Key Clinical Questions
Which hospitalized patients should be screened for sexually transmitted infections?
How should patients with vaginal or urethral discharge be diagnosed?
What are the common causes of genital ulcers?
What are the benefits of universal HIV screening in health care settings?
In the United States, there are 15 million cases of sexually transmitted infections (STIs) yearly, including 4 million cases of Chlamydia trachomatis alone, and the current seroprevalence of herpes simplex virus type 2 (HSV-2) is 22%. The prevalence of genital chlamydia and HSV-2 is thought to be similar in Europe and in other developed nations. Worldwide, there are an estimated 90 million new cases of genital chlamydia per year and 60 million cases of gonorrhoea per year. Syphilis has recently re-emerged in many regions where it had become uncommon, including the United States, Europe, and China. All STIs increase the risk of HIV acquisition. Most, but not all, cases of STIs occur in young people, who may be oblivious or indifferent to the associated dangers, which include pelvic inflammatory disease, infertility, cervical cancer, a higher risk of HIV acquisition, and cardiac and neurologic complications of syphilis. Up to 40% of sexually active females aged 15 to 19 in the United States have an STI.
There are many barriers to care for patients with STIs. These include privacy concerns, fear of disclosure, lack of health care access and affordability, ongoing mental health or substance abuse problems, and denial. Adolescents are a particularly vulnerable group: symptomatic female teens may take up to 10 days before seeking medical attention, and many more do not present because of the absence of symptoms. For many patients, an emergency room visit or hospitalization, often for an unrelated reason, may be the only opportunity for medical personnel to screen for HIV and other STIs, and provide point-of-care diagnosis and treatment and sexual risk reduction counselling.
The most important element in the diagnosis of an STI is a complete sexual history. The sexual history should be obtained in a professional, nonjudgmental, and thorough fashion. The interview should be in a private setting, with the patient physically comfortable and at eye level with the physician. The physician should emphasize the confidential nature of the information obtained, and that the questions asked are part of routine medical care. There should be no physical barrier, such as a desk, between the patient and physician, and the physician’s body language should suggest acceptance, with arms and legs uncrossed. The physician should make eye contact with the patient, nod encouragement, and employ strategic pauses when necessary. The physician should use terminology that the patient understands, and assess for comorbid mood disorders, alcohol, and drug abuse that may increase the patient’s risk of STIs. A useful format for the sexual history interview is the five Ps: partners, prevention of STIs (if any), prevention of pregnancy (if any), ...