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STDs: Detection, Counseling, and Referral

Our courses fulfill continuing nursing education requirements in all 50 states. For more accreditation information, click here. Nurse practitioners may apply these contact hours to pharmacy continuing education and prescriptive authorization.

This course is recommended for advanced practitioners and others who treat or counsel clients about STDs.

Wild Iris Medical Education has adapted the material for this course from the 2006 guidelines published by the Centers for Disease Control and Prevention (CDC). The original material was published by the National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Division of STD Prevention. The post test and learning objectives were prepared by Sharon A. Sanders, RN.

Sexually Transmitted Diseases Treatment Guidelines, 2006 was prepared for the CDC by Kimberly A. Workowski, MD, and Stuart M. Berman, MD. References may be viewed at http://www.cdc.gov/std/treatment/2006/rr5511.pdf.

These guidelines for the treatment of people who have sexually transmitted diseases (STDs) were developed by Centers for Disease Control and Prevention (CDC) after consultation with professionals knowledgeable in the field who met in Atlanta April 19–21, 2005. The information in this report updates the 2002 Sexually Transmitted Diseases Treatment Guidelines (CDC, 2002).

Included in these updated guidelines are:

• An expanded diagnostic evaluation for cervicitis and trichomoniasis
• New antimicrobial recommendations for trichomoniasis
• Additional data on the clinical effectiveness of azithromycin for chlamydial infections in pregnancy
• Discussion of the role of Mycoplasma genitalium and trichomoniasis in urethritis/cervicitis with treatment-related implications
• Emergence of lymphogranuloma venereum proctocolitis among men who have sex with men (MSM)
• Expanded discussion of the criteria for spinal fluid examination to evaluate for neurosyphilis
• The emergence of azithromycin-resistant Treponema pallidum
• Increasing prevalence of quinolone-resistant Neisseria gonorrhoeae in MSM
• Revised discussion concerning the sexual transmission of hepatitis C
• Postexposure prophylaxis after sexual assault
• An expanded discussion of STD prevention approaches

Wild Iris Medical Education has divided this material into four courses: (1) STDs: detection, referral, and counseling; (2) STDs affecting the reproductive system; (3) STDs: hepatitis, proctitis, and ectoparasitic infections; and (4) STDs related to sexual assault.

PART 1     Overview

Physicians and other healthcare providers play a critical role in preventing and treating STDs. The CDC guidelines are intended to assist with that effort. Although the guidelines emphasize treatment, they also discuss prevention strategies and diagnostic recommendations.

METHODS

This CDC report was produced through a multi-stage process. Beginning in 2004, professionals knowledgeable in the field of STDs systematically reviewed evidence, including published abstracts and peer-reviewed journal articles, about each of the major STDs, focusing on information that had become available since publication of the 2002 guidelines.

They wrote background papers and constructed tables of evidence summarizing the type of study (eg, randomized controlled trial, case series), study population and setting, treatments or other interventions, outcome measures assessed, reported findings, and weaknesses and biases in study design and analysis. The group then drafted a document based on their reviews.

In April 2005, CDC staff members and invited consultants assembled in Atlanta for a three-day meeting to present the key questions that emerged from the evidence-based reviews along with the information available to answer those questions. The questions focused on four principal outcomes of STD therapy for each individual disease:

• Microbiologic cure
• Alleviation of signs and symptoms
• Prevention of sequelae
• Prevention of transmission

The CDC group further discussed cost effectiveness and other advantages (eg, single-dose formulations). The consultants then attempted to arrive at answers using the available evidence. In addition, the consultants evaluated the quality of evidence supporting the answers based on the number, type, and quality of the studies.

In several areas, the process diverged from that previously described. The sections on hepatitis B virus (HBV) and hepatitis A virus (HAV) infections are based on previously or recently approved recommendations of the advisory committee on immunization practices. The recommendations for STD screening during pregnancy were developed after CDC staff reviewed contributions from other knowledgeable groups.

This report discussed the evidence used as the basis for specific recommendations only briefly. More comprehensive, annotated discussions will appear in background papers to be published in a supplement issue of Clinical Infectious Diseases. When more than one therapeutic regimen is recommended, the sequence is in alphabetical order unless the choices for therapy are prioritized based on effectiveness, convenience, or cost.

For STDs with more than one recommended treatment regimen, it can be assumed that all regimens have similar effectiveness and similar rates of intolerance or toxicity, unless otherwise specified. Clinicians treating STDs should generally use recommended regimens; alternatives can be considered in instances of substantial drug allergy or other contraindications.

These recommendations were developed in consultation with public and private-sector professionals knowledgeable in the treatment of people with STDs. The recommendations may be applied in a variety of patient-care settings, including family planning clinics, private physicians' offices, managed care organizations, and other primary care facilities.

These recommendations are meant to serve as a source of clinical guidance: healthcare providers should always consider the individual clinical circumstances of an individual in the context of local disease prevalence.

These guidelines focus on the treatment and counseling of individual people and do not address other community services and interventions that are important in STD/human immunodeficiency virus (HIV) prevention.

CLINICAL PREVENTION GUIDANCE

The prevention and control of STDs are based on the following five major strategies:

1. Education and counseling of people at risk about ways to avoid STDs through changes in sexual behaviors
2. Identification of asymptomatically infected people and of symptomatic people unlikely to seek diagnostic and treatment
3. Effective diagnosis and treatment of infected people
4. Evaluation, treatment, and counseling of sex partners of people already infected with an STD
5. Pre-exposure vaccination of people at risk for a vaccine-preventable STD

Primary prevention of STD begins with changing the sexual behaviors that place people at risk for infection. Healthcare providers have a unique opportunity to provide education and counseling to their patients. As part of the clinical interview, healthcare providers should routinely and regularly obtain sexual histories from their patients and address management of risk reduction as indicated in the CDC guidelines.

Guidance in obtaining a sexual history is available through the CDC prevention and training centers at http://www.stdhivpreventiontraining.org. Counseling skills—characterized by respect, compassion, and a nonjudgmental attitude toward all patients—are essential to obtaining a thorough sexual history and to delivering prevention messages effectively.

Key techniques that can be effective in facilitating rapport with patients include the use of:

1. Open-ended questions (Tell me about any new sex partners you've had since your last visit and What has your experience been with using condoms?)
2. Understandable language (Have you ever had a sore or scab on your penis?)
3. Normalizing language (Some of my patients have difficulty using a condom every time they have sex. How is it for you?).

One approach to eliciting information about five key areas of interest is summarized in the following box.

Patients should be reassured that they will be treated regardless of individual circumstances (eg, ability to pay, citizenship or immigration status, language spoken, or specific sex practices). Many patients seeking treatment or screening for a particular STD should be evaluated for all common STDs; even so, all patients should be informed concerning all the STDs for which they are being tested and whether testing for a common STD (eg, genital herpes) is not being performed.

STD/HIV PREVENTION COUNSELING

Effective delivery of prevention messages requires that providers integrate communication—providing both general risk-reduction messages and specific actions that can reduce the risk for STD/HIV transmission (eg, abstinence, condom use, limiting the number of sex partners, modifying sexual behaviors, vaccination).

Interactive counseling, directed at a patient's personal risk and the situations in which risk occurs, and the use of goal-setting strategies are effective in STD/HIV prevention. One such approach, client-centered prevention counseling, involves tailoring a discussion of risk reduction to the patient's individual situation. Client-centered counseling can increase the likelihood of patients' using risk reduction practices and thus reduce the risk for future acquisition of an STD.

One effective client-centered approach is Project RESPECT, which demonstrated that a brief counseling intervention was associated with a reduced frequency of STD/HIV risk-related behaviors and with a lowered acquisition of STDs. Practice models based on Project RESPECT have been successfully implemented in clinics. Other approaches use motivational interviewing to move clients toward achievable risk reduction goals. The CDC provides additional information on these and other effective behavioral interventions at http://effectiveinterventions.org.

Interactive counseling can be used effectively by all healthcare providers or it can be conducted by specially trained counselors. The quality of counseling is best ensured when:

• Providers receive basic training in prevention counseling and skill-building
• Professionals with expertise in counseling do periodic observation of counseling and give immediate feedback
• Counselor and patient satisfaction are evaluated periodically
• Expert assistance or referral is available for challenging situations

Training in client-centered counseling is available through the CDC STD/HIV prevention training centers at http://www.stdhivpreventiontraining.org. Prevention counseling is most effective when provided in a nonjudgmental manner appropriate to the patient's culture, language, sex, sexual orientation, age, and developmental level.

In addition to individual prevention counseling, some video and large-group presentations provide explicit information about how to use condoms correctly. These have been effective in reducing the occurrence of additional STDs among people at high risk, including adolescents and STD clinic patients.

Because the incidence of some STDs, notably syphilis, has increased in HIV-infected people, public health agencies have strongly endorsed client-centered counseling for them. Consensus guidelines issued by CDC, the Health Resources and Services Administration, the HIV Medicine Association of the Infectious Diseases Society of America, and the National Institutes of Health emphasize that STD/HIV risk assessment, STD screening, and client-centered risk reduction counseling should be provided routinely to HIV-infected people. Several specific methods have been designed for the HIV care setting.

Prevention counseling does not need to be explicitly linked to the HIV-testing process. However, some patients might be more likely to think about HIV and consider their risks when undergoing an HIV test. HIV testing might present an ideal opportunity to provide or arrange for prevention counseling to assist with behavior changes that can reduce risk for acquiring HIV-infection. Prevention counseling should be offered and encouraged in all healthcare facilities serving patients at high risk and in those (eg, STD clinics) where information on HIV-risk behaviors is routinely elicited.

PREVENTION METHODS

This section is devoted to client-initiated interventions to reduce sexual transmission of STD/HIV as well as unintended pregnancy.

Abstinence and Reducing Number of Sex Partners

The most reliable way longterm to avoid transmission of STDs is to abstain from sex (oral, vaginal, and anal) or to be in a long-term, mutually monogamous relationship with an uninfected partner. Counseling that encourages abstinence is crucial for people who are being treated for an STD (or whose partners are undergoing treatment) and for people who want to avoid STD/HIV and unintended pregnancy.

For people embarking on a mutually monogamous relationship, screening for common STDs before initiating sex may reduce the risk for future transmission of asymptomatic STDs.

Pre-Exposure Vaccination

Pre-exposure vaccination is one of the most effective methods for preventing transmission of some STDs. For example, because HBV infection is frequently sexually transmitted, hepatitis B vaccination is recommended for all unvaccinated, uninfected people being evaluated for an STD. In addition, hepatitis A vaccine is licensed and is recommended for men who have sex with men (MSM) and illicit drug users (both injecting and noninjecting).

A quadrivalent vaccine against human papillomavirus (HPV types 6, 11, 16, 18) is now available and licensed for females aged 9 to 26 years. Vaccine trials for other STDs are being conducted.

Barrier Methods

MALE CONDOMS

When used consistently and correctly, male latex condoms are highly effective in preventing the sexual transmission of HIV-infection. The use of condoms can also reduce the risk for other STDs, including chlamydia, gonorrhea, and trichomoniasis, and might reduce the risk of women developing pelvic inflammatory disease (PID). Condom use might reduce the risk for transmission of herpes simplex virus-2 (HSV-2), although data are limited on this.

Condom use might reduce the risk for HPV-associated diseases (eg, genital warts, cervical cancer) and mitigate the adverse consequences of infection with HPV. A limited number of studies have demonstrated a protective effect of condoms on the acquisition of genital HPV; one recent study of college women who were newly sexually active demonstrated that consistent condom use was associated with a 70% reduction in risk for HPV transmission.

Condoms are regulated as medical devices and are subject to random sampling and testing by the Food and Drug Administration (FDA). Each latex condom manufactured in the United States is tested electronically for holes before packaging. Rates of condom breakage during sexual intercourse and withdrawal are approximately 2 broken condoms per 100 condoms used in the United States. The failure of condoms to protect against STD transmission or unintended pregnancy usually results from inconsistent or incorrect use rather than condom breakage.

Male condoms made of materials other than latex are available in the United States. Although they have had higher breakage and slippage rates when compared with latex condoms and are usually more costly, the pregnancy rates among women whose partners use these condoms are similar to latex condoms. Two general categories of nonlatex condoms exist.

The first type is made of polyurethane or other synthetic material and provides protection against STD/HIV and pregnancy equal to that of latex condoms. These can be substituted for people with latex allergy. The second type is natural membrane condoms (frequently called natural condoms or, incorrectly, lambskin condoms). These condoms are usually made from lamb cecum and can have pores up to 1500 nm in diameter. Whereas these pores do not allow the passage of sperm, they are more than 10 times the diameter of HIV and more than 25 times that of HBV. Moreover, laboratory studies demonstrate that viral STD transmission can occur with natural membrane condoms. Using natural membrane condoms for protection against STDs is thus not recommended.

Patients should be advised that condoms must be used consistently and correctly to be effective in preventing STDs, and they should be instructed in the correct use of condoms. The following recommendations ensure the proper use of male condoms:

• Use a new condom with each sex act (oral, vaginal, and anal).
• Handle the condom carefully to avoid damaging it with fingernails, teeth, or other sharp objects.
• Put the condom on after the penis is erect and before any genital, oral, or anal contact with the partner.
• Use only water-based lubricants (K-Y Jelly, Astroglide, AquaLube, glycerin) with latex condoms. Oil-based lubricants (petroleum jelly, shortening, mineral oil, massage oils, body lotions, cooking oil) can weaken latex.
• Ensure adequate lubrication during vaginal and anal sex, which might require the use of water-based lubricants.
• To prevent the condom from slipping off, hold the condom firmly against the base of the penis during withdrawal, and withdraw while the penis is still erect.

FEMALE CONDOMS

Laboratory studies indicate that the female condom (trade name, Reality), which consists of a lubricated polyurethane sheath with a ring on each end that is inserted into the vagina, is an effective mechanical barrier to viruses, including HIV, and to semen. A limited number of clinical studies have evaluated the effectiveness of female condoms in providing protection from STDs, including HIV. If used consistently and correctly, the female condom might substantially reduce the risk for STDs.

When a male condom cannot be used properly, sex partners should consider using a female condom. Female condoms are costly as compared to male condoms. The female condom has also been used for STD/HIV protection during receptive anal intercourse. Whereas it might provide some protection in this setting, its effectiveness is undefined.

VAGINAL SPERMICIDES AND DIAPHRAGMS

Vaginal spermicides containing nonoxynol-9 (N-9) are not effective in preventing cervical gonorrhea, chlamydia, or HIV-infection. Furthermore, frequent use of spermicides containing N-9 has been associated with disruption of the genital epithelium, which might be associated with an increased risk for HIV transmission. Therefore, N-9 is not recommended for STD/HIV prevention.

In case-control and cross-sectional studies, diaphragm use has been demonstrated to protect against cervical gonorrhea, chlamydia, and trichomoniasis; a randomized controlled trial will be conducted. On the basis of all available evidence, diaphragms should not be relied on as the sole source of protection against HIV-infection. Diaphragm and spermicide use have been associated with an increased risk for bacterial urinary tract infections in women.

CONDOMS WITH N-9 VAGINAL SPERMICIDES

Condoms lubricated with spermicides are no more effective than other lubricated condoms in protecting against the transmission of HIV and other STDs, and those that are lubricated with N-9 pose the concerns just mentioned. Use of condoms lubricated with N-9 is not recommended for STD/HIV prevention because spermicide-coated condoms cost more, have a shorter shelf-life than other lubricated condoms, and have been associated with urinary tract infection in young women.

RECTAL USE OF N-9 SPERMICIDES

Recent studies indicate that N-9 might increase the risk for HIV transmission during vaginal intercourse. Although similar studies have not been conducted among MSM who use N-9 spermicide, N-9 can damage the cells lining the rectum, which might provide a portal of entry for HIV and other sexually transmissible agents. Therefore, N-9 should not be used as a microbicide or lubricant during anal intercourse.

Nonbarrier Risks

HORMONAL CONTRACEPTION, SURGICAL STERILIZATION, HYSTERECTOMY

Sexually active women who are not at risk for pregnancy might incorrectly believe they are at no risk for STDs, including HIV-infection. Contraceptive methods that are not mechanical barriers offer no protection against HIV or other STDs. Women who use hormonal contraception (oral contraceptives, Norplant, Depo-Provera), have intrauterine devices (IUDs), have been surgically sterilized, or have had hysterectomies should be counseled regarding the use of condoms and the risk for STDs, including HIV-infection.

EMERGENCY CONTRACEPTION (EC)

Emergency use of oral contraceptive pills containing levonorgesterol alone reduces the risk for pregnancy after unprotected intercourse by 89%. Plan B (two 750-mcg levonorgestrel tablets) has been approved by FDA and is available in the United States for the prevention of unintended pregnancy. Pills containing a combination of ethinyl estradiol and either norgestrel or levonorgestrel can be used; they reduce the risk for pregnancy by 75%.

Emergency insertion of a copper IUD is highly effective, reducing the risk by as much as 99%. Emergency contraception with oral contraceptive pills should be initiated as soon as possible after unprotected intercourse and definitely within 120 hours (5 days). The only medical contraindication to provision of EC is a current pregnancy.

Providers who manage people at risk for STDs should counsel women concerning the option for EC, if indicated, and provide it in a timely fashion if desired by the woman.

POSTEXPOSURE PROPHYLAXIS (PEP) FOR HIV

Guidelines for the use of PEP aimed at preventing HIV acquisition as a result of sexual exposure are spelled out in the Wild Iris course, STDs Related to Sexual Assault.

PARTNER MANAGEMENT

Partner notification, previously referred to as "contact tracing" but recently included in the broader category of partner services, is the process by which providers or public health authorities learn from people with STDs about their sex partners and help to arrange for those individuals' evaluation and treatment. Providers can seek this information and help to arrange for evaluation and treatment of sex partners, either directly or with assistance from state and local health departments.

The intensity of partner services and the specific STDs for which they are offered vary among providers, agencies, and geographic areas. Ideally, such services should be accompanied by health counseling and might include referral of patients and their partners for other services where appropriate.

In general, it is unclear whether partner notification effectively decreases exposure to STDs and whether it changes the incidence and prevalence of STDs in a community. The lack of supporting evidence regarding the effectiveness of partner notification has spurred exploration of alternatives. One such is to place partner notification in a larger context by making interventions in the sexual and social networks in which people are exposed to STDs.

Prospective evaluations—incorporating assessment of venues, community structure, and social and sexual contacts, in conjunction with partner notification—are promising in terms of increasing case-finding, and they warrant further exploration. Individual clinicians probably cannot provide such network-based approaches, but STD control programs might find them useful.

Many people benefit individually from partner notification. When partners are treated, the presenting patients have reduced risk for reinfection. At a population level, partner notification can break up networks of STD transmission and reduce disease incidence. Therefore, providers should encourage their patients with STDs to notify their sex partners and urge them to seek medical evaluation and treatment, regardless of whether assistance is available from health agencies.

When medical evaluation, counseling, and treatment of partners cannot be done because of the particular circumstances of a patient or partner or because of resource limitations, other partner management options can be considered. One option is patient-delivered therapy, a form of expedited partner therapy (EPT) in which partners of infected patients are treated without previous medical evaluation or prevention counseling (http://www.cdc.gov/std/treatment/EPTFinalReport2006.pdf).

The evidence supporting patient-delivered therapy is based on three clinical trials that included heterosexual men and women with chlamydia or gonorrhea. The strength of the supporting evidence differed by STD and by the sex of the initial patient when re-infection was the measured outcome. Despite this, patient-delivered therapy (medications, prescriptions) can prevent re-infection of the initial patient and has been associated with a higher likelihood of partner notification when compared with unassisted patient referral of partners.

Medications and prescriptions for patient-delivered therapy should be accompanied by treatment instructions, appropriate warnings about taking medications if pregnant, general health counseling, and advice that partners should seek personal medical evaluations—particularly women with symptoms of STDs or PID. Existing data suggest that EPT has a limited role in partner management for trichomoniasis. No data support its use in the routine management of syphilis. There is no experience with EPT for gonorrhea or chlamydia infection among MSM. Currently, EPT is not feasible in many settings because of operational barriers, including the lack of clear legal status of EPT in some states.

REPORTING AND CONFIDENTIALITY

The accurate and timely reporting of STDs is important for assessing morbidity trends, targeting limited resources, and assisting local health authorities in partner notification and treatment. STD/HIV and acquired immunodeficiency syndrome (AIDS) should be reported in accordance with state and local statutory requirements. Syphilis, gonorrhea, chlamydia, chancroid, HIV-infection, and AIDS are reportable diseases in every state. The requirements for reporting other STDs differ by state, and clinicians should be familiar with state and local reporting requirements.

Reporting can be provider-based and/or laboratory-based. Clinicians who are unsure of reporting requirements should seek advice from state or local health departments or STD programs. STD and HIV reports are kept strictly confidential. In the majority of jurisdictions, such reports are protected by statute from subpoena. Before public health representatives conduct a followup of a positive STD test result, they should consult the patient's healthcare provider to verify the diagnosis and treatment.

PART 2     Special Populations

PREGNANT WOMEN

Intrauterine or perinatally transmitted STDs can have severely debilitating effects on pregnant women, their partners, and their fetuses. All pregnant women and their sex partners should be asked about STDs, counseled about the possibility of perinatal infections, and assured access to treatment.

Recommended Screening Tests

All pregnant women in the United States should be tested for HIV-infection as early in pregnancy as possible. The woman is notified that she will be tested for HIV as part of the routine panel of prenatal tests unless she declines the test (opt-out screening). For women who decline HIV testing, providers should address their objections and, where appropriate, continue to strongly encourage testing.

Women who decline testing because they have had a previous negative HIV test should be informed of the importance of retesting during each pregnancy. Testing pregnant women is vital not only to maintain the health of the patient but also because interventions (antiretroviral, obstetrical) are available that can reduce perinatal transmission of HIV.

Retesting in the third trimester (preferably before 36 weeks' gestation) is recommended for women at high risk for acquiring HIV-infection (women who use illicit drugs, have STDs during pregnancy, have multiple sex partners during pregnancy, or have HIV-infected partners). Rapid HIV testing should be performed on women in labor with undocumented HIV status. If a rapid HIV test result is positive, antiretroviral prophylaxis (with consent) should be administered without waiting for the results of the confirmatory test.

A serologic test for syphilis should be performed on all pregnant women at the first prenatal visit. In populations where prenatal care is not routine, rapid plasma reagin (RPR) card test screening (and treatment, if that test is reactive) should be performed at the time a pregnancy is confirmed. Women who are at high risk for syphilis, live in areas of high syphilis morbidity, are previously untested, or have positive serology in the first trimester should be screened again early in the third trimester (28 weeks' gestation) and at delivery.

Some states require all women to be screened at delivery. Infants should not be discharged from the hospital unless the syphilis serologic status of the mother has been determined at least one time during pregnancy and preferably again at delivery. Any woman who delivers a stillborn infant should be tested for syphilis.

All pregnant women should be routinely tested for hepatitis B surface antigen (HBsAg) during an early prenatal visit (first trimester) in each pregnancy, even if they have been previously vaccinated or tested. Women who were not screened prenatally, those who engage in behaviors that put them at high risk for infection (more than one sex partner in the previous 6 months, evaluation or treatment for an STD, recent or current injecting-drug use, and HBsAg-positive sex partner), and those with clinical hepatitis should be retested at the time of admission to the hospital for delivery. Women at risk for HBV infection also should be vaccinated. To avoid misinterpreting a transient positive HBsAg result during the 21 days after vaccination, HBsAg testing should be performed before the vaccination.

All laboratories that conduct HBsAg tests should use an HBsAg test that is FDA-cleared and should perform testing according to the manufacturer's labeling, including testing of initially reactive specimens with a licensed neutralizing confirmatory test. When pregnant women are tested for HBsAg at the time of admission for delivery, shortened testing protocols may be used, and initially reactive results should prompt swift administration of immunoprophylaxis to infants.

All pregnant women should be routinely tested for Chlamydia trachomatis at the first prenatal visit. Women under 25 years of age and those at increased risk for chlamydia (i.e., women who have a new or more than one sex partner) also should be retested during the third trimester to prevent maternal postnatal complications and chlamydial infection in the infant. Screening during the first trimester might prevent the adverse effects of chlamydia during pregnancy, but supportive evidence for this is lacking. If screening is performed only during the first trimester, a longer period exists for acquiring infection before delivery.

All pregnant women at risk for gonorrhea or living in an area in which the prevalence of Neisseria gonorrhoeae is high should be tested at the first prenatal visit for N. gonorrhoeae. A repeat test should be performed during the third trimester for those at continued risk.

All pregnant women at high risk for hepatitis C infection should be tested for hepatitis C antibodies at the first prenatal visit. Women at high risk include those with a history of injecting-drug use and those with a history of blood transfusion or organ transplantation before 1992.

Evaluation for bacterial vaginosis (BV) might be conducted during the first prenatal visit for asymptomatic patients who are at high risk for preterm labor (those who have a history of a previous preterm delivery). Evidence does not support routine testing for BV.

A Papanicolaou (Pap) smear should be obtained at the first prenatal visit if none has been documented during the preceding year.

Other Concerns

Women who are HBsAg-positive should be reported to the local and/or state health department to ensure that they are entered into a case management system and that timely and appropriate prophylaxis is provided for their infants. Information concerning the pregnant woman's HBsAg status should be provided to the hospital in which delivery is planned and to the healthcare provider who will care for the newborn. In addition, household and sex contacts of women who are HBsAg-positive should be vaccinated.

Women who are HBsAg-positive should be provided with, or referred for, appropriate counseling and medical management. Pregnant women who are HBsAg-positive should receive information regarding hepatitis B that addresses:

• Modes of transmission
• Perinatal concerns (breastfeeding is not contraindicated)
• Prevention of HBV transmission, including the importance of postexposure prophylaxis for the newborn infant and hepatitis B vaccination for household contacts and sex partners
• Evaluation for and treatment of chronic HBV infection

No treatment is available for HCV-infected pregnant women. However, all women with HCV-infection should receive appropriate counseling and supportive care. No vaccine is available to prevent HCV transmission.

In the absence of lesions during the third trimester, routine serial cultures for HSV are not indicated for women who have a history of recurrent genital herpes. Prophylactic cesarean section is not indicated for women who do not have active genital lesions at the time of delivery. In addition, insufficient evidence exists to recommend routine HSV-2 serologic screening among previously undiagnosed women during pregnancy, nor does sufficient evidence exist to recommend routine antiviral suppressive therapy late in gestation for all HSV-2 positive women.

The presence of genital warts is not an indication for cesarean section.

Not enough evidence exists to recommend routine screening for Trichomonas vaginalis in asymptomatic pregnant women.

ADOLESCENTS

The rates of many STDs are highest among adolescents. For example, the reported rates of chlamydia and gonorrhea are highest among females aged 15 to 19 years, and many people acquire HPV infection during their adolescent years.

Among adolescents with acute HBV infection, the most commonly reported risk factors are having sexual contact with a chronically infected person or with multiple sex partners, or reporting their sexual preference as homosexual. As part of a comprehensive strategy to eliminate HBV transmission in the United States, The CDC's advisory committee on immunization practices has recommended that all children and adolescents be administered HBV vaccine.

Younger adolescents (people <15 years) who are sexually active are at particular risk for STDs, especially youth in detention facilities, STD clinic patients, male homosexuals, and injecting-drug users (IDUs). Adolescents are at higher risk for STDs because they frequently have unprotected intercourse, are biologically more susceptible to infection, often engage in sexual partnerships of limited duration, and face multiple obstacles to using healthcare.

Several of these issues can be addressed by clinicians who provide services to adolescents. Clinicians can address adolescents' lack of knowledge and awareness regarding the risks and consequences of STDs by offering guidance about healthy sexual behavior and thereby prevent the establishment of patterns of behavior that can undermine sexual health.

With a few exceptions, all adolescents in the United States can legally consent to the confidential diagnosis and treatment of STDs. In all fifty states and the District of Columbia, medical care for STDs can be provided to adolescents without parental consent or knowledge. In addition, in the majority of states, adolescents can consent to HIV counseling and testing. Consent laws for vaccination of adolescents differ by state.

Several states consider provision of vaccine similar to treatment of STDs and provide vaccination services without parental consent. Because of the crucial importance of confidentiality, healthcare providers should follow policies comply with state laws for STD services.

Despite the prevalence of STDs among adolescents, providers frequently fail to inquire about sexual behavior, assess risk for STDs, provide counseling on risk reduction, and screen for asymptomatic infection during clinical encounters. The style and content of counseling and health education on these sensitive subjects should be adapted for adolescents. Discussions appropriate for the patient's developmental level and should be aimed at identifying risky behaviors (eg, sexual, drug-use). Careful, nonjudgmental, and thorough counseling are particularly vital for adolescents who might not be willing to acknowledge that they engage in high-risk behaviors.

CHILDREN

Management of children who have STDs requires close cooperation among clinicians, laboratory personnel, and child-protection authorities. Official investigations, when indicated, should be initiated promptly. Some diseases (gonorrhea, syphilis, chlamydia), if acquired after the neonatal period, are virtually 100% indicative of sexual contact. For other diseases (HPV infection, vaginitis), the association with sexual contact is not as clear.

MEN WHO HAVE SEX WITH MEN (MSM)

Some men who have sex with men (MSM) are at high risk for HIV-infection and other viral and bacterial STDs. The frequency of unsafe sexual practices and the reported rates of bacterial STDs and incident HIV-infection have declined substantially in MSM from the 1980s through the mid-1990s. However, during the previous ten years, increased rates of infectious syphilis, gonorrhea, and chlamydial infection and of higher rates of unsafe sexual behaviors were documented among MSM in the United States and virtually all industrialized countries. The effect of these behavioral changes on HIV transmission has not been ascertained, but preliminary data suggest that the incidence of HIV-infection might be increasing again among some MSM.

These adverse trends probably are related to changing attitudes concerning HIV-infection that arise from:

• The effects of improved HIV/AIDS therapy on quality of life and survival
• Changing patterns of substance abuse
• Demographic shifts in MSM populations
• Changes in sex partner networks resulting from new venues for partner acquisition

Clinicians should assess the risks of STDs for all male patients, including a routine inquiry about the sex of patients' sex partners. Men who have sex with men, including those with HIV-infection, should routinely undergo nonjudgmental STD/HIV risk assessment and client-centered prevention counseling to reduce the likelihood of acquiring or transmitting HIV or other STDs.

Clinicians must be familiar with local community resources available to assist MSM at high risk in facilitating behavioral change. Clinicians should also ask sexually active MSM routinely about symptoms consistent with common STDs, including urethral discharge, dysuria, genital and perianal ulcers, regional lymphadenopathy, skin rash, and anorectal symptoms consistent with proctitis. Further, clinicians should maintain a low threshold for diagnostic testing of symptomatic patients.

Routine laboratory screening for common STDs is indicated for all sexually active MSM. The following screening recommendations are based on preliminary data. These tests should be performed at least annually for sexually active MSM, including men with or without established HIV-infection:

• HIV serology, if HIV-negative or not tested within the previous year
• Syphilis serology
• Test for urethral infection with N. gonorrhoeae and C. trachomatis in men who have had insertive intercourse* during the preceding year
• Test for rectal infection† with N. gonorrhoeae and C. trachomatis in men who have had receptive anal intercourse* during the preceding year
• Test for pharyngeal infection† with N. gonorrhoeae in men who have acknowledged participation in receptive oral intercourse* during the preceding year; testing for
• C. trachomatis pharyngeal infection is not recommended

* Regardless of history of condom use during exposure
† Providers should use a culture or test that has been cleared by the FDA or locally verified in accordance with applicable statutes.

In addition, some specialists would consider type-specific serologic tests for HSV-2, if infection status is unknown. Routine testing for anal cytologic abnormalities or anal HPV infection is not recommended until more data are available on the reliability of screening methods, the safety and response to treatment, and programmatic considerations.

More frequent STD screening (at 3–6 month intervals) is indicated for MSM who have multiple or anonymous partners, have sex in conjunction with illicit drug use, use methamphetamine, or whose sex partners participate in these activities.

Vaccination against hepatitis A and B is recommended for all MSM in whom previous infection or immunization cannot be documented. Pre-immunization serologic testing might be considered to reduce the cost of vaccinating MSM who are already immune to these infections, but this testing should not delay vaccination. Vaccinating people who are immune to HAV or HBV infection because of previous infection or vaccination does not increase the risk for vaccine-related adverse events.

WOMEN WHO HAVE SEX WITH WOMEN (WSW)

Few data are available on the risk of STDs conferred by sex between women, but transmission risk probably varies by the specific STD and sexual practice (oral-genital sex; vaginal or anal sex using hands, fingers, or penetrative sex items; and oral-anal sex). Practices involving digital-vaginal or digital-anal contact, particularly with shared penetrative sex items, present a possible means for transmission of infected cervicovaginal secretions.

This possibility is most directly supported by reports of metronidazole-resistant trichomoniasis and genotype-concordant HIV transmitted sexually between women who reported these behaviors and by the high prevalence of BV among monogamous WSW. Transmission of HPV can occur with skin-to-skin or skin-to-mucosa contact, which can occur during sex between women.

HPV deoxyribonucleic acid (DNA) has been detected through polymerase chain reaction (PCR)-based methods from the cervix, vagina, and vulva in 13% to 30% of WSW, and high-and low-grade squamous intraepithelial lesions (SIL) have been detected on Pap tests in WSW who reported no previous sex with men. However, the majority of self-identified WSW (53–99%) have had sex with men and might continue this practice. Therefore, all women should undergo Pap test screening using current national guidelines, regardless of sexual preference or sexual practices.

HSV-2 genital transmission between female sex partners is probably inefficient, but the relatively frequent practice of orogenital sex among WSW might place them at higher risk for genital infection with HSV-1. This hypothesis is supported by the recognized association between HSV-1 seropositivity and previous number of female partners among WSW. Transmission of syphilis between female sex partners, probably through oral sex, has been reported. Although the rate of transmission of C. trachomatis between women is unknown, WSW who also have sex with men are at risk and should undergo routine screening according to guidelines.

PART 3     HIV-Infection

Infection with HIV produces a spectrum of disease that progresses from a clinically latent or asymptomatic state to AIDS as a late manifestation. The pace of disease progression varies. In untreated patients, the time between infection with HIV and the development of AIDS ranges from a few months to as long as 17 years (median, 10 years).

The majority of adults and adolescents infected with HIV remain symptom-free for extended periods, but viral replication is active during all stages of infection and increases substantially as the immune system deteriorates. In the absence of treatment, AIDS will develop eventually in nearly all HIV-infected people.

In nonemergent situations, the initial evaluation of HIV-positive patients usually includes the following:

• Detailed medical history, including sexual and substance-abuse history; vaccination history; previous STDs; and specific HIV-related symptoms or diagnoses
• Physical examination, including a gynecologic examination for women
• Testing for N. gonorrhoeae and C. trachomatis (and for women, a Pap test and wet mount examination of vaginal secretions)
• Complete blood and platelet counts and blood chemistry profile
• Toxoplasma antibody test
• Tests for antibodies to HCV; testing for previous or present HAV or HBV infection is recommended if determined to be cost-effective before considering vaccination (see hepatitis A and hepatitis B)
• Syphilis serology
• CD4 T-lymphocyte analysis and determination of HIV plasma viral load
• Tuberculin skin test (sometimes referred to as a purified protein derivative)
• Urinalysis
• Chest radiograph

Some specialists recommend type-specific testing for HSV-2 if herpes infection status is unknown. A first dose of hepatitis A and/or hepatitis B vaccination for previously unvaccinated people for whom vaccine is recommended should be administered at this first visit.

In subsequent visits, when the results of laboratory and skin tests are available, antiretroviral therapy may be offered, if indicated, after initial antiretroviral resistance testing is performed and specific prophylactic medications are administered to reduce the incidence of opportunistic infections (eg, Pneumocystis jiroveci pneumonia, toxoplasma encephalitis [TE], disseminated Mycobacterium avium complex [MAC] disease, and TB). The vaccination series for hepatitis A and/or B should be offered for those in whom vaccination is recommended. Influenza vaccination should be offered annually, and pneumococcal vaccination should be given if it has not been administered in the previous 5 years.

Providers should be alert to the possibility of new or recurrent STDs and should treat such conditions aggressively. The occurrence of an STD in an HIV-infected person is an indication of high-risk behavior and should prompt referral for counseling. Because many STDs are asymptomatic, routine screening for curable STDs (syphilis, gonorrhea, chlamydia) should be performed at least yearly for sexually active people. Women should be screened for cervical cancer precursor lesions by annual Pap smears. More frequent STD screening might be appropriate depending on individual risk behaviors, the local epidemiology of STDs, and whether incident STDs are detected by screening or by the presence of symptoms.

DETECTION

Improvements in antiretroviral therapy and increasing awareness among both patients and healthcare providers of the risk factors associated with HIV transmission have led to more testing for HIV and earlier diagnosis, frequently before symptoms develop. However, the conditions of nearly 40% of people who acquire HIV-infection continue to be diagnosed late—within 1 year of acquiring full-blown AIDS. Prompt diagnosis of HIV-infection is essential for many reasons.

Treatments are available that slow the decline of immune system function; their use has been associated with substantial declines in HIV-associated morbidity and mortality in recent years. HIV-infected people who have altered immune function are at increased risk for infections for which preventive measures are available, including Pneumocystis jiroveci pneumonia, TE, disseminated MAC disease, tuberculosis (TB), and bacterial pneumonia.

Because of its effect on the immune system, HIV affects the diagnosis, evaluation, treatment, and followup of various other diseases and might affect the effectiveness of antimicrobial therapy for some STDs. Finally, the early diagnosis of HIV enables healthcare providers to counsel infected patients, refer them to various support services, and help prevent HIV transmission to others. Acutely infected people may have elevated HIV viral loads and, therefore, might be more likely to transmit HIV to their partners.

Proper management of HIV-infection involves a complex array of behavioral, psychosocial, and medical services. Some services may not be available in STD treatment facilities; therefore, referral to a healthcare provider or facility experienced in caring for HIV-infected patients is advised. Providers working in STD treatment facilities should be knowledgeable about the options for referral available in their communities. While receiving care in STD treatment facilities, HIV-infected patients should be educated about the various options available for support services and HIV care.

Screening and Testing

All people who seek evaluation and treatment for STDs should be screened for HIV-infection. Screening should be routine, regardless of whether the patient is known or suspected to have specific behavioral risks for HIV-infection.

HIV screening should be voluntary and conducted only with the patient's knowledge and understanding that testing is planned. People should be informed orally or in writing that HIV testing will be performed unless they decline (opt out). Oral or written communications should include an explanation of positive and negative test results, and patients should be offered an opportunity to ask questions and to decline testing.

DIAGNOSTIC TESTING

HIV-infection usually is diagnosed by tests for antibodies against HIV-1. Some combination tests also detect antibodies against HIV-2 (ie, HIV-1/2). Antibody testing begins with a sensitive screening test (the enzyme immunoassay [EIA] or rapid test). The advent of HIV rapid testing has enabled clinicians to make a substantially accurate presumptive diagnosis of HIV-1 infection within half an hour. This testing can help to identify the more than 250,000 people living with undiagnosed HIV in the United States.

Reactive screening tests must be confirmed by a supplemental test (Western blot, WB) or an immunofluorescence assay (IFA). If confirmed by a supplemental test, a positive antibody test result indicates that a person is infected with HIV and is capable of transmitting the virus to others. HIV antibody is detectable in at least 95% of patients within 3 months after infection. Although a negative antibody test result usually indicates that a person is not infected, antibody tests cannot exclude recent infection.

The majority of HIV-infections in the United States are caused by HIV-1. However, HIV-2 infection should be suspected in people who have epidemiologic risk factors, including being from West Africa (where HIV-2 is endemic) or having sex partners from endemic areas, having sex partners known to be infected with HIV-2, or having received a blood transfusion or nonsterile injection in a West African country.

HIV-2 testing is also indicated when clinical evidence of HIV exists but tests for HIV-1 antibodies or HIV-1 viral load are not positive, or when HIV-1 WB results include the unusual indeterminate pattern of gag (p55, p24, p17) plus pol (p66, p51, p31) bands in the absence of env (gp160, gp120, gp41) bands.

Healthcare providers should be knowledgeable about the symptoms and signs of acute retroviral syndrome, which is characterized by fever, malaise, lymphadenopathy, and skin rash. This syndrome frequently occurs in the first few weeks after HIV-infection, before antibody test results become positive.

Suspicion of acute retroviral syndrome should prompt nucleic acid testing (HIV plasma ribonucleic acid, RNA) to detect the presence of HIV, although not all nucleic acid tests are approved for diagnostic purposes; a positive HIV nucleic acid test should be confirmed by subsequent antibody testing to document seroconversion (using standard methods, EIA, and WB). Acutely infected patients may be highly contagious because of increased plasma and genital HIV RNA concentrations and might be continuing to engage in risky behaviors. Current guidelines suggest that people with recently acquired HIV-infection might benefit from antiretroviral drugs and be candidates for clinical trials.

Therefore, patients with acute HIV-infection should be referred immediately to an HIV clinical care provider. Diagnosis of HIV-infection should prompt efforts to reduce the risk behavior that resulted in HIV-infection and could result in transmission of HIV to others. Early counseling and education are particularly important for people with recently acquired infection because HIV plasma RNA levels are characteristically high during this phase of infection and probably constitute an increased risk for HIV transmission.

The following are specific recommendations for diagnostic testing for
HIV-infection:

• HIV screening is recommended for all people who seek evaluation and treatment for STDs.
• HIV testing must be voluntary.
• Consent for HIV testing should be incorporated into the general consent for care (verbally or in writing) with an opportunity to decline (opt-out screening).
• HIV rapid testing must be considered, especially in clinics where a high proportion of patients do not return for HIV test results.
• Positive screening tests for HIV antibody must be confirmed by a supplemental test (WB or IFA) before being considered diagnostic of HIV-infection.
• People who have positive HIV test results (screening and confirmatory) must receive initial HIV prevention counseling before leaving the testing site. Such people should
• receive a medical evaluation and, if indicated, behavioral and psychological services; or be referred for these services.
• Providers should be alert to the possibility of acute retroviral syndrome and should perform nucleic acid testing for HIV when indicated. Patients suspected of having recently acquired HIV-infection should be referred for immediate consultation with a specialist.

COUNSELING AND REFERRAL

Expect people to be distressed when first informed of a positive HIV test result and be prepared to provide support. Individuals newly diagnosed face major adaptive challenges, including:

• Accepting the possibility of a shortened life span
• Coping with the reactions of others to a stigmatizing illness
• Developing and adopting strategies for maintaining physical and emotional health
• Initiating changes in behavior to prevent HIV transmission to others

Many people will require assistance with making reproductive choices, gaining access to health services, confronting possible employment or housing discrimination, and coping with changes in personal relationships. Therefore, behavioral and psychosocial services are an integral part of healthcare for HIV-infected people. Such services should be available on site or through referral when HIV-infection is diagnosed.

Innovative and successful interventions to decrease risk taking by HIV-infected patients have been developed by the CDC for diverse populations. Practice settings offering HIV care differ depending on local resources and needs. Primary care providers and outpatient facilities should ensure that appropriate resources are available for each patient to avoid fragmentation of care.

Although a single source that is capable of providing comprehensive care for all stages of HIV-infection is preferred, the limited availability of such resources frequently results in the need to coordinate care among medical and social service providers in different locations. Avoid long delays between diagnosis of HIV-infection and access to additional medical and psychosocial services (eg, through he use of HIV rapid testing).

Recently identified HIV-infection may not have been recently acquired. People newly diagnosed with HIV might be at any stage of infection. Therefore, healthcare providers should be alert for symptoms or signs that suggest advanced HIV-infection (fever, weight loss, diarrhea, cough, shortness of breath, oral candidiasis). The presence of any of these symptoms should prompt urgent referral for specialty medical care.

Similarly, providers should be alert for signs of psychologic distress and be prepared to refer patients accordingly. Diagnosis of HIV-infection reinforces the need to counsel patients regarding high-risk behaviors because the consequences of such behaviors include the risk for acquiring additional STDs and for transmitting HIV (and other STDs) to other people. Such attention to behaviors in HIV-infected people is consistent with national strategies for HIV prevention. Providers should refer patients for prevention counseling and risk-reduction support concerning high-risk behaviors.

In many recent studies, researchers have developed successful prevention strategies for specific HIV-infected populations that can be adapted to individuals. People with newly diagnosed HIV-infection who receive care in the STD treatment setting should be educated concerning what to expect as they enter medical care for HIV-infection.

Newly diagnosed HIV-infected people should receive or be referred for a thorough psychosocial evaluation, including ascertainment of behavioral factors indicating risk for transmitting HIV. Patients might require referral for specific behavioral intervention (eg, a substance abuse program), mental health disorders (eg, depression), or emotional distress. They might require assistance with securing and maintaining employment and housing. Women should be counseled or appropriately referred regarding reproductive choices and contraceptive options. Patients with multiple psychosocial problems might be candidates for comprehensive risk-reduction counseling and services.

The following are specific recommendations for HIV counseling and referral:

• People who test positive for HIV antibody should be counseled, either on site or through referral, concerning the behavioral, psychosocial, and medical implications of HIV-infection.
• Healthcare providers should be alert for medical or psychosocial conditions that require immediate attention.
• Providers should assess newly diagnosed patients' needs for immediate medical care or support and link them to services experienced in caring for HIV-infected people. Such people might need medical care or services for substance abuse, mental health disorders, emotional distress, reproductive counseling, risk-reduction counseling, and case management. Providers should follow up to ensure that patients have received the needed services.
• Patients should be educated regarding what to expect in followup medical care.
• Several innovative interventions for HIV prevention have been developed for diverse at-risk populations, and these can be locally replicated or adapted. Involvement of nongovernmental organizations (NGOs) and community-based organizations may complement efforts in the clinical setting.

Management of Sex Partners

Clinicians evaluating HIV-infected people should collect information to determine whether any partners should be notified concerning possible exposure to HIV. When referring to people who are infected with HIV, the term partner includes not only sex partners but also injection-drug users who share syringes or other injection equipment.

The rationale for partner notification is that the early diagnosis and treatment of HIV-infection in these partners might reduce morbidity and it provides the opportunity to encourage risk-reducing behaviors. Partner notification for HIV-infection is confidential and depends on the voluntary cooperation of the patient. Specific guidance regarding spousal notification may vary by jurisdiction.

Two complementary notification processes, patient referral and provider referral, can be used to identify partners. With patient referral, patients directly inform their partners of their exposure to HIV-infection. With provider referral, trained health department personnel locate partners on the basis of the names, descriptions, and addresses provided by the patient.

During the notification process, the confidentiality of the patient is protected; names are not revealed to partners who are notified. Many state and local health departments provide these services.

The following are specific recommendations for implementing partner notification procedures:

• HIV-infected patients are encouraged to notify their partners and refer them for counseling and testing. If requested by the patient, healthcare providers should assist in this process, either directly or by referral to health department partner notification programs.
• If patients are unwilling to notify their partners or if they cannot ensure that their partners will seek counseling, physicians or health department personnel should use confidential partner notification procedures.
• Partners who are contacted within 72 hours of a high risk sexual or injecting-drug exposure to an HIV-infected partner, which involves exposure to genital secretions and/or blood, should be offered PEP—a 28-day course of combination antiretroviral therapy.

SPECIAL CONSIDERATIONS

Pregnancy

All pregnant women in the United States should be tested for HIV-infection as early in the pregnancy as possible. Testing should occur after the patient is notified that she will be tested for HIV as part of the routine panel of prenatal tests, unless she declines (opts out). For women who decline, providers should continue to strongly encourage testing and address concerns that pose obstacles to testing.

Women who decline testing because they have had a previous negative HIV test should be informed of the importance of retesting during each pregnancy. Testing pregnant women is particularly important not only to maintain the health of the patient but also because interventions (antiretroviral, obstetrical) can reduce the risk of perinatal transmission of HIV.

After pregnant women have been identified as HIV-infected, they must be educated about the risk of perinatal infection. Evidence indicates that, in the absence of antiretroviral and other interventions, 15% to 25% of infants born to HIV-infected mothers will become infected with HIV; such evidence also indicates that an additional 12% to 14% will become infected during breastfeeding where HIV-infected women breastfeed their infants into the second year of life.

The risk of perinatal HIV transmission can be reduced to less than 2% through the use of antiretroviral regimens and obstetrical interventions (zidovudine or nevirapine and elective cesarean section at 38 weeks of pregnancy) and by avoiding breastfeeding. Pregnant women who are HIV-infected should be counseled concerning their options (either on-site or by referral), given appropriate prenatal treatment, and—for women living in the United States, where infant formula is readily available and can be safely prepared—advised not to breastfeed their infants.

Infants and Children

Diagnosis of HIV-infection in a pregnant woman indicates the need to consider whether other children of that woman might be infected. Infants and young children with HIV-infection differ from adults and adolescents with respect to the diagnosis, clinical presentation, and management of HIV disease. For example, because maternal HIV antibody passes through the placenta, antibody tests for HIV are expected to be positive in the sera of both infected and uninfected infants born to seropositive mothers. A definitive determination of HIV-infection for an infant aged <18 months is usually based on HIV nucleic acid testing. Management of infants, children, and adolescents who are known or suspected to be infected with HIV requires referral to physicians familiar with the manifestations and treatment of pediatric HIV-infection.

ILLITERACY AND HEALTH

Illiteracy is often silent, yet it is a potentially deadly problem in healthcare. In a field where vocabulary is unfamiliar to many and information is often presented at the college level (despite the fact that the average American reads at the eighth-grade level!) a client who has difficulty reading or calculating numbers is at a terrible disadvantage when it comes to understanding what they need to be healthy (Marcus, 2006).

A client's language difficulties, which may range from poor skills to no skills, may be the result of:

• Never having acquired reading and calculating skills
• Having had them but lost them due to an illness or accident
• Possessing them only in another language

The problem is frequently made worse by the shame and embarrassment that research has shown often accompanies illiteracy. It is a situation requiring tact and understanding on the part of healthcare staff (Marcus, 2006).

All clients benefit when healthcare providers:

• Develop an awareness of signs that may indicate a patient cannot read
• Learn simple tests to quietly confirm that suspicion
• Work out alternative methods to convey medical information

The lack of reading or calculating skills should be considered in when a client is noncompliant, and staff should be alert when clients repeatedly say they cannot fill out a form because they "forgot their reading glasses" or "have a headache." Once aware of a possible problem, diagnostic techniques can be as simple as handing a client an instruction sheet upside down and asking them to read it out loud, watching to see if they turn it right side up before they begin (Ratnayake , 2006).

Alternative methods for delivering information requires adapting the information to the needs of clients. Be aware that even simple pictures do not always have shared meanings. Healthcare providers need to familiarize themselves with the literature on the subject and the resources that are currently available. For example, Medlineplus, an online medical information provider, includes over 160 strictly audio/video presentations on common illnesses, tests, and procedures (Doyle, 2003).

Remember too that office staff are often in a position to notice any problems clients may have with forms (Marcus, 2006). Be sure to share your knowledge!

Posted November 10, 2006

Expires December 1, 2008

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