Best Practices in Patient-Centered Screening and Treatment for STIs

Best Practices in Patient-Centered
Screening and Treatment for STIs
Bradley Stoner, MD, PhD
Washington University School of Medicine
Disclosure:
Bradley Stoner, MD, PhD
Commercial Interest Role
Nothing to disclose
Status
Objectives
 Describe
the theoretical bases of patient-centered
approaches to clinical care
 Utilize patient-centered methods for sexual
history elicitation and risk-reduction readiness
 Implement CDC evidence-based
recommendations for STI screening and treatment
in clinical a variety of clinical contexts
Objectives
 At
the end of this presentation, learners
will be able to:
– Describe theoretical bases of patient-centered
approaches to clinical care
– Utilize patient-centered methods for sexual history
elicitation and risk-reduction readiness
– Implement CDC recommendations for STI
screening and treatment in clinical a variety of
clinical contexts
The Issue?

Estimated19.7 million STIs each year in US
– half among young persons (ages 15-24)

Estimated 1.1 million Americans living with HIV,
approximately 50,000 new infections/year
Incidence and prevalence of STIs in US
Satterwhite CL et al, Sex Transm Dis 2013; 40:187-93
Satterwhite CL et al, Sex Transm Dis 2013; 40:187-93.
• Chlamydia
2.8% in US
• Gonorrhea
5.1% in US
• Syphilis (P&S)
15.1% in US
Bacterial STI Trends in the U.S.
Chlamydia (CT) – 1,441,789 reported cases in 2014
 Most chlamydia cases go undiagnosed

Estimated cases are 2x this number
 CT testing is recommended for all sexually active females
under the age of 26
Source: CDC. Sexually Transmitted Disease Surveillance 2014. Atlanta: U.S. Department of Health and Human Services; 2015.
Bacterial STI Trends in the U.S.
Gonorrhea (GC) – 350,062 reported new cases in 2014
– GC rates increasing among men who have sex with men (MSM)
– Disproportionate rates among minority communities
Source: CDC. Sexually Transmitted Disease Surveillance 2014. Atlanta: U.S. Department of Health and Human Services; 2015.
Gonorrhea (GC)
(cont.)
Antimicrobial resistance of growing concern
Increasing reports of resistance to front-line antibiotics
Knowing about the existence of antibiotic-resistant GC may
increase patient perception of disease severity

May increase population motivation toward treatment and prevention.
Bacterial STI Trends in the U.S.
Syphilis – 19,999 reported new cases in 2014
 Rate of 1° & 2 ° syphilis increased 14.4% among men, 22.7% among women
 Highest rates among MSM
 Minority populations disproportionately represented
 Congenital syphilis cases also on the rise
Source: CDC. Sexually Transmitted Disease Surveillance 2014. Atlanta: U.S. Department of Health and Human Services; 2015.
STI – HIV Connection

STIs increase the chance of acquiring HIV:
 Open sores and breakdown of cell layers provide easy entry for HIV
into the body
 White blood cells migrate to the STD site, serve as HIV receptors
 Infections change natural defenses in vagina
(pH and loss of lactobacillus)
14
STI – HIV Connection (cont.)
STIs
increase the chance of transmitting HIV
infection to others:

Open sores and breakdown of cell layers provide easy exit for HIV
out of the body

White blood cells containing HIV are closer to skin surface, fighting
at the STI site

Increase in the amount of HIV in semen (ex. 8x higher w/ gonorrhea)

Treating STIs can reduce HIV transmission rates community wide
So then, what is Sexual Health?
a
state of physical, mental and social well-being
in relation to sexuality; it is not merely the
absence of disease
 It
requires a positive and respectful approach to
sexuality and sexual relationships, as well as
the possibility of having pleasurable and safe
sexual experiences, free of coercion,
discrimination and violence
World Health Organization
Sexual Health in Prevention?
Sexual health is an integrated care-delivery and
prevention concept that recognizes sexual expression
as normative and encompasses preventive and
treatment services throughout the life span.
Source: Swartzendruber & Zenilman, JAMA 304:310-11, 2010
What do patients think about this?
Effectiveness of Prevention in Care Settings
Brief, provider-delivered methods help patients
change behaviors related to:
(Kamb 1998, Richardson 2004, Fischer 2004)
Numerous opportunities…
 Clinical
providers interface daily with populations at risk
 Patients
want to talk about sex, and need support for to
reduce risks for themselves and their partners
 These
conversations can be integrated in routine
clinical care delivery
Patient Education
Health education is any combination of learning
experiences designed to help individuals and
communities improve their health, by
increasing their knowledge or influencing their
attitudes.
World Health Organization
Education vs. Counseling
Education
• Deliver informationwritten, verbal, visual
• Can be one-way
communication
• Usually prescriptive:
tells patient what to do
Counseling
• Requires relationship
development-even for
brief sessions
• Patient Centered-they get
to choose
• Requires two way
communication/listening
Client-Centered Counseling
The belief that individuals have within themselves
the ability to guide their own lives in a manner that
is personally satisfying and socially constructive.
Through trusting relationships we can assist
individuals in finding their own inner wisdom and
confidence, facilitating the development of a
personal risk-reduction plan.
Essential Concepts of CCC

Individualized sessions

Partnership

Active listening techniques

Context

Feelings first

Information alone does not lead to change
Three conditions:
Genuineness
Empathy
Unconditional
Positive Regard
Effective CCC Is!
 Tailored
 Client
to the unique needs of the client
identifies his/her priorities
 Non-judgmental,
 Supports
client understanding of behaviors and feelings
 Empowers
 Limited
provider maintains neutral stance
client to talk responsibility
role of counselor
Effective CCC Is! (cont.)
 Offering
options, not directives
 Supporting
 Respects
 Clients
strengths and previous successes
cultural differences
are experts in their own lives
 Managing
our own discomfort and judgments
 Partnership
 Showing
with client
genuine curiosity
Active Listening & CCC Techniques
 Repeating
(“parroting”)
 Paraphrasing
 Reflecting
 Curiosity
 Reframing
 Interpretation
 Process
Comment
 Open-ended questions
 Non-verbal communication
 Silence
 Constructive confrontation
Barriers to Counseling in Care?
 Not
what clinicians want to do
Not what they feel they are trained to do

Time
 Reimbursement
 Need
new skills and practice
Introductory Statement
“I will be asking you some personal questions about your
sexual health & sexual practices.
Everything we discuss is confidential and will not leave
this room.
What we discuss today will help me take better care of you.
Just so you know, I ask all my patients these questions
regardless of age, gender, or marital status.
If it’s ok with you, let’s begin.”
The 5 “P”s of Sexual Health
 Partners
 Practices
 Protection
from STIs
 Past history of STIs
 Prevention of pregnancy
→
Who
What
How
Sonya
22 year old patient, requests IUD for birth control
•
Partners: 1 new partner, 4 in past year (all men), total lifetime 8
•
Practices: vaginal and oral, occasionally anal
•
Protection from STIs: condoms
•
Past history of STI’s: chlamydia 2 yrs ago, no testing since
•
Prevention of pregnancy: condoms, but not consistent; worried
about weight gain with OCPs
Sonya
•
Results a couple days later
• GC negative
• CT positive
•
Sonya returns to the office for treatment:
• “I am so glad you came in and we found out you have chlamydia. We
can treat that. Let’s discuss how to avoid it in the future.”
How Behavior Change Occurs
 Over
time
– Small steps forward
– Temporary steps back
 With
support
 Occasional
slips
 Successful
experiences
Behavior Change (cont.)
 Knowledge
 Motivation
alone is not enough
comes from within the individual
 Self-efficacy
(the belief that “I can”) is key
 More
likely if what, when, where and how is chosen
by the client
 Less
 Is
likely to change what they are told to change
complex and influenced by may factors
Determinants
 Knowledge
 Attitudes
and beliefs
 Perceived
consequences
 Self-efficacy
 Intentions
 Skills
 Perceived social norms
 Social
Support
 Actual consequences
 Access
 Emotion and arousal
 Contributing or competing
conditions
 Policy
Stages of Change
Maintenance
Action
Preparation
Contemplation
PreContemplation
What would you do?
A medical report has just been released. It has been
found that cell phones call brain damage.
Who
will quit using cell phones today?
Who
might use cell phones in certain circumstances?
Who
will not change how they use cell phones?
Motivational Interviewing
Motivational interviewing is a directive, clientcentered counseling style for eliciting behavior
change by helping clients to explore and resolve
ambivalence.
Miller and Rollnick, 2001
Four Principles of MI
 Express
Empathy
 Develop Discrepancy
 Roll with Resistance
 Support Self-efficacy
Four Strategies Used in MI
O – open ended questions
A – affirmations
R – reflective listening
S - summarizing
The Power of Questions



Open ended
Reflective
Curious
Helpful Phrases






So you think … ?
It sounds like you … ?
You’re wondering if … ?
Anything else … ?
Tell me more about that
Tell me a story
Open vs Closed Questions
Mix open/closed to elicit information from the patient
Closed:
Open:
Are you here today for testing?
What brings you here today?
Closed:
Open:
Do you have sex with men, women or both?
Tell me more about the people you have sex with.
Reflective Listening Responses
 So
you want to be tested for STI’s after a one night stand
you had last week?
 It
sounds like you plan on drinking less when you hang out
with your friends? Did I get that right?
 It
sounds like you are worried about how your boyfriend will
react to discussing condoms?
 So
you are not sure if condoms really help?
Importance + Confidence = Motivation
Not ready
Ready
 On
a scale of 1-10, how important is it for you to
protect yourself from another STD?
 How
confident (sure) are you that you can discuss
condom use with your partners?
 Why
that number?
Reducing Risks
 Use
latex condoms
 Limit the number of sex
partners
 Avoid risky situations (i.e.,
people and places)
 Talk with sex partners
about his or her HIV
status and safer sex
 Avoid
alcohol
 Avoid drugs
 Abstain from sex
 Safer sex activities
Putting It All Together
Open the conversation
Stage readiness
Reflect what you are hearing
Elicit motivation for change
Debrief / Brainstorming

What challenges might you face in implementing
Client Centered Counseling?

What could you implement right away in practice?
Resources for Patients
Medically accurate and interesting…
– www.gyt.org
– www.sexetc.org
– www.goaskalice.columbia.edu
– www.itsyoursexlife.com
– www.scarletteen.com
– www.beforeplay.org
– www.teenwire.com
– www.stdhelp.org
– www.ASHASTD.org
Thank You!
Questions?