safer sex advice
The following patients should receive safer sex advice and individual behaviour change interventions:
- adolescents
- people from, or who have visited countries with high rates of HIV and/or other STIs
- men who have sex with men (MSM)
- individuals with a history of
- frequent partner change or sex with multiple concurrent partners
- early onset sexual activity
- previous bacterial STI
- attendance as a contact of STI
- alcohol or substance abuse (the use of recreational and stimulant drugs has been associated with HIV seroconversion in MSM,although a history of intravenous drug use (IVDU) has been associated with a lower risk of acute STI)
A range of other demographic and behavioural factors may be used to identify groups believed to be at risk of poor sexual health outcomes e.g. -
- those with poor mental health
- prisoners
- sex industry workers and their clients
- looked after and accommodated adolescents
- those with learning disability
- those with sexual compulsion and addiction (1)
Advice regarding safer sex
The content of advice given to all those at continued risk of STI should be tailored to the individual's needs and understanding, based on the sexual history.
Advice regarding condom use:
- condom efficacy
- 100% use of the male latex condom should be recommended to all those at risk of STIs including HIV
- non-latex condoms are an acceptable alternative to male latex condoms for vaginal sex but have higher rates of breakage
- female condoms are (at least) equivalent to male latex condoms in the prevention of STIs and should be offered as an alternative or supplement to male condoms to all women
- men should be made aware of the availability and use of female condom
- female condoms can be used as an alternative to male condoms for anal sex but are preferred to latex male condoms by a minority of MSM who have used them
- condom effectiveness
- less than 100% condom use will offer some protection - advise that using condoms as much as possible is better than not at all
- men who have sex with men (MSM) should be advised that thicker condoms are no less likely than standard condoms to break or slip off than standard condoms during anal sex
- non-oil based lubricant should be applied all over the condom and inside the anus, but not inside the condom, before anal sex
- there is no advantage, in terms of condom safety, in the routine use of lubricant use for vaginal sex
- both men and women should be instructed on the correct use of male condoms and the importance of applying a condom before penetration and avoiding early removal
- providing a range of condom sizes is a quick and more practical alternative to formal condom sizing
- motivation for condom use
- advice should be based on an exploration of reasons for condom use and recognise that for heterosexual couples, the avoidance of pregnancy rather than STI is a major motivator
Advice on oral sex
- safer sex advice should include information on the risks of oral sex, recognising that individuals must make an informed decision on the level of risk that is acceptable to them, and supporting pragmatic alternative risk reduction techniques. The risk of transmission of bacterial and viral STIs including HIV applies to both oral and genital partners but the risk to the genital partner is thought to be considerably lower. The risks of transmission associated with oral sex are (considerably) lower than for unprotected vaginal or anal sex except in the case of HSV-1. Advice on further reducing risk includes:
- avoiding oral sex with ejaculation reduces the risk of HIV and possibly other infections
- insertive fellatio is lower risk than receptive
- avoiding brushing teeth or flossing before having oral sex reduces risk of HIV and possibly other infections
- avoiding oral sex if oral cuts or sores are present, or a sore throat
- using condoms for fellatio and dental dams for cunnilingus and oro-anal contact
Advice on other sexual practices
- no form of sexual contact is entirely without risk of STI transmission. Non-penetrative contact carries the lowest risk
- in penetrative sex (including fingering, using sex toys and fisting) the risk of transmission is related to the degree of trauma. The use of gloves should be recommended for traumatic digital penetrative sex
Abstinence
- the promotion of abstinence alone as a routine component of effective safer sex advice is not recommended
Partner reduction
- safer sex advice should include discussion regarding reduction in number of partners or the number of unprotected sex partners, and in particular, the risks associated with concurrent partnerships in those at increased risk of HIV infection
- advice should include reduction in the number of partners with whom the individual has oral sex
Repeat testing for STIs
- re-testing for asymptomatic STIs should be recommended to all individuals with a prior STI diagnosis including HIV
- screening for asymptomatic STIs should be recommended at least annually (and in some cases as frequently as every three months) to all individuals at risk of acquisition or transmission of HIV
- HIV testing should be routinely recommended to all individuals attending GUM or sexual health services. Pre- and post-test discussions and counselling support should be available
Hepatitis vaccination
- advice on the sexual transmission of Hepatitis A and Hepatitis B and the availability of vaccination should be given to all those at elevated risk of acquisition (1)
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