Chapter 22

Avoiding STIs

Family planning providers can help their clients in various ways to prevent STIs, including HIV.

Prevention measure Notes
HPV vaccine See Vaccine Available for Prevention
Hepatitis B vaccine Hepatitis B infection is prevented by vaccines, which are usually given to newborns and children. Adolescents and adults at increased risk of infection (see Who Is at Risk for STIs?) are also recommended for vaccination, including people living with HIV, household and sexual contacts of people with chronic hepatitis B virus infection, men who have sex with men, people with multiple sexual partners, persons in prisons, and persons who inject drugs.
Condoms The correct and consistent use of male or female condoms offers effective protection against STIs, including HIV. See Chapters 14 and 15.
Pre-Exposure Prophylaxis (PrEP) PrEP can be an effective tool to prevent HIV when taken as prescribed. See section on Preventing HIV Acquisition.
Post-Exposure Prophylaxis (PEP) PEP can be offered to prevent HIV infection after exposure, for emergency situations. It must be started within 72 hours after the possible exposure. See Preventing HIV Acquisition.
Lubricant The use of lubricants is recommended for anal sex, and it can also help vaginal lubrication when needed or wanted. Lubricants prevent micro tears in the anorectal and vaginal mucosa, which can create entry points for STIs. Water-based lubricants are recommended when used with condoms.
Male circumcision Male circumcision can reduce men’s risk of HIV infection by 50–60% when having vaginal sex with a female partner. Male circumcision can also reduce a female partner’s risk of acquiring STIs.
Preventing and treating STIs Diagnosing and treating STIs helps prevent the client from acquiring additional STIs; this is because sores or ulcers associated with existing STIs can make it easier for other STIs (including HIV) to infect the person. For example, herpes simplex virus 2 (HSV-2) infection (genital herpes) increases the risk of acquiring HIV 3-fold, syphilis 2-fold, and trichomoniasis 1.5-fold.

A family planning provider should inform clients about practices or behaviors that increase someone’s risk of getting a STI, including HIV (see Who Is At Risk for STIs?). Clients can then think about their own circumstances and practices to assess their risk of acquiring an STI. If a client seeks further advice or counseling, then depending on the needs of each client, providers should tailor their advice about effective strategies to reduce the risk of an STI, and should always do this in a private setting and with respect for confidentiality.

The decision to use particular prevention measure(s) should be an informed choice, made voluntarily by the client. Providers should not allow their personal views to influence clients’ prevention choices. It is important to remember that clients might choose to use different strategies in different situations and with different partners, as well as at different times in their lives. The best strategy is the one that a person can practice effectively.

Family planning providers can help with HIV prevention, and its early diagnosis and treatment, particularly among people at higher risk of infection and in countries where many people are living with HIV. See Chapter 23 – Family Planning for Adolescents and Women at High Risk for HIV.

Safer Conception for HIV Serodiscordant Couples

When a couple wants to have a child and one partner is living with HIV while the other is not (a serodiscordant couple), providers should: 

  • Make sure that the partner living with HIV is receiving consistent and correct antiretroviral therapy (ART) and is regularly tested to monitor viral load (or CD4 cell count, if viral load testing is not available). Successful ART with viral suppression prevents HIV transmission to sexual partners: there is no transmission when viral load is undetectable or suppressed (less than or equal to 1,000 copies/mL)
  • Offer PrEP to the HIV-negative partner if the other partner, who is living with HIV, still has detectable viral load. PrEP should be used until the partner living with HIV has achieved viral suppression. Some HIV-negative partners may choose to continue with PrEP even after this point.
  • Reassure the couple that this new approach means conception by artificial insemination is no longer necessary.
  • Inform the couple that both partners need to be screened and treated for any other STIs before trying for conception.

For information on family planning methods for people living with HIV, see Contraceptives for Clients With STIs, including HIV

 

Choosing a Dual Protection Strategy

Family planning providers can talk to clients about how they can protect themselves both from STIs, including HIV, and from pregnancy (known as “dual protection”).

Strategy 1: Use male or female condoms consistently (with every sex act) and correctly

  • One method is used to help protect against both pregnancy and STIs.
Strategy 2: Use male or female condoms consistently and correctly plus another family planning method

  • Using two methods provides extra protection from pregnancy in case the condom is not used, is used incorrectly, or breaks.
  • This strategy may be a good choice for those who want to feel reassured about avoiding pregnancy if they cannot always be sure of consistent and correct condom use.
Strategy 3: If both partners know that they are not infected with any STIs, or if one partner is living with HIV but has achieved viral suppression through ART, then use any family planning method to prevent pregnancy and agree to stay in a mutually faithful relationship

  • Many family planning clients believe they are in this group and thus feel protected from STIs, including HIV, without using condoms.
  • This strategy depends on good communication and trust between partners.
Another dual protection strategy, which does not involve using condoms or any other contraceptives, is:
 
Strategy 4: Engage only in sexual intimacy that avoids penetration or otherwise prevents semen and vaginal fluids from coming into contact with each other’s genitals or mouths (for example, mutual masturbation)

  • This strategy may not prevent syphilis, genital herpes, genital warts, or other infection with HPV, depending on the type of physical interaction that occurs. These STIs can be spread by skin-to-skin contact.
  • This strategy depends on good communication, trust, and self-control.
  • If this is the couple’s first-choice strategy, it is best to have condoms available in case penetrative sex occurs.

Many clients will need help, support, and guidance to make their dual protection strategy succeed. For example, they may need help preparing to talk with their partners about STI protection, learning how to use condoms and other methods of contraception, and handling practical matters such as where to get supplies and where to keep them. Providers unable to help with such matters should refer the client to someone who can provide more counseling or skills-building, such as role-playing to practice negotiating condom use.