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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.

PopulationAll sexually active adolescentsAdults at increased risk of STIsNon–sexually-active adolescents and adults not at increased risk of STIs
RecommendationOffer high-intensity counseling
Grade: B
Offer high-intensity counseling
Grade: B
No recommendation
Grade: I (insufficient evidence)
Risk assessmentAll 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.
InterventionsCharacteristics of successful high-intensity counseling interventions:
  • Multiple sessions of counseling

  • Often delivered in group settings

Suggestions for practiceHigh-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 USPSTFUSPSTF 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.uspreventiveservicestaskforce.org/recommendations.htm.

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.

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