Sexually Transmitted and Blood Borne Infections (STBBI) prevention guide

On this page

• Overview of STBBI in Canada
• Primary and secondary STBBI prevention
• Person centered approach
• STBBI risk factors
• Barrier protection
• Vaccination
• References

Overview of STBBI in Canada

Sexually transmitted and blood-borne infections (STBBI) are a significant public health concern in Canada. Consequences of STBBI include pain and discomfort, infertility, adverse birth outcomes such as miscarriage and stillbirth, congenital conditions, some cancers, immunodeficiency, and psychological distress. Certain STBBI can also enhance the transmission of human immunodeficiency virus (HIV). With treatment, most STBBI are curable or manageable.

Chlamydia, gonorrhea and infectious syphilis rates have been trending upward in Canada^{Footnote 1Footnote 2Footnote 3Footnote 4}. In 2021, 104,426 cases of chlamydia were reported for a rate of 273.2 cases per 100,000 people. Chlamydia is the most common reportable sexually transmitted infection in Canada^{Footnote 1Footnote 2}. In 2021, 32,192 cases of gonorrhea were reported for a rate of 84.2 cases per 100,000 people^{Footnote 2}. The reported rate of gonorrhea doubled between 2012 and 2021^{Footnote 2}. In 2021, 11,540 cases of infectious syphilis were reported, for a rate of 30.2 cases per 100,000 people. The rate of infectious syphilis reported in 2021 was five times higher than the rate reported in 2012. Dramatic increases in infectious syphilis among females in the reproductive age group has coincided with increases in reported cases of early congenital syphilis, from an average of 3 cases per year between 2012 and 2016 to 96 cases in 2021^{Footnote 2Footnote 4}.

At the end of 2020, approximately 62,790 people (0.17% of the population) in Canada were living with HIV^{Footnote 5}. Since 2012, yearly cases and rates of HIV diagnoses in Canada have been stable. In 2021, 1,472 new diagnoses of HIV were reported in Canada for a rate of 3.8 per 100,000 people^{Footnote 6}.

Reported rates of acute hepatitis B in Canada have been persistently low since 2012, with further reductions in 2019 and 2020^{Footnote 7}. In 2020, 123 cases of acute hepatitis B were reported for a rate of 0.34 cases per 100,000 people^{Footnote 7}. Nearly half of people with chronic hepatitis B in Canada may be unaware of their status^{Footnote 7Footnote 8}.

Cases and rates of hepatitis C have been trending downward since peaking in 2018 at 12,560 cases or 34.0 cases per 100,000 people^{Footnote 9Footnote 10}. In 2020, 6,736 cases of hepatitis C were reported for a rate of 18.4 new hepatitis C diagnoses per 100,000 people. Rates varied significantly between jurisdictions^{Footnote 10}. In 2019, estimates indicated that 24% of the 387,000 people who have ever had a hepatitis C infection were undiagnosed^{Footnote 11}.

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 STBBI in Canada and achieve global STBBI targets by 2030^{Footnote 12}. The contribution of primary care and public health professionals will be essential to meet the following goals^{Footnote 13}:

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

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 sexually transmitted infections (STI): 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 STBBI^{Footnote 14}. 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 STBBI.

Sexual health and STBBI prevention are an integral part of everyone's health care. All individuals can benefit from preventive counselling and care, including those who are not yet or not currently sexually active. Health 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 STBBI and the asymptomatic nature of many infections
• Helping individuals recognize and minimize their risk for STBBI
• Offering vaccination for STBBI, 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

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^{Footnote 12}.

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 15}.

STBBI risk factors

To discuss STBBI and assess the person's healthcare needs, health 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 STBBI.

STBBI transmission routes vary by infection, and include spread via direct epithelial or mucosal contact, percutaneous exposure, contact with contaminated objects, and vertical transmission. Refer to etiology-specific guides for additional information.

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

• Multiple partners (concurrently or over time)^{Footnote 16}
• Anonymous or casual sex partners^{Footnote 17}
• Sex without the use of barrier protection^{Footnote 18}
• Sex with person(s) with an STBBI^{Footnote 16}
• Previous STBBI^{Footnote 16}
• Substance use (drugs, alcohol or both)^{Footnote 19}
• Use of medications for erectile dysfunction^{Footnote 20}
• History of intimate partner or sexual violence^{Footnote 21}
• Social environments (e.g. bath houses, circuit parties, post-secondary institutions)^{Footnote 22Footnote 23Footnote 24}

Some STBBI such as hepatitis C can be transmitted between people through substance use equipment that is shared or reused by another person^{Footnote 25}. It is critical that health professionals adopt a harm reduction approach so that people who use drugs are supported in a respectful and meaningful way while reducing the negative consequences associated with substance use. Health professionals can facilitate safer substance use practices by supporting people with access to new equipment, testing, education and supportive environments such as supervised consumption services^{Footnote 26}.

STBBI do not affect all people in the same way. People facing social and medical challenges may be more vulnerable to some STBBI. Syndemics are linked to health equity and the social determinants of health (SDoH). As SDoH can influence health practices, examining 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 STBBI include^{Footnote 27}:

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

Epidemiological evidence has revealed that certain populations are disproportionately affected by STBBI, such as^{Footnote 27}:

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

Health professionals should discuss sexual health and STBBI 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 STBBI 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 STBBI, 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 STBBI, including HIV, HBV, HCV, chlamydia and gonorrhea. They do not provide complete protection against syphilis, HPV, Herpes simplex virus type 1 or type 2 (HSV-1 or HSV-2), or mpox because lesions and (for HSV-1 and HSV-2) 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 28Footnote 29}. 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 STBBI by causing disruptions and lesions in the genital and anal mucosa^{Footnote 30}.

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

Offer vaccination for hepatitis A virus (HAV), HBV, HPV, and mpox to people at risk of these infections as per the Canadian Immunization Guide. Refer to for more information. Refer to provincial or territorial vaccination schedules for more information.

References