Sexual Health Detection Time Education and Sexual Health Protocol (SHP) Algorithm Tool for Provider Use in the Retail Health Clinic

1. SEXUALHEALTH DETECTION TIME
EDUCATIONAND SEXUALHEALTH
PROTOCOL(SHP)ALGORITHM TOOLFOR
PROVIDER USE IN THE RETAILHEALTH
CLINIC
Presented by:
Ariane Wood MSN, CRNP-BC, FNP-BC
Touro University Nevada

2. Background:
Nearly 20 million new STIs a year in the U.S.
Globally, 357 million new STIs in 2012.
This accounts for almost 16 billion in health care costs.
Sources: Centers for Disease Control and Prevention (2015). Sexually Transmitted Disease Surveillance. Atlanta: U.S. Department of Health
and Human Services. https://www.cdc.gov/std/stats
World Health Organization (2016). Sexually transmitted infection (STIs). Fact sheet. http://www.who.int/mediacentre/factsheets/fs110/en/

3. Importance of Obtaining Sexual Health
History During Medical Visits:
 Less than 40% of medical providers conduct sexual
histories with patients.
Source: Lanier, Y., Castellanos, T., Barrow, R. Y., Jordan, W. C., Caine, V., & Sutton, M. Y. (2014). Brief Sexual Histories and Routine
HIV/STD Testing by Medical Providers. AIDS Patient Care and STDs, 28(3), 113–120. http://doi.org/10.1089/apc.2013.0328

4. Current National Guidelines:
 The USPSTF and the CDC recommend routine sexual
health discussions between patients and medical providers.
 This is a proactive method for increasing routine HIV and
STI testing during medical visits.
Sources: Centers for Disease Control and Prevention Sexually Transmitted Disease Surveillance (2011). Atlanta: U.S. Department of Health
and Human Services. http://www.cdc.gov/std/sta uts11/Surv2011.pdf
U.S. Preventive Services Task Force (2017). USPSTF A and B Recommendations.
https://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/

5. Sexual Health Discussions:
 Use a non-judgmental manner
 Educate patients on preventative screenings
 Allow for multiple sexual health issues and referrals to be
addressed at the same time during a patient’s visit
 Leads to a more comprehensive package of services
Source: Ford, J. V., Barnes, R., Rompalo, A., & Hook, E. W. (2013). Sexual Health Training and Education in the U.S. Public Health Reports,
128(Suppl 1), 96–101.

6. Retail Clinics:
 Can be utilized as a venue to help screen and prevent
against STIs
 Easily accessible informative visits about sexual health can
help educate patients
 Can help in recommending STI screenings

7. Significance:
Research shows that STI treatment and counseling promotes safer
sexual behaviors in those who test positive for an STI in addition
to curing disease. This allows for a “teachable moment” where
counseling can be directed towards sexual risk behaviors.
Source: Sznitman, S., Stanton, B. F., Vanable, P. A., Carey, M. P., Valois, R. F., Brown, L. K., Romer, D. (2011). Long-Term Effects of Community-based
STI Screening and Mass Media HIV Prevention Messages on Sexual Risk Behaviors of African American Adolescents. AIDS and Behavior, 15(8), 1755–
1763. http://doi.org/10.1007/s10461-011-9946-6

8. STI Complications:
 Silent infections that are asymptomatic, such as chlamydia and
gonorrhea, may be left untreated if not medically screened
 Untreated infections can cause damage to the fallopian tubes or uterus
and also lead to pelvic inflammatory disease (PID)
 May cause infertility, chronic pelvic pain, and ectopic pregnancies
 STIs can linger for months to years untreated and undetected
 If a person is asymptomatic, this can lead to spreading of the
infections to others and possible irreversible damage to the
reproductive organs
 STI status is important to the population to help prevent the continued
passing of pathogens to other sexual partners
Source: Li, Z., Liu, H., & Tu, W. (2015). A sexually transmitted infection screening algorithm based on semiparametric regression
models. Statistics in Medicine, 34(20), 2844–2857. http://doi.org/10.1002/sim.6515
Skala, S. L., Secura, G. M., & Peipert, J. F. (2012). Factors associated with screening for sexually transmitted infections. American
Journal of Obstetrics and Gynecology, 206(4), 324.e1–324.e6. http://doi.org/10.1016/j.ajog.2012.02.020

9. Prevention and Control:
The prevention and control of STDs are based on the following five major
strategies:
 Accurate risk assessment, education, and counseling of persons at risk on ways to avoid
STIs through changes in sexual behaviors and use of recommended prevention services.
 Pre-exposure vaccination of persons at risk for vaccine-preventable STIs.
 Identification of STI detection times.
 Effective diagnosis, treatment, counseling, and follow-up of infected persons.
 Evaluation, treatment, and counseling of sex partners of persons who are infected with an
STI.
Source: Centers for Disease Control and Prevention (2015). Sexually Transmitted Disease Surveillance. Atlanta: U.S. Department of Health and Human
Services. https://www.cdc.gov/std/stats

10. How toApproach a Patient Regarding
Their Sexual Health History:
 Be respectful
 Be compassionate,
 Use a non-judgmental attitude
These elements are effective counseling skills that can be
carried out to deliver effective prevention counseling.

11. The “Five P’s” approach:
This approach to obtaining a sexual history is one strategy for
eliciting information concerning five key areas of interest.
The Five P’s are:
 Partners
 Practices
 Prevention of Pregnancy
 Protection from STIs
 Past History of STIs

12. The “Five P’s” approach:
Partners
“Do you have sex with men, women, or both?”
“In the past 2 months, how many partners have you had sex
with?”
“In the past 12 months, how many partners have you had sex
with?”
“Is it possible that any of your sex partners in the past 12 months
had sex with someone else while they were still in a sexual
relationship with you?”

13. The “Five P’s” approach continued:
Practices
“To understand your risks for STDs, I need to understand the kind of sex
you have had recently.”
“Have you had vaginal sex, meaning ‘penis in vagina sex’?” If yes, “Do you
use condoms: never, sometimes, or always?”
“Have you had anal sex, meaning ‘penis in rectum/anus sex’?” If yes, “Do
you use condoms: never, sometimes, or always?”
“Have you had oral sex, meaning ‘mouth on penis/vagina’?”
For condom answers:
If “never”: “Why don’t you use condoms?”
If “sometimes”: “In what situations (or with whom) do you use condoms?”

14. The “Five P’s” approach continued:
Prevention of pregnancy
“What are you doing to prevent pregnancy?”

15. The “Five P’s” approach continued:
Protection from STDs
“What do you do to protect yourself from STDs and
HIV?”

16. The “Five P’s” approach continued:
Past history of STDs
“Have you ever had an STD?”
“Have any of your partners had an STD?”

17. The “Five P’s” approach continued:
Additional questions to identify HIV and viral hepatitis
risk include:
“Have you or any of your partners ever injected drugs?”
“Have your or any of your partners exchanged money or
drugs for sex?”
“Is there anything else about your sexual practices that I
need to know about?”
Source: Centers for Disease Control and Prevention (2015). Sexually Transmitted Disease Surveillance. Atlanta: U.S. Department
of Health and Human Services. https://www.cdc.gov/std/stats

18. Counseling:
After obtaining a sexual history from their patients, all providers should encourage risk
reduction by providing prevention counseling. Prevention counseling is most effective
if:
 Provided in a nonjudgmental
 Provided in an empathetic manner
 Appropriate to the patient’s:
 Culture
 Language
 Gender
 Sexual orientation
 Age
 Developmental level
Source: Centers for Disease Control and Prevention (2015). Sexually Transmitted Disease Surveillance. Atlanta: U.S. Department
of Health and Human Services. https://www.cdc.gov/std/stats

19. Sexual Health Protocol (SHP)
The following is a Sexual Health algorithm flow chart for
providers to utilize that includes a simple guide for when to
initiate sexual health history and STI screenings of patients
during Genitourinary and contraceptive clinic visits at the
retail medical clinic.

20. SHP
I. Purpose: The purpose of the SHP algorithm use is to promote sexual health
assessments and STI screenings.
II. Scope: Nurse practitioners at the organization that are involved in direct
patient care.
III. Responsibility: This protocol applies to nurse practitioners responsible for
the assessment of patients presenting with a genitourinary or contraceptive
care visit.
IV: Procedure: The SHP algorithm flow chart should be utilized during
medical visits related to genitourinary and contraceptive care visits. This
should be initiated during the subjective assessment of the patient.

21. Sexual Health Protocol (SHP)
Patient visit related to
genitourinary or contraceptive
care visit.
No Yes
Have you been sexually active
with anyone in the past?
Yes
When was the last time you have
been screened for STIs? And
would you like to be screened
today while you are here?
No
Do you have any questions or
concerns about being sexually
active?

22. Case Study:
The patient presents to the clinic with complaint of recurrent
yeast infections over the last two years. According to the SHP,
what would be your next course of action?
 Ask the patient if she has been sexually active in the past.
 Refer the patient to the OBGYN for further management.
 Prescribe the patient diflucan.

23. Answer:
 Ask the patient if she has been sexually active in the past.
Any visit related to a genitourinary concern should initiate
the SHP algorithm flow chart which would begin by asking
if the patient has been sexually active with anyone in the
past.

24. Current STI Detection Time Guidelines at Retail Clinic:
 Pathogen: Chlamydia
Detection Time: Poorly defined: 8-21 days, or longer after exposure to the
bacteria.
 Pathogen: Gonorrhea
Detection Time: Symptoms possibly appearing as early as 1 day or as late as 2
weeks after sexual contact.
 Pathogen: Trichomoniasis
Detection Time: Not clearly defined though average=5 to 28 days after
exposure.

25. Current STI Detection Time Guidelines at Retail Clinic
Continued:
 Pathogen: Hepatitis B
Detection Time: 45-180 days, usually 60-90 days after exposure
 Pathogen: Hepatitis C
Detection Time: 6-7 weeks after exposure
 Pathogen: HIV
Detection Time: Average=2-6 weeks after exposure. May take up to 6 months
after exposure to the HIV virus before converting.

26. Current STI Detection Time Guidelines at Retail Clinic
Continued:
 Pathogen: Syphillis
Detection Time: 10-90 days (average, 21 days) after sexual contact.
 Pathogen: Genital Warts (HPV)
Detection Time: 2 week to 8 months, with majority of genital warts appearing
2-3 months after infection.

27. Case Study:
The patient reports rumors of students at his college contracting
chlamydia and is concerned because he had unprotected sex
about 3 weeks ago.
What is the detection time for chlamydia?

28. Answer:
Pathogen: Chlamydia
Detection Time: Poorly defined: 8-21 days, or longer after
exposure to the bacteria.

29. References
Centers for Disease Control and Prevention (2015). Sexually Transmitted Disease Surveillance. Atlanta: U.S. Department of Health and
Human Services. https://www.cdc.gov/std/stats
Centers for Disease Control and Prevention Sexually Transmitted Disease Surveillance (2011). Atlanta: U.S. Department of Health and
Human Services. http://www.cdc.gov/std/sta uts11/Surv2011.pdf
Ford, J. V., Barnes, R., Rompalo, A., & Hook, E. W. (2013). Sexual Health Training and Education in the U.S. Public Health Reports,
128(Suppl 1), 96–101.
Lanier, Y., Castellanos, T., Barrow, R. Y., Jordan, W. C., Caine, V., & Sutton, M. Y. (2014). Brief Sexual Histories and Routine HIV/STD
Testing by Medical Providers. AIDS Patient Care and STDs, 28(3), 113–120. http://doi.org/10.1089/apc.2013.0328
Li, Z., Liu, H., & Tu, W. (2015). A sexually transmitted infection screening algorithm based on semiparametric regression models. Statistics
in Medicine, 34(20), 2844–2857. http://doi.org/10.1002/sim.6515
Revere, D., Hills, R., Dixon, B., Gibson, P. J., & Grannis, S. (2017). Notifiable condition reporting practices: implications for public health
agency participation in a health information exchange. BMC Public Health. 2017; 17: 247. doi: 10.1186/s12889-017-4156-4
Skala, S. L., Secura, G. M., & Peipert, J. F. (2012). Factors associated with screening for sexually transmitted infections. American Journal of
Obstetrics and Gynecology, 206(4), 324.e1–324.e6. http://doi.org/10.1016/j.ajog.2012.02.020
Sznitman, S., Stanton, B. F., Vanable, P. A., Carey, M. P., Valois, R. F., Brown, L. K., Romer, D. (2011). Long-Term Effects of Community-
based STI Screening and Mass Media HIV Prevention Messages on Sexual Risk Behaviors of African American Adolescents. AIDS and
Behavior, 15(8), 1755–1763. http://doi.org/10.1007/s10461-011-9946-6
U.S. Preventive Services Task Force (2017). USPSTF A and B Recommendations.
https://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/
World Health Organization (2016). Sexually transmitted infection (STIs). Fact sheet. http://www.who.int/mediacentre/factsheets/fs110/en/