Behavioral Counseling to Prevent Sexually Transmitted Infections: U.S. Preventive Services Task Force Recommendation Statement

Summary of Recommendation and Evidence

The USPSTF recommends high-intensity behavioral counseling to prevent sexually transmitted infections (STIs) for all sexually active adolescents and for adults at increased risk for STIs. This is a grade 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 for STIs. This is an I statement.

See the Clinical Considerations section for information on risk assessment and suggestions for practice regarding the I statement.

See the Figure for a summary of the recommendation and suggestions for clinical practice.

Table 1 describes the USPSTF grades, and Table 2 describes the USPSTF classification of levels of certainty of net benefit. Both are also available at http://www.annals.org.

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 clinicians and teams can identify adolescents and adults who are at increased risk. (See the Clinical Considerations section below for information on risk assessment.)

Effectiveness of Counseling to Change Behavior

There is convincing evidence that high-intensity behavioral counseling interventions targeted to sexually active adolescents and adults at increased risk for STIs reduce the incidence of STIs. These results were found 6 and 12 months after counseling took place.

The USPSTF has identified the absence of studies and evidence on behavioral counseling interventions directed toward adults not at increased risk for 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 for 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 for STIs.

Clinical Considerations

Patient Population under Consideration

This recommendation applies to all sexually active adolescents and adults.

Assessment of Risk

All sexually active adolescents are at increased risk for STIs and should be offered counseling. Adults with current STIs or infections in the past year are at increased risk for future STIs. In addition, adults who have multiple current sexual 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. Clinicians should also consider the communities they serve. If the 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 3 to 9 hours. Little evidence suggests that single-session interventions or interventions lasting less than 30 minutes were effective in reducing STIs (1). Although 2 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 HIV 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 clinicians, patients, and the health system; and the potential missed opportunity for the provision of higher-priority, evidence-based preventive services, primary care clinicians should consider not routinely offering behavioral counseling to prevent STIs to adults who are not at increased risk for infection. The USPSTF found limited evidence on the counseling of non–sexually active adolescents, with no effect or harms from brief counseling in 1 small study. Although clinicians 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 significant 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.

Other Considerations

Implementation

High-intensity behavioral counseling may be delivered in primary care settings or in other sectors of the health system after referral from the primary care clinician or system. In addition, risk-reduction counseling may be offered by community organizations. Strong linkages between the primary care setting and the community may greatly improve the delivery of this service.

Research Needs and Future Directions

Effective moderate- and low-intensity interventions are greatly needed to make the delivery of behavioral counseling more widely feasible. Future research on behavioral counseling interventions should use biologically confirmed outcomes to assess effectiveness. Given that individuals may be at increased risk for acquiring STIs for many reasons, additional work is needed to develop and evaluate counseling interventions for particular populations, including individuals with mental illness and individuals in relationships with partners who have other partners. Additional research is also needed on the effectiveness of behavioral counseling among men and adolescent boys. Improved methods are needed to identify sexually active adolescents in primary care. Future research should evaluate interventions targeted to adults who are not currently at increased risk. Finally, continuity of care may be an important understudied research variable as well as an underutilized practical tool for reducing STIs and increasing the effectiveness of STI counseling.

Discussion

Burden of Disease

Each year, an estimated 19 million new STIs occur in the United States, almost half of them among people from 15 to 24 years of age. Sexually transmitted infections common in the United States include Chlamydia trachomatis, hepatitis B, hepatitis C, herpes simplex, HIV, human papillomavirus, Neisseria gonorrhoeae, syphilis, and Trichomonas vaginalis. Their direct medical costs are estimated at $15 billion annually (1).

Scope of Review

The USPSTF reviewed the evidence on the benefits and harms of counseling to prevent STIs. This review included studies evaluating behavioral counseling interventions that were actually conducted in primary care settings, those judged feasible to be conducted in primary care, and those to which patients might be referred to from primary care. The USPSTF defined behavioral counseling interventions as any intervention provided to patients that included some provision of education, skill training, or support for changes in sexual behavior that promote risk reduction or risk avoidance. The review included studies targeting both adults and adolescents.

Effectiveness of Counseling to Change Behavior

Most of the evidence found by the review concerns high-intensity interventions given to sexually active adolescents and adults who were at increased risk for STIs. Five of 6 trials demonstrated statistically significant reductions in biologically confirmed STIs at 6 and 12 months after the interventions. The absolute risk reduction rate ranged from 2.6% to 11.1%, with generally higher rates of reduction among adolescents. As noted, the interventions in this group were considered “high-intensity”; they included a single 4-hour session, three 1-hour sessions over 3 consecutive weeks, four 4-hour sessions, and a 10-session intervention. One fair-quality study found that HIV testing in combination with two 20-minute individual counseling sessions (a less intensive intervention than the others reviewed) led to a significant reduction in new STIs, including chlamydia, gonorrhea, syphilis, and HIV, at both 6 and 12 months after the intervention. Another study found that a single, 20-minute, one-to-one skills counseling session delivered in a primary care office may reduce STIs 12 months thereafter among women who are at increased risk for STIs (5). Because the reported results combined women who received this low-intensity intervention with a group of women who received 200 minutes of group counseling, additional research is needed to determine whether lower-intensity interventions can be effective. The review did not identify any trials evaluating behavioral counseling interventions directed at adults or adolescents who are not at increased risk for STIs.

Potential Harms of Counseling

The review identified no evidence of significant behavioral or biological harms as a result of risk-reduction counseling. Multiple trials showed no evidence of increases in unprotected sex or number of sexual partners. Among adolescents, 1 trial noted a transitory increase in vaginal intercourse at 3 months without any associated increase in self-reported pregnancy. This effect on vaginal intercourse was not observed at the 9-month follow-up. Another study found that risk reduction counseling did not lead to earlier sexual debut among boys.

Estimate of Magnitude of Net Benefit

The USPSTF concluded that there is at least moderate certainty that high-intensity behavioral counseling interventions can lead to moderate net benefits for sexually active adolescents and adults who are at increased risk for STIs. Evidence was insufficient to estimate the balance of benefits and harms for nonsexually active adolescents and adults who are not at increased risk for STIs.

Recommendations of Others

The American Academy of Family Physicians recommends counseling adolescents and adults on the risks for sexually transmitted diseases and how to prevent them (6). The American Academy of Pediatrics does not have a specific recommendation regarding behavioral counseling to prevent STIs; however, in related recommendation statements, they recommend counseling for adolescents regarding abstinence and the importance of barrier contraceptives (7). The American College of Obstetricians and Gynecologists recommends counseling all women regarding partner selection and use of barrier contraception to prevent STIs (8). In addition, they recommend counseling female adolescents about what constitutes responsible, consensual sexual behavior and that abstinence from sexual intercourse is the only definitive way to prevent pregnancy and STIs (9). The American Medical Association encourages all physicians to educate their patients about sexually transmitted diseases and proper condom use (10, 11).