Canadian Guidelines on Sexually Transmitted Infections
[Table of Contents]
Section 2 - Primary Care and Sexually Transmitted Infections
Prevention, Diagnosis and Clinical Management of Sexually Transmitted Infections in the Primary Care Setting
It is important for practitioners to
recognize that sexually transmitted infection (STI) risks will vary from person
to person and should be viewed as dynamic across the lifespan.
- Only through proper assessment can a patient’s
risk for STIs be identified.
- Assumptions and inferences about patient STI
risk may prove inaccurate.
- Sexually inactive individuals can be made aware
of STI risks in the course of routine care.
Primary care providers can incorporate STI
primary and secondary prevention in the course of routine patient care by doing
- Assessing and discussing STI risk.
- Informing patients about signs and symptoms of
STIs (and lack thereof).
- Helping patients recognize and minimize STI
- Offering patient-centred counselling.
- Offering hepatitis A (HAV) and B (HBV)
immunization when indicated.
- Offering STI screening and testing.
- Appropriately treating, following up and
counselling infected patients and their partners.
This chapter provides an overview of best
practices for the prevention and clinical management of STIs in primary care
settings. It includes recommendations for the assessment, counselling,
screening, diagnosis and management of STIs, including partner notification and
public health reporting.
prevention and management of STIs requires the following elements on the part
of the health care practitioner:
- Assessing the reason for a consultation.
- Knowing about STI risk factors and epidemiology.
- Performing a brief patient history and STI risk assessment.
- Providing patient-centred education and
- Performing a physical examination.
- Selecting appropriate screening/testing.
- Diagnosing by syndrome or by organism and
- Reporting to public health and partner
- Managing co-morbidity and associated risks.
- Following up.
Each of these elements is outlined in more detail below.
1. Assessing the Reason for a Consultation
seek medical attention for issues unrelated to sexual health, but they may be
at risk for STIs and benefit from interventions to address identified risk
factors. For example, consultation for contraception often has implications for
STI prevention counselling and STI screening; management of contraception and
management of STI risk are closely related. When patients present for
contraceptive advice, it can be an ideal time to assess and discuss STI risk.
The type of STI risk a patient may encounter also has implications for
appropriate contraceptive choice.
In some cases,
patients may consult to inquire about signs or symptoms related to a possible
STI, to request STI testing or to discuss prevention issues. Identifying a
person who has STI concerns, who is at risk for an STI or who has an STI
provides an opportunity for discussing barriers to risk reduction and means to
Figure 1. STI risk assessment in primary care settings
Text Equivalent - Figure 1
Enlarge Figure 1
2. Knowing about STI Risk Factors and Epidemiology
Identifying the index of suspicion of STI infection in a patient requires the health care
practitioner to understand the epidemiologic trends of STIs, as well as the
risk factors associated with STI transmission and infection.
Summarized in Table 1 are the key epidemiologic trends for bacterial and viral STIs in Canada, as well as patient risk factors for STIs.
Table 1. Epidemiology of STIs in Canada
|| How common in
|| Trends in
|| Most affected
- hepatitis B surface antigen
- human papilloma virus
- herpes simplex virus
- men who have sex with men
- sexually transmitted infection
- Table 1 - Footnote *
data is subject to change. Surveillance and Epidemiology Section, Community
Acquired Infections Division, Public Health Agency of Canada, published data,
- Table 1 - Footnote †
- National Microbiology Laboratory, Public Health Agency of Canada, unpublished data, 2005
Note: For up-to-date epidemiologic information, consult the Public Health Agency of Canada website:
- Most commonly diagnosed and reported
- Cases reported in Canada in 2002: 56,241
- Cases reported in Canada
2006: 65,000 (preliminary data)
increasing in Canada since 1997
- Young women aged 15–24
- Young men aged 20–29
- Second most commonly diagnosed and reported bacterial STI
- Cases reported in Canada in 2002: 7,367
- Cases reported in Canada 2006: 10,808 (preliminary data)
- From 1997-2004 (preliminary data), rate has increased by approximately 94%
- Quinolone resistance has increased from <1% in the early 1990s to 15.7% in 2005 (national rate)
- Males account for ⅔ of reported cases
- Increase in MSM
- Young men aged 20–29
- Young women aged 15–24
- Previously rare in Canada
- Cases reported in Canada in 2002: 463
- Cases reported in Canada 2006: 1,493 (preliminary data):
national increases noted since 1997 related to regional outbreaks across Canada
- MSM (HIV positive and negative) aged 30–39
- Sex workers and their clients
- Acquisition in endemic regions
- Exceedingly rare
- Acquisition in
- Exceedingly rare
- Acquisition in
- Previously rare
- Recent outbreaks in Canada have resulted in the development and implementation of an enhanced surveillance system
- Acquisition in
| Human papilloma
- Very common: 70%
of the adult population will have had at least one genital HPV infection over
- True incidence
not known, as HPV is not a reportable disease
- Adolescent and
young adult women and men (but affects women and men of all ages)
| Genital herpes
(HSV-1 and -2)
- True incidence not known, as HSV is not a reportable disease
- Seroprevalence studies indicate rates of at least 20%
- Very common in both adolescent and adult men and women
- Women are more affected than men
- Rare in general practice
- 2,529 cases reported in Canada in 2004
- 20% rise in
number of HIV+ test reports in Canada (2000–2004)
- Acquisition in endemic regions
- Injection drug users
- Young women aged 15–19
| Hepatitis B
- Low to moderate in general practice and varies in different populations
- Approximately 700 acute cases per year in Canada
- Acute hepatitis B is twice as high for men than for women
- Peak incidence rates are found in the 30–39 age group
- Infants born to HbsAg+ mothers
- Injection drug users who share equipment
- Persons with multiple sexual partners
- Acquisition in endemic regions
- Sexual and household contacts of an acute or chronic carrier
STI risk factors
STI risk factors are associated with increased incidence of STIs:
- Sexual contact with person(s) with a known STI.
- Sexually active youth under 25 years of age.
- A new sexual partner or more than two sexual
partners in the past year.
- Serially monogamous individuals who have one partner
at present but who have had a series of one-partner relationships over time.
- No contraception or sole use of
non-barrier methods of contraception (i.e., oral contraceptives, Depo Provera,
- Injection drug use.
- Other substance use, such as alcohol or
chemicals (pot, cocaine, ecstasy, crystal meth), especially if associated with
- Any individual who is engaging in unsafe sexual
practices (i.e., unprotected sex, oral, genital or anal; sex with blood
exchange, including sadomasochism; sharing sex toys).
- Sex workers and their clients.
- “Survival sex”: exchanging sex for money, drugs,
shelter or food.
- Street involvement, homelessness.
- Anonymous sexual partnering (i.e., Internet,
bathhouse, rave party).
- Victims of sexual assault/abuse.
- Previous STI.
3. Performing a Brief Patient History and STI Risk Assessment
- Information should be requested in a simple,
non-judgmental manner, using language understandable to the patient.
- History should enquire about the following:
- Genital symptoms associated with STIs
(discharge, dysuria, abdominal pain, testicular pain, rashes, lesions).
- Systemic symptoms associated with STIs (fever,
weight loss, lymphadenopathy).
- Personal risk factors and prevention (condom
use, vaccination against hepatitis B and, in the case of individuals at risk,
- Patient’s knowledge of increased risk of STIs.
- Other pertinent elements of a general history,
such as relevant drug treatments, allergies and follow-up of previous problems.
- A brief risk assessment should aim to quickly
identify or rule out major risk factors associated with increased risk of STIs.
Use of an STI risk assessment script such as the following may be helpful in
rapidly assessing risk:
- “Part of my job is to assess sexual and
reproductive health issues. Of course, everything we talk about is completely
confidential. If it is OK with you, I would like to ask you a few questions in
- Are you sexually active now, or have you been
sexually active? This includes oral sex or anal sex, not just vaginal sex.
- Do you
have any symptoms that might make you think that you have an STI? (Do you have
any sores on or around your genitals? Does it hurt or burn when you pee? Have
you noticed an unusual discharge from your penis, vagina or anus? Do you have
pain during sex?)
- What are you doing to avoid pregnancy? (Do you
or your partner use any type of birth control?)
- What are you doing to avoid STIs including HIV?
- Do you have any concerns about sexual or
relationship violence or abuse?
- Have you or your partner(s) used injection or
other drugs (e.g., crystal meth)?”
- For women also ask:
- “When was your last menstrual period?
- When was your last Pap test?”
Performing a focused risk assessment
whose current or past history identifies a potential risk factor for STIs
should have a more detailed history completed. The focused STI risk assessment
questionnaire (Table 2) is intended to serve as a practical guide to assist
clinicians in further evaluating an individual patient’s risk factors and
behaviours, as well as guiding counselling and testing recommendations.
Table 2. STI risk assessment questionnaire
| Category and elements
|| Important questions to guide your
- Do you have a regular sexual partner?
- If yes, how long have you been with this person?
- Do you have any concerns about your relationship?
- If yes what are they? (e.g., violence, abuse, coercion)
|Sexual risk behaviour
- When was your last sexual contact? Was that contact with your regular partner or with a different partner?
- How many different sexual partners have you had in the past 2 months? In the past year?
- Sexual preference, orientation
- Are your partners, men, women or both?
- Do you perform oral sex (i.e., Do you kiss
your partner on the genitals or anus)?
- Do you receive oral sex?
- Do you have intercourse (i.e., Do you
penetrate your partners in the vagina or anus [bum]? Or do your partners
penetrate your vagina or anus [bum])?
- Have any of your sexual encounters been with
people from a country other than Canada? If yes, where and when?
- How do you meet your sexual partners (when
travelling, bathhouse, Internet)?
- Do you use condoms, all the time, some of the
- What influences your choice to use protection
- If you had to rate your risk for STI, would
you say that you are at no risk, low risk, medium risk or high risk? Why?
- Have you ever been tested for STI/HIV? If yes,
what was your last screening date?
- Have you ever had an STI in the past? If yes, what and when?
- When was your sexual
contact of concern?
- If symptomatic, how long have you had the
symptoms that you are experiencing?
|Reproductive health history
- Do you and/or your partner use contraception?
If yes, what? Any problems? If no, is there a reason?
- Known reproductive problems
- Have you had any reproductive health problems?
If yes, when? What?
- Have you ever had an abnormal Pap test? If
yes, when? Result if known.
- Have you ever been pregnant? If yes, how many
times? What was/were the outcome(s) (number of live births, abortions,
- Share equipment for injection
you use alcohol? Drugs? If yes, frequency and type?
- If injection drug use, have you ever shared
equipment? If yes, what was your last sharing date.
- Have you had sex while intoxicated? If yes,
- Have you had sex while under the influence of
alcohol or other substances? What were the consequences?
- Do you feel that you need help because of your
risk other than drug injection
- Do you have tattoos or
piercings? If yes, were they done using sterile equipment (i.e.,
- Sex trade worker or client
- Have you ever traded sex for money, drugs or
- Have you ever paid for sex? If yes, frequency,
duration and last event.
- Have you ever been forced to have sex? If yes,
when and by whom?
- Have you ever been sexually abused? Have you
ever been physically or mentally abused? If yes, when and by whom?
- Do you have a home? If no, where do you sleep?
- Do you live with anyone?
4. Providing Patient-Centred Education and Counselling
the risk assessment, a number of topics may be identified where sexual health–
or STI-related education may be indicated for a given patient. Below are a
number of common counselling topics and recommendations for information to
share with patients, as well as some tips on how to approach sexual health
education/counselling using a patient-centred approach.
Common counselling topics
It is important
for practitioners to recognize and address the issue of serial monogamy. Serial
monogamy consists of a series of faithful, monogamous relationships, one after
the other. Although they may “feel safe” and “look safe,” serially monogamous
relationships, with known and committed partners, do not themselves provide
adequate protection from STIs. Consistent condom use and STI testing followed
by mutual monogamy are far safer strategies than relying on serially
monogamous partners’ apparent safety.
For youth contemplating initiation of sexual activity
Many youth will
ask for contraceptive information prior to becoming sexually active. Many young
women will begin using oral contraception for cycle control as opposed to
contraceptive reasons. Both represent excellent opportunities to counsel on
safer sex practices.
- When discussing non-barrier contraceptive
options, discussion of safer sex and condom use should occur.
- Promote partner testing prior to becoming
sexually active for partners who have already been sexually active.
- Let patients know the benefits of preventive
Oral contraceptive prescription is commonly
associated with cessation of condom use. It has been documented that
prescription of oral contraception is very often associated with the offset of
barrier method use and increased incidence of STIs. Individuals in
relationships very often move on from initial barrier protection to oral
contraception without the benefit of STI testing. Clinicians need to counsel
about alternatives to this risky pattern (e.g., testing before cessation of
condom use), particularly when prescribing oral contraceptives.
Plan and motivate prevention and risk-reduction strategies
Acceptance of sexuality
- Individuals must accept the fact that they are
or might be sexually active before they can plan for STI prevention. Primary
care providers, by their actions, can show understanding of patient sexuality
by initiating a non-judgmental, two-way dialogue that will help individuals
examine the choices they make related to their sexuality. Examining these
choices can be useful in helping patients to proactively plan for risk
reduction measures appropriate to their specific situation.
patients to plan if and how they will discuss STI preventive actions with their
partners, or take STI preventive actions unilaterally (e.g., put on a condom),
and how they will practice safer sex consistently.
- Assess whether patients know where they can
comfortably obtain condoms in their community, if they know how to use condoms
correctly, if they are aware of the signs of STIs and if they know how to seek
testing and treatment if needed.
- Individuals who take STI preventive action need
to engage in a number of advance preparations, such as buying condoms, seeking
STI/HIV testing and talking about STIs with their health care provider(s).
Primary care providers can discuss setting and maintaining personal limits with
their patients and identify the most “user-friendly” local STI prevention
- Health care practitioners can help patients to
plan for prevention by openly discussing safer sex using a continuum approach
(i.e., masturbation/mutual masturbation, low risk; oral sex, moderate risk for
STIs and low risk for HIV; unprotected vaginal or anal intercourse, high risk
for STIs and HIV). This can be useful in helping patients understand the risks
associated with various activities, make informed choices about the initiation
and maintenance of STI preventive actions and deal with possible partner
- Provide easy-to-apply information:
- Discuss limiting alcohol or drug intake prior to
sexual activity, as they decrease inhibitions and could affect decision-making
and negotiation skills.
- Reinforce that it is not possible to
assess the chances that a partner has an STI on the basis of knowing the
partner’s sexual history, being in a close relationship with a partner or being
monogamous with a partner who has a sexual history and who has not been tested.
- It is important to tell patients that we do not
and cannot routinely test for all STIs (e.g., human papilloma virus [HPV],
herpes simplex virus [HSV]), so even if they or their partner’s tests are all
negative they may still have an asymptomatic STI.
counselling as a primary or secondary prevention strategy should include the
following at minimum:
- STI modes of transmission.
- Risks of various sexual activities (oral,
- Abstinence, mutual monogamy and barrier-method
options and availability (male condom, female condom, dental dam).
- Harm-reduction counselling: determining which
prevention measures are appropriate and realistic to implement, given the
patient’s personal sexual situation(s) (e.g., if practising receptive anal
intercourse, always use a condom and extra lubrication, and avoid use of
Statements related to the fact that
effective safer-sex practice requires negotiation and is something that should
be discussed with partners may be approached by stating: “If you or your
partner(s) have ever had another sexual partner, there are a number of options
open to you for safer sex. Always using a condom, or getting tested for STI/HIV
with your partner followed by mutual monogamy are a few of these options. Do
you think any of these might work for you and your partner?”
Proper use of condoms
condom failure are most often the result of improper or inconsistent use. For
counselling guidelines and instructions on use, see Appendix A and Appendix B.
Efficacy of condoms in STI prevention
- Although latex and polyurethane condoms are
effective in preventing the majority of STIs, including HIV, HBV, chlamydia and
gonorrhea, they do not provide complete protection against
HPV or HSV infection.
- Natural skin condoms may be permeable to HBV and
- An allergy to latex may be an issue for some
patients; male or female polyurethane condoms can offer needed protection in
- The female condom (a polyurethane vaginal pouch)
is commercially available and represents an alternative to male condoms or in
persons who have a latex allergy for both STI and pregnancy prevention. Female
condoms are available in most drug stores and are more expensive than male
condoms, approximately $3.00 each. For instructions on use of a female condom
see Appendix B.
Female condom use for anal intercourse
are using the female condom for anal intercourse, although the manufacturer
does not provide recommendations for use in this way. What limited studies have
been done on the use of female condoms for anal intercourse have found that
there tends to be higher incidence of rectal bleeding and condom slippage in
comparison to the male condom.
concluded that modifications, training and research on the clinical
significance of safety outcomes are needed for the use of female condoms with
anal sex, and redesign of the female condom could increase
acceptability and use by men who have sex with men (MSM) and address
possible safety concerns.,
Warning re: non-oxynol 9
lubricated condoms are coated with a lubricant containing nonoxynol-9 (N-9),
which may provide added protection against pregnancy. N-9 may increase the risk
of infection/transmission of HIV and STIs by causing disruptions and lesions in
the genital/anal mucosal lining. N-9 should not be recommended as
an effective means of HIV or STI prevention. The best STI and HIV barrier is a
latex condom without N-9.
- N-9 should never be used rectally. Even low
doses used infrequently cause massive disruption of the rectal mucosal lining,
which is likely to increase the risk of infection by HIV and other STIs.
- If N-9 is used as an
aid to contraception, its benefit should be carefully considered in light of
the increased risk of genital lesions and the resulting potential for an
increased risk of HIV transmission.
Motivational interviewing techniques
Motivational interviewing is an intervention strategy
that has been used to promote primary and secondary prevention of STIs.
Motivational interviewing strategies are well researched clinician-implemented
intervention techniques that may be helpful in encouraging patients to practice
safer sexual behaviour.– Motivational interviewing strategies
can be used to enhance safer sex practices and condom use among patients who
may require focused counselling., Table 3 provides an
example of a motivational interviewing script.
Table 3. Motivational interviewing script
(Adapted from techniques suggested in Rollnick, et al.)
“Let me ask you a couple of
questions about condoms…”
Health care provider asks:
Q1. “On a scale of 1 to 10,
where 1 is “not at all important” and 10 is “very important,” how
important is it to you to… always use condoms?
If patient responds
with a score of 8 or more, proceed to Q3.
If patient responds
with a score of 7 or less, ask: “Why did you say X and not lower?” (This paradoxical question challenges
patients to come up with reasons why it is important to use condoms.)
Q2. “What would it
take or what would have to happen for it
to become more important to you to use condoms?” (Patients are the
world’s foremost experts in what it would take to change their views, and
they will tell the clinician what it would take to make condom use more
important to them personally. Health care provider and patient can then
discuss these responses.)
Q3. “On a scale of 1 to 10,
how confident are you that you (or you and your partner) could always use condoms?
If patient responds
with a score of 8 or more, ask about and explore possible barriers that could
occur and how patient might deal with them.
If patient responds
with a score of 7 or less, ask: “Why did you say X and not lower?” (This paradoxical question prompts patients to think about their strengths in
managing condom use.)
Q4. “What would it
take or what would have to happen for you to become
more confident that you (or you and your partner) could always use condoms?” (Patients again are the world’s foremost experts in what it would take to
change their behaviour, and they will tell the clinician what it would take
to do so. Patient and health care provider can use this as a context for
problem solving around condom use.)
5. Performing a Physical Examination
examination may be embarrassing for some patients. Therefore, physicians should
develop a trusting environment:
- Some patients may feel more comfortable having
an assistant of the same gender present.
- All patients should be assured that
confidentiality will be maintained at all times.
Table 4. Components of a physical examination
common to both sexes
- Search for systemic signs of STIs, such as
weight loss, fever, enlarged lymph nodes (palpate inguinal lymph nodes)
- Inspect mucocutaneous regions, including
- Inspect external genitalia for cutaneous
lesions, inflammation, genital discharge and anatomical irregularities
- Perform a perianal inspection
- Consider anoscopy (or, if unavailable, digital
rectal examination) if patient has practised receptive anal intercourse and has rectal symptoms
- For prepubertal females and males, see Sexual Abuse in Peripubertal and Prepubertal Children chapter
Components specific to adolescent and adult males
- Palpate scrotal contents with attention to the
- When foreskin is present, retract it to
inspect the glans
- Have the patient or examiner “milk” the
urethra to make any discharge more apparent
Components specific to adolescent and adult females
- Be sure to separate labia so as to adequately
visualize vaginal orifice
- Perform an illuminated speculum examination to
visualize cervix and vaginal walls and to evaluate endocervical and vaginal
discharges. Obtain specimens as indicated in the Laboratory Diagnosis of
Sexually Transmitted Infections chapter.
- Perform a bimanual pelvic examination to
detect uterine or adnexal masses or tenderness
- In certain circumstances, such as primary
genital herpes or vaginitis, speculum and bimanual examination may be
deferred until the acute symptoms have subsided
6. Selecting Appropriate Screening/Testing
- Selecting the appropriate laboratory tests for
patients is a crucial step in the diagnosis and management of STIs. The
selection of appropriate laboratory tests and biologic samples and specimens
should be based on patient history, risk factors and findings on physical
- Be aware of the “I have been tested” syndrome.
There are two dimensions to this syndrome:
- The false sense of security that individuals at
risk may develop after multiple STI screenings with repeat negative results.
These individuals may develop a sense that “it can never happen to me.” This
can be a focus for counselling. (See Providing Patient-Centred Education and Counselling, above.)
- The individual who has had some form of medical
attention (i.e., a physical, been in a hospital, Pap smear, given blood) and
thinks they have been tested for STIs. This is an educational opportunity.
- Simply asking a patient if he or she has been
screened for STI is not enough. There is a need to be infection-specific and
clarify for the individual that routine blood work at an annual exam does not
include syphilis or HIV testing, that a pelvic examination does not include
testing for chlamydia and gonorrhea and that a routine urine for culture and
sensitivity (C&S) does not screen for chlamydia, etc.
7. Diagnosing by Syndrome or by Organism and Post-test Counselling
- The results of microbiologic testing are not
immediately available in most offices.
- When particular symptoms and signs are present,
a syndromic diagnosis may be made and treatment and post-test counselling
provided. (See Syndromic Management of Sexually Transmitted Infections chapter for a summary table.)
- When microbiologic results are available,
treatment and counselling should be directed at specific pathogens; see
Post-test counselling is an integral part of management of the individual with a newly diagnosed STI and
should include, at minimum, the following:
- Organism- or syndrome-specific advice.
- Safer sex practices that can remove or reduce the risk of
transmitting the STI to a partner or reduce the risk of re-infection in the
- Treatment information and issues that differ as
a function of whether the infection is bacterial (curable) versus viral
- Case reporting requirements to local public health unit.
- Partner notification either via the index case,
the physician or a public health official, and the implications of partners not
being tested or treated.
Post-test prevention counselling can also
be a very important educational opportunity for individuals who have presented
with STI concerns but tested negative for STIs.
Motivational interviewing strategies, as discussed
above, can be effective in promoting risk-reduction behaviour change for
patients who have tested positive for an STI.– The difference in
motivational interviewing as a primary or secondary prevention strategy is
simply in the wording. For example: The health care provider may begin
by asking, “I ask all of my patients who are dealing with a sexually
transmitted infection a couple of questions. Could you tell me how important it
is for you now to always use condoms (or always carry out another
relevant STI-prevention/harm-reduction strategy)?” (Follow the
motivational-interviewing script in Table 3, above.)
can be curative in the case of bacterial, fungal and parasitic infections or
palliative/suppressive in the case of viral STIs. For more specific discussion
about particular issues, see Syndromic Management of Sexually Transmitted Infections chapter or infection-specific chapters.
In some provinces and territories, free treatment is
available for index cases and their contacts for bacterial STIs.
Patients, whether symptomatic or not,
should be told not to share their medications with partners and to complete the
full course of their prescribed medication, even if their signs and symptoms
resolve before they finish their medication. Patients should also be advised
that if vomiting occurs more than 1 hour post-administration, a repeat dose is
diagnosed with a bacterial STI or trichomonal infection should be advised that
they and their partners should abstain from unprotected intercourse until 7
days after treatment of both partners is complete (e.g., 7 days after
9. Reporting to Public Health and Partner Notification
STI reporting requirements and confidentiality
should be advised of the provincial/territorial public health acts and the Child
Protection Act, which supersede physician/patient confidentiality and
require release of personal information without patient consent for all
reportable STIs and in cases where child abuse is suspected.
in agencies receiving personal information are bound by ethical, legal and
professional obligations to protect the confidentiality of this information.
Patients need to be informed that the information will be reported to
authorities only as required by law as noted above but will otherwise remain
confidential. This is often a crucial concern for young people who come forward
for STI care.
applies to all persons, including infected persons, sexual/needle-sharing
partners, all youth who are competent to understand their infection and care,
and people who may be involved in cases of child sexual abuse.
notification is a secondary prevention process through which sexual partners
and other contacts exposed to an STI are identified, located, assessed,
counselled, screened and treated. Partner notification not only produces a
public health benefit (e.g., disease surveillance and control) but dramatically
reduces the risk of re-infection for the original patient.
notification is sometimes construed as an exercise in societal vs. individual
rights, its aim is clearly to assist people in honouring the individual rights
of their partners to know they have been put at risk and to make informed
decisions regarding their health and in some instances their life.
A review of the
evidence supports several recommendations related to the partner-notification
process. There is good evidence to show that partner notification
can be an effective means of finding at-risk and infected persons and that
health care provider referral generally ensures that more partners are notified
and medically evaluated.,
Who performs partner notification?
notification may be done by the patient, health care providers or public health
authorities. Often, more than one strategy may be used to notify different
partners of the same infected person.
- Self- or patient referral: the infected person
accepts full responsibility for informing partners of the possibility of
exposure to an STI and for referring them to appropriate services.
- Health care provider/public health referral:
with the consent of the infected person, the health care provider takes
responsibility for confidentially notifying partners of the possibility of
their exposure to an STI (without ever naming the index case).
- Contract referral: the health care provider
negotiates a time frame with the infected person (usually 24–48 hours) to
inform his or her partners of their exposure and to refer them to appropriate
circumstances (i.e., apparently monogamous relationships) the partner may
deduce who the index case is by the process of elimination. The health care
provider is still required to maintain confidentiality related to the index
case, and no information related to the index case can be released to the
If the index
case does not wish to notify partners, or if partners have not come forward:
- Explore impediments/barriers to partner
notification (see below).
- If needed, report to public health authorities.
Barriers to partner notification
or feared physical or emotional abuse that may result from partner notification
(e.g., conjugal violence): health care provider/public health referral may be
the best option in these cases so as to protect the index case. If there is a
threat to patient safety, public health officials should be notified of this so
that proper safety precautions are taken to protect the index case. Safety
always trumps the notification process.
of losing a partner due to a STI diagnosis (blame/guilt): discuss the
asymptomatic nature of STIs and the benefits of asymptomatic partner(s) knowing
that they may be infected.
legal procedures: cases need to be advised that their identity is protected at
all times, and unless their records are subpoenaed, no information can be
of re-victimization on the part of sex crime victims: health care provider/public
health referral may be the best option for notification of partners in these
partnering is a significant barrier to partner notification: wherever possible,
encourage patient referral.
Actual or suspected child sexual
abuse must be reported to your local child protection agency. The Child
Protection Act supersedes all other acts and requires health
professionals to release the names of any named contacts of a minor to the
Children’s Aid Society for further investigation.
All persons named as suspects in
child sexual abuse cases should be located and clinically evaluated;
prophylactic treatment may or may not be offered and the decision to treat or
not should be based on history, clinical findings and test results (See Sexual abuse in Peripubertal and Prepubertal Children chapter).
Novel partner-notification practices
trends in STI rates and transmission, research is being conducted to look at
the feasibility of alternative methods of partner notification. One such method
is the use of expedited patient-initiated treatment of sex partners. The index
case is given medication, together with safety information and
contraindications, to give to partners for presumptive treatment without
assessment to reduce gonorrhea or chlamydia reinfections and to increase the
proportion of partners treated. Although still controversial, this method may
be beneficial in high-risk and hard-to-reach populations.,
Practice points to maximize partner notification
- Request a notification form for STIs from the
local public health unit or call the communicable disease reporting line for
- Develop a notification plan, including which
partners will be notified by whom.
- Refer to Table 5 for recommendations on partners
to notify and the recommended trace back period for reportable and
Table 5. Partner notification reference chart
|| Trace-back period
|| Who to
- children of maternal case
- hepatitis B immunoglobulin
- household contacts
- lymphogranuloma venereum
- mucopurulent cervicitis
- newborns of infected mothers
- non-gonococcal urethritis
- needle-sharing partners
- post-exposure prophylaxsis
- pelvic inflammatory disease
- sexual partners
- Footnote *
- Trace-back period refers to the time period prior to symptom onset or date of specimen collection (if asymptomatic).
- The length of time for
the trace-back period should be extended:
- to include additional time up to the
date of treatment
- if the index case states that there were
no partners during the recommended trace-back period, then the last partner
should be notified
- if all partners traced (according to
recommended trace-back period) test negative, then the partner prior to the
trace-back period should be notified.
| Chlamydia (LGV and non LGV serovars)
|| 60 days
- If no sexual
partner(s) in the last 60 days, trace back to last sexual partner
- Partner notification
is not required in most provinces and territories as a public health measure
but is highly recommended for NGU, MPC, PID and epididymitis
|| 60 days
|| 14 days
| Non-gonococcal urethritis
|| 60 days
| Mucopurulent cervicitis
|| 60 days
| Pelvic inflammatory disease
|| 60 days
|| 60 days
| Primary syphilis
|| 3 months
| Secondary syphilis
|| 6 months
| Early latent syphilis
|| 1 year
| Late latent syphilis/stage undetermined
| Genital herpes
|| In some jurisdictions
- Partner notification is not required as a public
health measure but is highly recommended
|| In some jurisdictions
- No need to test
partners; treat as for index case
| Human papilloma virus
notification is not required as a public health measure. Patients should be
encouraged to notify their sexual partners, but there is no proof that this
will lower the risk to the partner
| Acute hepatitis B
unvaccinated/non-immune contacts should be notified. May benefit from PEP
- Newborns must receive
HBIG and vaccine post-natally
- All unvaccinated/non-immune contacts should be notified. May benefit from PEP
- Newborns must
receive HBIG and vaccine post-natally
- Start with recent
sexual and needle-sharing partners; outer limit is onset of risk behaviour or
to last known negative test
prophylaxis may be considered by health care providers for individuals who
have been in contact with HIV and appropriately timed initiation of
antiretroviral therapy is associated with a better prognosis and is a
prerequisite to prevention of further transmission of disease. Please consult
with an expert in HIV
10. Managing Co-morbidity and Associated Risks
Many STIs are
transmitted in the context of other medical and social challenges. Recurrent
exposure and infection are likely unless underlying issues are dealt with.
Specific management for conditions such as drug addiction and mental health
conditions should be integrated into the overall multidisciplinary health care
counselling and testing for STIs, it is important to include HIV pre-test
counselling and offer testing. Being infected with an STI (including syphilis,
genital herpes, chlamydia, gonorrhea and trichomonas) increases the risk of
transmission and acquisition of HIV. HIV-infected individuals may be less
responsive to STI treatment and require special monitoring post-treatment to
ensure treatment effectiveness and to prevent long-term complications arising
from inadequately treated STIs.
diagnosed with chronic viral hepatitis — either HBV or hepatitis C virus (HCV)
— co-infection with HIV impacts on the choice of treatment, the response to
treatment and natural evolution of the disease. These patients should be
referred to a specialist for treatment and management recommendations. Testing
for viral hepatitis B and HIV in any patient with chronic hepatitis C is
required to ensure proper management of the infection. In addition, for those
infected with HCV, ensuring vaccination against HAV and HBV is essential to
prevent co-infection, which can further assault the liver, complicate treatment
options and compromise response to treatment and patient prognosis.
lymphogranuloma venereum (LGV) is suspected and linked to a current outbreak in
Canada, it is also important to test for HCV, because there is a high rate of
11. Following up
Ideally, follow-up should be conducted by
the same health care provider to ensure resolution of symptoms, follow-up
testing as indicated and follow-through on partner notification to reduce the
likelihood of reinfection. Where this is not possible, patients should be
directed to the appropriate community resources, counselled on when to get
follow-up (especially if tests were done) and advised of indicators of treatment
failure. (See infection-specific chapters for follow-up recommendations.)
For individuals identified at ongoing risk
for STIs, recommend screening for gonorrhea, chlamydia, syphilis and HIV at
3-month intervals and reinforce safer sexual practices.
Appendix C contains a list of current sexual health/STI/safer sex resources to
assist in counselling and assessing patient risk. Appendix D contains a
list of provincial and territorial STI directors and resource people.
[Table of Contents]