Conversations Surrounding STI Prevention

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Conversations Surrounding STI Prevention - #84

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While sexually transmitted infections (STIs) are on the rise among older adults, medical providers may associate this problem with younger populations, missing prevention and treatment opportunities.

Assessment

Prevention Counseling2

WHO?

The CDC recommends STI/HIV prevention counseling to all sexually active adults who:

  1. Currently have an STI
  2. Have had an STI within the past year
  3. Have multiple sexual partners

HOW?

Effective STI prevention counseling is characterized by:

  1. Empathetic and nonjudgmental tone
  2. Dynamic conversations that engage the patient’s point of view
  3. Discussion of available prevention resources
  4. Patient-centered counseling targeting the adult’s personal risk, situation and goals

Possible Reasons for the increase of STIs in older adults1:

  • Lack of STI screening and treatment
  • Physiologic changes (e.g., weakened immune system, thinning mucosal tissue)
  • Changing relationships (e.g., widow/widowerhood, divorce)
  • Increased availability of medication for intercourse (e.g. sildenafil)
  • Misinformation/misunderstanding (e.g., risks of unprotected sex, need for condom use even for postmenopausal women, STI transmission routes)
  • Inaccessibility to STI protection in community living environments

Conversations about “safer sex” may be difficult and uncomfortable for providers and patients but are vital to maintain patients’ health.  Having open, nonjudgmental discussions about individual risk factors may lead to safer sexual practices.

Interviewing and counseling must be founded on respect, compassion, and a nonjudgmental attitude toward all patients. Establishing rapport and a safe environment for these challenging conversations is essential.  Older adults may not anticipate this conversation and questions.  Prefacing the questions and conversation with a “warning shot” and following that with normalizing statements will reduce surprise and may open communication.  These normalizing statements may include:

  • “It may seem awkward or too personal to talk with your physician about sexuality but talking about this will help me to keep you healthy.”
  • “I think it’s important for your health to find out if you have any sexual concerns or problems.  Would it be ok for me to ask you a few questions about this?”
  • “Sexuality is a part of people regardless of our age – and because of that, I’d like to ask you a few questions.  Is that alright?”

Essential Interviewing Skills:

  • Open ended questions
    • “Can you tell me about any new sex partners you’ve had since your last visit?”
    •  “What has your experience with using condoms been like?”
  • Nonjudgmental and direct language
    • “Are your sex partners men, women, or both?”
    • “Have you ever had a sore on your penis?”
  • Normalizing language
    • “Some patients have difficulty using condoms. Is that the case for you?”

Aspects of a sexual history may include the following P’s:

P’s2 Questions to Facilitate Conversation
Partners
  • “Do you have sex with men, women, or both?”
  • “In the past 2 months, how many partners have you had sex with?”
  • “Is it possible that any of your sex partners in the past year had sex with someone else while they were still in a sexual relationship with you?”
Practices

“To understand your risks for STIs, I need to understand the kind of sex you have had recently.”

  • “Have you had vaginal sex, meaning ‘penis in vagina sex’?” If yes, “Do you use condoms: never, sometimes, or always?”
  • “Have you had anal sex, meaning ‘penis in rectum/anus sex’?” If yes, “Do you use condoms: never, sometimes, or always?”
  • “Have you had oral sex, meaning ‘mouth on penis/vagina’?”

For condom answers:

  • If “never”: “is there a reason you don’t you use condoms?”
  • If “sometimes”: “In what situations (or with whom) do you use condoms?”
Protection “What do you do to protect yourself from STIs and HIV?”
Past History
  • “Have you ever had an STI?”
  • “Have any of your partners had an STI?”
Prevention of HIV/ viral hepatitis
  • “Have you or any of your partners ever injected drugs?”
  • “Have your or any of your partners exchanged money or drugs for sex?”
  • “Is there anything else about your sexual practices that I need to know about?”

 

Context

Sexually active older adults seen in an outpatient practice setting.

Action

Use the communication skills and question suggestions to better assess risk of STI infection in older adult patients.

Definition

 

Incidence / Prevalence

According to an analysis of athenahealth network data, the incidence of herpes simplex, gonorrhea, syphilis, chlamydia, hepatitis B, and trichomoniasis increased 23% in patients older than 60 from 2014 to 2017.3  Percent increase in STI treatment rate per 100,000 people, 2014-20173:

Age 20-29 7%
Age 30-39 14%
Age 40-49 13%
Age 50-59 17%
Age 60+ 23%

 

Underlying Sciences

As the body ages, the vaginal tissue thins, predisposing post- menopausal women to sexually transmitted infections. Testing must be done to determine infection so appropriate treatment plans may be made for the patient. Delay of accurate diagnosis and treatment facilitates the spread of sexually transmitted infections.1,3

Science Principles

Behavioral & Social Sciences including Bioethics

Objectives

  1. Identify possible reasons underlying the increased incidence of STIs in older adults
  2. Identify individuals who may benefit from prevention counseling
  3. List counseling skills to aid in taking a sexual history with older adults
  4. Identify direct, targeted questions to understand patient STI risk

Keywords/Tags

Review of Systems (ROS)

Sexuality

Geriatric Topics

Prevention, Safety and Transitions of Care

ACGME Compentencies

Communication Skills

Science Principles

Behavioral & Social Sciences including Bioethics

References

  1. Harvard Health Publishing. (2018, February). Sexually transmitted disease? At my age? Retrieved from https://www.health.harvard.edu/diseases-and-conditions/sexually-transmitted-disease-at-my-age
  2. Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention. (2017, October 10). 2015 Sexually Transmitted Diseases Treatment Guidelines. Retrieved from https://www.cdc.gov/std/tg2015/clinical.htm#risk
  3. Patients over 60? Screen for STIs. Athenahealth, 16 May 2018, www.athenahealth.com/insight/over-60-stis-may-not-be-done-you.
This GFF ___ my competence in geriatrics.

Authors

Emily Kistler, Student Pharmacist, University of Pittsburgh School of Pharmacy

Diana Mansour, Student Pharmacist, University of Pittsburgh School of Pharmacy

Jennifer Pruskowski, PharmD, BCPS, BCGP, CPE, Assistant Professor | University of Pittsburgh School of Pharmacy, Department of Pharmacy and Therapeutics, Palliative Care Clinical Pharmacy Specialist | UPMC Palliative and Supportive Institute (PSI)

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