Prevention
Prevention Counseling
Providers can engage patients in person-centered counseling to help them identify personal risk factors and strategies they can use to reduce their risk. Providers should tailor their counseling approach to each patient’s individual risk factors while also aligning it with their specific needs and desires. Prevention counseling can include information about common STIs and their transmission and training in skills to reduce risk—including training in condom use and communication about safer sex. Providers should offer information about the risk of STI transmission associated with different sexual activities so the individual has the information they need to reduce their individual risk and communicate about safer sex with their partner(s).
Providers should strive to use patient-centered language that is specific and accessible rather than vague or jargony. For example:
| Instead of. . . | Use. . . |
|---|---|
| “Always use condoms” | “What could you do that would make condoms more accessible to you (for example, putting condoms on the nightstand beside the bed)?” “Tell me about the last time you used a condom. What has worked for you in the past?” |
| “Have fewer, safer partners” | “What have you been doing to protect yourself?” “What conversations have you had with your partner(s) about protecting yourselves from STIs?” |
| “Have safer sex” | "What questions might come up for you when considering whether to have sex with someone who is also having sex with other people?"47 |
Wherever possible, condoms (external and internal) should be provided to all patients free of charge at clinical sites to increase access to condoms in the community.
Pre-Exposure Vaccination
Pre-exposure vaccination is the most effective method of preventing certain diseases caused by viruses that can be transmitted sexually— including hepatitis A virus (HAV), hepatitis B virus (HBV), human papillomavirus (HPV), and Mpox. Providers can discuss vaccination with all patients, give clear recommendations, and either provide vaccination or referral for vaccination in accordance with recommendations from the CDC118 and medical professional organizations. Section 10, Screening and Other Preventive Health Care Services, provides an overview of vaccination recommendations based on age and risk factors.
Pre-Exposure Prophylaxis for HIV
Pre-exposure prophylaxis (PrEP) is recommended for HIV prevention in adults who have had anal or vaginal sex in the last six months and have any of the following risk factors: an HIV-positive sexual partner; a bacterial STI in the past six months; history of inconsistent or no condom use with sexual partner(s); and (for persons who inject drugs) an HIV-positive injecting partner or sharing injection equipment. However, providers should not limit discussion of PrEP to only those deemed at risk of acquiring HIV; rather, information about PrEP can be provided to all sexually active individuals, including those without known risk factors.115, 116 When discussing STIs and strategies to prevent STIs, providers can ask, “Are you aware of PrEP, there are medications that can prevent HIV? Have you ever used it or considered using it?” Providers should attempt to assess each patient’s risk of acquiring HIV before initiating PrEP. However, because people may not feel comfortable reporting sexual or injection behaviors that put them at risk for HIV, PrEP should be offered to any person who requests it. Providers can refer to the CDC Clinical Practice Guideline on Preexposure Prophylaxis for the Prevention of HIV Infection in the United States for detailed guidance on providing PrEP services.117
Post-Exposure Prophylaxis for HIV and STIs
Non-occupational post-exposure prophylaxis (nPEP) consists of a combination of antiretroviral medications administered after a potential exposure to HIV. CDC provides detailed guidance for offering nPEP, including timing, recommended testing, and medication regimens.119 When considering nPEP, providers and patients can discuss whether the reported exposure presents a substantial risk of transmission (for example, having unprotected sex with, being sexually assaulted by, or sharing needles with someone who is known to be HIVpositive) or if the exposure was to someone with unknown HIV status. Sexually active patients who receive nPEP should be evaluated for PrEP after completing nPEP and testing negative for HIV.
Because of high rates of bacterial STI (syphilis, chlamydia, and gonorrhea) among cisgender men who have sex with men (MSM) and transgender women (TGW), CDC recommends all MSM and TGW who have been diagnosed in the past 12 months with a bacterial STI receive counseling about doxycycline postexposure prophylaxis (doxy PEP).120 Doxy PEP involves taking doxycycline within 72 hours after having oral, vaginal, or anal sex. CDC recommendations offer detailed information about research, prescribing, and shared decisionmaking considerations. Although the pharmacokinetics of doxycycline and experience in treating bacterial STIs suggest that doxy PEP should be effective in other populations, clinical data to support doxy PEP in other populations (for example, cisgender women, cisgender heterosexual men, transgender men, and other queer and nonbinary persons assigned female at birth) are limited. As a result, providers can use clinical judgment and shared decision making to inform use of doxy PEP among those not currently included in CDC recommendations.120, 121, 122