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Chapter 11: Controlling STDs: Roles Of The Health Department, The Patient, And The Provider
Sexually transmitted diseases (STDs) are among the most frequent infections seen by many family physicians, general practitioners, gynecologists, urologists, and general internists. Despite their frequency, few health care providers receive formal training in the management of STDs. Lack of familiarity with these diseases, plus their sensitive and personal nature, frequently inhibit communication between health care providers and patients. Conversely, fear and poor under- standing of STDs on the part of patients mean there is an important need for counseling and patient education regarding these diseases.
Since it may not be easy for many patients, especially adolescents or sexually inexperienced adults, to be candid about sexual behavior, the discussion requires sensitivity. Obtaining an accurate and comprehensive sexual history also requires self-awareness on the clinician's part in order to deal with his or her own possible discomfort.
Perhaps the most important aspect of STD control (beyond diagnostic and therapeutic skill) is communication between provider and patient. The health care provider must obtain sensitive information in an accurate manner, while the patient ideally provides this information, adheres to treatment instructions and post treatment follow-up, informs sexual contacts as needed, and if indicated initiates a change in his or her behavior to optimize sexual health. Without communication skills on the part of the clinician and willingness to cooperate on the part of the patient, successful STD control cannot be effected.
It is important to present clear and nonjudgmental messages to the patient regarding the diagnosis, its implications, and treatment. This should be provided in a language that the patient will comprehend. Sexual experience does not imply sexual knowledge. Several studies have shown that physicians tend to overestimate patient compliance and knowledge about STDs, and that physicians cannot reliably predict whether or not a patient will comply with management recommendations (Tables 11-1 and 11-2).
More specifically, patients should be clearly counseled about:
- Medication, if any, they are to take.
- The need to take all medication and not share it with partners, even if symptoms resolve.
- What to do if they experience side effects or miss a dose.
- What they should expect from the medication in relief of symptoms, possible side effects, and incompatible substances or behavior (e.g., tetracycline with antacids or meals; metronidazole with alcohol).
Factors that may promote non adherence include not fully understanding the directions, the complexity and duration of the regimen (i.e., frequent doses or multiple doses), and occurrence of possible side effects. Repetition of instructions, asking patients to repeat instructions, and providing directions in a language (including in the native language of the patient) that is easily understood should improve adherence.
Patients should also understand the importance of a follow-up appointment and test-of-cure, if appropriate; when and where these tests will be done; and the potential consequences of not obtaining them. Having the patient make this appointment before leaving the office, giving them a reminder card, and perhaps providing a reminder call, all may increase the likelihood of compliance. Table 11-3, by way of example, shows what information a physician should minimally provide to a patient with NGU.
Finally, practitioners are encouraged to discuss additional STD testing, including HIV, as part of standard clinical practice, among patients that present with an STD. Female patients that present with an acute STD would benefit from pregnancy testing and contraceptive counseling as well.
DISEASE REPORTING AND THE ROLE OF THE HEALTH DEPARTMENT
Once a reportable sexually transmittable disease is diagnosed, make certain that this information is reported to the responsible local agency. In some states, the physician is responsible for reporting these diseases to the health department; in others both the laboratory and the physician are responsible. The physician should inform the patient that disease reporting is required, and that the patient may be contacted by a representative of the health department. It should be emphasized to the patient that this information is confidential. It is helpful if the physician explains the reason for this reporting to the patient.
The health department uses the information to trace sources of infection, ensure treatment of partners, document neighborhoods in need of specific services, and record the types of infections that exist in the community in order to improve diagnosis, treatment, and prevention. Physicians should be aware of and take advantage of the variety of services offered by local health departments. These include provision of contact tracing services and counseling for patients with STDs; telephone consultations for physicians with questions about patient management; provision of educational materials for patients; and often, depending on locale, selected laboratory testing.
|Common Erroneous Assumptions Of Patients|
|Common Erroneous Assumptions Of Physicians|
|Example Of Disease Specific Patient Education|
|Chlamydia (C. trachomatis)||1. Patient education regarding disease and its manifestations||1. Caused by Chlamydia trachomatis, a sexually transmitted bacteria; manifestations resemble gonorrhea; may spread to epididymitis (scrotal pain, swelling).|
|2. Medication advice: how and when to take pills, possible side effects, incompatibilities||2. Treat with doxycycline (1 pill, 2 times daily; take 1 hour before or 2 hours after food; take with fluids to avoid pill sticking in your throat; avoid iron, milk products, yogurt; take all the medicine; if rash, nausea, vomiting or diarrhea develop, call) OR one azithromycin (1 pill or liquid which I will give you now)|
|3. Importance of contact tracing||3. Women are usually asymptomatic yet risk developing PID and infertility; need for empiric treatment of partners.|
|4. How to prevent reinfection||4. Must avoid sex during Rx (or for one week after single-dose azithromycin) and until partner(s) treated.|
|5. Importance of follow-up||5. Call for test results and return for reevaluation if symptoms persist or recur.|
PARTNER IDENTIFICATION AND TREATMENT
Identification and treatment of all possibly infected sexual partners of the infected patient are of paramount importance in preventing reinfection and promoting disease control. Ideally, partners should be examined promptly (usually within 24 to 48 hours of the index patient's visit) in order to minimize reinfections from untreated partners and possible progression of disease in these partners. However, the most important intervention is to provide appropriate antibiotic therapy to recent sex partners, whether or not they can be examined. An approach called expedited partner therapy (EPT), discussed below, allows for this, and has been successful in reducing the rates of repeat infections in the patient with the original STD detected. Of particular importance are new sexual contacts (possible index cases). Physicians should bear in mind that for some STD, especially syphilis, some local health departments can provide the services of experienced disease intervention specialists (DIS) who have been specifically trained to carry out this service in a tactful and confidential manner.
The disease intervention specialist (DIS) will contact the index patient and counsel him or her regarding the 5 messages of STD control:
- disease manifestations,
- risk reduction,
- partner referral, and
- test-of-cure, when appropriate.
For cases in which the health department is not involved in interviewing the patients, three basic options for referral of sexual partners have been most successfully used–clinician referral and self-referral.
With clinician referral, the clinician elicits the names of the sexual partners and takes the responsibility for seeking them out for treatment by referring these names to the local health department for investigation, monitoring, and control. This method requires some additional paperwork on the part of the referring physician but maintains the anonymity of the patient and increases the likelihood of epidemiologically treating all eligible sexual partners.
Appropriate information on them (the specific disease, incubation period, possibility of asymptomatic infection, where and when the partner(s) can obtain medical evaluation, and potential complications of the disease) can be given to the patient to give to his or her partner(s). Some patients may need assistance in deciding how to present information to partners in a manner which will increase acceptance of the information and elicit the desired outcome. Role-playing and modeling conversations may be helpful here. Monitoring the partner's subsequent evaluation and compliance is difficult, especially since they often seek care elsewhere. However, most patients, given the motivation and assistance of a communicative health care provider, will inform their partners.
Expedited Partner Therapy (EPT)
Patients with gonorrhea or chlamydia whose partners are unlikely to seek treatment may be offered EPT, which is increasingly allowed in many states (check www.cdc.gov/std/ept to determine if PDPT is allowed in a particular area). One form of EPT is patient-delivered partner therapy (PDPT), in which the provider gives the patient either medication or a prescription to fill. Another approach is for the provider to call a prescription in directly for the partner's treatment. PDPT has not been evaluated in MSM populations or with STDs other than gonorrhea and chlamydia.
Patients require education about three major aspects of their disease:
- First, the possible causative agent(s) and what tests will be done to identify them requires explanation, including mechanisms of transmission and the consequences of inadequate therapy.
- Second, patients need an explanation of the medication they will take, including dose, duration, possible side effects, and expected effects of the drug on the infection. The importance of adherence and not splitting their medication (versus EPT among heterosexual partners) with their sexual partner needs to be stressed.
- Third, prevention of future infection by behavior modification and education about safer sex practices (male and female condoms) should be provided.
In addition to counseling patients about their specific STD, it is helpful to counsel them that asymptomatic herpes and genital wart infections are very common, to help reinforce their motivation to consistently use condoms.
Physicians who frequently see patients with STDs should consider providing patients with brief written pamphlets describing their disease and its management. Such pamphlets are available from local health departments or organizations such as the American Social Health Association (ASHA) (website: www.ashastd.org or call 1-800-783-9877). Alternatively, the patient can be given the telephone number for the national STD hotline (1-800-227-8922) or The National AIDS hotline (1- 800-HIV-0440), toll free numbers through which patients can obtain accurate and personal answers to their questions. Other useful patient resources are the herpes counseling and support organizations, such as HELP groups available in many cities.
The final message with which the patient should leave the office is that he or she has the ability to reduce the risk of reinfection and subsequent STDs. Taking medication as directed, returning for a follow-up if symptoms persist or other questions arise, and assuring the treatment of sexual partners all promote cure. Patients should also be taught to recognize signs and symptoms of STDs in themselves and in their partners. It should be stressed that STDs in both men and women are frequently asymptomatic. The use of male and female condoms provides at least partial protection against most STDs and should be recommended.