Sexually Transmitted and Blood Borne Infections (STBBI) prevention guide

This guide includes an overview of practices for the prevention and management of sexually transmitted and blood-borne infections (STBBI) by healthcare professionals practicing in public health or primary care settings.

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STBBIs are a significant public health concern in Canada. They can have sexual, reproductive and maternal-child health consequences, including genital and extragenital symptoms, pregnancy complications, cancer, infertility and psychosocial consequences. Certain STBBIs can also enhance the transmission of human immunodeficiency virus (HIV). With treatment, most STBBIs are curable or manageable.

In Canada, since 1997, the rates of chlamydia and gonorrhea have increased steadily and since 2001, the rates of syphilis have also increasedFootnote 1Footnote 2Footnote 3. Between 2014 and 2018, rates of chlamydia increased by 18%Footnote 4, gonorrhea by 110%Footnote 4 and infectious syphilis by 151%Footnote 5. In 2019, the number of congenital syphilis cases was the highest ever reported in CanadaFootnote 6.

In 2018, the Public Health Agency of Canada (PHAC) released the Pan-Canadian Sexually Transmitted and Blood-borne Infections Framework for Action which established strategic goals and guiding principles to address STBBIs in Canada and achieve global STBBI targets by 2030Footnote 7. The contribution of primary care and public health professionals will be essential to meet the following goalsFootnote 8:

Refer to etiology-specific guides for recommendations on screening, diagnostic testing, treatment and management of specific pathogens.

The STI-associated Syndromes guide outlines the management of an individual based on signs and symptoms, prior to laboratory confirmation of the pathogen for the following syndromes associated with STIs: anogenital ulcers, cervicitis, epididymitis, pelvic inflammatory disease (PID), proctitis, urethritis, and vaginitis.

Individuals who require advanced diagnostics or hospitalization should be cared for in consultation with an experienced colleague or referred to a specialist.

Primary and secondary STBBI prevention

Primary and secondary STBBI prevention measures at the individual-level have population-level benefits and are key to reducing the incidence (newly acquired infections) and prevalence (current infections) of STBBIsFootnote 9. Primary prevention aims to prevent infection by providing person-centred counselling and education about how to reduce risk. Secondary prevention aims to minimize the impact and spread of infection through early detection, treatment, counselling and partner notification. Primary care and public health professionals play a pivotal role in the prevention and control of STBBIs.

Sexual health and STBBI prevention are an integral part of everyone’s health care. All individuals can benefit from preventive clinical interventions, including those who are not yet or not currently sexually active. Healthcare professionals can incorporate primary and secondary STBBI prevention in the course of routine care by:

A person-centred approachFootnote 7

Taking into account a person’s circumstances, experiences, needs, goals and values helps to ensure that they are treated with respect and dignity. A person-centred approach is particularly important when addressing STBBI prevention, screening, testing and treatment. This is because of the stigma often attached to sexuality, STBBI, substance use and the potentially emotional or sensitive nature of these topics.

Furthermore, a syndemics approach can help with understanding how health is affected by social, economic, environmental and political conditions and settings. It illustrates how co-existing social and health conditions can negatively reinforce each other and thereby increase vulnerability and worsen health outcomesFootnote 10.

STBBI risk factors

To discuss STBBIs and assess the person’s healthcare needs, healthcare professionals should understand the risk factors associated with STBBI transmission and acquisition, as well as current epidemiologic trends. They should also be prepared to offer basic information and counselling on common STBBIs.

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

STBBIs do not affect all people in the same way. People facing social and medical challenges may be more vulnerable to some STBBIs. Syndemics are linked to health equity and the social determinants of health (SDoH). SDoH can influence health practices and the examination of the SDoH can lead to more holistic and coordinated approaches to STBBI prevention and care. It is also important to acknowledge the uniqueness, strength and resilience of people regardless of potentially challenging circumstances.

The SDoH that can impact vulnerability and resilience to STBBIs includeFootnote 20:

Epidemiological evidence has revealed that certain populations are disproportionately affected by STBBIs, such asFootnote 20:

Healthcare professionals should discuss sexual health and STBBIs with everyone as part of routine care rather than making assumptions about sexual activity or behaviours. For example, older adults, people with physical or intellectual disabilities, people in long-term relationships and youth may all benefit from discussions about sexual health and STBBI prevention.

It is also important to avoid making assumptions about sexual or substance use behaviours based on a person’s culture or population group. Being a member of a population disproportionately affected by STBBIs does not necessarily increase risk.

Additional resources

Barrier protection

External condoms (covering the penis), internal condoms (inserted in the vagina or anus) and dental dams (used during oral sex) create a protective barrier and prevent the exchange of bodily fluids between sexual partners. There are three types of condoms: latex, synthetic polymer and natural membrane (made from the intestinal lining of sheep).

Natural membrane condoms are permeable and do not protect against some STBBIs, including HIV.

Consistent and correct use of latex and synthetic polymer condoms and dental dams can decrease the risk of acquiring and transmitting the majority of STBBIs, including HIV, HBV, chlamydia and gonorrhea. They do not provide complete protection against syphilis, HPV or HSV because lesions and asymptomatic shedding can occur in areas not covered by these barrier methods.

Synthetic polymer condoms and dental dams can be used by persons who have a latex allergy.

Petroleum or oil-based lubricants should not be used with latex condoms. These substances weaken the latex and can lead to breakage. The risk of condom slippage varies with different sexual practices; lubricant can reduce the risk of slippage in some situations, while increasing the risk in othersFootnote 21Footnote 22. Some medications intended for vaginal use (e.g., estrogen, antifungal medications) can weaken latex condoms.

Spermicidal lubricated condoms containing nonoxynol-9 (N-9) are not recommended for STBBI prevention because N-9 can increase the potential for transmission of STBBIs by causing disruptions and lesions in the genital and anal mucosaFootnote 23.

Package labels should be consulted for information on safe usage of condoms and lubricant. User information on condoms and dental dams, as well as how to make a dental dam, can be found in the additional resources listed below.

Since many people do not use barrier protection consistently and correctly, it’s important that STBBI screening be included in routine care.

Vaccination

HAV, HBV and HPV are vaccine-preventable infections. Offer vaccination for HAV, HBV and HPV to people at risk of these infections as per the Canadian Immunization Guide. Refer to province or territory vaccination schedules for more information.

HAV

HAV is transmitted via the fecal-oral route, which can occur from direct person-to-person contact, from contaminated objects, or through contaminated food or water. Transmission through infected blood has also been reported. Some sexual practices and sharing of drug use equipment can put people at risk for HAVFootnote 24.

HBV

HBV is transmitted via percutaneous or mucosal contact with infectious biological fluids, including through sex, sharing of drug use equipment and from mothers with active or chronic HBV to their newborns. Saliva is considered infectious if it contains visible blood or in the case of bite wounds that break the skinFootnote 24.

HPV

HPV is the most common STBBI. In North America, approximately 70% of sexually active people will acquire sexually transmitted HPV at least once in their lifetimeFootnote 25Footnote 26. HPV vaccination is recommended routinely for men and women of certain ages and for those at increased risk of acquiring HPV, regardless of whether they have previously been exposed to HPV or been diagnosed with an HPV infection or HPV-related diseaseFootnote 24.

HPV vaccination prior to onset of sexual activity - and exposure to HPV - maximizes the benefit from vaccination. People who are already sexually active and those with HPV can still benefit from the vaccine because it will protect them against genotypes to which they have not been exposed. Providing information on HPV and HPV vaccination to those who have not been vaccinated may increase vaccine uptakeFootnote 27Footnote 28Footnote 29Footnote 30Footnote 31.

Vaccination is effective at preventing acquisition of the HPV genotypes responsible for most anogenital warts (AGWs) and HPV-related cancers, but does not protect against all HPV genotypes. In addition, it has no effect on existing HPV infection or AGWs. Thus, healthcare providers should recommend the continued use of preventive measures and cancer screening (e.g. Pap test) following vaccination.

References

Footnote 1

Choudhri Y, Miller J, Sandhu J, Leon A, Aho J. Chlamydia in canada, 2010-2015. Can Commun Dis Rep. 2018;44(2):49-54.

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Footnote 2

Choudhri Y, Miller J, Sandhu J, Leon A, Aho J. Gonorrhea in canada, 2010-2015. Can Commun Dis Rep. 2018;44(2):37-42.

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Footnote 3

Choudhri Y, Miller J, Sandhu J, Leon A, Aho J. Infectious and congenital syphilis in canada, 2010-2015. Can Commun Dis Rep. 2018;44(2):43-48.

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Footnote 4

Public Health Agency of Canada. Notifiable diseases online. Notifiable diseases on-line Web site. https://diseases.canada.ca/notifiable/charts?c=pl. Updated 2020. Accessed 10/2020, 2020.

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Footnote 5

Public Health Agency of Canada. Infectious syphilis in canada, 2018. CCDR. 2018;45(11).

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Footnote 6

Public Health Agency of Canada. Syphilis in women and congenital syphilis in canada, 2019. CCDR. 2020;46(10).

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Footnote 7

Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada. A summary of the pan-canadian framework on sexually-transmitted and blood-borne infections. Can Commun Dis Rep. 2018;44(7/8):179-81.

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Footnote 8

Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada. Report on sexually transmitted infections in canada, 2017. 2019;1923-2977:1-67.

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Footnote 9

World Health Organization. Preventing and treating sexually transmitted and reproductive tract infections. www.who.int/hiv/topics/sti/prev/en/print.html. Updated 2006. Accessed 1/17, 2006.

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Footnote 10

Hart L, Horton R. Syndemics: Committing to a healthier future. Lancet. 2017;389(10072):888-889. doi: S0140-6736(17)30599-8 [pii].

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Footnote 11

Sonnenberg P, Clifton S, Beddows S, et al. Prevalence, risk factors, and uptake of interventions for sexually transmitted infections in britain: Findings from the national surveys of sexual attitudes and lifestyles (natsal). The Lancet. 2013;382(9907):1795-1806.

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Footnote 12

Matteelli A, Carosi G. Sexually transmitted diseases in travelers. Clinical Infectious Diseases. 2001:1063-1067.

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Footnote 13

MacDonald NE, Wells GA, Fisher WA, et al. High-risk STD/HIV behavior among college students. JAMA. 1990;263(23):3155-3159.

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Footnote 14

Bajaj S, Ramayanam S, Enebeli S, et al. Risk factors for sexually transmitted diseases in canada and provincial variations. Social Medicine. 2017;11(2):62-69.

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Footnote 15

Jena AB, Goldman DP, Kamdar A, Lakdawalla DN, Lu Y. Sexually transmitted diseases among users of erectile dysfunction drugs: Analysis of claims data. Ann Intern Med. 2010;153(1):1-7.

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Footnote 16

Champion JD, Piper JM, Holden AE, Shain RN, Perdue S, Korte JE. Relationship of abuse and pelvic inflammatory disease risk behavior in minority adolescents. J Am Acad Nurse Pract. 2005;17(6):234-241.

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Footnote 17

Haghir E, Madampage C, Mahmood R, Moraros J. Risk factors associated with self-reported sexually transmitted infections among postsecondary students in canada. Int J Prev Med. 2018;9(49).

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Footnote 18

O'Byrne P, Holmes D. Drug use as boundary play: A qualitative exploration of gay circuit parties. Subst Use Misuse. 2011;46(12):1510-1522.

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Footnote 19

Guadamuz TE, Friedman MS, Marshal MP, et al. Health, sexual health, and syndemics: Toward a better approach to STI and HIV preventive interventions for men who have sex with men (MSM) in the united states. In: The new public health and STD/HIV prevention.Springer; 2013:251-272.

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Footnote 20

Public Health Agency of Canada. A pan-canadian framework for action. https://www.canada.ca/en/public-health/services/infectious-diseases/sexual-health-sexually-transmitted-infections/reports-publications/sexually-transmitted-blood-borne-infections-action-framework.html. Updated 2018.

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Footnote 21

Canadian Aboriginal AIDS Network. Pre and post HIV counselling guide: Aboriginal community and healthcare professionals. Updated 2012. Accessed Sept/04, 2020.

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Footnote 22

Smith A, Jolley D, Hocking J. Does additional lubrication affect condom slippage and breakage?. 1998.

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Footnote 23

Public Health Agency of Canada. Nonoxynol-9 and the risk of HIV transmission. HIV/AIDS Epi Update. 2003;April.:Accessed December 19, 2005.

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Footnote 24

Public Health Agency of Canada. Canadian immunization guide. https://www.canada.ca/en/public-health/services/canadian-immunization-guide.html. Updated 2018.

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Footnote 25

Brianti P, De Flammineis E, Mercuri SR. Review of HPV-related diseases and cancers. New Microbiol. 2017;40(2):80-85. doi: 496M898 [pii].

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Footnote 26

Public Health Agency of Canada. Human papillomavirus vaccine: Canadian immunization guide - for health professionals - https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-4-active-vaccines.html Web site. Updated 2017. Accessed 08/13, 2020 Aug 13.

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Footnote 27

Krawczyk AL, Perez S, Lau E, et al. Human papillomavirus vaccination intentions and uptake in college women. Health Psychology. 2012;31(5):685.

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Footnote 28

Public Health Agency of Canada. Government of canada. canadian immunization guide: Part 3: Vaccination of specific populations. https://www.canada.ca/en/public-health/services/canadian-immunization-guide.html?=undefined&wbdisable=true. Updated 20202020.

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Footnote 29

Gilkey MB, Malo TL, Shah PD, Hall ME, Brewer NT. Quality of physician communication about human papillomavirus vaccine: Findings from a national survey. Cancer Epidemiology and Prevention Biomarkers. 2015;24(11):1673-1679.

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Footnote 30

Gerend MA, Shepherd MA, Lustria ML, Shepherd JE. Predictors of provider recommendation for HPV vaccine among young adult men and women: Findings from a cross-sectional survey. Sex Transm Infect. 2016;92(2):104-107. doi: 10.1136/sextrans-2015-052088 [doi].

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Footnote 31

Rosenthal S, Weiss TW, Zimet GD, Ma L, Good M, Vichnin M. Predictors of HPV vaccine uptake among women aged 19–26: Importance of a physician's recommendation. Vaccine. 2011;29(5):890-895.

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