December 18, 2019 03:56 pm Michael Devitt – On Dec. 17, the U.S. Preventive Services Task Force posted a draft recommendation statement and draft evidence review on behavioral counseling interventions to prevent sexually transmitted infections. The USPSTF's action comes slightly more than a year after a 2018 CDC report found that for each of the top three reportable STIs in the United States -- chlamydia, gonorrhea and syphilis -- case numbers reached their highest levels in at least five years.
Based on its review of the evidence, the USPSTF recommended behavioral counseling for all adolescents who are sexually active and for adults at increased risk for contracting STIs. This is a "B" recommendation.
"Behavioral counseling interventions can help prevent STIs and increase safer sexual behaviors," said USPSTF vice chair Alex Krist, M.D., M.P.H., in a news release. "These interventions generally provide basic information about STIs, assess individual risk, communicate about safer sex and aim to increase commitment to safer sex practices."
The draft recommendation on behavioral counseling joins a long list of USPSTF recommendations on screening for specific STIs and related conditions, including
The USPSTF has also published a recommendation on offering preexposure prophylaxis to prevent HIV infection.
The latest draft recommendation differs slightly from the task force's 2014 final recommendation on the topic, which the AAFP supported at the time.
In that previous statement, the agency recommended intensive behavioral counseling to prevent STIs -- which the recommendation defined as total contact time of 30 or more minutes -- for all adolescents who are sexually active and adults at increased risk for STIs.
To update the previous recommendation, the USPSTF commissioned a systematic review of literature on the benefits and harms of behavioral counseling interventions to prevent STI acquisition, including both randomized and nonrandomized controlled trials in adolescents or adults of any sexual orientation, level of reported sexual activity or pregnancy status published after 1999.
The review found that although interventions consisting of more than 120 minutes of contact time, group counseling, or both were generally more effective in reducing STI acquisition, several interventions with low or moderate contact time or without group counseling also yielded statistically significant reductions in STI acquisition in STI clinic patients.
As a result, the USPSTF modified its recommendation to incorporate a broader range of counseling approaches, including those that involve less than 30 minutes of total contact time.
According to task force member Melissa Simon, M.D., M.P.H., clinicians can provide those approaches in a variety of formats.
"Clinicians can offer behavioral counseling to their patients directly during primary care visits, refer them to other providers, or connect them to media-based interventions, such as videos and websites," Simon said in the release. "Through this recommendation, we hope more clinicians will consider various ways to offer behavioral counseling interventions to prevent STIs."
At the same time, the USPSTF continues to conclude that current evidence on the benefits and harms of offering behavioral counseling to prevent STIs in adolescents who are not sexually active and in adults who are not at increased risk for STIs in insufficient to formulate any sort of recommendation.
The CDC estimates that nearly 20 million new STIs occur in the United States each year, with about half of all infections occurring in young people 15 to 24. If left untreated, STIs can cause complications that range from chronic pelvic pain to infertility and even death. As a primary source of care for many young people, family physicians can play a pivotal role in reducing the number of STIs and in treating individuals who contract these types of infections.
Scott Hartman, M.D., a member of the Academy's Commission on Health of the Public and Science from Rochester, N.Y., and the commission's chair for 2020, co-authored the Screening for Sexually Transmitted Infections Practice Manual published by the AAFP earlier this year. Hartman told AAFP Newsthat like the practice manual, the draft recommendation contains important points for FPs to consider.
"The take-home for FPs is that effective behavioral counseling can likely take a variety of forms," Hartman said, adding, "FPs should realize that although group interventions in STI clinics appeared most effective in the evidence review, brief interventions during primary care encounters are still critical in STI prevention."
Hartman suggested that FPs take an open approach when talking with patients about STIs.
"For younger patients, and really all patients, we should assume nothing," Hartman said. "We must employ the best of our listening skills (at which many FPs excel) and meet patients where they are. We can't make assumptions about sexual orientation, gender identity or sexual practices. A detailed and open-ended sexual history will allow us to best assess risk factors and provide appropriate counseling and screening."
Hartman also shared that although he acknowledges the effectiveness of group medical visits and longer interventions, the reality is that most FPs will discuss STIs with patients during brief, individual office visits. "Point-of-care sexual history-taking, screening tests and counseling can be super effective, particularly when they start with nonjudgmental history-taking," he said. Patient encounters and interventions that focus on judgment instead of identifying and mitigating tasks are least effective, he added.
The USPSTF is accepting comments on the draft recommendation statement and draft evidence reviewon behavioral counseling interventions to prevent STIs until 8 p.m. ET on Jan. 21, 2020. All comments received will be considered as the task force prepares its final recommendation.
The AAFP will review the USPSTF's draft recommendation statement and supporting evidence and will provide comments to the task force. The Academy will release its own recommendation on the topic after the task force finalizes its guidance.
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