gonococcal infection must be evaluated promptly and treated appropriately. 1 Treatment is incomplete until partners receive treatment, as reinfection commonly occurs from untreated partners. 1

Preventive Treatment Considerations

Selective prophylactic treatment based on epidemiologic indications can interrupt transmission chains and prevent ascending infections. 1 For confirmed gonococcal infection, concurrent treatment for chlamydia is indicated due to high coinfection rates. 1

Implementation in Clinical Practice

Routine Sexual History

All providers must routinely obtain sexual histories from patients, including: 1

• Number and gender of sexual partners 1
• Types of sexual practices (vaginal, anal, oral) 1
• Condom use consistency 1
• History of STIs 1
• Substance use patterns 1

Clinical Settings

Effective programs can be implemented in: 1

• Primary care offices 1
• STI clinics 1
• Urgent care and walk-in clinics 3
• University health centers 3
• Annual well-woman visits 1

Evidence-Based Program Characteristics

Programs teaching condom use skills or communication/negotiation skills achieve approximately 30% reduction in STI incidence. 4 Abstinence-only interventions show no effect. 4