Reducing Sexually Transmitted Infections

Overview

This guideline covers interventions to prevent sexually transmitted infections (STIs) in people aged 16 and over. It aims to reduce the transmission of all STIs, including HIV, and includes ways to help increase the uptake of STI testing and vaccines for human papillomavirus (HPV) and hepatitis A and B.

This Guidelines summary has been produced for use by primary healthcare professionals involved in delivering or signposting to sexual health services. For the complete set of recommendations, including guidance on improving uptake and increasing the frequency of STI testing, refer to the full guideline.

Reducing the Risk of People Getting and Transmitting Sexually Transmitted Infections (STIs) 

Accessing Sexual Health Services

• Form a network of services, including online services, providing sexual healthcare for an area. Ensure that:
  • everyone is signposted to, and can access, the care they need
  • local pathways are in place to link people, including underserved communities, to the best possible care
  • details of the network are kept up to date and all staff understand what each service offers.
• Determine the most appropriate settings for services and interventions in consultation with groups with greater sexual health or access needs (see also recommendations in the section, Improving Uptake and Increasing the Frequency of STI Testing, in the full guideline). Include online and non-clinical settings.
• Reduce barriers to services for groups with greater sexual health or access needs by:
  • emphasising confidentiality, empathy and a non-judgemental approach
  • offering access to a professional translator or interpreter instead of waiting for the person to ask, to ensure they are fully able to communicate and to understand the discussion
  • making sure staff understand that services are free and available to everyone regardless of where they live (or are from), and they do not refuse access to someone who is entitled to the service
  • supporting people to attend appointments and engage with treatment
  • providing outreach activities.

Meeting the Needs of Groups With Greater Sexual Health or Access Needs

• Target interventions at groups with greater sexual health or access needs.
• Identify local needs and priorities using data from the Joint Strategic Needs Assessment (JSNA) and other data sources.
• Engage with groups with greater sexual health or access needs to understand how best to meet their sexual health and wellbeing needs. Take into account factors such as existing barriers to access (for example, for people with learning difficulties, or because of their gender or sexuality), language and other socioeconomic factors, including deprivation.

Co-producing Interventions to Reduce STI Transmission

• Co-produce (plan, design, implement and evaluate) services and interventions in consultation with the groups that they are for, in line with NICE’s guideline on community engagement.
• Ensure that interventions are culturally competent. This includes being delivered in a suitable language for people whose main language is not English. It might also involve recognising that people may be engaged in activities that are stigmatised by their communities (therefore, discretion may be particularly important for them).
• Ensure that interventions include some or all of the following components:
  • information and education about:
    • STIs
    • the impact of alcohol and drugs on sexual decision making
  • information about:
    • sexual health services available, including that they are free, confidential and open access
    • the rates of STIs to explain why some groups are at higher risk
    • the impact of stigma
  • sex-positive approaches to providing advice on the consistent and correct use of barrier methods, including providing external condoms in different sizes and textures, and internal condoms (see NICE’s guideline on sexually transmitted infections: condom distribution schemes)
  • risk assessment and risk-reduction activities, for example developing personalised risk-reduction plans, identifying triggers and setting goals
  • Information–Motivation–Behavioural skills (IMB) model approaches and motivational interviewing techniques to guide conversations about risk reduction or safer-sex practices and address informational, motivational and skills-based barriers to change
  • activities to increase sexual self-efficacy (for example, talking about sexual consent, negotiating the use of barrier methods and negotiating sexual preferences) and broader self-efficacy (for example, self-esteem)
  • activities exploring the links between emotion and sexual behaviour, and coping skills (for example, using cognitive behavioural approaches)
  • a plan for follow up (for example, repeated contact to review progress or make new plans).
• Take into account the recommendations in the NICE guidance on behaviour change (see the NICE topic page on behaviour change) when co-producing interventions to reduce STIs.
• Tailor interventions to the needs of the groups identified. Take into account safety concerns (such as sexual violence or coercion), stigma and discrimination. See also the NICE guideline on domestic violence and abuse: multi-agency working.

Delivering and Evaluating Interventions to Reduce STI Transmission

• Deliver interventions to reduce STIs across a range of services, including within broader support interventions and community services (for example, in drug and alcohol services, abortion care services, HIV care and mental health services).
• Think about whether one-to-one or group delivery is the most appropriate for the community the intervention is aimed at, and the content and aims of the intervention. Take into account people’s preferences and any resource impact.
• Ensure that people have the opportunity to have interventions that are delivered by peers or other trusted people they can relate to, who share a cultural or group background with the target group.
• When delivering interventions:
  • Avoid making assumptions about people or judging them. This could include using inclusive language (until the person expresses a preference) and recognising a range of relationships and sexual behaviours.
  • Be sex and identity positive (for example, by using gender-affirming language and being respectful of their sex life). Focus on self-worth and empowering people to have autonomy over their bodies and their sexual decision making.

For recommendations on improving uptake and increasing the frequency of STI testing, including self-sampling and tailoring interventions, refer to the full guideline.

Partner Notification

• Advise people diagnosed with an STI about the importance and benefits of partner notification, the possibility of sex partners being infected even if asymptomatic, and the risk of reinfection. Encourage them to engage in partner notification, regardless of where they are tested, and discuss the different methods of partner notification with them.
• Help people decide how to notify their sex partners. Discuss ways of having these potentially difficult conversations and suggest ways to deliver this information. Discuss the best method of partner notification in light of the person’s relationship status and other circumstances. Alternative methods of disclosure may need to be used in different contexts (for example, those who may be at risk of domestic violence, or if the person expresses a need for anonymity).
• If a person feels unable to tell their sex partners about the STI or is showing signs of difficulty dealing with their diagnosis, refer them to specialist sexual health services that can offer them more support with partner notification
• Ensure that there is a clear referral pathway to specialist sexual health services that can help with partner notification so that people can be referred seamlessly and without the need for self-referral.
• Partner notification on behalf of a person with an STI should be carried out by professionals with expertise in contact tracing and counselling in line with the British Association for Sexual Health and HIV (BASHH) statement on partner notification for sexually transmitted infections.
• Consider how geospatial networking apps (for example, Grindr or Tinder) may be used for partner notification, for example by:
  • suggesting that people who use geospatial networking apps to find sex partners use the apps to notify partners about contacting a sexual health service for STI testing
  • using app profiles to inform contacts of their need to be tested when notifying partners on behalf of a person with an STI.

HPV and Hepatitis A and B Vaccination in Gay, Bisexual and Other Men Who Have Sex With Men

• Be aware that gay, bisexual and other men who have sex with men are not the only groups eligible for human papillomavirus (HPV), hepatitis A and hepatitis B vaccination (see NHS information on HPV vaccine eligibility, hepatitis A vaccine eligibility and hepatitis B vaccine eligibility).
• Consult local gay, bisexual and other men who have sex with men to identify their needs and the barriers to vaccine uptake and course completion.
• Opportunistically promote HPV, hepatitis A and hepatitis B vaccination with gay, bisexual and other men who have sex with men who are eligible for the vaccines. Give them information on HPV, hepatitis A and hepatitis B vaccination, including:
  • the diseases and their potential severity
  • the risks and benefits of vaccination, including individual benefits and, if relevant, population benefits (protecting other people in their community)
  • the importance of having all doses of a vaccination course.
• Where possible, consider providing HPV and hepatitis vaccination during other routine health appointments for gay, bisexual and other men who have sex with men.
• Identify gay, bisexual and other men who have sex with men who do not return for follow-up vaccinations (second and third doses), and send reminders that highlight the importance of completing the course.See also the NICE guideline on vaccine uptake in the general population.

Pre-exposure Prophylaxis for HIV

These recommendations should be read together with NICE’s guideline on HIV testing: increasing uptake among people who may have undiagnosed HIV.

Raising Awareness of Pre-exposure Prophylaxis for HIV

• Raise awareness of pre-exposure prophylaxis (PrEP) among local groups with greater sexual health or access needs:
  • Use methods designed to target specific populations (for example, social media and relevant local organisations or groups).
  • Follow the advice in NICE’s guideline on community engagement.
  • Pay particular attention to groups in which PrEP is less well-known or uptake is lower, such as trans people, cisgender women, young people (aged 16 to 24), people with a Black African or Caribbean family background and people from a lower socioeconomic status background.
• Give relevant local community groups support and information resources to help them raise awareness of PrEP and increase trust in services.
• Ensure that people in groups with greater sexual health or access needs understand that PrEP is for HIV prevention only and that it does not protect against other STIs, therefore barrier methods are also important. See NICE’s guideline on sexually transmitted infections: condom distribution schemes.
• Co-produce materials that target specific information gaps and causes of stigma within the target population.
• Use peer support to normalise PrEP use, reduce all forms of stigma (originating from the person themselves, professionals and the wider society) and increase trust in services.
• Tell trans people undergoing medical transition that there are no clinically significant interactions expected between PrEP and the common hormones used in this process, and that using PrEP is not expected to affect their transition.

Service Design for PrEP Services

• Ensure that services offering PrEP are welcoming and accessible (see the second recommendation in the section, Meeting the Needs of Groups With Greater Sexual Health or Access Needs) for all the different population groups who are eligible, for example by co-designing services with the key population groups. Ensure that tailoring services to specific communities does not exclude or alienate other eligible groups.
• Raise awareness among healthcare professionals (particularly those in primary care, community settings and gender identity clinics) about which groups of people are eligible for PrEP. This could be done through continuing education o through commissioning (for example, through local networks [see the final recommendation in the section, Accessing Sexual Health Services]).
• Provide protected time for healthcare professionals who have day-to-day contact with people eligible for PrEP to have training on relevant issues.

Access to PrEP Services

• Services that do not provide PrEP should connect people who are interested in PrEP and eligible for it to a service that can prescribe it.
• Ensure there are clear referral pathways between services that do not provide PrEP and those that do.
• Make provision for people who want to be referred to services outside their local area or community. 

See also the final recommendation in the section, Accessing Sexual Health Services.

Prescribing PrEP

The recommendations in this section support recommendations in the British HIV Association (BHIVA) and BASHH guidelines on the use of PrEP for HIV and should be implemented with reference to them.

• Offer PrEP to people at higher risk of HIV, using the criteria in the BHIVA/BASHH guidelines.
• Support people who are taking PrEP, for example in decisions around the use of barrier methods and attending follow-up appointments. Continue to offer them all other relevant sexual health services, such as information, behavioural support and condom provision.
• Support people who are taking PrEP to get regular HIV testing and STI screening (every 3 months).
• Give people taking PrEP tailored information and education on effectiveness, adherence, side effects and monitoring risks (see NICE’s guideline on shared decision making).
• Follow up people taking PrEP in line with the good practice points an monitoring recommendations in the BHIVA/BASHH guidelines.
• Monitor the kidney function of people taking PrEP, and any other adverse health events.
• Help people taking PrEP to maximise adherence to treatment. Follow the general principles in NICE’s guideline on medicines adherence and address factors specific to the use of PrEP, including those listed in the BHIVA/BASHH guidelines.