STBBI prevention guide: Assessment and counselling

On this page

• Sexual health assessment
  • Physical examination
• Counselling
  • Pre- and post-test counselling
• References

Sexual health assessment

This guide uses medical words, such as vagina and penis, to describe genitals. People use different words to talk about their bodies and their genitals. As well, some people use gender neutral pronouns such as “they”. Using language that the person prefers is respectful, affirming and empowering.

Healthcare visits, particularly when focused on sexual health, can feel intrusive. Sensitive topics may be discussed and the physical examination can sometimes be uncomfortable or painful. Healthcare professionals should be mindful that many people have a history of trauma. There are strategies to make it easier to discuss sexual health, STBBIs, substance use, gender identity, gender expression and sexual orientation. One strategy is to provide culturally aware and trauma-informed care within a safe, private and respectful environment that is free of judgement. The following practices can improve conversations about sexual health and STBBIs:

• Ask what pronoun(s) they prefer
• Ask which terms they prefer to use to identify their sex organs and use these terms
• Advise the person that the information they provide is confidential andtell them about limitations to confidentiality
• Check whether the person is comfortable with the discussion
• Ask questions relevant to the person’s care
• Explain why you are asking a particular question
• Inform the person that they are not obligated to answer questions that make them feel uncomfortable
• Use simple and non-judgmental language (e.g., What are the sex and gender of your sexual partners?)
• Use open-ended questions to encourage the person to share their own stories (e.g., What are you doing to avoid STBBIs?)

Taking time to obtain a brief sexual health history during routine care can provide the opportunity to discuss STBBIs. Using a person-centred approach will help identify STBBI risk factors and health needs, which may include counselling, vaccinations, screening, testing or treatment. A brief routine sexual health assessment is preferred because extensive assessments may make some people uncomfortable and deter them from seeking care. Use discretion and only ask questions that correspond to the person’s health and well-being needs. Adapt or change which questions are asked depending on the nature of the visit, the rapport with the person and their understanding of STBBIs. Some individuals may not be ready to discuss these topics or may wish to address them at another time.

Physical examination

A physical examination is not usually required for routine STBBI screening^{Footnote 1}. The use of non-invasive samples (urine or self-obtained vaginal or rectal swabs) can increase acceptance of screening for STBBIs.

Physical examination is strongly encouraged when an STBBI is suspected. Depending on the person’s situation, a physical examination for STBBIs should include assessment of the skin, pharynx, lymph nodes, urogenital and anal area, and neurologic system as well as a search for systemic signs of infection^{Footnote 2Footnote 3Footnote 4}. Symptomatic individuals should be managed using a syndromic approach.

Samples and specimens collected for diagnostic tests should be based on clinical presentation, history, risk factors, sexual practices and substance use, as well as findings on physical examination. Depending on the type of sexual activity, it may be necessary to collect specimens from multiple anatomical sites.

If a speculum or bimanual examination is indicated for assessment of a symptomatic person, it may be appropriate to defer the exam until acute symptoms have subsided (e.g. in the case of primary genital herpes).

Counselling

In the context of STBBI prevention and control, counselling is a person-centered intervention that aims to support decision making. It should focus on knowledge, attitudes and behaviours that^{Footnote 5}:

• Maintain or increase safer practices appropriate for the individual
• Increase screening and testing
• Prevent acquisition and transmission of STBBIs
• Increase treatment adherence
• Increase vaccination rates

Motivational interviewing is a person-centred approach to counselling that involves enhancing a person’s motivation to change by using the following four principles^{Footnote 6}:

• Resist the righting reflex
• Understand the person’s motivations
• Listen with empathy
• Empower the person

Using motivational interviewing techniques can help healthcare professionals and individuals:

• Understand the context in which STBBI exposure and transmission occur
• Identify which prevention practices are acceptable and realistic for the individual
• Explore barriers to the adoption and maintenance of prevention practices, and approaches to overcome them

The following example of a motivational interviewing script could be used to discuss condoms as a STBBI prevention strategy. (Adapted from techniques suggested in Rollnick, et al.)^{Footnote 7}

1. May I ask you a few questions about condoms?
2. On a scale of 1 to 10, where 1 is “not at all important” and 10 is “very important,” how important is it for you to always use condoms?
   • If the person responds with a score of 8 or more, proceed to Q4.
   • If the person responds with a score of 7 or less, ask: Why did you say X and not lower? (This paradoxical question challenges the person to come up with reasons why it is important to use condoms.)
3. What would it take or what would have to happen to make it more important for you to use condoms?
   • The person and the healthcare provider can discuss these responses.
4. On a scale of 1 to 10, how confident are you that you and your partner(s) could always use condoms?
   • If person responds with a score of 8 or more, ask about and explore possible barriers that could occur and how person might deal with them.
   • If person responds with a score of 7 or less, ask: Why did you say X and not lower? (This paradoxical question prompts persons to think about their strengths in managing condom use.)
5. What would it take or what would have to happen for you to become more confident that you (or your partner) could use condoms every time you have sex?
   • The person and the healthcare provider can use this as a context for problem solving around condom use.

Pre- and post-test counselling^{Footnote 8Footnote 9}

Pre- and post-test counselling should be tailored to the needs of the person. Some people may require comprehensive counselling, while others may need only a short discussion to supplement information they already have.

Pre-test counselling includes discussing concerns and answering questions prior to STBBI screening or testing. The primary purpose of pre-test discussion is to ensure that the individual has sufficient information to make an informed decision about STBBI screening and testing^{Footnote 10}.

Screening or testing for STBBI - including HIV - is voluntary and requires informed consent^{Footnote 11}. Verbal consent is sufficient, and in-depth behaviour-based risk assessments and extensive pre- and post-test counselling are not required^{Footnote 12}. People are considered capable of providing consent to proceed with screening or testing if they understand the advantages and disadvantages of screening or testing; are able to interpret the meaning of the test result; and understand how STBBIs can be transmitted. Healthcare providers should be confident that the person has access to support in the event of a positive test result.

Post-test counselling depends largely on whether the results are positive or negative.

Pre-test and post-test counselling may include discussion about any of the following:

• Modes of transmission of STBBIs
• Risk of exposure associated with various substance use and sex practices (e.g. There can be an increased potential for trauma and exposure to blood with anal sex.)
• Risk reduction and prevention measures adapted to the person’s situation (e.g., how to access low or no cost harm reduction supplies such as condoms, dental dams, lubricant, PrEP and PEP)
• Travel history: Prevalence of certain STBBIs varies between countries and vulnerability will depend on individual behaviours while travelling^{Footnote 13}
• Vaccination: HPV, HBV and HAV
• Approaches to discuss sexual health and safer practices with partner(s)
• Screening or diagnostic testing options, applicable window periods and meaning of results

In addition to the above topics, when an STBBI is suspected or diagnosed, etiology- or syndrome-specific counselling may include:

• Information about treatment and expected outcomes, which differ for curable or chronic and manageable STBBIs
• The importance of treatment adherence and follow-up (e.g. test of cure, confirmatory testing)
• Benefits to partner(s) being tested and treated (as appropriate) and implications of partners not being tested or treated (e.g. potential health consequences for the partner and potential source for reinfection)
• Psychosocial impacts of STBBI diagnosis and need for post-test support
• Mandatory reporting and limits to confidentiality
• Process of partner notification by either the person, healthcare provider or a public health professional

References