U.S. Preventive Services Task Force

Behavioral Counseling to Prevent Sexually Transmitted Infections: Recommendation Statement

Am Fam Physician. 2010 Mar 15;81(6):763-764.

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This clinical content conforms to AAFP criteria for evidence-based continuing medical education (EB CME). See CME Quiz on page 709.

Summary of Recommendation and Evidence

The U.S. Preventive Services Task Force (USPSTF) recommends high-intensity behavioral counseling to prevent sexually transmitted infections (STIs) for all sexually active adolescents and for adults at increased risk of STIs (Table 1). B recommendation.

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of behavioral counseling to prevent STIs in non–sexually active adolescents and in adults not at increased risk of STIs (Table 1). I statement.

Table 1.

Behavioral Counseling to Prevent Sexually Transmitted Infections: Clinical Summary of the USPSTF Recommendation

Population

All sexually active adolescents

Adults at increased risk of STIs

Non–sexually-active adolescents and adults not at increased risk of STIs

Recommendation

Offer high-intensity counseling Grade: B

Offer high-intensity counseling Grade: B

No recommendation Grade: I (insufficient evidence)

Risk assessment

All sexually active adolescents are at increased risk of STIs and should be offered counseling.

Adults should be considered at increased risk and offered counseling if they have:

Current STIs or have had an STI within the past year

Multiple current sex partners

In communities or populations with high rates of STIs, all sexually active patients in nonmonogamous relationships may be considered at increased risk.

Interventions

Characteristics of successful high-intensity counseling interventions:

Multiple sessions of counseling

Often delivered in group settings

Suggestions for practice

High-intensity counseling may be delivered in primary care settings, or in other sectors of the health system and community settings after referral. Delivery of this service may be greatly improved by strong links between the primary care setting and community.

Evidence is limited regarding counseling for adolescents who are not sexually active. Intensive counseling for all adolescents to reach those who are at risk but have not been appropriately identified is not supported by current evidence. Evidence is lacking regarding the effectiveness of counseling for adults not at increased risk of STIs.

Other relevant recommendations from the USPSTF

USPSTF recommendations on screening for infection with chlamydia, gonorrhea, genital herpes, hepatitis B, hepatitis C, HIV, and syphilis, and on counseling for HIV, can be found at http://www.preventiveservices.ahrq.gov.


note: For the full USPSTF recommendation statement and supporting documents, visit http://www.preventiveservices.ahrq.gov.

HIV = human immunodeficiency virus; STI = sexually transmitted infection; USPSTF = U.S. Preventive Services Task Force.

Table 1.   Behavioral Counseling to Prevent Sexually Transmitted Infections: Clinical Summary of the USPSTF Recommendation

View Table

Table 1.

Behavioral Counseling to Prevent Sexually Transmitted Infections: Clinical Summary of the USPSTF Recommendation

Population

All sexually active adolescents

Adults at increased risk of STIs

Non–sexually-active adolescents and adults not at increased risk of STIs

Recommendation

Offer high-intensity counseling Grade: B

Offer high-intensity counseling Grade: B

No recommendation Grade: I (insufficient evidence)

Risk assessment

All sexually active adolescents are at increased risk of STIs and should be offered counseling.

Adults should be considered at increased risk and offered counseling if they have:

Current STIs or have had an STI within the past year

Multiple current sex partners

In communities or populations with high rates of STIs, all sexually active patients in nonmonogamous relationships may be considered at increased risk.

Interventions

Characteristics of successful high-intensity counseling interventions:

Multiple sessions of counseling

Often delivered in group settings

Suggestions for practice

High-intensity counseling may be delivered in primary care settings, or in other sectors of the health system and community settings after referral. Delivery of this service may be greatly improved by strong links between the primary care setting and community.

Evidence is limited regarding counseling for adolescents who are not sexually active. Intensive counseling for all adolescents to reach those who are at risk but have not been appropriately identified is not supported by current evidence. Evidence is lacking regarding the effectiveness of counseling for adults not at increased risk of STIs.

Other relevant recommendations from the USPSTF

USPSTF recommendations on screening for infection with chlamydia, gonorrhea, genital herpes, hepatitis B, hepatitis C, HIV, and syphilis, and on counseling for HIV, can be found at http://www.preventiveservices.ahrq.gov.


note: For the full USPSTF recommendation statement and supporting documents, visit http://www.preventiveservices.ahrq.gov.

HIV = human immunodeficiency virus; STI = sexually transmitted infection; USPSTF = U.S. Preventive Services Task Force.

Rationale

Importance. Despite advances in the screening, diagnosis, and treatment of STIs, they remain an important cause of morbidity and mortality in the United States.

Recognition of behavior. Primary care physicians and teams can identify adolescents and adults who are at increased risk.

Effectiveness of counseling to change behavior. There is convincing evidence that high-intensity behavioral counseling interventions targeted at sexually active adolescents and adults at increased risk of STIs reduce the incidence of STIs. These results were found six and 12 months after counseling took place.

The USPSTF has identified the absence of studies and evidence on behavioral counseling interventions directed towards adults not at increased risk of STIs and non–sexually active adolescents as a critical gap in the literature.

Harms of counseling. No evidence of significant behavioral or biological harms resulting from behavioral counseling about risk reduction has been found. The USPSTF concluded that the potential harms of counseling are no greater than small.

USPSTF assessment. The USPSTF concludes that there is moderate certainty that high-intensity behavioral counseling has a moderate net benefit for sexually active adolescents and for adults who are at increased risk of STIs.

The USPSTF concludes that the evidence is currently insufficient to assess the balance of benefits and harms of behavioral counseling for non–sexually active adolescents and for adults who are not at increased risk of STIs.

Clinical Considerations

  • Patient population. This recommendation applies to all sexually active adolescents and adults.

  • Assessment of risk. All sexually active adolescents are at increased risk of STIs and should be offered counseling. Adults with current STIs or infections within the past year are at increased risk of future STIs. In addition, adults who have multiple current sex partners should be considered at increased risk and offered counseling to prevent STIs. Married adolescents may be considered for counseling if they meet the criteria described for adults. Physicians should also consider the communities they serve. If a practice's population has a high rate of STIs, all sexually active patients in nonmonogamous relationships may be considered to be at increased risk.

  • Effective behavioral counseling interventions. Among the studies reviewed, successful high-intensity interventions were delivered through multiple sessions, most often in groups, with total durations from three to nine hours. Little evidence suggests that single-session interventions or interventions lasting less than 30 minutes were effective in reducing STIs.1 Although two studies of moderate-intensity interventions did not demonstrate effect,2,3 a third study 4 demonstrated that two 20-minute counseling sessions before and after human immunodeficiency virus testing resulted in a clinically and statistically significant reduction in STIs. The USPSTF found no studies of abstinence-only counseling programs delivered in the clinical setting.1

  • Suggestions for practice regarding the I statement. Because of the lower incidence of STIs among adults who are not at increased risk, the potential net benefit of behavioral counseling is likely to be smaller for this population than for those at increased risk. Given the current lack of evidence of effectiveness; the substantial costs in time and money for physicians, patients, and the health system; and the potential missed opportunity for the provision of higher-priority, evidence-based preventive services, primary care physicians should consider not routinely offering behavioral counseling to prevent STIs to adults who are not at increased risk of infection. The USPSTF found limited evidence on the counseling of non–sexually active adolescents, with no effect or harms from brief counseling in one small study. Although physicians may not be able to identify all adolescents who are sexually active, intensive counseling for all adolescents to reach those who are not appropriately identified as at risk is not supported by current evidence and would require considerable resources. The effectiveness of less intensive counseling has not been established and the benefits of intensive counseling for adolescents who are identified as at risk may not be generalizable to those who deny sexual activity.


This recommendation statement was first published in Ann Intern Med. 2008;149(7):491–496, W95.

The “Other Considerations,” “Discussion,” and “Recommendations of Others” sections of this recommendation statement are available at http://www.ahrq.gov/clinic/uspstf/uspsstds.htm.

The U.S. Preventive Services Task Force 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.

REFERENCES

1. Lin JS, Whitlock E, O'Connor E, Bauer V. Behavioral counseling to prevent sexually transmitted infections: a systematic review for the U. S. Preventive Services Task Force. Ann Intern Med. 2008;149(7):497–508.

2. Danielson R, et al. Reproductive health counseling for young men: what does it do? Fam Plann Perspect. 1990;22(3):115–121.

3. Wenger NS, et al. Effect of HIV antibody testing and AIDS education on communication about HIV risk and sexual behavior. A randomized, controlled trial in college students. Ann Intern Med. 1992;117(11):905–911.

4. Kamb ML, et al. Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases: a randomized controlled trial. Project RESPECT Study Group. JAMA. 1998;280(13):1161–1167.

This summary is one in a series excerpted from the Recommendation Statements released by the U.S. Preventive Services Task Force (USPSTF). These statements address preventive health services for use in primary care clinical settings, including screening tests, counseling, and preventive medications.

A collection of USPSTF recommendation statements reprinted in AFP is available at http://www.aafp.org/afp/uspstf.

The complete version of this statement, including supporting scientific evidence, evidence tables, grading system, members of the USPSTF at the time this recommendation was finalized, and references, is available on the USPSTF Web site at http://www.ahrq.gov/clinic/uspstf/uspsstds.htm.


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