Sexually Transmitted and Blood Borne Infections (STBBI) prevention guide

On this page

• Primary and secondary STBBI prevention
• Person centered approach
• STBBI risk factors
• Barrier protection
• Vaccination
• References

STBBIs are a significant public health concern in Canada. They can have sexual, reproductive and maternal-child health consequences, including genital and extragenital symptoms, pregnancy complications, cancer, infertility and psychosocial consequences. Certain STBBIs can also enhance the transmission of human immunodeficiency virus (HIV). With treatment, most STBBIs are curable or manageable.

In Canada, since 1997, the rates of chlamydia and gonorrhea have increased steadily and since 2001, the rates of syphilis have also increased^{Footnote 1Footnote 2Footnote 3}. Between 2014 and 2018, rates of chlamydia increased by 18%^{Footnote 4}, gonorrhea by 110%^{Footnote 4} and infectious syphilis by 151%^{Footnote 5}. In 2019, the number of congenital syphilis cases was the highest ever reported in Canada^{Footnote 6}.

In 2018, the Public Health Agency of Canada (PHAC) released the Pan-Canadian Sexually Transmitted and Blood-borne Infections Framework for Action which established strategic goals and guiding principles to address STBBIs in Canada and achieve global STBBI targets by 2030^{Footnote 7}. The contribution of primary care and public health professionals will be essential to meet the following goals^{Footnote 8}:

• Reduce the incidence of STBBIs in Canada
• Improve access to testing, treatment and ongoing care and support
• Reduce stigma and discrimination that create vulnerabilities to STBBIs

Refer to etiology-specific guides for recommendations on screening, diagnostic testing, treatment and management of specific pathogens.

The STI-associated Syndromes guide outlines the management of an individual based on signs and symptoms, prior to laboratory confirmation of the pathogen for the following syndromes associated with STIs: anogenital ulcers, cervicitis, epididymitis, pelvic inflammatory disease (PID), proctitis, urethritis, and vaginitis.

Individuals who require advanced diagnostics or hospitalization should be cared for in consultation with an experienced colleague or referred to a specialist.

Primary and secondary STBBI prevention

Primary and secondary STBBI prevention measures at the individual-level have population-level benefits and are key to reducing the incidence (newly acquired infections) and prevalence (current infections) of STBBIs^{Footnote 9}. Primary prevention aims to prevent infection by providing person-centred counselling and education about how to reduce risk. Secondary prevention aims to minimize the impact and spread of infection through early detection, treatment, counselling and partner notification. Primary care and public health professionals play a pivotal role in the prevention and control of STBBIs.

Sexual health and STBBI prevention are an integral part of everyone’s health care. All individuals can benefit from preventive clinical interventions, including those who are not yet or not currently sexually active. Healthcare professionals can incorporate primary and secondary STBBI prevention in the course of routine care by:

• Assessing and discussing risk for STBBI
• Educating people about signs and symptoms of STBBIs and the asymptomatic nature of many infections
• Helping individuals recognize and minimize their vulnerability to STBBIs
• Offering vaccination for STBBIs, when indicated
• Offering STBBI screening and testing, as appropriate
• Providing treatment, follow up and counselling to individuals and their partner(s)

A person-centred approach^{Footnote 7}

Taking into account a person’s circumstances, experiences, needs, goals and values helps to ensure that they are treated with respect and dignity. A person-centred approach is particularly important when addressing STBBI prevention, screening, testing and treatment. This is because of the stigma often attached to sexuality, STBBI, substance use and the potentially emotional or sensitive nature of these topics.

Furthermore, a syndemics approach can help with understanding how health is affected by social, economic, environmental and political conditions and settings. It illustrates how co-existing social and health conditions can negatively reinforce each other and thereby increase vulnerability and worsen health outcomes^{Footnote 10}.

STBBI risk factors

To discuss STBBIs and assess the person’s healthcare needs, healthcare professionals should understand the risk factors associated with STBBI transmission and acquisition, as well as current epidemiologic trends. They should also be prepared to offer basic information and counselling on common STBBIs.

Personal or behavioural factors that can increase risk for STBBIs include:

• Multiple partners (concurrently or over time)^{Footnote 11}
• Anonymous or casual sex partners^{Footnote 12}
• Sex without the use of barrier protection^{Footnote 13}
• Sex with person(s) with an STBBI^{Footnote 11}
• Previous STBBI^{Footnote 11}
• Substance use (drug, alcohol or both)^{Footnote 14}
• Use of medications for erectile dysfunction^{Footnote 15}
• History of intimate partner or sexual violence^{Footnote 16}
• Social environments (e.g. bath houses, circuit parties, post-secondary institutions)^{Footnote 17Footnote 18Footnote 19}

STBBIs do not affect all people in the same way. People facing social and medical challenges may be more vulnerable to some STBBIs. Syndemics are linked to health equity and the social determinants of health (SDoH). SDoH can influence health practices and the examination of the SDoH can lead to more holistic and coordinated approaches to STBBI prevention and care. It is also important to acknowledge the uniqueness, strength and resilience of people regardless of potentially challenging circumstances.

The SDoH that can impact vulnerability and resilience to STBBIs include^{Footnote 20}:

• Education
• Income and employment
• Stable and appropriate housing
• Food security
• Early childhood development
• Disability
• Gender and gender norms
• Culture and race
• Social and support networks
• Access to health and social services

Epidemiological evidence has revealed that certain populations are disproportionately affected by STBBIs, such as^{Footnote 20}:

• Indigenous Peoples
• Gay, bisexual and other men who have sex with men (gbMSM)
• Transgender people
• Youth and young adults
• People who use drugs
• Incarcerated or previously incarcerated people
• People from countries where HIV, hepatitis B (HBV) or hepatitis C (HCV) are endemic
• People engaged in the sale or the purchase of sex

Healthcare professionals should discuss sexual health and STBBIs with everyone as part of routine care rather than making assumptions about sexual activity or behaviours. For example, older adults, people with physical or intellectual disabilities, people in long-term relationships and youth may all benefit from discussions about sexual health and STBBI prevention.

It is also important to avoid making assumptions about sexual or substance use behaviours based on a person’s culture or population group. Being a member of a population disproportionately affected by STBBIs does not necessarily increase risk.

Barrier protection

External condoms (covering the penis), internal condoms (inserted in the vagina or anus) and dental dams (used during oral sex) create a protective barrier and prevent the exchange of bodily fluids between sexual partners. There are three types of condoms: latex, synthetic polymer and natural membrane (made from the intestinal lining of sheep).

Natural membrane condoms are permeable and do not protect against some STBBIs, including HIV.

Consistent and correct use of latex and synthetic polymer condoms and dental dams can decrease the risk of acquiring and transmitting the majority of STBBIs, including HIV, HBV, chlamydia and gonorrhea. They do not provide complete protection against syphilis, HPV or HSV because lesions and asymptomatic shedding can occur in areas not covered by these barrier methods.

Synthetic polymer condoms and dental dams can be used by persons who have a latex allergy.

Petroleum or oil-based lubricants should not be used with latex condoms. These substances weaken the latex and can lead to breakage. The risk of condom slippage varies with different sexual practices; lubricant can reduce the risk of slippage in some situations, while increasing the risk in others^{Footnote 21Footnote 22}. Some medications intended for vaginal use (e.g., estrogen, antifungal medications) can weaken latex condoms.

Spermicidal lubricated condoms containing nonoxynol-9 (N-9) are not recommended for STBBI prevention because N-9 can increase the potential for transmission of STBBIs by causing disruptions and lesions in the genital and anal mucosa^{Footnote 23}.

Package labels should be consulted for information on safe usage of condoms and lubricant. User information on condoms and dental dams, as well as how to make a dental dam, can be found in the additional resources listed below.

Since many people do not use barrier protection consistently and correctly, it’s important that STBBI screening be included in routine care.

Vaccination

HAV, HBV and HPV are vaccine-preventable infections. Offer vaccination for HAV, HBV and HPV to people at risk of these infections as per the Canadian Immunization Guide. Refer to province or territory vaccination schedules for more information.

HAV

HAV is transmitted via the fecal-oral route, which can occur from direct person-to-person contact, from contaminated objects, or through contaminated food or water. Transmission through infected blood has also been reported. Some sexual practices and sharing of drug use equipment can put people at risk for HAV^{Footnote 24}.

HBV

HBV is transmitted via percutaneous or mucosal contact with infectious biological fluids, including through sex, sharing of drug use equipment and from mothers with active or chronic HBV to their newborns. Saliva is considered infectious if it contains visible blood or in the case of bite wounds that break the skin^{Footnote 24}.

HPV

HPV is the most common STBBI. In North America, approximately 70% of sexually active people will acquire sexually transmitted HPV at least once in their lifetime^{Footnote 25Footnote 26}. HPV vaccination is recommended routinely for men and women of certain ages and for those at increased risk of acquiring HPV, regardless of whether they have previously been exposed to HPV or been diagnosed with an HPV infection or HPV-related disease^{Footnote 24}.

HPV vaccination prior to onset of sexual activity - and exposure to HPV - maximizes the benefit from vaccination. People who are already sexually active and those with HPV can still benefit from the vaccine because it will protect them against genotypes to which they have not been exposed. Providing information on HPV and HPV vaccination to those who have not been vaccinated may increase vaccine uptake^{Footnote 27Footnote 28Footnote 29Footnote 30Footnote 31}.

Vaccination is effective at preventing acquisition of the HPV genotypes responsible for most anogenital warts (AGWs) and HPV-related cancers, but does not protect against all HPV genotypes. In addition, it has no effect on existing HPV infection or AGWs. Thus, healthcare providers should recommend the continued use of preventive measures and cancer screening (e.g. Pap test) following vaccination.

References