Evidence Review:
Prevention of Sexually
Transmitted Infections,
with a Focus on Bacterial
Sexually Transmitted
Infections
Population and Public Health
BC Ministry of Health
September 2014
This is a review of evidence and best practice that should be seen as a guide to understanding
the scientific and community-based research, rather than as a formula for achieving success.
This review does not necessarily represent ministry policy, and may include practices that are
not currently implemented throughout the public health system in BC. This is to be expected as
the purpose of the Core Public Health Functions process—consistent with the quality
improvement approach widely adopted in private and public sector organizations across
Canada—is to put in place a performance improvement process to move the public health
system in BC towards evidence-based best practice. Health authorities will develop public
performance improvement plans with feasible performance targets and will develop and
implement performance improvement strategies that move them towards best practice in the
program component areas identified in the Model Program Paper. These strategies, while
informed by the evidence in this review, will be tailored to local context.
This Evidence Review should be read in conjunction with the accompanying Model Core Program
Paper.
Evidence Review accepted by:
Population and Public Health, Ministry of Health (March 2014)
© BC Ministry of Health, 2014
Edited by:
Gina Ogilvie, MD MSc FCFP DrPH
Former Medical Director
Clinical Prevention Services, BC Centre for Disease Control
Associate Professor, Faculty of Medicine
University of British Columbia
Mark Gilbert, MD, FRCPC
Former Physician Epidemiologist
Leader, Epidemiology and Surveillance
Online Sexual Health Services
Clinical Prevention Services, BC Centre for Disease Control
Clinical Associate Professor
School of Population and Public Health
Faculty of Medicine, University of British Columbia
Darlene Taylor, RN MSc, PhD
Research Program Manager
Clinical Prevention Services, BC Centre for Disease Control
Richard Lester, MD, FRCPC
Former Medical Head STI/HIV Control
Clinical Prevention Services, BC Centre for Disease Control
Clinical Assistant Professor
Division of Infectious Diseases,
University of British Columbia
Bobbi Brownrigg, RN, BScN, MBA
Leader Public Health Initiatives and Innovation
Clinical Prevention Services, BC Centre for Disease Control
Ciro Panessa, NP(F), MSN
Former Director Blood Borne Pathogens
Population and Public Health, BC Ministry of Health
Adjunct Professor
School of Nursing, University of British Columbia
Gina McGowan, MSc
Director of Blood Borne Pathogens
BC Ministry of Health
Prepared by:
Audrey Campbell, MD MHSc FRCPC
Clinical Research Associate, BC Centre for Disease Control
Communicable Disease Control and Public Health
Emergency Management
Public Health Physician Consultant
Course Director, Doctor, Patient, and Society 420
Vancouver-Fraser Medical Program
Clinical Instructor, Department of Pediatrics
Faculty of Medicine, University of British Columbia
Brian E. Ng, MD, MPH, CCFP*
Public Health Consultant and Family Physician
Clinical Instructor, Department of Family Practice
University of British Columbia
Course Director, Doctor, Patient, and Society 420,
Vancouver-Fraser Medical Program
Site Faculty for Research and Evidence-based Medicine
Vancouver-Fraser Family Practice Residency Program
*Denotes Professional Corporation
Paul Blasig, RN, BSN
Community Health Nurse
Nurse Consultant
Reviewed by:
James Blanchard, MD, MPH, PhD
Professor, Department of Community Health Sciences
Director, Centre for Global Public Health
University of Manitoba
Colin Q-T Lee, MD, MSc, CCFP (EM), FRCPC
Associate Medical Officer of Health
Simcoe Muskoka District Health Unit, Barrie Ontario
Ameeta Singh, BMBS (UK), MSc, FRCPC
Medical Director, AHS-Edmonton STI Clinic
Clinical Professor
Division of Infectious Diseases
University of Alberta
Marc Steben, MD, Dess, CCFP, FCFP
Medical Advisor, STI Unit,
Institut National de Santé Publique du Québec
Core Public Health Functions for BC: Evidence Review
Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
Table of Contents
Executive Summary............................................................................................................................ i
1.0
Overview/Setting the Context ...................................................................................................1
1.1
1.2
1.3
2.0
Methodology ............................................................................................................................4
2.1
2.2
2.3
2.4
2.5
3.0
Primary Evidence Review .......................................................................................................... 5
2.1.1 Micro-level Interventions ............................................................................................. 6
2.1.2 Meso- and Macro-level Interventions .......................................................................... 7
Supplemental Evidence Review: Youth ..................................................................................... 7
Supplemental Evidence Review: MSM ...................................................................................... 8
Strength of Evidence ................................................................................................................. 9
Expert Review Panel ................................................................................................................ 11
Background ............................................................................................................................ 12
3.1
3.2
3.3
3.4
4.0
The Core Functions Framework ................................................................................................ 1
Introduction to the Core Public Health Program of Communicable Disease ............................ 2
Organization of this Report ....................................................................................................... 3
Health Implications.................................................................................................................. 12
Special Considerations for Youth ............................................................................................ 12
Special Considerations for MSM ............................................................................................. 13
Review of Epidemiology of STI in BC ....................................................................................... 13
3.4.1 Chlamydia ................................................................................................................... 14
3.4.2 Gonorrhea .................................................................................................................. 14
3.4.3 Infectious Syphilis ....................................................................................................... 14
3.4.4 Other Data from BC Studies ....................................................................................... 14
Micro-Level Interventions ....................................................................................................... 16
4.1. STI/HIV Prevention Counselling and Behavioural Interventions ............................................. 16
4.1.1 General Behavioural Interventions ............................................................................ 17
4.1.2 Behavioural Interventions Stressing Ethnic Pride and Skill-building .......................... 19
4.1.3 Youth-focused Behavioural Interventions (Youth Supplemental Review) ................. 20
4.1.4 MSM-focused Behavioural Interventions (MSM Supplemental Review) ................... 20
4.1.5 Cognitive-behavioural Interventions Aimed at Preventing STIs ................................ 22
4.1.6 Brief Behavioural Interventions ................................................................................. 23
4.2 Small Group Sessions............................................................................................................... 25
4.3 Peer Education ........................................................................................................................ 25
4.4 Online Interventions Targeting Youth (Youth Supplemental Review) ..................................... 26
4.5 Screening and Treating Chlamydia to Prevent Pelvic Inflammatory Disease ......................... 28
4.5.1 Youth-focused Home-based STI Screening (Youth Supplemental Review) ................ 29
4.5.2 MSM-Focused STI Screening (MSM Supplemental Review) ....................................... 30
4.6 Abstinence and Reduction of Sexual Partners ........................................................................ 32
4.7 Male Condoms ........................................................................................................................ 32
4.8 Female Condoms ..................................................................................................................... 33
4.9 Cervical Diaphragms ................................................................................................................ 33
4.10 Topical Microbicides and Spermicides .................................................................................... 34
4.11 Male Circumcision ................................................................................................................... 34
4.11.1 Male Circumcision for MSM (MSM Supplemental Review) ....................................... 35
Population and Public Health, Ministry of Health
Core Public Health Functions for BC: Evidence Review
Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
4.12
4.13
4.14
4.15
4.16
4.17
4.18
5.0
Syphilis Chemoprophylaxis for MSM (MSM Supplemental Review) ....................................... 35
Partner Management .............................................................................................................. 36
Provider referral ...................................................................................................................... 37
Patient-delivered partner therapy (PDPT) .............................................................................. 37
CDC and PHAC: guidelines: Special populations ..................................................................... 39
CDC and PHAC Guidelines: Interventions................................................................................ 39
Conclusion ............................................................................................................................... 39
Meso-level Interventions ........................................................................................................ 40
5.1
Social Diffusion ........................................................................................................................ 41
5.1.1 Community Opinion Leaders ...................................................................................... 41
5.1.2 Peer Mentors within a Social Network....................................................................... 42
5.2 Group Education...................................................................................................................... 43
5.3 Parental Monitoring of Youth (Youth Supplemental Review) ................................................. 45
5.4 Worksite-based Programming for Parents of Youth (Youth Supplemental Review) ............... 47
5.5 Multi-component Programs Targeting Children/Younger Youth (Youth Supplemental
Review) .................................................................................................................................... 48
5.5.1 Multi-component Approach Involving Children, Parents and Teachers (Youth
Supplemental Review) ................................................................................................ 48
5.5.2 Multi-component Approach Involving Youth and Community Service (Youth
Supplemental Review) ................................................................................................ 49
Multi-component Approach Targeting Youth in High School (Youth Supplemental Review) 50
5.6 Peer Education (Youth Supplemental Review)........................................................................ 51
5.6.1 Peer Education Combined with Outreach Screening (Youth Supplemental Review) . 51
5.7 Clinic-based Interventions ....................................................................................................... 52
5.7.1 Disease Intervention Specialists in Clinic Settings...................................................... 52
5.7.2 Electronic Technologies in the Clinic Setting.............................................................. 52
5.7.3 Syphilis Testing during HIV Care in the Clinic Setting ................................................. 54
5.7.4 Clinic Guidelines on STI Screening .............................................................................. 54
5.7.5 Male clinics ................................................................................................................. 55
5.7.6 Mobile Clinics ............................................................................................................. 55
5.8 Outreach: Venue- or Group-based Screening ......................................................................... 56
5.8.1 School-based STI Screening and Treatment Programs .............................................. 56
5.8.2 Other Studies.............................................................................................................. 58
5.8.3 STI Screening in School-based Health Centres (Youth Supplemental Review)........... 58
5.8.4 Sport-related Settings ................................................................................................ 61
5.8.5 Occupational Groups .................................................................................................. 62
5.8.6 Family Court System ................................................................................................... 62
5.8.7 Prisons ........................................................................................................................ 63
5.8.8 Shelter Residents ........................................................................................................ 63
5.8.9 STI Testing of Commercial Sex Workers in Outreach Settings ................................... 64
5.8.10 MSM Sex on Premises Establishments, Saunas, Bathhouses ..................................... 64
5.8.11 Street .......................................................................................................................... 65
5.8.12 Other Studies.............................................................................................................. 66
5.9 Home-based STI Testing .......................................................................................................... 67
5.10 Internet-based Campaigns and Services for MSM (MSM Supplemental Review)................... 69
5.11 Online Initiatives to Promote STI Testing for Youth (Youth Supplemental Review)................ 72
5.12 Contact Tracing and Social Networks ...................................................................................... 74
Population and Public Health, Ministry of Health
Core Public Health Functions for BC: Evidence Review
Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
5.13 Presumptive Treatment .......................................................................................................... 75
5.13.1 One-time Presumptive Treatment ............................................................................. 76
5.13.2 Periodic Presumptive Treatment (PPT) ...................................................................... 77
5.14 Targeted Mass Treatment ....................................................................................................... 78
5.15 Patient-delivered Partner Therapy (PDPT) .............................................................................. 79
5.16 Conditional Cash Transfers ...................................................................................................... 79
5.17 Community Mobilization ......................................................................................................... 80
5.17.1 Other Multi-component Interventions ...................................................................... 81
5.18 MSM-focused Community Partnerships and Events (MSM Supplemental Review) ............... 82
5.19 Conclusion ............................................................................................................................... 82
6.0
Macro-level Interventions ....................................................................................................... 84
6.1
6.2
6.3
6.4
6.5
6.6
6.7
6.8
6.9
STI-specific Policy with an Evaluation of Impact on STIs ......................................................... 84
6.1.1 Condom Use Policy ..................................................................................................... 84
6.1.2 Integrated Policy and Community Mobilization Interventions .................................. 86
6.1.3 Performance Measures and Private Health Insurance .............................................. 87
6.1.4 Private Health Plan Reimbursement Law ................................................................... 88
6.1.5 Sex Worker Registration ............................................................................................. 88
STI-specific Policy without an Evaluation of Impact on STIs ................................................... 89
6.2.1 Screening Legislation .................................................................................................. 89
Non-STI-specific Policy with an Evaluation of Impact on STIs ................................................. 90
6.3.1 Alcohol Policy ............................................................................................................. 90
6.3.2 Other Policy ................................................................................................................ 96
Funding and Fees..................................................................................................................... 96
6.4.1 STI Clinic Fees ............................................................................................................. 96
6.4.2 Federal Funding .......................................................................................................... 97
Clinic-based Systems Interventions Focused on Youth (Youth Supplemental Review)........... 98
6.5.1 Clinical Practice Improvement Focused on Youth (Youth Supplemental Review) ..... 98
6.5.2 Primary Care Systems Intervention Focused on Youth (Youth Supplemental
Review) ....................................................................................................................... 98
Mass Media Targeting Youth (Youth Supplemental Review) .................................................. 99
Social Marketing and Public Awareness Campaigns for MSM (MSM Supplemental Review)
............................................................................................................................................... 101
CDC and PHAC Guidelines: Special Populations .................................................................... 104
6.8.1 Pregnant Women ..................................................................................................... 105
6.8.2 Adolescents .............................................................................................................. 105
6.8.3 Children .................................................................................................................... 105
6.8.4 Inmates and Persons in Correctional Facilities......................................................... 106
6.8.5 Men Who Have Sex with Men .................................................................................. 107
6.8.6 Women Who Have Sex with Women ....................................................................... 108
6.8.7 Sex Trade Workers ................................................................................................... 108
6.8.8 Neonates .................................................................................................................. 108
6.8.9 Aboriginal People ..................................................................................................... 109
CDC and PHAC Guidelines: Interventions.............................................................................. 110
6.9.1 Counselling ............................................................................................................... 110
6.9.2 Abstinence ................................................................................................................ 112
6.9.3 Male Condoms ......................................................................................................... 112
6.9.4 Female Condoms ...................................................................................................... 112
Population and Public Health, Ministry of Health
Core Public Health Functions for BC: Evidence Review
Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
6.9.5 Topical Microbicides and Spermicides ..................................................................... 112
6.9.6 Male Circumcision .................................................................................................... 112
6.9.7 Patient-delivered Partner Therapy (PDPT) ............................................................... 112
6.10 Evaluation of STI Control Strategies ...................................................................................... 114
6.10.1 Evaluation of STI Control Strategies at the Level of Populations ............................. 114
6.10.2 Evaluation of STI Control Strategies or Guidelines at the Institutional Level .......... 115
6.11 Conclusion ............................................................................................................................. 116
7.0
STI Control Strategies ............................................................................................................ 118
7.1
7.2
7.3
7.4
7.5
World Health Organization.................................................................................................... 118
England Department of Health ............................................................................................. 124
European Centre for Disease Prevention and Control .......................................................... 125
Department of Health and Ageing, Commonwealth of Australia ......................................... 127
Manitoba Health/Public Health, Communicable Disease Control Unit ................................ 128
Appendix A: Summary of Database Search Results .......................................................................... 133
Appendix B: Summary of Reviewed Studies .................................................................................... 137
Appendix C: Summary of Evidence Ratings ..................................................................................... 196
Appendix D: Descriptions of Selected Interventions ........................................................................ 210
Box 1: Philadelphia High School STD Screening Program (PHSSSP) ................................................ 210
Box 2: Family Court STD Screening Program................................................................................... 211
Box 3: Shelter-based screening program ........................................................................................ 211
Box 4: Description of the 100 % Condom Use Program (100% CUP) .............................................. 212
Box 5: Description of the CHAT intervention .................................................................................. 212
Box 6: The ImPACT intervention ..................................................................................................... 212
Box 7: Draw the Line/Respect the Line program ............................................................................ 212
Box 8: Safer Choices program ......................................................................................................... 213
Box 9: Clinical Practice Improvement Intervention ........................................................................ 213
Box 10: Example of a Florida SBHC program................................................................................... 214
Box 11: Policy 123 ........................................................................................................................... 215
Box 12: Features of the Get Tested Why Not program, Ottawa Public Health .............................. 215
Box 13: Challenges related to STI screening in prison and suggested solutions ............................ 216
Appendix E: Patient-Delivered Partner Therapy (PDPT)– The Policy and Legal Environment ............. 217
Appendix F: Examples of Social Marketing Campaigns..................................................................... 220
Appendix G: Recommended Knowledge Mobilization Partners ....................................................... 224
Abbreviations and Acronyms.......................................................................................................... 236
References..................................................................................................................................... 237
Population and Public Health, Ministry of Health
Core Public Health Functions for BC: Evidence Review
Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
“In asking for strong evidence I would, however, repeat emphatically that this does not imply crossing
every ‘t’, and swords with every critic, before we act.
All scientific work is incomplete – whether it be observational or experimental. All scientific work is
liable to be upset or modified by advancing knowledge. That does not confer upon us a freedom to
ignore knowledge we already have, or to postpone the action that it appears to demand at a given
time.”
Austin Bradford Hill(1)
Population and Public Health, Ministry of Health
Core Public Health Functions for BC: Evidence Review
Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
EXECUTIVE SUMMARY
In March 2005, the Ministry of Health released A Framework for Core Functions in Public Health (2)
(Core Functions Framework), which clearly defined the core functions of the public health system and
identified a comprehensive set of core public health programs intended to improve health and wellbeing, and/or reduce disease, disability and injury. This policy work formed the foundation of Promote,
Protect, Prevent: Our Health Begins Here, BC’s Guiding Framework for Public Health (3) (Guiding
Framework)—the 10-year directional document for the public health system released in March 2013.
The Guiding Framework reinforces Core Functions as the framework for public health program and
service delivery in the province, provides a strong foundation for all current public health efforts, and
builds on the critical elements necessary to consider when identifying future priorities.
Communicable disease is a core public health program, which is aligned with the Communicable Disease
Prevention goal in the Guiding Framework. Each core public health program is supported by an evidence
review and model core program paper, quality improvement tools that help the Ministry of Health and
health authorities ensure that public health policies, programs and services are based on evidence and
best practice. This evidence review complements the existing Communicable Disease Secondary
Transmission Evidence review, and fills a gap in the collation of evidence related to bacterial sexually
transmitted infections (STIs).
Therefore, this document is a new evidence review under the communicable disease core public health
program, and is intended to provide a foundation for effective prevention of STIs, given the unique
aspects of STIs compared to other communicable diseases. The evidence review will inform the Ministry
of Health’s work to develop a strategic framework on the prevention of STIs, which will support
achievement of ten-year targets in the Guiding Framework.
The prevention and control of sexually transmitted infections (STI) has been a critical task of
government agencies, health care practitioners, communities and individuals for decades. As STIs are
non-randomly distributed, occur as a result of the most intimate behaviours, and are often
disproportionately shouldered in certain communities, effective prevention and control programming
requires consideration beyond the approaches used for the control of other non-sexually transmitted
communicable diseases.
This evidence review identifies prevention interventions at the micro-, meso- and macro-levels that are
specific to bacterial STIs as provincial strategic policy guidance is already in place for two sexually
transmitted viral infections (HIV and hepatitis)(4)(5). The micro-level considers interventions between
individuals; the meso level considers interventions among the broader community, among bridging
groups and core networks; and the macro-level considers interventions such as legislation, regulation
and policy. Settings where people live, learn, work and play are considered.
Policy-makers and program planners must also consider multi-outcome interventions that increase the
cost-effectiveness of prevention approaches. A historically compartmentalized view of mental, social,
educational, behavioural and legal issues means the evidence base to support efforts that
simultaneously address common risk factors as they relate to STIs is not well developed. Yet it is the
accumulation of outcomes across health and social domains that offer the most convincing arguments
for investment in prevention (5). By addressing multiple outcomes, interventions can reduce the risk of
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Core Public Health Functions for BC: Evidence Review
Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
sexually transmitted infections, improve mental and physical health, and generate broader social and
economic benefits.
Interventions identified through this review have been evaluated against the BC Ministry of Health
Evidence Scale (see Figure 2) to determine which interventions have significant evidence for reducing
the burden of STIs. A directed and comprehensive, but non-systematic, literature review was conducted
in multiple phases to examine interventions at the micro-, meso-, and macro-levels with a special focus
on youth, gay, bisexual and other men who have sex with men (MSM). In addition, STI control strategies
from various jurisdictions were reviewed, with a focus on strategies from the World Health Organization
(WHO). Evidence related to electronic and virtual technologies are included in both the micro- and
meso-level sections of this report.
Resources dedicated to STI prevention and control efforts should be focused on interventions for which
there is good evidence to support their dissemination—three star evidence rating according to the BC
Ministry of Health Evidence Scale. Evidence for dissemination means these interventions have been
shown to be effective in both research settings and “real world” applications, and follow-up has
demonstrated sustained effects over time.
While no evidence with a three-star rating was found, the interventions that were assessed to be
significantly effective in impacting STI incidence/prevalence using these criteria are presented in Box 1
below.
Box 1: Interventions with evidence of outcome effectiveness
Prevention counselling and behavioural interventions
Screening and treating for STI to prevent pelvic inflammatory disease (PID)
Male condoms
Partner management – patient referral and patient-delivered partner therapy (PDPT)
Community mobilization, particularly in combination with other interventions (e.g., condom use policy, enhanced
access to health services, etc.)
At the same time, this does not mean that interventions without evidence of outcome effectiveness
need to be stopped, rather monitoring and evaluation efforts need to be improved, so that over time,
we can better assess the wide array of STI prevention interventions currently in place. The micro-, mesoand macro-level findings below were found to be of key importance.
Micro-level interventions (individual-level)
Micro-level interventions consider the interventions between individuals and how these impact the
prevention and control of sexually transmitted infections. Interventions to prevent the transmission of
STIs at the individual level, as well as those related to youth and MSM, are numerous. Appendix C lists
these interventions and the corresponding evidence rating scale score.
Most interventions reviewed have some evidence for implementation. Prevention counselling and
behavioural interventions have wide support for effectiveness in the literature. Topical microbicides and
spermicides, which studies have largely shown to be ineffective and possibly carry an increased risk of
STI transmission, are generally not recommended for use in STI prevention. Male condoms are an
effective means of STI prevention. Female condoms and cervical diaphragms have been shown to be
effective in preventing STI, but cost and safety concerns with anal intercourse limit recommendations
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Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
for usage, especially when male condoms are available. However, in instances where the male partner
refuses to use a male condom, female condoms and cervical diaphragms may be important to consider.
Male circumcision, while recommended in developing nations with high HIV prevalence as a strategy to
combat high STI and HIV rates, has had limited study in developed nations with typically lower HIV
prevalence. As such, neither the US nor Canadian guidelines recommend for or against it as a strategy
for STI control. Partner management remains a cornerstone of STI prevention and control. Various forms
of partner management have been identified in the literature, and recommendations of specific
strategies will vary according to local laws and regulation, resources, and cost.
New evidence shows promising results related to new electronic technologies (e.g., social media, shortmessage service [SMS], and other internet-enabled interventions) among youth, and reinforces that
there is evidence for implementation, particularly for impact on sexual risk behaviour, while impact on
STI rates is often uncertain. In addition, new evidence further supports the acceptance of these
interventions among youth, and includes a caveat that the most recent technology should be utilized as
youth may respond unfavourably to outdated modalities. Further, youth may use more than one type of
technology and therefore there may be an advantage to offering multiple methods to reach youth. The
evidence related to home-based STI screening among youth also supports the utility of this intervention
for promoting uptake; a limited literature base suggests effectiveness for the detection of STIs.
Meso-level interventions (community or organizational level)
Meso-level interventions occur at the level of communities and organizations, or among groupings such
as family, peers or sub-populations. There are multiple preventive interventions to consider at these
levels, including contact tracing using a social network approach for detection of STI cases, home-based
STI testing to support screening uptake, and screening commercial sex workers to facilitate access to
treatment. New evidence reinforces the importance of the long-established practice of group education,
but suggests that group education should go beyond simply providing information, but rather include
skill-building; this has been shown to be effective in decreasing STI positive test results.
Peer mentors providing informal education, specifically within their social network, have been found to
be effective in decreasing risk behaviour, but further research is required to assess the impact on STI
rates. Studies of community mobilization initiatives among sex trade workers in low- and middle-income
countries, reveal significant decreases in the incidence of STIs. Note that these programs are generally
multi-faceted in which community mobilization comprises an important but not sole component. The
emerging use of social networks in contact tracing has been found to lead to a broader, more
comprehensive identification of at-risk contacts, across settings and contexts, although long-term
impact on STI burden is uncertain.
Screening, follow-up and treatment, remains a cornerstone of STI prevention efforts. This topic
represented the largest area of study identified at the meso-level. Screening outreach efforts have been
conducted with diverse populations in a range of settings. While each study has unique findings,
generally a moderate to high proportion of most target populations were receptive to undergoing
screening, and voluntarily accessed their results. As well, treatment rates for cases were generally high.
Only a small selection of studies assessed STI rates over time, and the impact on incidence/prevalence
varied between studies. In a recent review article, higher participation rates were noted when screening
was delivered in existing “traditional” STI clinics, suggesting that conducting screening programs in such
sites may be advisable. However, there is also a literature base that supports the effectiveness of
promoting screening uptake in street-based settings were appropriate (e.g., with street-based sex trade
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Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
workers). Home-based testing has demonstrated effectiveness in promoting testing uptake, with a
limited literature base assessing STI rates over time; a randomized controlled trial (RCT) conducted
among youth in Denmark found that a home testing strategy was associated with a lower prevalence of
chlamydia and less reported PID.
There is evidence to support using school-based health centers (SBHC) as important venues for offering
screening to youth in schools in US studies, and have demonstrated the ability to detect high rates of
STIs. One study demonstrated that a chlamydia screening initiative that was widely advertised resulted
in a high uptake of screening among a population that largely had no other source for reproductive
health care. Another study suggests that this is an important way to engage asymptomatic young men in
screening. Further, high rates of reinfection with chlamydia were detected through a SBHC in a single
study, particularly among younger youth; this raises the question, however, of why reinfection rates
remained high despite interaction with the SBHC.
At the same time, the STI clinic setting still remains a key venue for effective STI treatment and care.
Strategies that operate within a clinic setting that have been shown to be effective in supporting
screening include new electronic technologies that provide computer alerts and text message
reminders, syphilis screening during HIV-related care, and electronic medical record alerts. Studies in
the US revealed that partner notification and treatment may be facilitated by involving Disease
Intervention Specialists (DIS) who have specialized expertise in STI-related outreach, counseling, contact
tracing, etc. Male health clinics were suggested as an important way to promote access to male-focused
STI care; the limited study identified on this topic, from a setting in India, reported a positive impact on
STI knowledge and reduced risk behaviour, however the impact on STI rates is not reported. Further, a
study of a mobile clinic in a US context revealed enhanced STI testing uptake and very high acceptability
by community residents, but long-term impact on STI rates was uncertain.
Parents and teachers comprised key areas of focus for a number of behavioural interventions. There was
consistent evidence of an association between parental monitoring and youth sexual risk behaviour, and
the association between parental monitoring on STI incidence was demonstrated in one prospective
cohort study. However, what is lacking is an assessment of parental monitoring interventions and their
impact on STI rates in a population.
There are multi-component interventions seeking to effect behavioural change among youth that also
have evidence for implementation. These included programs delivered to children/younger youth (i.e.,
elementary and middle school) as well as their parents and teachers, some of which also had community
service elements. Despite having different components, these studies consistently demonstrated that
comprehensive STI prevention interventions that attend to social context, delivered during earlier years,
can reduce sexual risk behaviour long-term. The impact on STI rates was assessed in one study, which
reported a significant impact only among African American youth. A similar multi-component
intervention implemented among high school students demonstrated some positive effects on sexual
risk behaviour, however impact on STI rates warrants further research.
The literature around group education involving risk reduction messages generally reports effectiveness
in reducing sexual risk behaviour and STI rates. Group education involving abstinence-only messaging
has had mixed results, and the impact on both behavioural and biological outcomes warrants further
research. The first large, multi-national trial of community opinion leaders found that this intervention
had little effect on STI rates; however the comparison control intervention itself incorporated a range of
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Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
strategies shown to be effective in STI prevention and this may have decreased the ability to detect a
difference between intervention and control groups.
Targeted presumptive STI treatment has also had mixed results in the literature; however, these are
short-term, temporary measures and other control measures must be implemented in order to maintain
STI reductions over the long-term.
While there have been many published studies on internet-based campaigns for MSM, most studies
have been observational or provide only descriptive statistics. More rigorous, controlled studies are
needed to determine if the many types of internet campaigns are indeed effective in decreasing STI
rates and improving sexual health outcomes.
Macro-level interventions (laws, policies and regulations level)
Macro-level interventions relate to policy instruments, including legislation, regulations, acts,
resolutions, and guidelines. The literature on macro-level interventions, although relatively smaller than
the micro- and meso-level literature base, contained a wide variety of policy-related interventions that
have evidence for implementation, including both STI-specific and non-STI specific policy. Some of these
interventions include STI Control Strategies and Guidelines and alcohol policy.
The majority of the macro-level literature is from outside of Canada (with many US-based studies as well
as studies from low- and middle-income countries). In the US, evidence is supportive of the positive
association between the amount of federal funding for syphilis elimination activities and a decrease in
subsequent incidence rates of syphilis at the state level. Evidence also showed that implementation of
co-payments had negative impacts on STI clinic visits and STI detection, particularly for higher risk
populations in the US. The 100% Condom Use Program (CUP) - a government policy - was discussed
widely in the literature, particularly in middle- and low-income countries. Studies have varied in the
demonstration of impact on STI rates, with the turnover of sex trade workers and new sex trade workers
thought to prevent challenges for program success.
Studies in low- and middle-income countries of combined community mobilization and policy initiatives
revealed significant decreases in STIs and risk behaviours among female sex workers. By implementing a
community solidarity project with a government policy intervention in commercial sex establishments
there was a significant decrease in the proportion of individuals with one or more STIs (chlamydia,
gonorrhea, Trichomoniasis) in the intervention site. In a single study, registration of sex workers with
the municipal health department was not found to be associated with a lower risk of testing positive for
STIs. Literature from private insurance contexts in the US suggests that performance measures matter
and can have a significant influence on STI screening practices.
The literature on alcohol policy includes examination of multiple variables (e.g., alcohol pricing,
minimum legal drinking age, zero-tolerance drunk driving laws) and finds that measures to reduce
alcohol access are associated with lower STI rates. There is a well-established mechanism for the
relationship between alcohol and STIs (i.e., the association between alcohol consumption and risky
behaviour). Many of the studies identified for this review are ecological with subsequent limitations in
establishing a causal relationship at the individual-level, however there is ample evidence corroborating
an association and the potential impact of alcohol control policies on STI reduction at the populationlevel.
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Social marketing is a research-driven approach to behaviour change and consists of five components:
branding, segmentation, price, placement, and promotion. Although various social marketing campaigns
targeting MSM have shown promise in uncontrolled studies, the evidence from controlled studies for
the use of social marketing campaigns for prevention of bacterial STIs is poor. More research is
warranted before this intervention is recommended.
There is a noted absence of population-based evaluations of STI-related laws and jurisdiction-wide STI
control strategies on the impact on STI incidence/prevalence among populations, in the academic
literature, or publicly available grey literature, using the specified search terms. An unpublished
evaluation of a provincial syphilis prevention campaign was identified and reviewed, as were evaluations
of the dissemination of CDC STI guidelines among health care providers (without an evaluation of an
impact on STI rates), and evaluation of STI guidelines/strategies at the level of local institutions.
Building the evidence base for STI control for future evaluation
This evidence review has revealed that STI prevention interventions at the meso- and macro-level form
key elements of a comprehensive STI prevention strategy across populations. It is important to note that
most of the interventions have been evaluated on a foundation of the core elements of an STI control
program, including surveillance, laboratory services, integrated and specialized clinic and public health
follow up. This review has also revealed that much of the data on interventions at these levels, come
from the US, Europe, Australia, or low- and middle-income countries. In addition, nascent endeavours,
such as online technologies, are still too new to have a mature evidence base, but should continue to be
examined given their potential role in STI prevention.
Overall, in the BC-context, without a population-based survey to be able to validate changes in
behaviour, and biological outcomes (e.g., STI incidence/prevalence), the ability to evaluate many
interventions at these levels is limited. This means that even well designed and implemented
interventions may not be able to be rated beyond a “warrants further research” designation owing to a
lack of evaluation data. As such, the existence of such a survey (that includes self-reported behavioural
and STI data, ideally linked to biological data) would be highly advantageous to the future evaluation of
programs and interventions delivered to populations within the province.
Effective prevention and control across the continuum of STIs and in whole populations requires more
structured monitoring and evaluation, as well as research to further expand the spectrum of available
interventions. Nevertheless, current evidence provides many options to program planners and policy
makers. Some interventions are “stand-alone,” and fall within the scope and mandate of health
authorities and primary care practitioners, while others require partnership and collaboration across
sectors. Whether delivered directly by the health system, or in partnership with other sectors,
sustainable implementation is enhanced by selecting programs that build on existing infrastructures and
resources. Wherever possible, STI prevention efforts should be structurally integrated with existing
health programs and social policies in schools, workplaces and communities (see knowledge
mobilization Appendix G for further information).
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1.0 OVERVIEW/SETTING THE CONTEXT
1.1
The Core Functions Framework
In March 2005, the Ministry of Health released A Framework for Core Functions in Public Health (2)(Core
Functions Framework) that clearly defined the core functions of the public health system and identified
a comprehensive set of public health services, based on the best available evidence and best practices.
This policy work formed the foundation of Promote, Protect, Prevent: Our Health Begins Here, BC’s
Guiding Framework for Public Health (3) (Guiding Framework)—the 10-year directional document for
the public health system released in March 2013. The Guiding Framework reinforces Core Functions as
the framework for public health program and service delivery in the province, provides a strong
foundation for all current public health efforts, and builds on the critical elements necessary to consider
when identifying future priorities (See Figure 1).
The original Core Functions Framework has been revised to reflect the alignment with the Guiding
Framework. It outlines the 20 core public health programs within the seven goal areas that health
authorities provide as they seek to improve the overall health of their populations. Four strategies
(health promotion; health protection; preventive interventions; and health assessment and disease
surveillance) are used to guide implementation.
Communicable Disease is a core public health program, and it is aligned with the Communicable Disease
Prevention goal (Goal 4) within the Guiding Framework.
Figure 1: Core Functions Framework
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Each core public health program is supported by quality improvement tools that help the Ministry of
Health and health authorities ensure that public health policies, programs and services are based on
evidence and best practice.
 An evidence review, which identifies and ranks the evidence of effective public health
interventions related to the core public health program.
 A model core program paper, which identifies the core elements of a comprehensive program,
including goals and objectives, principles, key components, best practices, and indicators and
potential performance measures. The information in the evidence review provides the
foundation for the main components and best practices outlined in the model core program
paper.
Health authorities are expected to use these quality improvement tools to inform planning, policy
development and delivery, and support ongoing quality improvement. Specifically to:
 Ensure programs and services are evidence-based and address health inequities.
 Develop and implement new public health priorities, as identified by the Guiding Framework
and other public health directional documents.
 Educate and inform internal and external stakeholders of the evidence and support them in
implementing evidence-based practices.
1.2
Introduction to the Core Public Health Program of Communicable
Disease
This document is a new evidence review under the communicable disease core public health program,
and is intended to provide a foundation for effective prevention of STIs, given the unique aspects of STIs
compared to other communicable diseases. The evidence review will inform the Ministry of Health’s
work to develop a strategic framework on the prevention of STIs, which will support achievement of tenyear targets in the Guiding Framework (3). This evidence review will ensure that any future, provincial
strategic STI prevention policy is supported by updated evidence in the prevention of STIs.
While STI prevention and control programs are built on the foundations of communicable disease
control, including legislation, surveillance, laboratory services, targeted and integrated clinical services,
partner services and evaluation, careful evaluation of interventions and practices are needed to
determine how to optimally disseminate and implement these interventions within these foundations,
to ensure they impact positively on rates of sexually transmitted infections at a population level. In BC,
as with many jurisdictions globally, STI rates have been increasing steadily again over the past few
decades. Strengthening of existing practices may be required, as well as development of new, innovative
ways to curb STI impact at the population level, both of which should be grounded in evidence.
Following initial dramatic declines in bacterial STI rates in the antibiotic era in the mid to late 1900s,
rates of reportable STI have been increasing in recent decades in BC, as they have in most of Canada, the
US, and other jurisdictions with STI control programs. In BC, chlamydia rates continue to rise steadily
with a broad distribution that includes teenage girls and younger women; gonorrhea rates have also
been increasing, albeit more concentrated among individuals with higher risk sexual behaviors. Rates of
infectious syphilis, while fluctuant, have peaked in recent years to their highest levels since the 1970s,
and have shifted from predominantly street involved and heterosexual populations in Vancouver to a
highly concentrated provincial epidemic among MSM. Antimicrobial resistance remains a recurring
challenge, particularly for gonorrhea control efforts. New technologies in testing and treatment support
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are also emerging. These general trends and challenges are seen internationally. Historical core public
health functions such as testing, treatment of cases, and partner notification are well established in BC
where there is a strong integration of province-wide surveillance, laboratory support, clinical outreach
and training; yet there may be room for improvements.
This evidence review describes prevention interventions specific to bacterial sexually transmitted
infections as provincial strategic policy guidance is already in place for two sexually transmitted viral
infections (HIV and hepatitis) (4,5). This work was identified as the first step to address the increasing
rates of bacterial sexually transmitted infections identified in Promote, Protect, Prevent: Our Health
Begins Here (3) and allows for identification of additional strategies or innovations within or in addition
to these core functions that may ultimately help in reducing infection rates and the burden of STI in the
population.
1.3
Organization of this Report
This report is divided into four sections: micro-level (e.g., individuals, relationships) interventions; mesolevel (e.g., institutions, society) interventions; macro-level (e.g., families, communities) interventions;
and STI-control strategies, with an additional focus on youth and MSM populations. Some interventions
do not clearly fit into one single intervention level category; therefore, these are discussed in multiple
sections where appropriate (e.g., electronic new technologies).
Appendix A presents the results of the database searches conducted for the evidence reviews. Appendix
B presents a summary of the reviewed studies that focus on STI incidence/prevalence or STI-related
morbidity. Within the text, a summary box is provided after most interventions or group of
interventions, containing an evidence rating scale and rationale for the assigned rating. Appendix C
contains a summary of the evidence ratings for all of the interventions reviewed. Appendix D presents a
description of selected interventions (e.g., programs, policies) that provide added context for some of
the meso- and macro-level interventions in particular. Appendix E presents a discussion of policy and
legal issues related to patient-delivered partner therapy (discussed in section 4.15). Appendix F provides
examples of social marketing campaigns (discussed in section 6.7). Appendix G discusses knowledge
mobilization.
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2.0 METHODOLOGY
This directed (non-systematic) evidence review is the product of an extensive search and critical
appraisal of the published and unpublished literature on STI prevention and control interventions and
strategies spanning micro (e.g., individuals, relationships), meso (e.g., institutions, society) and macro
(e.g., families, communities) levels. Literature focused on the general population, as well as numerous
other sub-populations nationally and internationally, including a special focus on youth and gay, bisexual
and other men who have sex with men (MSM), as populations with a demonstrated high
incidence/prevalence of STIs in BC was sought. The term “MSM” includes all men who have sex with
other men, regardless of self-identified sexual orientation. The limitation of the term MSM is
acknowledged as it overlooks important distinctions in sexual and gender identity, culture and
behaviour between men in this group that are relevant for effective programming (for example, services
for gay-identified men), this term and definition based on behaviour are more commonly used in the
published literature (7).
‘Youth’, a term that is not consistently defined in the literature (8). A number of sources classify youth as
15-24 years (9), others as age 12-17 years (10) or age 15-29 years (11). For the purposes of this report,
literature that states that the intervention targets “youth”, “adolescents”, “teenagers” or “young
people”, and has a study population that includes (but is not necessarily limited to) individuals between
the ages of 12-19 years (e.g., 10-19 years, 12-17 years, 15-24 years, <25 years, etc.), will be included in
this review. The limitations of this approach are recognized, however to exclude studies that have a
sample with an age range that is outside of the teenage years will result in the loss of many potentially
valuable studies. While there were a number of studies that assessed youth in the general population,
certain youth populations were the subject of increased study, including students in school and certain
ethnic minority groups in the United States (US) such as African-American youth.
The review focuses on reportable bacterial STIs (chlamydia, gonorrhea, and syphilis) and other STIs
(including viral infections) are not included. A number of terms and abbreviations are used in the
literature to refer to the bacterial STIs, however within this report the terms ‘chlamydia’, ‘gonorrhea’,
‘syphilis’ and ‘LGV’ will be used to refer to these bacterial STIs. As noted previously, infectious syphilis is
nationally reported, and therefore where this term is used in the literature, it will also be used in this
report.
HIV is not specifically included in this review in part for feasibility and because of less pressing need due
to the substantial efforts over the past few years at re-orienting HIV prevention and control through the
provincial Seek and Treat for the Optimal Prevention of HIV/AIDS program. However, it is recognized
that there will be considerable overlap between effective interventions for STI and HIV, particularly for
interventions included in this report where changes in sexual behaviour are used as a proxy outcome for
incidence of STI/HIV.
Evidence reviews of this nature are affected by publication lag for emerging and highly promising
strategies for STI prevention, which have yet to be implemented in large scale studies. This is particularly
relevant to emerging social media interventions and technology such as mobile health and online
testing. This promising field offers important opportunities to decrease STI rates in both priority
communities such as youth, MSM and in the general population, but given the nascent and dynamic
nature of this field, it requires more time and will benefit from a rigorous evaluation of their impact at
the population level.
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The report is structured by intervention types at micro-, meso- and macro-levels. While this approach
provides comprehensive information permitting evaluation on an intervention by intervention basis, it
does mask recent shifts within the field of STI prevention and control. The best example of this is the
shift over the past decade to develop and implement interventions for delivery through new digital
technologies, including through internet and mobile phones/text messaging, for which evidence is only
just beginning to accumulate. Where such evidence exists, these have been included within the relevant
intervention categories (for example, e-mail based partner notification programs included in the partner
notification section). However, these interventions are considered to hold great promise in reaching
populations at continued risk of STI and warrant further evaluation.
This evidence review occurred through multiple phases. First, a primary evidence review across all
populations was prepared, primarily based on a directed but non-systematic search of the published and
grey literature. Based on reviewer feedback, the review was expanded to include additional published
and unpublished literature sources. In addition to the primary review, supplemental reviews were
prepared specifically regarding youth and MSM populations which encompassed an additional search of
the published and grey literature, and consultation with experts. Finally, an expert panel reviewed the
primary evidence review, supplemental reviews and additional published and unpublished literature
sources were suggested and incorporated. Findings from the supplemental youth and MSM reviews
have been integrated with the primary review and have been identified as “Youth supplemental review”
and “MSM supplemental review”.
2.1
Primary Evidence Review
For the primary review, published and grey literature on the topic of bacterial STI prevention at the
micro-, meso- and macro-levels was searched. Common search terms were utilized to search key
databases (Medline, EMBASE, CINAHL, EBM Reviews and Health and Psychosocial Instruments - see
Table 1). Articles were first scrutinized by title, and if deemed potentially relevant, the abstract was
scrutinized. As previously mentioned, as the focus of this review was bacterial STIs, articles with HIV or
other non-bacterial STI outcomes were included only if they also had bacterial STI outcomes (e.g.,
incident cases of bacterial STIs as well as HIV were measured pre- and post-intervention). Articles with
outcomes that only focused on HIV or a focus on other non-bacterial STIs were excluded. RCTs,
observational studies and other evaluation methodologies including ecological studies were included.
Where relevant articles were identified, the reference lists were searched for additional articles.
Table 1 displays the search terms and search strategy. The results of the database searches are
presented in Appendix A.
Table 1: Search Terms and Strategy for the Primary Evidence Review (micro-, meso- and macro-level
interventions across populations)
Category
Search terms
STI term
Chlamydia
OR
Gonorrhea
OR
Syphilis
OR
Lymphogranuloma Venereum
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Combine within and between
(Boolean) terms
STI term AND Population term AND
Intervention term AND Prevention
term
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Category
Population
term
Intervention
term
Prevention
term
Search terms
Combine within and between
(Boolean) terms
Sexually Transmitted Diseases, Bacterial/
OR
Sexually transmitted infections (search as keyword, this
is not an indexed term, it is a sub-set of STDs, bacterial).
Child OR adolescent OR young adult OR aged OR middle
aged or aged, 80 and over
OR
High-risk population OR vulnerable populations OR
vulnerable population OR marginalized population
OR
Disabled persons
OR
Inequity OR inequality
OR
Substance related disorders OR alcoholism
Policy OR Health Policy OR Regulation OR Legislation
OR
Strategies OR Programs OR Services
OR
Family OR Community OR Schools OR Workplaces OR
Faith-based
OR
Interpersonal relations OR
Partner OR Individual
Prevention
OR
Health promotion
OR
Harm reduction
OR
Control
While this general approach was utilized to identify literature at all three levels of intervention, due to
the allotted time and large volume of STI prevention literature, the search for micro-level intervention
topics was approached differently.
2.1.1 Micro-level Interventions
Key documents
The US CDC guidelines and the Public Health Agency of Canada (PHAC) guidelines were two key
resources utilized in this review (12,13). This section of the review was structured based on the topics in
these documents, with the inclusion of additional literature found through the search.
Previously identified systematic reviews
Prior to conducting this review, three key systematic reviews on STI prevention and control were
identified (14–16). Manhart and Holmes (14) conducted a systematic review of randomized controlled
trials (RCTs) of micro-level interventions (in addition to population-level and multilevel interventions) for
preventing STIs. This was updated in 2010 by Wetmore, et al. (16) who included all of the RCTs from
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Manhart and Holmes, and were the main focus of this review. These reviews also augment and
complement the summary of the guidelines from the US CDC and PHAC.
Search
For this section of the report, the databases mentioned above were searched as well as the Cochrane
Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials. Articles that
were included in the previous reviews by Wetmore, et al. (16) and Manhart and Holmes (14) were not
analyzed again but are included as part of the summary. Because RCTs were included in these two
reviews, RCTs that were found in this search that were included in the previous reviews were not
included. RCTs that were not included in the previous review, as well as any other relevant non-RCTs,
were included.
2.1.2 Meso- and Macro-level Interventions
The search strategy described above was utilized for the micro-, meso-, and macro-level interventions;
however, the search for the meso-level interventions was supplemented by additional searches
surrounding specific topics that were felt to be informative (e.g., the legal and policy environment
related to patient-delivered partner therapy [PDPT]). Furthermore, in order to expand the review to the
topic of alcohol policy and STIs, an expert at the BC Ministry of Health identified published and
unpublished literature for review in the area of alcohol policy.
A search for STI Control Strategies was conducted using GoogleTM using the following search terms:
sexually, transmitted, diseases, illnesses, STI, STD, guidelines, policies, strategy, and strategies. Selected
STI Control Strategies were reviewed in detail, prioritizing strategies from the World Health Organization
(WHO), Canadian strategies, and strategies from other high-income countries. Further, in order to
specifically search for existing evaluations of jurisdiction-wide control strategies, the following terms, or
combination, were searched: strategic, evaluation, impact, review, guidelines, control, strategy,
strategies, sexually, transmitted, diseases, illnesses, STI, STD, government, governmental. Results were
reviewed until the hits were no longer relevant to the topic.
2.2
Supplemental Evidence Review: Youth
Database search
Published and grey literature was searched on the topic of bacterial STI prevention among youth at the
micro-, meso- and macro-levels. Key databases include Medline, EMBASE, CINAHL and EBM Reviews,
using a search strategy that combined a youth term, bacterial STI term, and prevention term (see Table
2). The same approach taken for the primary evidence review was followed for the assessment of
evidence for the supplemental evidence review focused on youth (i.e., scrutiny of titles, followed by
abstracts and full text, if relevant). Diverse study designs were included, and reference lists of included
articles were searched.
Expert consultation
Different from the primary evidence review, given the large amount of STI literature and in order to
ensure that key published papers on the topic of youth STI prevention were identified, along with very
current research and unpublished literature, experts were sought in the area of youth sexual health, and
requested their literature suggestions. These articles were reviewed per the process previously outlined.
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Table 2 displays the youth-focused search terms and search strategy. The results of the database
searches are presented in Appendix A.
Table 2: Search Terms and Strategy for the Supplemental Evidence Review Focused on Youth
Category
Search terms
STI term
Chlamydia infections or Chlamydia trachomatis
OR
Gonorrhea
OR
Syphilis
OR
Lymphogranuloma Venereum
OR
Sexually Transmitted Diseases, Bacterial/
OR
Sexually transmitted infections (search as keyword, this is not an
indexed term, it is a sub-set of STDs, bacterial).
Youth OR Adolescent
Population
term
Prevention
term
2.3
Combine within and between
terms
STI term AND Population term
AND Prevention term
Primary prevention
Secondary prevention
Tertiary prevention
Health promotion
Harm reduction
Supplemental Evidence Review: MSM
Database search
Key content experts were consulted and a literature search of Pubmed, EMBASE, CINAHL, EBM Reviews,
the Cochrane Central Register of Controlled Trials, and Health and Psychosocial Instruments was
conducted. Articles were limited to the English language. Three search terms were combined with the
Boolean operator AND: an STI term, a prevention and control term, and a term specifying MSM.
Appendix A details the search strategy and results for each search engine. References of articles were
also reviewed and articles were included that were relevant to preventive interventions for MSM. A
summary of reviewed studies is presented in Appendix B.
Expert consultation
As with the supplemental evidence review for youth, key content experts were consulted and a
literature search of key databases, along with reviewing the reference lists of included articles was
conducted.
Table 3 presents the MSM-focused search terms and search strategy. The results of the database
searches are presented in Appendix A.
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Table 3: Search Terms and Strategy
Category
Search terms
STI term
Chlamydia infections or Chlamydia trachomatis
OR
Gonorrhea
OR
Syphilis
OR
Lymphogranuloma Venereum
OR
Sexually Transmitted Diseases, Bacterial/
OR
Sexually transmitted infections (search as keyword, this is not an
indexed term, it is a sub-set of STDs, bacterial).
Homosexuality, male OR men who have sex with men
Population
term
Prevention
term
2.4
Combine within and between
terms
STI term AND Population term
AND Prevention term
Primary prevention
Secondary prevention
Tertiary prevention
Control OR Communicable Disease Control
Health promotion
Harm reduction
Strength of Evidence
Nutley, Powell & Davies state that there is no simple answer to the question of what counts as good
evidence, as it depends on what we want to know, for what reason and in what contexts the
information will be used (17). RCTs are often considered the gold standard among study designs.
Although it is common to base hierarchies of evidence on study design, there are a number of
challenges inherent in this approach:
 Hierarchies based on study design tend to underrate the value of good observational studies.
 Insufficient attention is paid to what works, for whom, in what circumstances, and why.
 There may be ethical and logistical challenges associated with conducting RCTs for some public
health interventions.
The application of the traditional hierarchy of evidence poses challenges particularly for macro-, and in
some cases meso-level, STI prevention interventions. RCTs, and even observational cohort studies
involving a control group, are often not conducted. Yet the value of the available non-RCT evidence
should not be minimized.
The BC Core Programs Steering Committee supports the evidence scale presented in Figure 2. This scale
considers both theoretical and empirical studies as well as other factors of relevance in population level
health interventions. The scale was used to rate the level of evidence available for the various topics
covered in the current document.
The application of the evidence rating scale was guided by the detailed description of components that
comprise each evidence rating (e.g., corroboration of literature sources, sound theoretical rationale,
operational details, acceptance, etc.). The intervention evidence scale considers theoretical and
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empirical grounds, corroboration of findings, as well as other factors of relevance in population-level
interventions. This review is directed but non-systematic, and therefore it is possible that some
literature sources have been missed (particularly unpublished literature). The evidence has been rated
based only on identified studies; therefore there may be literature that is potentially relevant, and
would influence the rating scale if included. This might particularly affect the criteria related to
‘corroboration of evidence’.
Figure 2: Evidence Scale
Symbol
0
Evidence Rating
Limited investigation

Evidence is contraindicative

Warrants further
research

Evidence for
implementation

Evidence for outcome
effectiveness

Evidence for
dissemination
Definition
No relevant effectiveness studies were located and there were no
empirical or theoretical grounds suggesting the intervention might
potentially impact the outcome; may also indicate that the evidence is
inconsistent or contradictory.
Evidence is contra-indicative for the use of this strategy to prevent the
targeted outcome; consistent null or negative findings in well-controlled
evaluation studies.
Applied to strategies that appeared theoretically sound or have some
promising evidence for their implementation or outcome, but the
operational specifics of the delivery format are not clearly resolved or have
been investigated only in small scale or inadequately controlled studies.
Policies and programs utilizing these strategies might be considered
priority targets for future research funding on innovations to better define
service delivery.
Published studies reported a sound theoretical rationale, a clearly
specified service delivery format, acceptance within service delivery
organizations, target population recruitment on a scale sufficient to
usefully contribute to population health impacts, and adequate consumer
approval measured using indicators such as program retention. The
proportion of positive demonstrations of impacts on risk factors,
protective factors or outcome behaviours was reported.
Although this rating requires a clear service delivery format, in some cases,
not all other criteria are satisfied and in such cases this is indicated in the
summaries. Policies and programs utilizing these strategies might be
supported for implementation where there are few costs and obvious
benefits. In other cases, wider implementation may await rigorously
controlled outcome evaluation to better establish benefits.
Applied where positive outcomes were consistently published in well
controlled interventions. Interventions were required to be of sufficient
scale to ensure outcomes within the constraints imposed by large-scale
population health frameworks. Policies and programs utilizing these
strategies might be carefully monitored for their impacts while being
supported for wide-scale dissemination.
Published reports of impacts where programs were delivered on a large
scale, not by research teams, but rather by government auspice bodies or
other service delivery agents. Evidence for dissemination was only sought
for strategies demonstrating evidence for outcomes. Policies and
programs utilizing these strategies might be accorded some priority for
dissemination. Initial Canadian dissemination trials should monitor for
impacts. Where possible, cost-effectiveness has been considered for
programs using these strategies.
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2.5
Expert Review Panel
Once the review was complete, feedback from established experts in the field of STI prevention and
control was solicited. This group consisted of Dr. James Blanchard (Professor, Department of Community
Health Sciences; Director, Centre for Global Public Health University of Manitoba), Dr. Colin Lee
(Associate Medical Officer of Health, Simcoe Muskoka District Health Unit, Barrie Ontario), Dr. Ameeta
Singh (Medical Director, AHS-Edmonton STI Clinic; Clinical Professor, Division of Infectious Diseases,
University of Alberta), and Dr. Marc Steban (Medical Advisor, STI Unit, Institut National de Santé
Publique du Québec ). This group conducted a comprehensive review of the document, identified any
critical interventions missed and provided review and input of the evidence ratings.
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3.0 BACKGROUND
3.1
Health Implications
The bacterial STIs, gonorrhea, chlamydia and syphilis constitute a significant source of morbidity
provincially, nationally and globally, and are reportable infections in BC and Canada. The potential
health implications of bacterial STIs (i.e., signs and symptoms, and complications of untreated infection)
have common elements across age groups. Complications of chlamydia and gonorrhea can include
infertility, PID, ectopic pregnancy, urinary tract infections, and chronic pelvic pain (18). Pregnant females
with untreated chlamydia may transmit chlamydia to their babies during childbirth, and this may cause
neonatal conjunctivitis and pneumonia (19). Complications of chlamydia in males may include conditions
such as epididymoorchitis (19). If untreated, lymphogranuloma venereum (LGV) can cause serious
sequelae such as lymphatic obstruction or anogenital ulcerations (20). Among females, complications of
untreated gonorrhea may include PID, infertility, ectopic pregnancy, and among males complications of
gonorrhea may include epididymitis (21). Further, although rare, gonorrhea can also affect the joints
and blood (19). Syphilis, if left untreated, can progress through stages of infections (i.e., primary,
secondary, early latent stages and late latent phases), and the late latent phase may lead to
complications including damage to the central nervous system, cardiovascular system, eyes, skin and
other internal organs (19). In addition, untreated syphilis causes a multitude of symptoms, can extend
through several stages and may result in paralysis, numbness, blindness, dementia and death (18).
3.2
Special Considerations for Youth
Among youth, the consequences of STIs “can last a lifetime” (22), and STIs in youth raise concerns about
reproductive health throughout the reproductive years. A special focus on youth is important for a
number of reasons. First, the burden of STIs is disproportionately high among this population (described
below). Further, adolescence is often a period of multiple transitions (e.g., biological, cognitive,
psychological, social, etc.), and adolescents may be more sensitive to influences related to their social
context (8). Guidance may be sought and/or required from multiple and diverse sources, such as
parents, peers, schools and other institutions, providing potentially unique considerations for preventive
interventions (8). As well, health behaviours that are developed during adolescence can have long-term
health implications throughout subsequent life-stages (8). Finally, adolescents are not “little adults” and
therefore understanding STI risk and effective prevention may be “relatively unique to this life-stage”
(8). DiClemente et al. (23) summarized a complex web of factors related to sexual risk and protective
behaviors, and assert that these diverse factors that affect adolescents’ STI-related risk behaviour
should influence the design and implementation of risk reduction interventions. These factors include





Individual characteristics (e.g., personality traits, psychological states, self-efficacy, and
individual cognitions)
Relational factors (e.g., length of relationship and age of partner)
Familial characteristics (e.g., parental monitoring and support)
Community factors (e.g., school connectedness, poverty, and condom availability)
Societal factors (e.g., media exposure)
The authors assert that a reliance on individual-level models is not sufficient, and advocate for a
broader, ecological perspective that includes interventions at the family-level, school/workplace-level,
media-level, etc.
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Similarly, Ethier & Orr (8) in their chapter on prevention and control of STIs among adolescents, highlight
the importance of social environmental factors and social context (i.e., “the important people [e.g.,
peers, parents], places [e.g., neighbourhoods], institutions [e.g., schools, health care organizations], and
social processes [e.g., culture and policy] that can influence adolescent behaviour and health.” These
factors are key considerations for STI preventive interventions.
A common theme in most of the youth-specific literature is that social and community context, including
relationships with parents, peers, teachers and others, are essential components of youth STI
prevention. Interventions of this nature should form a key part of any STI control strategy among this
population.
3.3
Special Considerations for MSM
In addition to HIV, certain STIs remain more prevalent among MSM. The disproportionate burden of STI
borne by MSM exists within a larger context of health inequities rooted in a profound legacy of social
marginalization and discrimination which persists to this day (24). To effectively deal with STI epidemics
in this population, this broader inequity needs to be acknowledged and a more comprehensive
approach to STI control is warranted, where both interventions to reduce sexual health inequities at the
level of individuals, relationships, communities, and within society are necessary.
Wolitski and Fenton (24) describe sexual health among MSM as much more than just the presence or
absence of disease. They state that
It is a holistic concept that includes how MSM approach their sexual behavior and relationships,
how they feel about them, and how their physical and mental health are affected by them. Good
sexual health is important not only for MSM, but is an essential component of the overall health
and well-being of all people.
The focus in this report parallels the thoughts of Wolitski and Fenton (24). Although specific
interventions are presented and the evidence for each of these preventive interventions summarized,
sexual health for MSM is more than the sum of parts, and to achieve optimal health, we require “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. For sexual health
to be attained and maintained, the sexual rights of all persons must be respected, protected, and
fulfilled” (25).
As most of the literature on sexual health and MSM involve HIV to some degree, most of the
interventions reviewed have specifically been designed to address HIV but are included here as the
behavioural risk factor outcomes and secondary outcomes of STI testing were relevant to this review.
3.4
Review of Epidemiology of STI in BC
In general, during the past few decades there have been increased rates of diagnosed chlamydia,
gonorrhea, and infectious syphilis. In this section, surveillance trends for these infections are reviewed
at a high level, and key findings summarized from other BC studies. Please refer to the most recent
Annual Surveillance Report for Sexually Transmitted Infections in BC for more detailed information (26).
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3.4.1 Chlamydia
Chlamydia is the most common reportable STI in BC, and rates have been increasing since 1998 among
both males and females. In BC, in 2012, the rate of genital chlamydia was 267.9 per 100,000 population.
Genital chlamydia infection rates are higher among females compared to males, and the highest rates
are among individuals aged 20-24 years followed by individuals aged 15-19 years.
The reasons for the increase in the rates of chlamydia are not entirely understood, but are likely related
to a number of factors including increased screening, introduction of more sensitive and acceptable
tests, and possibly changes in behaviour. Rates may be higher in females due to greater screening for
asymptomatic infection as a result of routine gynaecologic and contraceptive care. Increased chlamydia
rates may also be a paradoxical result of improved public health control programs where improved,
timelier treatment and partner notification may be affecting the development of immunity to chlamydia
infection and increasing susceptibility to reinfection (27).
3.4.2 Gonorrhea
Gonorrhea rates have also increased since 1998 in BC, although recently provincial rates appear to be
stabilizing, particularly among females (28). In 2012, the rate of genital gonorrhea in BC was 28.1 per
100,000 population, with higher rates of infection among young adult males in their twenties. As with
chlamydia, increasing rates are likely due to a number of factors related to screening, changes in tests,
and possibly changes in behaviour. A possible explanation for higher rates of gonorrhea infection among
men include the fact that gonorrhea infections are more likely to be symptomatic in men (and trigger
testing). A greater number of infections among MSM may also explain increasing rates and has been
observed in some US regions (29) (30).
3.4.3 Infectious Syphilis
Rates of infectious syphilis in BC began increasing in 1997, and while rates decreased in 2009-2010, the
provincial rate is dramatically increasing to the highest annual rates observed in past decades (8.1 per
100,000 in 2012) (28). In BC, the resurgence of infectious syphilis initially began among individuals who
were street-involved, sex workers or their patrons. Cases peaked among these populations in 2003 and
have declined steadily since. Infectious syphilis cases in individuals who acquired infection through
heterosexual sex also increased, and have remained relatively stable.
However, currently MSM are disproportionately represented among BC cases of infectious syphilis,
accounting for 84% of all cases in 2012, and the number of new infections in this population is
continuing to increase (preliminary figures for 2013 are over 470 cases, up from 313 in 2012)
representing the highest rate in more than 30 years (31). Infectious syphilis among MSM is concentrated
among HIV positive men (66% of all MSM cases in 2012), and the increase in syphilis may in part reflect
changes in sexual networks among HIV positive MSM, and synergy between HIV and syphilis
transmission.
3.4.4 Other Data from BC Studies
Further information regarding self-reported STI diagnosis is available from a regional analysis of the
2005 Canadian Community Health Survey, which found that 5.5% (95% CI 3.5, 7.0) of individuals aged
15-24 years in BC reported ever being diagnosed with a STI, with approximately half of the proportion
seen among individuals age 25-49 years (32). This proportion was 6.7% (95% CI 4.2, 9.3) in Metropolitan
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areas; 4.2% (2.4, 6.1) in Southern non-Metropolitan areas; and 2.9% (95% CI 0.6, 5.1) in Northern nonMetropolitan areas (32).
The Adolescent Health Survey (AHS) (33) provides a comprehensive picture of the physical and
emotional health of BC youth, including information related to sexual health. In 2008, over 29,000 BC
public school students in grades 7-12 completed the survey, with 78% of BC youth reporting never
having had sexual intercourse. Among the 22% of male and female youth who reported having sexual
intercourse, the most common age for first having sex was 15. Of sexually active students, 47% of males
and 55% of females reported having had sexual intercourse with one person in the past year; 13% of
males and 5% of females indicated having had sex with six or more people in the past 12 months.
Overall, 1% of students reported they had been told by a doctor or nurses that they had an STI; this rate
was 4% for sexually active students. The rates of STI among sexually active students was 2% who had
one partner in the past year and 22% for those who had six or more sexual partners in the past year.
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4.0 MICRO-LEVEL INTERVENTIONS
The aim of this section is to consider STI interventions that occur between individuals. Limited literature
was found that had morbidity as an outcome (e.g., Pelvic Inflammatory Disease [PID], etc.), and no
papers were identified that had mortality as an outcome. This is not surprising since mortality due to
bacterial STIs is rare, and therefore to detect any measurable difference resulting from interventions
would require a very large sample size and be prohibitively expensive and resource intensive. Moreover,
because of the rarity of mortality as an outcome, even if one were able to detect a significant difference
with a large enough sample, the intervention would not be cost-effective. Appendix B provides a
summary of reviewed studies of the micro-level interventions.
4.1. STI/HIV Prevention Counselling and Behavioural Interventions
The review conducted by Wetmore, et al. (16) reported that two-thirds of the 27 published RCTs showed
significant behavioural effects and effects on STI rates, with 16 showing positive results and relevant to
this review (trials reporting on non-bacterial STIs as the only outcomes (34–49) were excluded here but
were not excluded in the original review by Wetmore, et al.). Only one study (50) showed an increased
risk for STIs in a subgroup analysis. All of the behavioural interventions identified by Wetmore et al.
included risk reduction counselling, while more than half also included a skills-building component (e.g.,
condom use, negotiation, communication skills). These interventions were found to have varied
effectiveness in reducing the risk of gonorrhea and/or chlamydia infection (9-83% reduction in risk),
probably owing to the fact that the interventions’ outcome measures were not homogeneous across the
studies. In general, behavioural interventions delivered in a small group setting were more successful
than interventions delivered one-on-one (79% of studies showing significant effects on STI risk versus
42%) and interventions that included skills building were more often effective than those that did not
(73% of studies versus 50%). Most of the trials Wetmore, et al. (16) found were conducted in the US
(22/27 [81]%).
There were limited studies addressing cost or cost-effectiveness. Given that many studies have
components that vary, it would be difficult to estimate cost-effectiveness for the different types of
behavioural interventions.
Sixteen RCTs and three additional studies were found that looked at behavioural interventions (see
below). Of the 15 RCTs that reported behavioural outcomes, nine studies (51–59) demonstrated a
positive effect on behavioural risk modification for participants and five (60–64) showed no significant
differences. Of the five RCTs that reported on risk of STI acquisition, four (57,59,65,66) reported
decreases in transmission rates and one (60) reported no significant differences. Effect estimates for the
positive trials ranged from a reduction of 38% of incident non-viral STIs (59) (OR 0.62, 95% CI 0.40-0.96)
to a 63% (65) reduction in incident STIs over 12 months (4.8 versus 13.2%, p < 0.01). Strathdee, et al. (66)
reported a 50% reduction in HIV/STI rates and Thurman, et al. (57) reported 52% and 39% reductions
(52%, p = 0.04; 39%, p = 0.04, respectively) in gonorrhea and chlamydia infections at 6 months.
Because of the wide range of behavioural intervention types, each specific intervention will be reviewed
separately. Some interventions presented in the studies could rightfully fall in more than one category;
for ease of comparison these are included in only one category.
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4.1.1 General Behavioural Interventions
General behavioural interventions include interventions based on knowledge transfer, risk reduction
counselling, skill development, and motivational support, without an emphasis on any particular
element. Effect sizes for STI acquisition ranged from a reduction of 20-75%, with a non-significant 11%
increase in one trial. Of the trials examined, there were three trials with significant differences between
intervention and control groups in health behaviours including increased reported condom use (OR 2-3),
decreases in total episodes of vaginal sex, decreases in total number of sex partners, and increases in
condom carrying. An additional three trials however, found no significant differences between
intervention and control groups in health behaviours. This is discussed in more detail below.
Kamali, et al. (35) looked at behavioural and STI interventions (information giving, education, and
communication activities) in rural Uganda and found that the incidence of active syphilis and prevalence
of gonorrhea were lower in the behavioural and STI intervention group than in the control group (RR for
syphilis: 0.52, 95% CI 0.27 – 0.98; prevalence ratio for gonorrhea: 0.25, 95% CI 0.10-0.64).
Harvey, et al. (61) looked at a health behaviour change model among heterosexual couples but found no
significant intervention effect found among couples at 3 months or among women at 6 months.
Chacko, et al. (60) looked at a client-centered motivational behavioural intervention to increase uptake
of STI check-ups in young women. They found no significant difference between study groups in seven
risk behaviours including: consistent condom use and movement along the stages of change compared
to baseline.
Kalichman, et al. (53) conducted a study involving a three-hour behavioural skills building intervention
that included educating women about the female condom, motivation of female condom use, and
behavioural skills building relevant to the female condom among African American women. Those who
received the intervention used the female condom to a greater extent at three months than the control
group (for those with one partner, 18.9% in the intervention group versus 16.6% in the health skills
comparison; and for those with two or more partners, 4.3% versus 1.4% used the female condom; p <
0.05).
Morrison-Beedy, et al. (55) looked at a sexual risk-reduction intervention, supplemented with post
intervention booster sessions for low-income, urban, teenage girls. Those receiving the sexual riskreduction intervention showed significant decreases in total episodes of vaginal sex at all follow-up visits
(mean number of episodes 15.94 at baseline, 10.94 at three months, 10.75 at six months, and 14.54 at
12 months for the intervention versus 14.68 at baseline, 13.13 at three months, 15.64 at six months, and
16.02 at 12 months, respectively for the control group, p < 0.05). A similar effect was seen in the
number of unprotected vaginal sex acts at three and 12 months (mean number of episodes for the
intervention 6.68 at baseline, 4.47 at three months, and 7.03 at 12 months versus 6.37 at baseline, 5.17
at three months, and 8.09 at 12 months in the non-intervention women). Finally the total number of sex
partners at six months was also lower in the intervention arm (0 versus 1, OR 0.536, 95% CI 0.311-0.926;
0 versus 2 or more, OR 0.368, 95% CI (0.191-0.706).
Kamb, et al. (36) compared two interactive HIV/STD counselling interventions (enhanced counselling and
brief counselling) to didactic prevention messages typical of current practice in heterosexual, HIVnegative patients aged 14 years or older. At three and six month follow-up visits, self-reported condom
use was 100% higher in both the enhanced counselling and brief counselling arms compared to those in
the didactic messages arm. At 12-month follow-up, there was a 20% absolute reduction of STI incident
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infections compared to the didactic messages arm (p = 0.008). During the second six months, rates of
infection were 9.1 versus 17.7% (p = 0.008). Over the entire 12 months, rates of infection were 16.8 in
the counselling arms versus 26.9% in the didactic messages arm (p = 0.004).
James, et al. (52) looked at an individually-focused counselling and skills training intervention, that
included three intervention arms: 1) participants receiving written materials with counseling 2)
participants receiving written materials only and 3) a control group in a genitourinary clinic in the United
Kingdom (UK). Participants in Arm 1 were significantly more likely than Arms 2 and 3 to report carrying
condoms when anticipating sexual intercourse with new partner (71% (Arm 1) versus 49% (Arm 2)
versus 63% (Arm 3), p < 0.05). There were no significant effects on levels of knowledge about correct
condom use, attitudes to condoms, self-reported condom use or incidence of STI.
Thurman, et al. (57) looked at the Sexual Awareness For Everyone (SAFE) behavioural intervention in
African- or Mexican-American adolescents and adults who were had been diagnosed with an STI. They
found that adults and teens randomized to the SAFE intervention had significant decreases in high-risk
sexual behaviours such as unprotected sex with an untreated partner (adjusted OR 10.53, 95% CI 4.3725.42) and in rapid (less than three months) partner turnover (adjusted OR 3.28, 95% CI 1.23-8.76).
Witte, et al. (64) studies an enhanced behavioural intervention based on social cognitive theory and a
relationship-oriented ecological perspective but did not find any significant differences in behavioural
outcomes between groups.
The one trial that had a behavioural intervention associated with an increased risk of STIs was in the
RESPECT-2 Trial (50). They looked at risk reduction counselling with rapid HIV testing among male and
female attendees aged 15-39 years of STI clinics in three US cities. They reported a non-significant
difference in incident STIs: 19% in the rapid HIV testing group and 17.1% of the standard testing group
(RR 1.11, 95% CI 0.96-1.29). In a subgroup analysis, this difference was significant among men (RR 1.35,
95% CI 1.06-1.70).
In a retrospective chart review of non-RCTs, In-iw, et al. (67) reported that those having health
education counselling were less likely to have recurrent STIs (adjusted OR 2.24, p = 0.041). In a pre-post
intervention study conducted by Ulibarri, et al. (68) the rate of unprotected sex that female Mexican sex
workers had with their clients was 2.23 times than the rate at follow-up p=<0.001) following a
behavioural intervention promoting condom use.
Summary: Results for trials looking at general behavioural interventions and risk reduction counseling
have been mixed. There is some evidence to support implementation of this strategy in limited settings
but further studies should be done evaluating the impact of this intervention on a wider scale.
Intervention
General behavioural
interventions and
risk reduction
counselling
Behavioural
outcomes

STI
incidence/prevalence

Population and Public Health, Ministry of Health
Contextual considerations and comments
Results of trials looking at general behavioural
interventions have been mixed. There is some
evidence to support implementation of this
strategy in limited settings but further studies
should be done evaluating the impact of this
intervention on a wider scale.
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4.1.2 Behavioural Interventions Stressing Ethnic Pride and Skill-building
Studies involving interventions stressing ethnic pride and skill-building were reviewed. These types of
interventions were generally found to be most effective for reducing the risk of acquiring STIs in ethnic
minorities (reduction of 40-83%). The first is a behavioural intervention (38) that involved four, fourhour group sessions for African American girls aged 14-18 years. The sessions emphasized ethnic and
gender pride, HIV knowledge, communication, condom use skills, and healthy relationships. Here the
rate of new chlamydia infections was significantly reduced (OR:0.17; 95% CI, 0.03-0.92, p = 0.04).
However, the results did not reach significance for trichomonas (OR: 0.37, 95% CI, 0.09-1.46, p = 0.16) or
gonorrhea (OR 0.14, 95% CI, 0.01-3.02, p = 0.21). Although the decreased rates or trichomonas and
gonorrhea were not significant there was a trend toward a reduction in risk.
Another study by Wingood, et al. (39) showed a large reduction in infection risk. They looked at a
behavioural intervention targeting mostly African American women (85%) emphasizing gender pride,
maintaining current and identifying new network members, HIV transmission knowledge,
communication and condom use skills, and healthy relationships in women with HIV in Alabama and
Georgia. They found that women in the intervention arm reported fewer episodes of unprotected
vaginal intercourse (1.8 versus 2.5, p = 0.022), and were less likely to report never using condoms (OR =
0.27, p = 0.008). They also found that women in the intervention group had a lower incidence of
chlamydia and gonorrhea (OR = 0.19, p = 0.006).
Other skills building interventions targeting ethnic minorities in the US included studies by Jemmott, et
al. (42,43) and Marion, et al (49). In 2005, Jemmott, et al. (42) looked at a skill-based HIV/STI riskreduction intervention in African American and Latino adolescent girls. Skills-intervention participants
reported significantly fewer episodes of unprotected sex at 12 months (mean [Standard Error], 2.27
[0.81] versus 4.04 [0.80], p = 0.03), and fewer sexual partners (mean 0.91 [0.05] versus 1.04 [0.05], p =
0.04). There was also fewer reports of new STIs (chlamydia, gonorrhea, and trichomonas) among the
skills-intervention participants (10.5% [2.9] versus 18.2% [2.8%], p = 0.05).
In 2007, Jemmott, et al. (43) looked at a brief HIV/STI risk reduction intervention in African American
women. Those in the skill-building interventions reported less unprotected sexual intercourse (Cohen’s
d[d] = 0.23, p = 0.02), and a greater proportion of protected sex (d = 0.21, p = 0.05). Intervention
participants were also less likely to test positive for an STI than control participants (d = 0.20, p = 0.03).
Marion, et al. (49) looked at a nurse practitioner directed, culturally specific, intensive intervention in
African American women having past STIs. Here, the probability of an intervention participant having an
STI at 15 months was 20% less than a control participant.
Summary: Behavioural interventions stressing ethnic pride and skill-building have been shown to be
effective in African- and Latino-American populations.
Intervention
Behavioural
interventions stressing
ethnic pride and skillbuilding
Behavioural
outcomes

STI
incidence/prevalence

Population and Public Health, Ministry of Health
Contextual considerations and comments
Behavioural interventions stressing ethnic
pride and skill-building have been shown to
be effective in African- and Latino-American
populations.
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4.1.3 Youth-focused Behavioural Interventions (Youth Supplemental Review)
Downs et al. (69) conducted a RCT involving a computer-based education initiative, that included a skillbuilding component, with a six month follow-up period. The intervention arm involved an interactive
video that was intended to increase the ability of young females to make fewer risky sexual decisions,
and was implemented among a sample of 300 adolescent girls (75% African American) in an urban
setting in Pittsburgh. The video included information about negotiation with sexual partners to reduce
STI risk, information about STIs, and condom access and use, and was intended to stand-alone (i.e., not
requiring a facilitator). The first control arm had the same content but in book form, and the second
control arm used brochures. These interventions were delivered at baseline, and had booster sessions at
one, three and six months. Adolescents in the intervention arm were significantly less likely to report
having been diagnosed with a STI (OR 2.79, p 0.05). However, the STI data was underpowered and
objective chlamydia diagnostic data did not detect a significant difference (OR -2.79, p = 0.56). Further,
based on self-report, females in the intervention arm were more likely to be abstinent in the first three
months following initial exposure to the intervention (OR -2.50, p = 0.027), however this did not
continue at the six month point. There were no significant differences in how frequently participants
reported using condoms, however between three and six months, intervention arm participants
reported significantly fewer condom failures.
Intervention
Computer-based
education and skill
building
behavioural
intervention for
youth
Behavioural
outcomes

STI
incidence/prevalence

Contextual considerations and comments
Note that the review of this study is intended to
complement the previous discussion of individuallevel behavioural interventions, and not stand on
its own. This particular computer-based program
that combined education and skill-building had
some positive behavioural outcomes (while others
did not differ from traditional print-based
materials) as well as lower rates of self-reported
STIs. However, objective STI data is uncertain.
4.1.4 MSM-focused Behavioural Interventions (MSM Supplemental Review)
The European Centre for Disease Control (ECDC) published a systematic review looking at behavioural
interventions in MSM (70). They looked at four RCTs and two controlled before-after studies. One of the
RCTs found significant differences in risk behaviours while the other three RCTs and two before-after
studies did not. The RCT that did find significant differences was that by Amirkhanian, et al. (71) They
looked at an educational session for Russian MSM in which a social network leader attended a group
training program which taught the leaders how to effectively communicate HIV prevention messages
and personal risk reduction advice to those in their network. They found that there was a significant
reduction in unprotected anal intercourse (UAI) at three months (RR 0.62, 95% CI 0.47-0.81), and UAI
with multiple partners at 12 months (RR 0.47, 95% CI 0.22-0.99). The other studies were by Harding, et
al. (72), Imrie, et al. (73), van Kesteren, et al. (74) (unpublished), Elford, et al. (75), and Flowers, et al.
(75). Harding, et al. looked at four group sessions about safer sex led by volunteers at a communitybased, volunteer-led organization. Imrie, et al. looked at standard 20 minute sexual risk behaviour
counselling plus one day of cognitive behavioural group workshop delivered by trained counsellors,
while van Kesteren, et al. looked at a self-help booklet with a face-to-face and telephone motivational
interviews delivered by specialist nurses. Elford, et al. looked at HIV risk-reduction education by trained
popular opinion leaders and Flowers, et al. looked at gay-specific services with a sexual health
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information hotline and bar-based sexual health promotion by trained peers. Only Imrie, et al. reported
on STI rates; all of the rest of these studies reported UAI with steady and casual partners with no
significant differences found for any of the reported outcomes. Imrie, et al. found that 58% (53/91) of
men in the intervention group and 43% (35/81) of men in the control group (adjusted odds ratio 1.84,
95% CI 0.99-3.40) were diagnosed with a new STI.
Herbst, et al. (76) looked at data from 33 studies and 65 citations. In their meta-analysis, they found that
overall interventions were associated with a significant decrease in unprotected anal intercourse (OR
0.77, 95% CI 0.65-0.92), reduction in number of sexual partners (OR = 0.85, 95% CI 0.61-0.94), and a
significant increase in condom use during anal intercourse (OR 1.61, 95% CI 1.16-2.22). They found
several intervention characteristics that were associated with effectiveness:
 Theoretical models—based on diffusion of peer norms or relapse prevention
 Interpersonal skills training—training MSM on negotiation and communication of safer sex and
assertiveness training
 More than four delivery methods, including counselling, group discussions, lectures, live
demonstrations, and role plays/practice
 Exposure complexity, including having more than one session, greater than four hours of total
exposure and more than a three week time span.
Johnson, et al. (77) published a Cochrane Review looking at behavioural interventions aimed at reducing
the risk of sexual transmission of HIV. They found 44 studies evaluating 58 interventions with a total of
18,585 participants. Forty interventions that compared to minimal or no HIV prevention intervention
reduced occasions for UAI by 27% (95% CI 15-37%). The other 18 interventions reduced UAI by 17%
when compared with other standard therapies (95% CI 5-27%). They included 26 small group
interventions, 21 individual-level interventions, and 11 community-level interventions. Studies found to
be most effective were:
 Those with a shorter intervention span, suggesting that a clear and focused risk reduction
message may be most effective
 Those that include efforts to promote personal skills, such as keeping condoms readily available,
avoiding excess intoxicants, self-reinforcement for behaviour change, and behavioural selfmanagement
 Those that focus on losses rather than gains, i.e., the discussion of the adverse effects of risky
sexual behaviour and HIV/STI infection are important
MSM who were classified as “non-gay” were found to be more responsive to behavioural interventions
than MSM who identified as “gay”. The authors postulate that this may be due to non-gay MSM having
less knowledge about STI and HIV prevention so that their initial exposure may have had greater impact.
It is interesting to note that although the reviews by Herbst, et al. (76) and Johnson, et al. (77) both
report findings from similar studies, the inclusion of newer studies by Johnson altered their findings that
interventions with a shorter intervention span were found to be more effective.
Summary: There is evidence to suggest that behavioural interventions are effective in reducing sexual
risk behaviours among MSM. However, there is a paucity of data for effectiveness in reducing STI and
HIV transmission risk. Interventions that were found to be most effective are those based on theoretical
models, interpersonal skills training, with multiple delivery methods, and a focus on the adverse effects
of risky sexual behaviour and HIV/STI infections.
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Intervention
Behavioural
interventions for
MSM
Behavioural
outcomes

STI
incidence/prevalence

Contextual considerations and comments
There is evidence to suggest that
behavioural interventions are effective in
reducing sexual risk behaviours among
MSM. However, there is a paucity of data for
effectiveness in reducing STI and HIV
transmission risk. Interventions that were
found to be most effective are those based
on theoretical models, interpersonal skills
training, with multiple delivery methods, and
a focus on the adverse effects of risky sexual
behaviour and HIV/STI infections.
4.1.5 Cognitive-behavioural Interventions Aimed at Preventing STIs
Boyer, et al. (40) looked at a cognitive-behavioural intervention on preventing STIs and unintended
pregnancies in female marine recruits. They found a higher risk of post-intervention STI or unintended
pregnancy among the control group compared to the intervention group (OR 1.41, 95% CI 1.01-1.98).
Among participants with no history of STIs or pregnancy but who engaged in risky sexual behaviours, the
control group was more likely to acquire an STI (OR 3.24, 95% CI 1.74-6.03).
Champion and Collins (65) looked at cognitive behavioral interventions versus enhanced counselling
among abused ethnic minority adolescent women. Although they did not report on any behavioural
outcomes, they reported that the cognitive behavioral intervention group had fewer STIs at 0-6 months
(0 versus 6.6%), 6-12 months (3.6 versus 7.8%) and 0-12 months (4.8 versus 13.2%) (all p < 0.01).
Peipert, et al. (45) looked at a transtheoretical model-tailored expert system intervention. Intervention
group participants were more likely to report use of dual contraceptive methods during follow-up
(adjusted hazard ratio, 1.7, 95% CI 1.09-2.66) but there were no differences among rates of STIs. They
also reported fewer sexual partners (2.06 versus 4.15, p < 0.001) and fewer acts of unprotected sex
(12.3 versus 29.4, p = 0.045). Those receiving the intervention were also less likely to acquire
subsequent STIs (50.4% versus 31.9%, p = 0.002).
Scholes, et al. (56) looked at a theory-based tailored minimal self-help intervention in women aged 1824 years. The intervention group reported significantly more condom use overall (adjusted OR 1.86, 95%
CI 1.32-2.65) and with recent primary partners (OR 1.97, 95% CI 1.37-2.86). They also reported using
condoms for a higher proportion of intercourse episodes, carried condoms, discussed condoms with
partners, and had higher self-efficacy to use condoms with primary partners.
Summary: There is some evidence that cognitive-behavioural interventions can help reduce the risk of
STIs and improve health behaviours.
Intervention
Cognitivebehavioural
interventions
Behavioural
outcomes

STI
incidence/prevalence

Population and Public Health, Ministry of Health
Contextual considerations and comments
There is some evidence that cognitivebehavioural interventions can help reduce the
risk of STIs and improve health behaviours.
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4.1.6 Brief Behavioural Interventions
Brief behavioural interventions consist of interventions that are intended to be delivered over a short
period of time (less than half an hour). Generally, these interventions have shown to be effective in
decreasing the risk of STI acquisition by 40-50% and in reducing risky sexual behaviours.
Patterson, et al. (44) looked at a brief behavioural intervention to promote condom use among Mexican
female sex workers. They addressed four main areas: (1) motivations for practicing safer sex; (2) barriers
to condom use; (3) techniques for negotiating safer sex with clients; and (4) enhancement of social
supports. There were increases in the number and percentage of protected sex acts with clients (p <
0.05). Cumulative STI incidence in the intervention versus control groups was 13.8 versus 24.92 per 100
person-years (p = 0.034); a 40% decline.
Warner, et al. (46) looked at brief STI prevention messages in a video shown at a high volume STI clinic.
Patients assigned to the intervention had significantly fewer STIs compared with the control group
(hazard ratio, 0.91, 95% CI 0.84-0.99).
Crosby, et al. (47) looked at a brief, clinic-based safer sex program administered by a lay health adviser in
young African American men newly diagnosed with an STI. Those receiving the intervention were more
likely to report using condoms during last sexual intercourse than the control group (72.4% versus
53.9%, p = 0.008).
Grimley and Hook (48) looked at a brief face-to-face behavioural intervention among African Americans.
The intervention consisted of a computer program designed to assess risk behaviours and generate
brief, tailored counselling messages. In the intervention group, 32% reported consistent condom use
versus 23% in the comparison group (p = 0.03). Moreover, the combined gonorrhea and chlamydia
incidence declined to 6% in the intervention group versus 13% in the comparison group (p = 0.04).
Guilamo-Ramos, et al. (51) looked at a parent-based intervention delivered to Latino and African
American mothers in a pediatric clinic. They found statistically significant, reduced rates of transitioning
to sexual activity and frequency of sexual intercourse at 9-month follow-up in the control versus
intervention group (22.2 versus 6.8%, p < 0.05).
Krauss, et al. (54) looked at a brief one pretest assessment session intervention for female partners of
male injection drug users aimed at influencing perceptions of partner risk, HIV knowledge, correct
condom usage, and self-reported consistent safer sex. Women were randomly assigned to three
education modalities. They found that a higher proportion of women who took the pretest assessment
reported consistent safer sex (66.7%) versus those who did not (55.6%). The adjusted OR was 0.22 (95%
CI 0.06-0.78). Among women who did not take pretests, 76.9% of women who were randomized to an
interactive education session reported consistent safer sex versus 33.3% of women who received a noninteractive safer sex pamphlet.
Proude and D’Este (62) looked at the impact of a brief advice intervention initiated in routine
consultations in family practice settings for young adults. Self-reported behaviour did not change
significantly.
Senn, et al. (63) looked at a motivational brief intervention and provision of condoms. There was no
significant difference among the groups in terms of condom use.
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Strathdee, et al. (66) looked at brief combination interventions with four different groups: Group A was
defined as didactic injection risk intervention and didactic sexual risk intervention; Group B was defined
as an interactive injection risk intervention and didactic sexual risk intervention; Group C was defined as
an interactive sexual risk intervention and didactic injection risk intervention; Group D was defined as an
interactive injection risk intervention and interactive sexual risk intervention. They found that the
adjusted RR for HIV/STI incidence for group B was 0.88 (95% CI 0.40-1.94), for group C, 0.38 (95% CI
0.16-0.89), for group D, 0.37 (95% CI 0.16-0.89), relative to group A. HIV/STI incidence decreased by over
50% in the interactive sex intervention compared to didactic controls.
Trent, et al. (58) looked at a brief behavioural intervention provided at the time of diagnosis of pelvic
inflammatory disease (PID) in young adolescents aged 15-21 years. The intervention groups had higher
rates of PID at 72-hour follow-up (32 versus 16%) and higher rates partner treatment (71 versus 53%), p
= 0.1. There were no differences in medication completion, sexual abstinence or partner notification.
Laughon, et al. (78) conducted a study examining the impact of an intervention consisting of a 10 minute
counselling session with intimate partner violence information, danger assessment, safety planning and
options and reviewing resources as components. They reported no significant difference in behavioural
outcomes.
Gold, et al. (79) looked at youth and young adults aged 16-29 years recruited from a music festival in
Melbourne, Australia. Participants completed a survey and provided their mobile phone numbers. They
then received SMS messages every two weeks relating to sexual health for four months, and then
completed an online follow-up survey. With 40% follow-up, 80% found the SMS entertaining, 68% found
it informative, and 73% showed the SMS to others. There was a significant increase in knowledge (p <
0.01) and STI testing (p < 0.05) over time in both males and females.
Jones, et al. (80) examined the influence of a Facebook page that addressed the signs, symptoms,
treatment, screening, and prevention of chlamydia infection. Educational components included: reasons
adolescents and young adults have unprotected intercourse; signs, symptoms, and complications of
chlamydia infection; treatment and testing information with links to area providers; myths and facts
about chlamydia contagion; STI prevention and transference, including correct condom application and
safe sex practices, and how to talk to one’s partner and parents once a diagnosis occurs. Video links and
links to other website (US CDC) were on the page. Participants “friended” on the site were invited to
complete a follow-up survey. The authors found a 23% increase in self-reported condom use and a 54%
reduction in positive chlamydia cases among 15- to 17-year olds.
Summary: There is evidence that cognitive-behavioural interventions can help reduce the risk of STIs
and improve health behaviours. Many of these studies were done in African- and Latino-American
populations and young adults.
Intervention
Brief
behavioural
interventions
Behavioural
outcomes

STI
incidence/prevalence

Population and Public Health, Ministry of Health
Contextual considerations and comments
There is evidence that brief behavioural
interventions can help reduce the risk of STIs and
improve health behaviours. Many of these studies
were done in African- and Latino-American
populations and young adults.
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4.2
Small Group Sessions
Small group sessions generally have been found to be effective in reducing the risk of STIs by 30-40%.
Shain, et al.(37) looked at three small-group sessions, lasting three to four hours each, designed to help
women recognize personal susceptibility, acquire necessary skills and commit to changing their
behavior. This study was conducted with Mexican American and African American females with nonviral STIs. During the first six months, rates of subsequent infection among the intervention group was
11.3% compared to 17.2% in the control group (p = 0.05).
Shain, et al. (34) looked at standard and enhanced support small group interventions that were genderand culture-specific for Hispanic American and African American women. Adjusted chlamydia and/or
gonorrhea infection rates were higher in controls than in the enhanced in year one, year two, and
cumulatively (26.8 versus 15.4% (p = 0.004), 23.1 versus 14.8% (p < 0.03), 39.8 versus 23.7% (p < 0.001),
respectively) and in the standard arm (26.8 versus 15.7% (p = 0.006), 23.1 versus 14.7% (p = 0.03), 39.8
versus 26.2% (p < 0.008), respectively).
Summary: Small group sessions have been shown to positively affect risk behaviours and reduce the risk
of STIs in African- and Latino-American women.
Intervention
Small group
sessions
4.3
Behavioural
outcomes

STI
incidence/prevalence

Contextual considerations and comments
Small group support sessions have shown to
positively affect risk behaviours and reduce the risk
of STIs in African- and Latino-American women.
Peer Education
Feldblum, et al. (41) looked at peer education supplemented by individual risk reduction counselling by a
clinician compared to condom promotion by peer educators among female sex workers in Madagascar.
The OR for chlamydia, gonorrhea, Trichomoniasis and aggregate STI were 0.7 (95% CI, 0.4-1.0), 0.7 (95%
CI, 0.5-1.0), 0.8 (95% CI, 0.6-1.2) and 0.7 (95% CI,0.5-0.9), respectively.
Ramesh, et al. (81) looked at the impact of a large-scale HIV prevention program for female sex workers
in India. Over 85% of female sex workers reported contact by a peer educator and having visited a
project STI clinic. Compared with baseline, there were reductions in high-titre syphilis (adjusted OR 0.53,
95% CI 0.37-0.77, p = 0.001) and chlamydia and/or gonorrhea (adjusted OR 0.72, 95% CI 0.54-0.94, p =
0.02). Reported condom use at last sex increased significantly for repeat clients (adjusted OR 1.98, 95%
CI 1.58-2.48, p < 0.001).
Bhattacharjee, et al. (82) looked at the role of membership in peer groups in reducing HIV-related risk
and vulnerability among female sex workers. They found that peer group members participating in the
integrated biological and behavioural assessments had a lower prevalence of chlamydia and/or
gonorrhea (5.2 versus 9.6%, p > 0.001) and of syphilis (8.2% versus 10.3%, p < 0.05) compared to nonmembers.
Summary: Peer education sessions have been shown to be effective in reducing STI rates and increasing
condom usage among female sex workers in developing nations.
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Intervention
Peer
education
4.4
Behavioural
outcomes

STI
incidence/prevalence

Contextual considerations and comments
Peer education sessions have been shown to be
effective in reducing STI rates and increasing condom
usage among female sex workers in developing
nations.
Online Interventions Targeting Youth (Youth Supplemental Review)
The importance of STI screening and treatment in detecting STIs (including asymptomatic infection) and
preventing STI sequelae, is well recognized. However, barriers exist to accessing screening in traditional
health care facility settings, including for individuals age 15-24 years (e.g., lack of transportation, cost,
and confidentiality issues) (83). Online (internet-based) sexual health interventions are proposed as a
potential intervention to promote access for young populations. Online/computer-based interventions
may offer advantages over face-to-face interventions, in that access can be anonymous, repeated and
utilized at convenient times (84). Such services may include those described in box 2 below.
Box 2: Internet-based sexual health services (85)



Testing services (e.g., online risk assessment questionnaires, lab test requisition forms)
Counseling and education services (e.g., online counseling delivered through chat, forums or emails, as
well as referrals to services elsewhere)
Partner notification (e.g., online documents sent “peer-to-peer” either with personal identifiers or
anonymously)
Acceptance for online services has been studied by Shoveller et al. (85) who explored the perspectives
of sexually active individuals age 15-24 years in the Vancouver, BC area (n = 38 males and 14 females) on
online STI/HIV risk assessment, testing, and online sexual health counseling and education. Participants
felt that online testing allowed for immediate access to testing, rather than waiting for clinic
appointments, which was rated favourably in terms of convenience. The anonymity of the online
environment, rather than having to deal with health professionals face-to-face, was also rated
favourably by many participants, while a small number expressed concern that an online service may
not be as comprehensive as an in-person assessment. The opportunity to receive counseling and
education online (e.g., chatting live with a nurse) was rated favourably for potentially prompt responses
while maintaining anonymity. Email communication was rated less favourably due to less expediency.
Similarly, there were apprehensions expressed about posting questions on a forum that could be read
by others, although reading the posts by others was more acceptable. Generally it was important to
participants that technologies should be up-to-date (e.g., printing lab requisition forms was viewed
unfavourably).
The online interventions identified among youth are categorized in their appropriate intervention
category where applicable (e.g., screening outreach). Where the intervention does not fall into a specific
category, or it crosses multiple categories, it is presented below.
Guse et al. (86) conducted a systematic review of the impact of “new digital media” (i.e., the internet,
text messaging, social networking, etc.) on sexual health knowledge, attitudes and/or behaviours of
youth age 13-24 years. With respect to behaviour, three included studies demonstrated a significant
impact of new digital media on youth behaviours (e.g., lower likelihood of sex initiation and changes
public profiles including the removal of references to sex). Impacts on self-efficacy for condom use were
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inconsistent, and a number of other psychosocial variables (e.g., perceived susceptibility, intention to
engage in sex) also had inconsistent results. The feedback about the new digital media interventions
themselves were generally positive.
A 2010 Cochrane Review by Bailey et al. (84) examined RCTs of interactive computer-based
interventions (ICBI) for sexual health promotion. For the purpose of this review, interactive was defined
as “packages that require contributions from users (e.g., entering data, making choices) to produce
tailored material and feedback that is personally relevant.” This review included participants of any age
and therefore was not limited to youth; however young people are identified as a higher risk group and
it is acknowledged that the internet is a particularly appropriate way to deliver sexual health promotion
to young people in high-income countries because they are often frequent and are confident users of
internet technology. A number of studies focused on youth. Results from the meta-analysis showed that
ICBI had a statistically significant effect on sexual knowledge and behaviour, however, there was
insufficient data to conduct a meta-analysis of biological outcomes. Implications for youth specifically
were difficult to ascertain given the broad population inclusion criteria.
Among individuals age 15-24 years in a community in the US Midwest, an STD prevention education
intervention was disseminated through Facebook (80). The site was named Caryn Forya to reflect a
focus on caring for youth (“caring for ya”), and to resemble the name of an actual Facebook user. The
site contained information about the reasons youth have unprotected intercourse, information about
chlamydia infection, testing information and links to testing sites, STI prevention information, how to
talk to partners and parents if an individual is diagnosed with a STI, etc. Although a number of
encouraging findings were reported, concerns about study limitations make interpretation difficult.
Based on self-reports by individuals who accessed the Facebook site and were willing to complete the
questionnaire, the reported proportion of participants testing positive for chlamydia declined from 26%
in 2008 to 14% in 2010, and there was a there was a 23% increase in condom utilization. Yet it appears
that of over 800 individuals who “friended” the site, and an unknown number of others who viewed the
site but did not “friend” it, only 70 completed a study questionnaire (70% female and 30% male).
Summary: Evidence suggests that there is acceptability among youth to utilize online/computer based
interventions to access information related to sexual health and to test for STI, which can have a positive
impact on behavioural outcomes.
Intervention
Online interventions
targeting youth (general
or multiple
interventions)
Behavioural
outcomes

STI
incidence/prevalence

Contextual considerations and comments
Systematic review/meta-analysis data
suggests that “new digital media/interactive
computer-based” interventions, can have a
positive impact on behavioural outcomes.
Determining impact on STI rates would
benefit from further research.
Acceptance is high among youth.
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4.5
Screening and Treating Chlamydia to Prevent Pelvic Inflammatory
Disease
Gottlieb, et al. (87) conducted a systematic review on screening and treating for chlamydia infection to
prevent PID. They evaluated four RCTs:




Scholes, et al. (88) randomly assigned women enrollees in a US health maintenance organization
to either receive testing for chlamydia trachomatis or to receive usual care. The women were
followed for one year. Sixty-four percent of the 645 women in the screening group were tested
for chlamydia; 7% tested positive and were treated. At the end of one year, nine verified cases
of PID occurred in the screening group, while 33 occurred in the group receiving usual care for a
RR of 0.44 (95% CI, 0.20-0.90).
Ostergaard, et al. (89) compared the effectiveness of a screening program for urogenital
chlamydia infections based on home sampling with that of a screening program based on
conventional swab sampling performed at a physician’s office (control group) in Denmark. At
one year, 51.1% of the 867 women in the intervention group and 58.5% of the women in the
control group were followed up. Nine women (2.1%) in the intervention group, and 20 (4.2%) in
the control group required treatment for PID (p = 0.045).
Andersen, et al. (90) conducted a study involving 4000 women and 5000 men in a county in
Denmark. Participants were offered an opportunity to be tested for chlamydia trachomatis by
means of a home sample that was mailed directly back to the laboratory. The control group was
the rest of the population living in the county (11,459 women and 9980 men). All were followed
for nine years by Danish health registers. At the end of the study period, among women, there
were no significant differences between the intervention group and control group in terms of
PID, ectopic pregnancy, infertility, IVF treatment, or births. In men, there was no significant
difference in epididymitis.
The most methodologically rigorous of these studies, the POPI trial conducted by Oakeshott
(91), involved female college students in the United Kingdom. They found that the incidence of
PID in screened women was 1.3% compared with 1.9% in controls (RR 0.65, 95% CI 0.34-1.22).
Taken together, although these results demonstrate direct evidence that chlamydia screening and
treatment can reduce the risk of PID, the effect of interventions ranges form no significant difference to
45%. This has caused some research to state that the benefits of screening may be overstated (87).
Several other articles were found that looked at various forms of screening with behavioural outcomes.
Scholes, et al. (92) examined the use of chart prompts for health care providers to screen for chlamydia.
The chart prompt intervention had no significant effect on screening among participants. Furthermore,
Walker, et al. (93) looked at computer reminders for chlamydia screening in Australian general practices.
In this cluster randomized trial, chlamydia testing increased from 8.3% to 12.2% in the intervention
group and from 8.8% to 10.6% in the control group (both p < 0.01). Overall the intervention group had a
27% (OR 1.3, 95% CI 1.1-1.4) greater increase in testing. Short messaging service (SMS) has been looked
at in several settings as reminders for youth to get screened, and also as a health promotion tool.
Dokkum, et al. (94) evaluated a chlamydia screening reminder program that used email and SMS. This
study was conducted in the Netherlands in which a register and internet-based Chlamydia Screening
Implementation (CSI) was started in 2008 in several regions among 16-29 year old sexually active youth
and young adults. Automated respondent reminders were sent by letter, email and SMS, in sequential
order. Forty-two percent of all package requests were made after the reminder letter. There was a
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significant increase of invitees returning a sample (10 – 14%) after email/SMS reminders. STI rates were
not reported.
Summary: Taken together, although these results demonstrate direct evidence that chlamydia screening
and treatment can reduce the risk of PID, the effect of interventions ranges from no significant
difference to 45%. Chart and computer prompts and reminders for STI screening may increase testing
but more research on this intervention is warranted.
Intervention
Screening and
treating for STI to
prevent PID
Behavioural
outcomes
N/A
STI
incidence/prevalence

Contextual considerations and comments
RCTs have shown a decreased risk of PID in
those screened for chlamydia in studies in
developed nations, but the benefits of screening
may be overstated.
4.5.1 Youth-focused Home-based STI Screening (Youth Supplemental Review)
Using screening tests at home, rather than attending a health clinic may address the barriers of privacy,
embarrassment, clinic accessibility, time and finances associated with health care visits (95).
Cook et al. (95) conducted a RCT (the Detection Acceptability Intervention for STDs in Youth [DAISY]
study) among females age 15-24 years who had a recent STI (chlamydia, gonorrhea or Trichomoniasis)
or had certain risk factors including age <20 years, African American, monthly douching, >1 sexual
partner in the past year or living in a neighbourhood with higher chlamydia rates (n = 403); 70% of the
sample was African American. The intervention group received a home testing kit for testing at 6, 12 and
18 months (serial home screening tests) that the majority received by mail, while a small number picked
up the kit from their neighbourhood clinic. The comparison group received a postcard invitation to
attend a medical clinic for testing during the same intervals (serial clinical attendance invitations). The
home testing group mailed samples directly to the study laboratory. Seventy-one percent of the
intervention group returned at least one home test, and 10% of these tests were positive for chlamydia
and/or gonorrhea. Although significantly more chlamydia and gonorrhea tests overall were completed
per year by the home testing group (1.94 vs. 1.41 test per women-year, p <0.001), and more specifically
asymptomatic tests (1.18 vs. 0.7 tests per woman-year, p<0.001), there was no significant difference in
the incidence rate of STIs detected (20.4 vs. 24.1 infections per 100 woman-years, p = 0.28) as well as
when disaggregated for chlamydia or gonorrhea.
A RCT conducted in Denmark by Østergaard et al. (89) involved a sample of students in highschool. The
intervention group (n = 867) were tested for chlamydia by home sampling and the control group (n =
833) were tested in a physician’s office. At one year, 2.9% of the intervention group had a new
chlamydia infection, compared to 6.6% of the control group (p = 0.026). Furthermore, significantly fewer
women in the intervention group reported being treated for PID compared to the control group (2.1%
vs. 4.2%, p = 0.045). Therefore, this study suggests that a home sampling screening strategy for youth is
associated with a lower prevalence of chlamydia and less reported PID.
Similarly, Østergaard et al. (96) conducted a cluster RCT to evaluate home testing for chlamydia.
Seventeen highschools in Denmark were randomized to a home sampling intervention arm
(approximately 188 students), or standard of care testing (i.e., students were offered testing at their
doctors or at the local clinic) as a control arm (approximately 1400 students). Significantly higher testing
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rates were observed among the intervention group (93.4%) compared with 7.6% in the control group (p
< 0.001); a similar effect was seen among males (97.3% vs.1.6%) (p < 0.001). Forty-three women were
found to be infected with chlamydia (4.6%) compared with five in the control group (0.6%), representing
a significantly higher detection rate in the intervention group (p <0.001). A similar increase in detection
rates were seen among the males (11 [2.5%] and 1 [0.4%), (p < 0.05). Note that among those that
presented for testing, a significantly higher proportion of control group participants reported symptoms.
Finally, a large population-based RCT in Denmark (97) among individuals age 21-23 years (n = 30,439)
also found a significantly higher chlamydia testing rate with home sampling. This study involved three
groups: Group 1 was mailed a home sampling kit directly to their residence address; Group 2 was mailed
a reply card to their home address that participants could use to order a home sampling kit; and Group 3
had access to usual care (i.e., participants could visit a physician for usual testing). The two intervention
groups (Groups 1 and 2) also had the opportunity to receive usual care in a physician’s office. The rate of
testing for female participants in Groups 1 and 2 was three to four times higher than the rate in Group 3
(relative risk [RR] 4.1 [959% CI 3.8-4.4] and 3.5 [95% CI 3.2-3.9], respectively). A similar difference was
observed among males (RR 19.1 [95% CI 16.0-22.8] and 11.8 [95% CI, 9.8-14.2] in Groups 1 and 2,
respectively). Among the women in Groups 1 and 2 that submitted samples, 6.5% and 8.0% tested
positive for chlamydia, respectively (p = 0.37); in Group 1, 54.8% of infections were asymptomatic and in
Group 2, 50.0% (21/42) were asymptomatic. Among males, 5.9% and 5.7% tested positive for chlamydia
in Groups 1 and 2, respectively; 76.3% and 77.3% of infections in Groups 1 and 2 were asymptomatic,
respectively. Note that the prevalence of chlamydia was higher among those who sought testing in a
physician’s office (both among intervention participants who also sought care in a physician office and
for the control group – 12.6%, 9.0% and 10.0% for females, and 27.0%, 19.4% and 19.3% for males,
respectively). More women in Group 1 disliked the intervention strategy of having the kit mailed directly
to their home, which suggests that the use of a reply card (Group 2) may be preferred among female
participants. However, for men, more infections were detected using the direct kit mailing strategy
which suggests this might be preferred over sending a card to initiate kit distribution.
Summary: Using screening tests at home rather than attending a health clinic may address some barriers
to STI screening that youth experience. Some studies suggest that home STI screening for youth is
associated with a higher uptake and detection of STI testing.
Intervention
Home-based
STI testing for
youth
Behavioural
outcomes
For promoting
testing and STI
detection
STI
incidence/prevalence

Contextual considerations and comments
Although not all studies have found a differential
impact on STI detection, the bulk of the evidence
suggests that home-based STI testing has
advantages over traditional face-to-face/clinic
testing in promoting testing uptake among youth,
as well as detecting STIs.
4.5.2 MSM-Focused STI Screening (MSM Supplemental Review)
Despite the recommendations of selective testing by US and Canadian public health bodies, there is
evidence to suggest that such screening will miss many STIs. Van Liere, et al. (98) found that the
sensitivity of selective symptom- and sexual history-based testing for anorectal chlamydia and
gonorrhea was 52% for homosexual MSM, 40% for bisexual MSM, 43% for bisexual male swingers
(defined as heterosexual couples who have sex with other heterosexual couples and their self-identified
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heterosexual sex partners), 40% for heterosexual male swingers, and 47% for female swingers. Cachay,
et al. (99) also looked at the sensitivity for self-reported exposure to predict anorectal STI. They found
the sensitivity for self-reported exposure to be 86-100% in a primary care clinic, but only 12-35% in a
high resolution anoscopy clinic. Thus, certainly in high risk patients, screening based on sexual history
alone will miss many infections.
Sexton, et al. (100) looked at self-collection testing for pharyngeal and rectal chlamydia and gonorrhea
in a sample of patients in a large US city. They randomized patients to either self-sampling first or to
have provider-collected testing. Instructions as to how to collect samples at the two sites were given to
patients. The Kappa coefficient in comparing provider and patient test results were significant in testing
for rectal and pharyngeal gonorrhea (0.76 and 0.79, respectively). In 23 cases the patient identified a
positive result when the provider’s result was negative and in only one case did a provider identify a
positive result when the patient’s result was negative. One limitation of this study is that the four
providers who performed the testing were not physicians (one was a nursing student, one was a medical
student, and two were clinical research assistants), although they were all previously trained in STI
testing techniques.
Chesson, et al. (101) looked at two different mathematical models for rectal chlamydia and gonorrhea
screening to prevent HIV infection in MSM—a base case, in which only benefits to those screened were
included; and a dynamic version, in which the population impacts were also looked at. The cost per
quality-adjusted life year (QALY) gained through screening MSM for rectal chlamydia and gonorrhea was
$16,300 in the static version of the model and the cost per quality adjusted life year gained was less
than $0, meaning the measure was cost-saving. Future costs and benefits were discounted at 3%
annually to arrive at a present value in 2011 US dollars. It is important to note that this analysis looked
only at the costs associated with HIV, as the authors note that those with a recent history of rectal
chlamydia and/or gonorrhea are at increased risk of acquiring HIV than MSM with no history of rectal
chlamydia or gonorrhea (102–104).
Tuli, et al. (105) looked at three different mathematical models to examine the cost effectiveness of a
screening, treatment, and condom provision intervention for MSM inmates at the Los Angeles County
Men’s Jail. In the first scenario, in which no sex occurs in the jail, the costs of the screening program over
10 years is estimated to be about $180,000 in March 2000 US dollars, assuming a 3% discount rate. The
program would be cost saving in two scenarios: those in which men continue to have sex with other
men as before incarceration, and in a scenario in which men continue to have sex with other men but
with 20% condom use.
Vriend, et al. (106) used a mathematical model to compare anorectal chlamydia screening among MSM
in care at HIV treatment centres. Costs were discounted at 4% per year. They found that once yearly,
routine screening in MSM for anorectal chlamydia was cost saving if they did not seek care elsewhere.
Costs included in this analysis included referral to an STI clinic for further testing, treatment, counselling,
and partner notification. They also added a delay for the start of costs of HIV treatment with
combination antiretroviral drug therapy. The authors took into account costs associated with chlamydia
treatment, partner notification, and counselling, unlike the study by Chesson, et al. (101).
Summary: While one study showed some promise in self-screening, limitations in the control group
mean that this strategy cannot yet be recommended and more research is needed. There is evidence for
once yearly anorectal screening for chlamydia and gonorrhea among MSM and that selective screening
based on history may miss many infections.
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Intervention
Self-screening
Universal anorectal
screening for
chlamydia and
gonorrhea for MSM
4.6
Behavioural
outcomes
N/A
STI
incidence/prevalence

N/A

Contextual considerations and comments
While one study showed some promise in selfscreening, limitations in the control group mean
that this strategy cannot yet be recommended.
More research is needed.
There is evidence for once yearly universal
anorectal screening for chlamydia and gonorrhea
among MSM. This recommendation rests on the
fact that three studies have shown this to be costsavings and the fact that selective screening based
on history may miss many infections.
Abstinence and Reduction of Sexual Partners
Abstinence-related literature, while intended to affect individual behaviour, is often implemented in a
group setting (e.g., through a group education program). Therefore, the published literature on this
topic is presented in the meso-level interventions section. Furthermore, among individuals who are
currently being treated for an STI, counselling that encourages abstinence until completion of the entire
course of medications is recommended (CDC, 2010). For those starting a mutually monogamous
relationship, screening for common STIs before initiation of sex might reduce the risk for future disease
transmission.
4.7
Male Condoms
Latex condoms use can lower the risk of recurrent PID, chronic pelvic pain or infertility, following an
initial episode of PID (107). Ness (107) conducted a cohort study among African American females aged
24 years or younger who had an initial episode of PID. After adjusting for confounders, the RR was 0.5
(95% CI, 0.3-0.9) for recurrent PID, 0.4 (95% CI 0.2-0.9) for infertility, and 0.7 (95% CI, 0.5-1.2) for chronic
pelvic pain. Holmes, et al. (108) conducted a systematic review looking at the effectiveness of condoms
in preventing bacterial STIs. They found four studies (109–112) addressing condom usage in preventing
bacterial STIs. Ahmed, et al. (109) found that in a cohort study in Uganda, consistent condom use
reduced the risk of syphilis (OR 0.71, 95% CI 0.53-0.94), and gonorrhea/chlamydia (OR 0.50, 95% CI 0.250.97). Crosby, et al. (110) conducted a study among American youth aged 14-18 years. They found that
the RR of acquiring chlamydia gonorrhea or Trichomoniasis among youth with non-consistent condom
use compared to those reporting 100% condom use was 1.69 (95% CI, 1.16-2.46). Macaluso, et al. (112)
found that among American female patients at STI clinics who were considered to be at high-risk for
STIs, consistent and correct use of latex male or female condoms was associated with a statistically
significant reduction in combined incidence of gonorrhea, chlamydia or syphilis compared to use of less
than 50% (effect size not available). Sánchez, et al. (111) conducted a study among Peruvian female sex
workers at two STI clinics. Compared with women who did not report consistent condom use, there was
a statistically significant 62% reduction in the risk of acquiring gonorrhea and 26% reduction in the risk
of acquiring chlamydia. Taken together, these studies show that, at least for self-reported consistent
condom use, there likely is a clinically significant reduction in risk of transmission (30-70%) of bacterial
STIs.
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Summary: Male condoms have been shown to be highly effective in preventing the transmission of STIs.
Studies have been done in a variety of settings in North America and in developing nations.
Intervention
Male
condoms
4.8
Behavioural
outcomes
N/A
STI
incidence/prevalence

Contextual considerations and comments
Male condoms have been shown to be highly effective
in preventing the transmission of STIs. Studies have
been done in a variety of settings in North America and
in developing nations.
Female Condoms
Female condoms have been shown to be an effective mechanical barrier to viruses and to semen (113).
Wetmore, et al. (16) found three trials (114–117) looking at female condoms; in comparison to male
condoms, none of the three trials found any significant reduction in the risk of STI acquisition. Follow-up
rates were over 75% in these trials, but uptake of the female condom was low. There is also a lack of
safety data on anal intercourse. Although female condoms are costly, a female condom is recommended
when a male condom cannot be used properly or when male condom use cannot be negotiated.
Intervention
Female
condoms
4.9
Behavioural
outcomes
N/A
STI
incidence/prevalence

Contextual considerations and comments
Although the female condom, as a technology, is
effective as a mechanical barrier to viruses and semen,
poor uptake of the female condom and cost limit its
recommendation for wide dissemination. However, it
should be noted that there is a lack of safety data on
usage during anal intercourse.
Cervical Diaphragms
The cervical diaphragm is a barrier form of birth control and has been shown to protect against cervical
gonorrhea, chlamydia and Trichomoniasis in observational studies (113). The diaphragm has not been
shown to be more effective than male condoms. Wetmore, et al. (16) found one study done in Southern
Africa (117) that examined the use of a cervical diaphragm, lubricant gel and male condoms in women,
compared to male condoms alone; there was no significant difference in the rate of acquisition of
chlamydia or gonorrhea.
It should also be noted that the use of the diaphragm and nonoxynol-9 (N-9) spermicide has been
associated with an increased risk for urinary tract infections in women (118).
Intervention
Cervical
diaphragms
Behavioural
outcomes
N/A
STI
incidence/prevalence

Population and Public Health, Ministry of Health
Contextual considerations and comments
The use of diaphragms for STI prevention is as
effective as male condoms, as a technology. However,
poor uptake may limit its recommendation for wide
dissemination.
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4.10 Topical Microbicides and Spermicides
Wetmore, et al. (16) found 10 trials looking at the spermicide, N-9. Each trial assessed the impact of
gonococcal infection. Three early trials (119–121) demonstrated marked reductions in risk of acquiring a
gonococcal infection of 74% and 60% among female sex workers in Thailand (119) and Kenya (120)
respectively, and 25% among female STI clinic attendees in the US (121). However, two subsequent
trials (122,123) demonstrated 50-80% increases in the risk of gonococcal infections. The results of other
studies were equivocal, with some demonstrating non-significant increases or decreases in risk of
gonococcal or chlamydial infection (124,125). In two of the RCTs that Wetmore, et al. (16) analyzed, they
found two studies (120,126) that reported an increased risk of HIV acquisition among N-9 users. Kreiss,
et al. (120) also found decreased risk for gonococcal cervicitis (RR 0.4, p < 0.0001) but an increased risk
of genital ulcers (RR 3.3, p < 0.001) and vulvitis (RR 3.3, p < 0.0001). For cellulose sulfate gels, two recent
trials (127,128) reported trends toward reduced risk of chlamydia and/or gonorrhea acquisition.
However, both of these trials were stopped early due to a significant increase in risk of HIV that was
noted in one trial (127).
Finally, Obiero, et al. (129) published a Cochrane Review looking at topical microbicides for the
prevention of STIs. Their conclusion was that there is some evidence that vaginal tenofovir microbicides
may reduce the risk of HIV and HSV-2 infection acquisition in women but that other types of topical
microbicides have not shown the same effect on HIV or STI acquisition.
Summary: Topical spermicides have not been shown to be effective in reducing the transmission of STI,
and in fact may facilitate the transmission of STI, especially in the case of N-9. Topical tenofovir has
shown promise in preventing the transmission of HIV only. More research is needed into whether other
microbicides is effective in preventing STI acquisition.
Intervention
Topical
spermicides
Topical
microbicides
Behavioural
outcomes
N/A
STI
incidence/prevalence

N/A

Contextual considerations and comments
Topical spermicides have not been shown to be
effective in reducing the transmission of STI, and in
fact may facilitate the transmission of STI, especially in
the case of N-9.
Topical tenofovir has shown promise in preventing the
transmission of HIV only. More research is needed
into whether other microbicides is effective in
preventing STI acquisition.
4.11 Male Circumcision
Male circumcision has been shown to reduce the risk of HIV and other STIs among heterosexual men.
Wetmore, et al. (16) looked at three RCTs involving male circumcision as the intervention and bacterial
STI endpoints (130–132). They also looked at one additional trial that assessed the risk of STI among the
female partners of the men randomized to circumcision (133). Mixed results were obtained for the
acquisition and transmission of trichomonas. One trial in Kenya (130) failed to demonstrate reduced
rates of acquisition of STIs. Equivocal results were reported for chlamydia infection (130,131). For
syphilis and gonorrhea, none of the trials that reported results showed a protective effect.
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Intervention
Male
circumcision
Behavioural
outcomes
N/A
STI
incidence/prevalence

Contextual considerations and comments
There is evidence to suggest that male circumcision is
effective in preventing transmission of STIs but most
studies have been done in developing nations with high
HIV prevalence. Limited evidence exists for a policy of
recommending male circumcision in developed nations.
Accordingly, the US CDC and Canadian guidelines have
not recommended for or against this strategy in
developed nations.
4.11.1 Male Circumcision for MSM (MSM Supplemental Review)
Although African trials have shown success in reducing HIV acquisition among heterosexuals, the data
are lacking for MSM (134). Templeton, et al. (135) conducted a systematic review, and found that, as of
2010, no RCTs of circumcision in MSM were in progress. For bacterial STIs, they found six studies looking
at the association between circumcision and STIs in MSM. For gonorrhea and chlamydia, two studies
found no significant association between circumcision status and urethral gonorrhea or chlamydia
(135,136). For syphilis, Templeton, et al. (134) found that only one study (135) reported a significantly
reduce risk of incident syphilis (OR 0.36, 95% CI 0.15-0.89). However, four other cross-sectional studies
did not find a difference (137–140).
Wiysonge, et al. (2011) completed a Cochrane Review looking at male circumcision for the prevention of
homosexual acquisition of HIV in men (141). They found one completed RCT and 21 observational
studies. For syphilis outcomes, eight pooled studies showed no significant association between male
circumcision and syphilis.
Summary: There is very limited evidence to support male circumcision in the prevention of bacterial
STIs. The quality of evidence is low hence randomized trials of MSM in the prevention STIs are
warranted.
Intervention
Male
circumcision
for MSM
Behavioural
outcomes

STI
incidence/prevalence

Contextual considerations and comments
There is very limited evidence to support male
circumcision in the prevention of bacterial STIs in
MSM. The quality of evidence is low hence
randomized trials of MSM in the prevention of both
HIV and STIs are warranted.
4.12 Syphilis Chemoprophylaxis for MSM (MSM Supplemental Review)
One article was found that looked at chemoprophylaxis for syphilis among gay men. Wilson, et al. (142)
conducted a mixed-methods study utilizing an online survey, focus groups, and a mathematical model
that simulated a population of Australian gay men to explore the potential impact of introducing
chemoprophylaxis for syphilis. They surveyed 2095 gay men; 52.7% of them (95% CI 50.6-54.8%)
indicated that they would be very likely or slightly likely to use chemoprophylaxis to reduce their
chances of acquiring syphilis. When told it would help reduce infections in the gay community, that
number rose to 75.8% (95% CI 74.0-77.6%). Their mathematical model showed that this could reduce
the number of syphilis cases by 50% after 12 months of use and 85% after 10 years.
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Intervention
Syphilis
chemoprophylaxis
for MSM
Behavioural
outcomes

STI incidence/
prevalence

Contextual considerations and comments
One mixed-methods study has shown acceptability among
gay men to use chemoprophylaxis to reduce the
transmission of syphilis. Running this through a model
shows the potential to reduce syphilis transmission rates by
85% over 10 years. More research is needed to demonstrate
that this would be an effective intervention, especially
balanced against the risks of antibiotic treatment.
4.13 Partner Management
Partner treatment is a cornerstone of STI control. When partners are treated there is a decreased risk of
reinfection for the index patient. The exact process by which partners are notified vary from jurisdiction
to jurisdiction but may involve health care providers of the index patient and/or the partner, the public
health agency where the index patient resides, or some other means. US CDC guidelines note, however,
that the data are limited in regards to whether partner notification actually decreases exposure and the
prevalence and incidence of STIs in a community. However, evaluations of partner notification and
contact tracing have shown that when partners are treated, index patients have a decreased risk of
reinfection (see below) (143). Health care providers can ask their infected patients about recent sexual
contacts and directly contact the sexual contacts and arrange for testing and treatment. Or, providers
can encourage patients to contact their sex partners themselves to notify them of an exposure and to
get tested and treated. Wilson, et al. (144) showed that when a health care provider spends time with
index patients counselling them on the importance of notifying partners, outcomes on notification are
improved (OR 1.8, 95% CI, 1.02-3.0).
The National Collaborating Centre on Infectious Diseases recently published an evidence review on
outcomes related to STI partner notification (145)(Box 3).
Box 3: A summary of the types of partner management strategies
Patient referral
Provider referral
Contact slips
Email
notification
Text message
notification
Patient delivered
partner therapy
(PDPT)
Occurs when the index case and his or her health care provider agree that the index case will
inform all of his or her sexual partners and ask them to seek testing and treatment. Taylor (145)
found that this is generally less effective than provider referral but is practiced more frequently as
it is less resource intensive. This review also found that in the literature, most patients prefer this
form of partner notification as it felt to be more private and confidential.
Occurs when a physician or public health practitioner (usually nurses) contact sexual partners and
notify them of possible exposure to an STI.
Occurs when a clinician provides a slip, containing information about the type of infection, for the
index case to give to his or her sexual partners.
Occurs when the health care provider or public health nurse sends an email to sexual partners of
the index case advising them of a possible STI exposure. This is done without identifying the index
case, although in some cases in which there is only one sexual partner, the identity of the index
case may be inferred.
Similar to email notification, occurs when the index case or health care provider or public health
nurse notifies sexual partners of exposure via short message service (SMS).
Occurs when partners of infected persons are treated without any medical evaluation, prevention
or medication counselling by a health care provider.
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Taylor (145) found that rates of reinfection range from 6-24%, and varies according to disease. Most of
the studies in this review did not address the effects of partner notification on reinfection rates, aside
from those addressing PDPT, reviewed below. Patient referral is generally less effective than provider
referral, as reviewed in the section below.
Internet-based partner notification (IPN) strategies were evaluated by Ehlman, et al (146). They looked
at internet partners (defined as sex partners for whom syphilis exposure notification was initiated by
email because no other locating information existed). From 361 early syphilis patients, they investigated
a total of 888 sex partners, of which 381 (43%) were done via IPN. There was an increase of 8% in the
overall number of syphilis patients with at least one treated sex partner, and 26% more partners being
medically examined and treated if necessary, and 83% more sex partners notified of their STI exposure.
Summary: Studies of partner notification and contact tracing have shown that when partners are
treated, index patients have a decreased risk of reinfection. When a health care provider spends time
with index patients counselling them on the importance of notifying partners, outcomes on notification
are improved. Other methods of partner notification show varying levels of efficacy.
Intervention
Patient
referral
Contact slips
Behavioural
outcomes
N/A
STI
incidence/prevalence

Contextual considerations and comments
N/A

More research is warranted into whether contact
slips can be used as a partner notification technique.
Patient referral is generally less effective than
provider referral and PDPT.
4.14 Provider referral
Low, et al. (147) looked at partner notification at a general practice immediately after diagnosis of an
STI. This study involved: 1) trained nurses contacting the index case by telephone follow-up by a health
advisor and 2) referral to a specialist health advisor at a genitourinary medicine clinic. A total of 65.3% of
participants receiving practice nurse-led partner notification had at least one partner treated compared
with 52.9% of those referred to a genitourinary medicine clinic (risk difference 12.4%, 95% CI -1.8% to
26.5%).
Intervention
Provider
referral
Behavioural
outcomes
N/A
STI
incidence/prevalence

Contextual considerations and comments
Although provider referral has shown some promise,
more research is needed before this strategy can be
recommended.
4.15 Patient-delivered partner therapy (PDPT)
US CDC guidelines recommend that when index patients indicate that their partner is not likely to seek
evaluation and treatment, PDPT, which is a form of expedited partner therapy (EPT), may be effective,
where legal. US CDC guidelines cite three trials (148–150) and a systematic review (151) that included
heterosexual men and women with chlamydia or gonorrhea in making these recommendations. Across
all the trials, there were reductions of 20% to 50% in chlamydia and gonorrhea at follow-up,
respectively. Six RCTs evaluated PDPT (148–154) with half of the participants demonstrating significant
protective effects against reinfection of the index patient. Results showed 1) relapse rate reduction of
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trichomonas of 78% for those in the PDPT group (p = 0.01) (152), 2) recurrent or persistent infection of
gonorrhea of 3% in the EPT group versus 11% in the non-EPT group (p = 0.01) (148) 3) increased testing
for chlamydia and/or gonorrhea in PDPT with booklet-enhanced partner referral) (151); (23.0% versus
14.3% versus 42.7%, p < 0.001).
Two additional RCTs (155,156) were found that looked at PDPT. The review by Trelle, et al. (150)
identified only one other article (157)that was not identified by the CDC, Wetmore et al. (16) or by our
search. Nuwaha, et al. (157) found that PDPT was more effective than patient-based partner referral in
treating their partners. For women, 86 of 103 partners were considered treated (83%) compared with
22% in the patient-based partner referral group (RR 4.55; 95% CI 2.92-7.08). For casual partners, the RR
was 1.43 (95% CI, 1.40-2.65). Kerani, et al. (155) found the number of partners treated per original
patient was 2.33 in the PDPT arm and 1.52 in the non-PDPT arms. They found that PDPT assignment
increased the mean number of partners treated per original patient by 54% (ratio of means 1.54, 95% CI,
1.01-2.34). Further, Schwebke and Desmond (156) randomized women diagnosed with Trichomoniasis
to self-referral of partners (PR), PDPT, or public health disease intervention (DIS), locating partners and
delivering medication in the field, if needed. They randomized 484 women, and found no significant
difference in repeat rates of infection at one and three month follow-up visits when PDPT and DIS were
compared to the reference PR. However, when PDPT was compared to DIS or PR/DIS combined, at one
month, the PDPT group had lower repeat infection rates (5.8 versus 15% and 5.8 versus 12.5%,
respectively).
Stephens, et al. (158) conducted a PDPT program evaluation in San Francisco. They found no significant
differences in one-year reinfection risk for chlamydia or gonorrhea (aRR 0.99, 95% CI 0.86-1.14; aRR
0.90, 95% CI 0.72-1.11, respectively). Interestingly, subgroup analysis did not find any significant
differences among MSM or men who have sex with women (MSW), or females.
Summary: PDPT has been shown in multiple studies, including randomized controlled trials, particularly
in chlamydia and gonorrhea, to reduce reinfection rates. Some caution, however, should be exercised
given that gonorrhea is becoming a multi-drug resistant organism and may require parenteral
treatment. PDPT should only be implemented for chlamydia in the heterosexual population. For MSM,
because there is a higher risk for HIV infection, PDPT may only be cautiously offered, if at all, to ensure
appropriate testing and counselling.
Intervention
PDPT
Behavioural
outcomes
N/A
STI
incidence/prevalence

Population and Public Health, Ministry of Health
Contextual considerations and comments
PDPT has been shown in multiple studies, including
randomized controlled trials, particularly in chlamydia and
gonorrhea, to reduce reinfection rates Some caution,
however, should be exercised given that gonorrhea is
becoming a multi-drug resistant organism and may
require parenteral treatment. PDPT should only be
implemented for chlamydia in the heterosexual
population. For MSM, because there is a higher risk for
HIV infection, PDPT may only be cautiously offered, if at
all, to ensure appropriate testing and counselling.
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4.16 CDC and PHAC: guidelines: Special populations
As part of the primary search strategy for this review, evidence identified for special populations is
integrated throughout, particularly in the meso- and macro-level interventions sections (e.g., venuebased STI screening and treatment programs for youth and MSM, presumptive treatment, etc.).
However, not all special populations were covered and it was felt that there was outstanding
information that should be included for all populations. Therefore, information was identified by
completing a review of the CDC and PHAC guidelines. This review is presented in the macro-level
intervention section of this report. No evaluation of these guidelines was identified.
4.17 CDC and PHAC Guidelines: Interventions
In addition to the reviews and primary research presented in the micro-level interventions section of
this review, interventions discussed in the CDC and PHAC guidelines are also reviewed in the macro-level
intervention section of this report.
4.18 Conclusion
Interventions to prevent the transmission of STIs at the individual level, as well as those related to youth
and MSM, are numerous. Appendix C lists these interventions and the corresponding evidence rating
scale score. Most interventions reviewed have some evidence for implementation. Prevention
counselling and behavioural interventions have wide support for effectiveness in the literature. Topical
microbicides and spermicides, which studies have largely shown to be ineffective and possibly carry an
increased risk of STI transmission, are generally not recommended for use in STI prevention. Male
condoms are an effective means of STI prevention. Female condoms and cervical diaphragms have been
shown to be effective in preventing STI, but cost and safety concerns with anal intercourse limit
recommendations for usage, especially when male condoms are available. However, in instances where
the male partner refuses to use a male condom, female condoms and cervical diaphragms may be
important to consider. Male circumcision, while recommended in developing nations with high HIV
prevalence as a strategy to combat high STI and HIV rates, have had limited study in developed nations
with typically lower HIV prevalence. As such, neither the US nor Canadian guidelines recommend for or
against it as a strategy for STI control. Partner management remains a cornerstone of STI prevention and
control. Various forms of partner management have been identified in the literature, and
recommendations of specific strategies will vary according to local laws and regulation, resources, and
cost.
New evidence shows promising results related to new electronic technologies (e.g., social media, shortmessage service, and other internet-enabled interventions) among youth, and reinforces that there is
evidence for implementation, particularly for impact on sexual risk behaviour, while impact on STI rates
is often uncertain. In addition, new evidence further supports the acceptance of these interventions
among youth, and includes a caveat that the most current technology should be utilized as youth may
respond unfavourably to outdated modalities. Further, youth may use more than one type of technology
and therefore there may be an advantage to offering multiple methods to reach youth. The evidence
related to home-based STI screening among youth also supports the utility of this intervention for
promoting uptake; and a limited literature base suggests effectiveness for the detection of STIs.
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5.0 MESO-LEVEL INTERVENTIONS
Meso-level interventions occur at the level of communities and organizations, or among groupings such
as family, peers or sub-populations (159). This evidence review has identified a number of meso-level
interventions, implemented in diverse settings and among a variety of target populations, that have
been assessed for impact on sexual behaviour, knowledge, or other outcomes such as screening uptake
or the identification of contacts. A lesser number of articles examined STI incidence/prevalence
outcomes. Similar to the micro-level intervention section, limited literature was found that had
morbidity as an outcome, and no papers were identified that had mortality as an outcome
For this section of the report, a description of the results of selected studies is supplemented by a
detailed description of the programs described in the studies (see Appendix D). Many of the programs
involve novel and unique elements, specific to the screening venue and/or population that might be of
interest to fully understand the intervention. This detail is intended to support a consideration of
applicability to the BC context. The studies that examine an impact on STI incidence or prevalence are of
particular interest; Appendix B contains a summary of reviewed studies. Appendix C is a summary of
evidence ratings for all interventions reviewed and specifies interventions that have and have not been
evaluated for direct impact on STI rates.
Application of the Rating Scale
The evidence rating scale was applied per the specification identified in the text portion of Figure 2. The
limitation of this approach in this directed, non-systematic review, is that often there were a limited
number of studies of a given meso-level intervention, which meant that corroboration (a component
within the scale) was not present. This meant that corroboration had to be weighed against the strength
of the theoretical rationale and other criteria.
A range of programs targeting various populations have been implemented and evaluated, with many
examining behavioural outcomes, as well as other outcomes such as promoting uptake of STI testing and
identification of contacts. A lesser proportion of the literature examines biological outcomes (i.e. STI
rates). Recognizing that self-reported behavioural endpoints are valuable in revealing the impact of
diverse interventions on sexual risk behaviour, of clear relevance to the discourse on STI prevention, it is
recognized that it may be difficult to control for variables that can affect self-report data (e.g., social
desirability biases). In the rating of evidence, where biological endpoints (e.g., STI incidence/prevalence
or morbidity) are not assessed, or are assessed to a limited degree, two ratings are offered: evidence of
impact on sexual risk behaviours, and evidence of impact on STI burden (unless otherwise indicated).
Distinguishing Level of Intervention
As previously mentioned, the distinction between micro-, meso- and macro-levels of interventions is not
always clear-cut. In particular, it was found that the distinction between micro- and meso-level
interventions was sometimes challenging to delineate. For example, an intervention that is intended to
be used at the individual level but is delivered as part of a community-wide program. Therefore, for the
purposes of this report, this distinction is determined as follows. Where there is an outcome at the
individual level of a study design that looks at specific individual-level outcomes, this is classified as a
micro-level intervention. Whereas, where there are interventions that look at outcomes of a specific
group or population, or uptake of an intervention by a group or population, this is classified as a mesolevel intervention.
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Some studies evaluate a single intervention, while others evaluate a combination of activities (e.g.,
condom promotion, community mobilization, increased STI services and educational interventions all
implemented at once). For the latter, it is difficult to disaggregate the relative contribution of each
intervention to the observed outcome; however, more importantly, such interventions suggest the
value of a combined approach.
5.1
Social Diffusion
A key question in the discourse on STI prevention is how does prevention knowledge and behaviour,
once it occurs in at least one person, diffuse through a given population, particularly when the main
method of spread is via person-to-person interaction (160). The literature that examines this area has
been classified as ‘social diffusion’ interventions for the purpose of this report. Clearly this topic has
elements of both micro- and meso-level prevention, however these are distinguished from the
individual (one-to-one) level in that while these interventions also aim to influence individual behaviour,
they specifically operate at the community-level or level of social networks. Two key interventions in
this category are the use of community popular opinion leaders, and peer mentors that operate within
their social network.
5.1.1 Community Opinion Leaders
“Popular opinion leaders” personally endorse HIV and other STI-risk prevention through messaging to
members of the community, with the intent that this changes norms for risk behaviour in the population
(161). This intervention is based on the diffusion of innovation theory which suggests that innovations
and changes often originate with a subset of the population who are opinion leaders and whose views
are adopted by others in the community (161).
The first large, international, multisite study to evaluate a Community Popular Opinion Leader (C-POL)
intervention was conducted between 2002-2007 by the National Institute of Mental Health
Collaborative HIV/STD Prevention Trial Group (161). Study sites were located in China, India, Peru,
Russia and Zimbabwe, and in each site a common protocol was followed, targeting at-risk population(s).
Study settings were community venues that were social gathering points for high-risk populations (e.g.,
school dormitories, wine shops and vendor markets, as well as neighbourhood settings), as the C-POL
intervention required informal conversation opportunities through which prevention messages were
shared (161). Venues were matched within each country and randomly assigned within matched pairs to
the C-POL intervention or a control condition. At both intervention and control sites, STI testing, preand post-test counseling, referral for treatment of incident STI cases, provision of educational materials,
as well as free or inexpensive condoms, were implemented. Additionally, among the C-POL sites, trained
community opinion leaders (identified through ethnographic observations, nominations by venue
gatekeepers and other key informants, nominations by other population members, or self-nomination)
conveyed STI prevention messages during informal conversations with friends and acquaintances (161).
Results among longitudinal cohorts in 20-40 community sites per country (n = 18,000+) over a 2-year
period, revealed that there was little effect of the C-POL intervention on STI rates, and mixed results for
risk behavior (161).
Chlamydia rates were compared in four countries, HSV-2 in all countries, and Trichomoniasis in three
countries. No significant differences in chlamydia incidence were found between intervention and control
venues in any of the four countries; nor for Trichomoniasis incidence in women in any of the three
countries (161). There were significantly decreased rates of HSV-2 among the intervention venues in China
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(average difference -1.26, p=0.012 across venues) and Russia (-1.50, p = 0.016) but this was not observed
in the other three countries (note however that there were a low number of incident cases of HSV-2 in
most countries). Comparison of gonorrhea and syphilis between intervention and control venues were not
performed due to low incidence rates in all countries (161). The proportion of participants reporting
unprotected sex with non-spousal/non-live in partners was lower among intervention sites in China,
Russia and Zimbabwe, while in India and Peru there was a greater reduction among comparison sites.
Therefore, overall, the C-POL intervention and control program had a similar effect on STI incidence and
self-reported unprotected extramarital sex acts (approximately 20% and 30% reduction, respectively)
(161). The authors speculated that this may have been because the comparison intervention was itself
quite comprehensive (i.e., community-wide education, counseling and testing, risk-assessment interview,
access to condoms and treatment in all sites) thus making it difficult to detect a difference.
Another study examined the impact of a community popular opinion leader HIV/STI intervention on
stigma in Peru and found that it had a positive impact on reducing STI/HIV-related stigma that, where
present, can be a barrier to engaging in HIV testing and treatment (162).
Summary: In a larger, randomized, multi-site study examining the effect of community opinion leaders,
no significant differences in chlamydia incidence were found between intervention and control venues
in any of the four countries; nor for Trichomoniasis incidence in women in any of the three countries
studied. Evidence related to sexual risk behaviour was also not conclusive.
Intervention
Community opinion
leaders
Behavioural
outcomes

STI
incidence/prevalence

Contextual considerations and comments
Community opinion leaders, based on
diffusion of innovation theory, are
postulated to influence community norms.
A large, randomized, multi-site study did
not demonstrate reduced STI incidence, yet
a comprehensive comparison intervention
may have made it difficult to detect a
difference.
Evidence related to sexual risk behaviour
was also not conclusive.
A small study suggests a beneficial effect on
reducing HIV/STI-related stigma.
Studies were from China, Russia, India, Peru
and Zimbabwe, thus no North American
studies were included.
5.1.2 Peer Mentors within a Social Network
A peer mentor intervention within a social network approach involves individuals that are trained in STI
risk reduction conducting outreach to people within their social network (40,163). This approach is
intended to bring about behavior change at the individual level (among individuals within the social
network), among the peer mentor, as well as serve as a bridge to change social network level norms and
affect a wider range of people (163).
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Davey-Rothwell et al. (163) evaluated the CHAT intervention, focused on the social networks of women
at high-risk of STI transmission, living in urban neighborhoods in Baltimore (see Appendix D). The CHAT
intervention consisted of five small group sessions and one individual session. Peer mentors were
encouraged to talk to their family, friends, and sex partners about a range of risk reduction options.
They conducted a randomized clinical trial (RCT) among 169 women, where a standard of care involving
voluntary counseling and testing and a single didactic session delivered by a female facilitator, was
compared to the peer mentor intervention. The majority of the sample were adult African American
heterosexual females, and 95% reported at least one risky sexual behavior in the past 90 days (163). At
six-months follow-up, the peer mentor group were significantly less likely to have multiple sex partners
(adjusted odds ratio [AOR]: 0.28, 95% CI: 0.13, 0.63); at 12 months, had lower odds of having
unprotected sex with a non-main sex partner (AOR: 0.36, 95%CI: 0.16, 0.84); and at 18 months had
lower odds of having unprotected anal or vaginal sex, unprotected sex with a main sex partner, and
unprotected sex with a non-main sex partner (163). Reductions of any sexual risk behavior were also
seen at 18 months. There was also an overall increase in having conversations with friends about
HIV/STIs among intervention group participants (AOR: 1.65, 95%CI: 1.04, 2.61) (163).
Intervention
Peer mentors
within a social
network
Behavioural
outcomes

STI
incidence/prevalence

Contextual considerations and
comments
The single identified study (RCT) on
the topic of a peer mentor
operating within their social
network, revealed encouraging
reductions of risky sexual
behaviour.
However impact on STI rates is
uncertain.
The majority of the sample group
were African American women.
5.2
Group Education
Individual (one-to-one) education has the potential benefits of delivery in a shorter timeframe and being
tailored to the individual, while group interventions can allow participants to learn from each other,
build group norms and provide opportunities for support (43). Group education may focus on different
ways of preventing STIs, including risk-reduction and abstinence.
Systematic reviews conducted by Chin et al. (164) examined the effectiveness of group-based riskreduction education, and group-based abstinence education, on the prevention of STIs among
adolescents as well as other outcomes (164). Comprehensive risk-reduction interventions resulted in a
31% decrease in the prevalence of STIs (risk ratio [RR] = 0.69); as well as a 12% decrease in sexual
activity (RR = 0.88), 14% decrease in the number of sexual partners (RR = 0.86); 25% decrease in
unprotected sexual activity (RR = 0.75) and a 13% increase in the use of protection (164). With respect
to abstinence education, the authors reported difficulty in assessing effectiveness because of too few
studies and weak study designs, as well as heterogeneity in the curriculum and implementation (164).
There was also found to be differential effects when stratified by study design. However, it is
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noteworthy that after completion of the abstinence education review, the authors identify the
publication of another key study (described below) that would have contributed to the analysis (164).
Jemmott et al. (165) evaluated the impact of an abstinence-only intervention among African American
students in grades six and seven (n = 662) in preventing sexual involvement (165). They conducted an
RCT in urban public schools, involving the following arms: eight-hour abstinence-only intervention
encouraging abstinence to eliminate the risk of pregnancy and HIV/STI (designed to increase HIV/STI
knowledge, behavioral beliefs supporting abstinence including the belief that abstinence can prevent
STI/HIV and that abstinence can foster attainment of future goals, and increase skills to negotiate
abstinence and resist pressure to have sex); eight-hour safer sex-only intervention targeting increased
condom use; eight-hour and twelve-hour comprehensive interventions targeting sexual intercourse and
condom use; and an eight-hour health promotion control intervention targeting health issues that are
unrelated to sexual behavior (165). The abstinence-only intervention was found to significantly reduce
sexual initiation (RR = 0.67, 95% CI: 0.48,0.96); and there were fewer reports of having sex in the
previous three months during follow-up compared to control participants. A model was used to
estimate the probability of ever having sexual intercourse by the 24-month follow-up, and this was
estimated to be 33.5% among the abstinence-only intervention and 48.5% in the health-promotion
control group. The safer sex and comprehensive intervention groups did not differ from the control
group regarding sexual initiation (165).
Kohler, et al. (166) studied a sample of 1719 adolescents age 15-19 years who were part of the National
Survey of Family Growth in the US, and reported their formal sex education that they received before
their first sexual intercourse. Compared to adolescents that received no formal sex education, neither
abstinence-only education nor comprehensive sex education, significantly reduced the likelihood of
engaging in vaginal intercourse, or reported STD diagnoses. For abstinence-only education, the adjusted
OR for engaging in vaginal intercourse was 0.8 (95% CI 0.51-1.31, p = 0.40), and for reported STD
diagnoses was 1.7 (95% CI 0.57-34.76, p = 0.36). For adolescents that received comprehensive sex
education, the adjusted ORs were 0.7 (95% CI 0.49-1.02, p = 0.06), and 1.8 (95% CI 0.67-5.0, p = 0.24),
respectively.
Trenhold et al. (167) examined the impact of four abstinence education programs delivered to
adolescents. A study sample of 2057 adolescents that had participated in the treatment arm in one of
these four programs was compared to those that had been assigned to control arms. The follow-up
period was fairly long, at 42-78 months. There were no significant differences between the intervention
and control participants regarding abstaining from sex, number of sexual partners, mean age at first
sexual intercourse (only among youth who had sex), and having unprotected sex (without a condom).
The intervention group did demonstrate a significantly higher level of knowledge related to
identification of STIs. One program in particular, called My Choice, My Future! demonstrated
consistently improved knowledge of the risks of unprotected sex and STIs.
Jemmott et al. (43) suggest that just providing information is not enough to induce sexual behaviour
change; rather, skill-building is important (e.g., condom use skills, condom-use negotiation skills, etc.).
They conducted a RCT among African American women (n = 564) in an inner city women’s health clinic
called “Sister-to-Sister: The Black Women’s Health Project”. Participants were randomly assigned to one
of five arms: 20-minute one-to-one HIV/STD behavioural skill building intervention; 200-minute group
HIV/STD behavioural skill building interventions; 20-minute one-to-one HIV/STD information
intervention; 200-minute group HIV/STD information intervention; or a 200-minute general health
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promotion intervention control group. At baseline, 20.3% tested positive for a STI (T vaginalis 11.3%,
chlamydia 8.9%, gonorrhea 2.6%). At 12-months post-intervention, those in the individual or group skillbuilding interventions were significantly less likely to test positive for a STI (i.e., chlamydia, gonorrhea,
or T vaginalis) compared to controls. The skill-building groups also reported significantly less
unprotected sex, and a higher proportion of protected sex, than participants in the information groups.
With respect to the group intervention specifically, compared to the individual intervention, the only
significant difference was that there was a greater increase in the proportion of protected sexual acts at
12-month follow-up.
Summary: Both individual-and group-level skill building interventions have contributed to decreased STI
rates and risky sexual behaviour. Studies demonstrating effects of abstinence-based and risk-reduction
interventions have shown some positive impacts.
Intervention
Group
education – risk
reduction
Group
education abstinence
Skill building in
group
education
5.3
Behavioural
outcomes



STI
incidence/prevalence



Contextual considerations and comments
Group education involving risk reduction has been
shown to be effective in impacting STI rates in some,
but not all, studies.
This intervention has also been shown to impact
sexual risk behaviour outcomes in some, but not all,
studies.
Group education with an abstinence message has
revealed a positive impact on sexual initiation in a
recent study. However a meta-analysis suggests that
conclusions cannot be drawn and some other studies
have not found an impact.
Impact on STI rates is uncertain based on the
reviewed literature.
As a general principle, in group education, beyond
just providing information, skill-building is an
important element. Both individual-and group-level
skill building interventions have contributed to
decreased STI rates and risky sexual behaviour.
Parental Monitoring of Youth (Youth Supplemental Review)
Parental monitoring, or youth perceptions of parental monitoring (i.e. that their parents know where
they are and who they are with), is inversely associated with sexual risk behaviours and STIs. However,
what is lacking is literature that evaluates a parental monitoring intervention on behavioural or
biological outcomes.
The association between parental monitoring and STI incidence was explored in an prospective cohort
study by Crosby et al. (168) involving a sample of sexually active African American female youth aged 1418 years (n = 217). In this study, testing for chlamydia, gonorrhea and trichomonas was performed at
baseline, as well as at 6-, 12- and 18-months. Youth that tested positive for a STI at baseline were
treated. Note that participants in this study were from the control arm of a HIV prevention program, and
received information related to health but unrelated to sexual behaviours. Youth who perceived that
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parental monitoring was infrequent at baseline were significantly more likely to acquire chlamydia or
Trichomoniasis during the study period, compared to youth who perceived greater levels of monitoring
(adjusted odds ratio [AOR] – adjusted for STI at baseline: 1.8 [95% CI 1.01-3.21] and 2.4 [95% CI 1.224.87], respectively). This inverse effect was not observed for gonorrhea. Similarly, over the entire 18month study period, youth that perceived that parental monitoring was infrequent were twice as likely
to test positive for a STI (OR 2.1 [95% CI 1.16-3.74).
Crosby et al. (168) examined the association between mother-daughter communication and other family
support-related factors, and STI history among pregnant African American females age 14-20 years. The
sample included females that were sexually active in the past two months and lived in an urban area in
the southern US. Sexual risk behaviours were assessed through interviews, conducted by young adult
African American female interviewers. Perceived family support (i.e. receipt of emotional support,
family efforts to help, being able to talk about problems), mother-daughter communication (i.e. having
discussions about sex, prevention of HIV/AIDS, and prevention of STIs), and STI history were assessed
through a survey. Urine samples were collected for STI testing. At baseline, 51.2% of participants
reported a past STI, and of these, 45% reported being treated for a STI within the past six months. With
respect to mother-daughter communication, only less frequent communication about the prevention of
AIDS was associated with self-reported STIs. Low perceived family support was not found to be
significant, nor was less frequent communication about STI prevention or less frequent discussion about
sex. The other significant association with reported STIs was not residing with a family member/relative
Stanton et al. (169) conducted a randomized controlled trial (RCT) among pairs of low-income African
American parents/guardians and youth aged 12-16 years (n = 237 dyads) who lived in urban public
housing developments. This study assessed the impact of parental monitoring on sexual behaviours;
however, impact on STIs is not known. Ninety-six percent of parents in the study sample were female,
while a mix of male and female youth were included (51% and 49%, respectively). The intervention
centered on parental monitoring, described as including both parental supervision and communication
with youth, and was termed “Informed Parents and Children Together (ImPACT)”. This 60-90-minute
home-based intervention included a parental monitoring video with associated discussion, role-play and
other activities, as described in Appendix D. This intervention included but was not limited to sexual risk
behavior. The control condition involved a program called “Goal for IT!”, which involved a video that
was also produced by the researchers that described planning for education and career training. At 6months post-intervention, a significantly greater proportion of youths and parents were performing
condom skills correctly overall (among youth intervention vs. control, 3.77% vs. 3.00 %, p < 0.001;
among parents intervention vs. control, 3.80% vs. 3.33%, p < 0.01). It is also important to note that
generally, across various risk behaviours, parents underestimated the actual risk behaviour that their
child was engaging in. Further, ImPACT increased the concordance of parent-youth reports of risk and
protective behaviours.
Crosby et al. (170) conducted a study among 522 sexually active African American female adolescents to
explore the joint influence of living with the mother within a supportive family environment. Data on
family support, living arrangements and sexual behaviour, were collected through a self-administered
survey and structured interview. Adolescents that lived with their mothers in a perceived supportive
family (46% of the sample) were compared with those who did not report this situation (54% of the
sample) with respect to various sexual risk behaviours. After adjusting for parent-adolescent
communication about sex-related issues, parental monitoring and age, adolescents living with their
mothers in a perceived supportive family were significantly less likely to have had any unprotected sex
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with a steady partner in the past 30 days (OR 0.52, 95% CI 0.33, 0.82; p=0.005), any unprotected sex
with any partner in the past 30 days (OR 0.55, 95% CI 0.35,0.85; p=0.008), and any sex with a non-steady
partner in the past six months (OR 0.51, 95% CI 0.30, 0.86; p=0.01); as well as having significantly more
frequent communication with sex partner(s) (OR 1.53, 95% CI 1.04, 2.53; p=0.03). No significant
differences were noted with respect to higher condom negotiation self-efficacy and more positive
attitudes towards condom use (although the latter was subsequently found to be significant when
dichotomous variables were converted to continuous variables).
Summary: Parental monitoring, or youth perceptions of parental monitoring is inversely associated with
sexual risk behaviours and STIs. Literature is lacking that evaluates a parental monitoring intervention on
behavioural or biological outcomes.
Intervention
Parental
monitoring of
youth
5.4
Behavioural
outcomes

STI
incidence/prevalence

Contextual considerations and comments
An association between parental monitoring and
sexual risk behaviours has been consistently
identified, and in one prospective cohort study, an
association between parental monitoring and STI
incidence was identified. Literature is lacking that
evaluates a parental monitoring intervention.
Worksite-based Programming for Parents of Youth (Youth
Supplemental Review)
Talking Parents, Healthy Teens is a parenting program, delivered in the workplace, that is intended to
help parents address sexual health with their adolescent children (grades six to 10) (171,172). This
program, which involved eight weekly one-hour sessions, was evaluated through a RCT conducted by
Schuster et al. (172) in 13 worksites in California (n = 569 parent participants as well as their children n =
683), with follow-up surveys at one week, three months and nine months after the program. At
baseline, 4% of parents reviewed how to use a condom with their adolescent child, however at nine
months, a significantly higher proportion of parents in the intervention group had reviewed how to use
a condom compared with parents in the control group (29% vs. 5%, 95% CI for the difference 13%-36%,
p <0.001). Parents and adolescents in the intervention group reported a significantly greater ability to
communicate with each other about sex, and reported more openness in their communication about
sex, compared to control dyads. As well, intervention parents were more likely to discuss more new
sexual topics with their adolescent children.
Intervention
Worksite based
programming for
parents of youth
Behavioural
outcomes

STI
incidence/prevalence

Population and Public Health, Ministry of Health
Contextual considerations and comments
A single identified study examining a workplacebased program for parents of adolescent children,
and demonstrated positive impact on parent-child
communication about sexual behaviour, but it is
uncertain how this impacts subsequent adolescent
sexual behaviour and STI rates.
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5.5
Multi-component Programs Targeting Children/Younger Youth
(Youth Supplemental Review)
Coyle et al. (173) evaluated a program specifically targeted to children in middle school (grades six
through eight), based on the rationale that it is important that younger youth be targeted with
prevention messages before they begin to have sexual intercourse with the aim of effecting delayed
intercourse or avoidance of unprotected intercourse. Draw the Line/Respect the Line is school-based
HIV/STD and pregnancy prevention program, aimed at reducing the number of students who initiate or
have sexual intercourse, and to increase condom use (see Appendix D). A cluster RCT was conducted
involving 19 middle schools in California, with a sample of 2829 students in grade six over a period of
three years (60% Hispanic). Ten intervention schools received the Draw the Line program, while the
control condition had usual classroom activities related to HIV/STD and pregnancy prevention that were
determined by the school. The study revealed significant impact on sexual risk behaviour specifically for
males. From grade six through grade nine, boys in the intervention arm were significantly less likely to
report ever having sex compared to boys from the control schools (p<0.01). Further, at each follow-up
measurement time (i.e., grades seven, eight and nine), significantly fewer boys in the intervention
schools reported having sex compared to boys in the control arm (p < 0.04, p < 0.01 and p < 0.02,
respectively). There were no significant effects regarding reports of having sex among girls. With respect
to having sexual intercourse in the past 12 months, while there was not a significant difference for
either males or females overall, when each follow-up assessment period was viewed separately (i.e., at
the seventh, eighth and ninth grades), males were significantly less likely to report having had sex in the
12 months before the survey compared to the control arm. There were no significant differences in
condom use for either males or females. With respect to knowledge there were a number of significant
differences, including that males in the intervention arm had stronger sexual limits (p = 0.004), higher
HIV and condom knowledge (p < 0.001), more positive attitudes towards not having sex (p = 0.003),
fewer situations where sexual behaviours might occur (p< 0.001), and perceived fewer peer norms
supporting sex (p = 0.001). Among females, intervention arm girls had significantly higher HIV and
condom knowledge (p < 0.05) and fewer incidents of unwanted sexual advances (p = 0.02).
5.5.1 Multi-component Approach Involving Children, Parents and Teachers (Youth
Supplemental Review)
Hawkins et al. (174) conducted a non-randomized controlled trial examining an intervention that
combined teacher training, parent education, and social competence training. This intervention was
somewhat unique in its duration; it was implemented among children in elementary school and
participants were followed for six years to determine the impact on adolescent health risk behaviours at
age 18 years, including sexual risk behaviours (n = 598). The intervention consisted of five days of inservice training for teachers of grades one through six; parenting classes for parents of children in
grades one through three and five through six; and social competence/skill-building training for children
in grades one through six (see a description of the intervention in Appendix D). A ‘late intervention’ arm
involved the same program, but it was implemented in grades five and six only; and the control arm
received no specific intervention. Participants were drawn from schools in high-crime areas in
Washington. Significantly fewer participants in the intervention group reported having sexual
intercourse (72.1% vs. 83.0%, p = 0.02) and multiple sex partners (49.7% vs. 61.5%, p = 0.04) at age 18
years, compared to the control group. Numerous other health risk behaviours were also significantly
lower among intervention students (e.g., violence and heavy drinking) while others showed no
difference (ie. drug use) and protective behaviours were significantly higher (e.g., commitment and
attachment to school) at age 18 years. Further, a dose effect was seen for many of the outcomes (i.e.
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the full intervention group demonstrated the most positive outcomes, followed by the late intervention
group, followed by the control group).
Lonczak et al. (175) examined the long-term impact of the program described previously by Hawkins et
al. (174), termed the Seattle Social Development Project, over a longer period to age 21 years. With
respect to STI diagnosis, although a significant difference was not found overall, after controlling for
poverty there was a significant difference among African Americans in the intervention versus control
arms: 7% vs. 34% reported being diagnosed with a STI in their lifetime (OR 0.11, p < 0.01) or a difference
of 27%. For non-African Americans, this difference was 3%. Participants in the full intervention group
had their first sexual experience significantly later than individuals in the control arm (15.8 years vs. 16.3
years, p <0.05), reported significantly fewer sexual partners in their lifetime (p < 0.05). While there was
no significant difference in reported condom use during first intercourse, individuals in the full
intervention group were significantly more likely to report condom use during last intercourse (among
African Americans, 79% vs. 36%, and among non-African Americans, 56% vs. 47%).
5.5.2 Multi-component Approach Involving Youth and Community Service (Youth
Supplemental Review)
O’Donnell et al. (176) conducted a RCT to evaluate the Reach for Health Community Service intervention
among children/younger youth in middle school, aimed at helping youth gain the knowledge, attitudes
and skills to avoid high-risk behaviours and make healthy choices. This program involved two
components: community field placements (e.g., service provision in nursing homes, senior centers,
daycare centers, etc). followed by reflection including sharing their experiences in their class and
reinforcing what they contributed to their community and why their community counted on them to
stay healthy and succeed; and health curriculum delivered in the classroom (e.g., risks related to early
and unprotected sex, violence and substance abuse, as well as healthy development and sexuality), with
interactive classroom activities to help students make healthy choices, communicate their needs and
avoid risk behaviours. Reflection is an integral part of the community services component. The target
population was African American and Latino youth, low socio-economic status, in a middle school;
classrooms were randomly assigned to the intervention and control arms. All students received a
classroom health curriculum, while the intervention students received the Reach for Health Community
Service intervention during grades seven and eight. Follow-up evaluation was conducted during grade
10. Individuals in the intervention arm were significantly less likely to have initiated sex at the time of
follow-up compared to controls; this was the case after two years of the intervention (OR 0.32, 95% CI
0.14-0.73) and one year of the intervention (OR 0.49, 95% CI 0.25-0.99), as well as less likely to report
recent sex (OR 0.39, 95% CI 0.20-0.76 after two years, and OR 0.48, 95% CI 0.24-0.96 after one year).
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Intervention
Multi-component
approaches
targeting
children/younger
youth
Behavioural
outcomes

STI incidence/
prevalence

Contextual considerations and comments
Interventions delivered to target populations of
children/young youth, varied in their components and
scope (e.g., involvement of parents and teachers,
community service elements). However, the studies in
this area all suggest that the period of childhood/early
adolescence is an important time for STI prevention
interventions and can reduce sexual risk behaviour over
the long-term. These studies also highlight the importance
of the social and community context for youth.
Impact on STI incidence/prevalence was only assessed in
one study, and a significant difference was only found
among African American individuals. Further study is
warranted.
Multi-component Approach Targeting Youth in High School (Youth Supplemental Review)
Coyle et al. (177) conducted a RCT to evaluate a program called Safer Choices in 20 highschools in
California and Texas (n = 3869 grade nine students), with a 31-month follow-up period. Safer Choices is a
school-based HIV/STI and pregnancy prevention program that is implemented over a two year period in
grades nine and 10. The aim is to reduce the number of students that begin to have sexual intercourse
during highschool and in doing so reduce student engagement in unprotected intercourse. As well, to
increase condom use among students who are sexually active. The program involves five components
(see Appendix D), and engage youth, teachers, parents and members of the wider community. The
results of this evaluation revealed that although there was no significant difference in the incidence of
sexual initiation between intervention and comparison arms, sexually experienced students reported a
significantly lower frequency of having intercourse without a condom during the three months
preceding the survey (OR 0.63, p = 0.05), and fewer partners with whom they had sexual intercourse
without using a condom in the prior three months (OR 0.73, p = 0.02). Further, intervention students
reported significantly more positive attitudes about condoms (p = 0.01), greater condom use selfefficacy (p = 0.00), fewer barriers to condom use (p = 0.01) and higher levels of self-perceived risk for
HIV and other STIs (p = 0.02 and p = 0.04, respectively), while there were no significant differences in
self-efficacy to refuse sex and to communicate with a partner about sexual limits.
Intervention
Multi-component
approach targeting
youth in highschool
Behavioural
outcomes

STI
incidence/prevalence

Contextual considerations and comments
Similar to the multi-component schoolbased interventions delivered to younger
students, along with their teachers and
parents, a multi-component intervention
among highschool students had numerous
positive impacts on sexual risk behaviour. In
this single study however, the intervention
did not seem to impact sexual initiation, but
did decrease sexual risk behaviours.
Impact on STI incidence/prevalence is
uncertain.
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5.6
Peer Education (Youth Supplemental Review)
The Youth United Through Health Education (YUTHE) is a peer-led outreach program that aims to
increase awareness and improve STI screening among youth (target population age 12-22 years) (178).
YUTHE is a collaboration between the San Francisco Department of Public Health and the Department of
Pediatrics at the University of California, San Francisco, consisting of a 15-minute standardized protocol
that consisted of: a recruitment script; STI/HIV risk assessment; STI/HIV prevention messages, including
information on non-invasive STI screening; condom distribution, if desired; and information on ‘youthfriendly’ STI services. Ozer et al. (178) evaluated the program among 1487 sexually experienced youth
that lived in two communities in San Francisco that historically have high youth STI rates (one YUTHE
intervention community where 46.5% reported participating in the YUTHE program, and one
comparison community matched by ethnicity and socioeconomic status); 81% of participants were
African American (178). In the intervention community, YUTHE was implemented in popular areas
where youth congregated (e.g., schools, recreation centers, public housing facilities, after-school
programs, etc.). Peer educations wore distinctive clothing with the YUTHE logo. Among participants in
the intervention compared to the comparison community, there was not a significant difference in the
intention to get an STI test in the next six months (OR 1.19, 95% CI 0.95-1.51), or having sought STI
testing in the prior year (OR 1.06, 95% CI 0.84-1.34). However, participants in the YUTHE outreach
community were significantly more likely to know that STI infections could be asymptomatic, know
about urine-based STI screening tests; perceive themselves to be at risk for acquiring a STI; and worried
about acquiring a STI. As well, participants that reported having contact with the YUTHE outreach staff,
were more likely to report receiving a STI test in the previous year (OR 2.21, 95% CI 1.62-3.01) as well as
the previous six months (OR 2.12, 95% CI 1.11-4.03 for a single contact with the YUTHE program, and OR
2.78, 95% CI 1.81-4.26 for multiple contacts) compared to those who reported having no contact with
the program.
5.6.1 Peer Education Combined with Outreach Screening (Youth Supplemental Review)
The focus of the article by Moss et al. (179) is the YUTHE initiative of the San Francisco Department of
Public Health, described previously. This initiative was further expanded to include STI screening, and
delivered in partnership with a local faith-based organization affiliated with the Baptist Church with a
longstanding history of helping the low-income residents of the target neighbourhoods. In addition to
peer education described previously, the program was expanded to include field-based STI screening for
youth (<25 years). This intervention was implemented in low-income neighbourhoods with high youth
STI rates, and predominantly African American populations. A partnership was established with a faithbased organization that provided staff to 1) help reach local youth, 2) secure local venues where
education and screening were conducted (e.g., YMCA, eateries, employment program, after-school
program, etc.), and 3) organize six youth rallies (including food and entertainment) to raise STI
awareness and offered STI screening and education. As well, outreach workers set up along four
geographic routes to cover separate gang turf areas. Participants provided urine samples. The YUTHE
staff notified individuals if they tested positive, provided therapy, and offered treatment packs for
partner therapy. Four hundred and seventy individuals were screened, 85% of whom were African
American and under 25 years of age. Thirty five percent of screened individuals came from other
neighbourhoods, suggesting success in outreach staff’s encouragement to bring friends and sexual
partners to screening sessions. Four percent of those screened tested positive for chlamydia or
gonorrhea and received treatment (delivered in the field). Twenty-six percent took treatment for their
sexual partners. The cost per person educated, counseled and screened for chlamydia and gonorrhea is
approximately $320, and cost per new case detected is $7900.
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Intervention
Peer education alone
and combined with
outreach screening for
youth in partnership
with a faith-based
organization
Behavioural
outcomes

STI
incidence/prevalence

Contextual considerations and comments
Peer education alone demonstrated
improvements in STI-related knowledge and
undergoing STI testing. This was expanded to
include outreach screening, in partnership with
a faith-based organization, which demonstrated
further positive impact in engaging youth in STI
screening
Impact on STI incidence/prevalence warrants
further research.
5.7
Clinic-based Interventions
A number of strategies that are implemented in clinic settings have been studied in the literature.
5.7.1 Disease Intervention Specialists in Clinic Settings
Taylor et al. (180) examined the impact of Disease Intervention Specialists (DIS) on partner elicitation as
part of contact tracing. DIS are a defined job category in the US with specialized expertise in STI-related
outreach, counseling, contact tracing, etc. (181) (190)(189)(188)(174). DIS were placed in three clinics
with providers that reported the highest number of syphilis cases outside of public STI clinics (these
clinics were all HIV clinics). DIS were placed in these clinics for one-half day per week, or on an on-call
basis, to conduct partner elicitation interviews with patients and to provide penicillin. A number of
positive outcomes were noted during the period of DIS placement, including a significantly greater
proportion of patients participating in the partner elicitation interview (94% vs. 81%); increased number
of partners located (1.1 vs. 0.6); increase in the average number of exposed or infected partners that
were brought to treatment (0.6 vs. 0.3); and there was a 9 day decrease in the time to interview (18
days vs. 9 days) (180).
Intervention
Disease Intervention
Specialists (DIS)
within a clinic setting
Behavioural
outcomes
 To support
partner
elicitation
STI
incidence/prevalence

Contextual considerations and comments
Limited study suggests a positive impact on
partner elicitation.
Research on the impact of DIS on STI rates is
needed (note that there is also a study of a
combined DIS and electronic technologies
intervention that demonstrates promising
results).
5.7.2 Electronic Technologies in the Clinic Setting
Zou et al. (182) conducted a systematic review to examine clinic-based strategies for increasing the
screening and detection of bacterial STIs among MSM. The results of this review revealed a number of
strategies for increasing screening, many of which involved the application of electronic technologies.
Among four studies that demonstrated significant increases in screening rates for gonorrhea and
chlamydia, strategies included the use of a computer alert on an electronic medical record, and short
text messaging reminders for repeat STI screening. Four studies revealed increases in syphilis testing,
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and strategies included the use of a computer alert on an electronic medical record; and an electronic
medical record system to enhance syphilis retesting after syphilis treatment of MSM (182). These
studies are examined in greater detail below.
Lister et al. (183) conducted a study at a sexual health clinic in Australia, and evaluated the dual
intervention of implementing screening guidelines for MSM, with a computer reminder/alert. This
initiative was undertaken due to awareness that screening MSM for rectal gonorrhea and chlamydia was
not being adequately implemented. At the one year point after introducing the guidelines and electronic
reminder system, there was a significant increase in rectal chlamydia testing (28% to 65%, p <0.001) and
significant reduction in pharyngeal chlamydia (65% to 28%, p <0.001) and gonorrhea testing (83% to
76%, p = 0.015). There was no difference in the proportion of positive tests at either the rectal or
pharyngeal sites, before vs. after implementation (7% vs. 7%).
Hotton et al. (184) found that after implementing electronic medical records, and enhanced follow-up
from DIS, timely follow up of MSM after diagnosis with early syphilis (i.e., return clinic visit within 6
months of the initial syphilis diagnosis) increased from 53% to 76%. Further, rescreening at the followup visit increased from 64% to 81%, and among patients that had timely follow-up, 70% were
rescreened.
Bourne et al. (185) examined how the use of a short message service (SMS) reminder system affected
HIV/STI re-testing rates among MSM in a sexual health clinic in Australia. The study population was HIVnegative males who had had previous HIV/STI tests and received a SMS reminder about re-testing
(recommended to occur 3-6 monthly for individuals considered high-risk based on self-reported sexual
behaviour). The intervention group (SMS reminder) was compared to a control group during the same
period, as well as retrospectively to the pre-SMS reminder period. It was found that in the intervention
(SMS) group, 64% were re-tested within 9 months; this was significantly higher than the control group
(30%, p < 0.001) and the pre-SMS group (31%, p <0.001). After controlling for baseline differences
between the groups, the SMS group was 4.4 times more likely to undergo retesting (95% CI 3.5-5.5)
compared to the comparison group, and 3.1 times more likely to be re-tested compared to the pre-SMS
group (95% CI 2.5-3.8).
Bissessor et al. (186) examined the impact of a computer alert that reminded health care providers to
test MSM that were at higher risk for syphilis, on syphilis testing. There was a significant increase in the
proportion of high-risk MSM who were tested for syphilis (from 77% to 89%, p > 0.001). There was also
an increase in the percentage of men diagnosed with asymptomatic syphilis (16% to 53%, p = 0.001).
Summary: Among four studies that demonstrated significant increases in screening rates for gonorrhea
and chlamydia, strategies included the use of a computer alert on an electronic medical record, and
short text messaging reminders for repeat STI screening. Four studies revealed increases in syphilis
testing, and strategies included the use of a computer alert on an electronic medical record; and an
electronic medical record system to enhance syphilis retesting after syphilis treatment of MSM.
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Intervention
Electronic
technologies in
STI clinic
settings
Behavioural
outcomes
 To support
testing STI
screening,
diagnosis, retesting
STI
incidence/prevalence

Contextual considerations and comments
The evidence is supportive of electronic
technologies, sometimes in conjunction with
another intervention (such as the introduction of
guidelines, or intensive DIS follow-up) being
effective in improving various outcomes related to
STI diagnosis and follow-up care (e.g., STI
screening, timely follow-up post-diagnosis,
rescreening).
Impact on STI rates over time is uncertain.
Studies are from high-income countries and utilize
technology that is of considerable interest in a
North American setting, such as electronic medical
records and SMS.
5.7.3 Syphilis Testing during HIV Care in the Clinic Setting
The systematic review by Zou et al. (182), discussed previously, also found that regular serological
screening for syphilis during routine HIV care, and syphilis serology included with blood tests performed
as part of HIV monitoring, were effective in increasing syphilis testing among MSM. Looking at the
original studies, Bissessor et al. (187) examined the effect of including routine syphilis testing with every
blood test performed as part of HIV monitoring, on the detection of early syphilis. This intervention was
compared to the traditional policy in the clinic of annual syphilis screening. A significantly higher
proportion of HIV-positive asymptomatic MSM were diagnosed with early syphilis in the 18 months
following the intervention compared to the 18 months before the intervention (85% vs. 21%, p = 0.006),
and there was a significantly shorter median time between the midpoint since last syphilis serology and
the diagnosis of syphilis after the intervention (45 days [range 23-235 days] vs. 107 days [range 9-362
days]).
Intervention
Syphilis testing
during routine HIV
monitoring
Behavioural
outcomes
 To support
syphilis
detection
STI
incidence/prevalence

Contextual considerations and comments
Including routine syphilis testing with every blood
test that is collected as part of HIV monitoring
resulted in a significant increase in early syphilis
detection, among HIV-positive MSM in an
Australian study.
Impact on STI rates is uncertain.
5.7.4 Clinic Guidelines on STI Screening
The systematic review by Zou et al. (182), discussed previously, also found that the introduction of clinic
guidelines on STI screening was effective in increasing screening rates for gonorrhea and chlamydia
among MSM. These are discussed later in this report in the section on evaluating STI control
strategies/guidelines.
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5.7.5 Male clinics
Sharma et al. (188) suggest that men may not feel comfortable seeking STI and other sexual health
services from family planning clinics, particularly young men, and that men need clinic services and staff
to provide confidential and non-judgmental care. The authors evaluated a men’s health clinic that was
established in a government health centre in India. At six months, there was a significant increase in STI
knowledge, and increase in the high-risk sexual activity score (which is presented as a positive change
but is difficult to interpret as the criteria for the score could not be accessed in the source journal).
Intervention
Male clinics
Behavioural
outcomes

STI
incidence/prevalence

Contextual considerations and comments
Male health clinics are suggested as an important way to
promote male access to STI care. The limited study
identified on this topic reported positive impact on STI
knowledge and suggests positive impacts on sexual risk
behaviour; impact on STI detection and STI rates was not
reported.
The single study on this topic is from India.
5.7.6 Mobile Clinics
The previous clinic-based interventions discussed in this section have all described interventions offered
in a standing facility. At the intersection of clinic-based initiatives and outreach is the mobile clinic. Kahn
et al. (189) evaluated the STI yield, and community acceptance, of a mobile clinic that set up at various
sites throughout a Louisiana area in neighbourhoods known to have high STI incidence. Screening sites
included stores, bars, restaurants, churches, vacant lots, and public housing facilities. The clinic offered
STI screening and treatment, and in order to avoid stigmatizing clients, it was advertised as the
“Community Health Outreach Project” in which various other free health promotion activities took place
(e.g., blood pressure testing and pregnancy testing). Individuals that tested positive for chlamydia,
gonorrhea or syphilis were notified of their results by telephone or home visits and referred to the local
health department for treatment. They were also instructed to refer their sexual partners to the local
health department for testing and treatment. During a three-year period, the rate of syphilis, chlamydia
and gonorrhea detection was 1.2%, 8.3% and 4.9%, respectively. Ninety-seven percent of respondents
to a survey assessing acceptability felt that neighborhood STI testing was a “good” or “very good” idea.
Intervention
Behavioural outcomes
Mobile
clinics
 To support screening
uptake
STI
incidence/prevalence

Contextual considerations and comments
A single US study revealed mobile clinics as a
feasible and acceptable way to reach
community members and test for STIs. Note
that general health services were also
offered in order to decrease stigma.
Impact on STI rates over time is not
examined.
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5.8
Outreach: Venue- or Group-based Screening
STI screening allows for the identification of an unrecognized infection (including asymptomatic
infection) and referral for follow-up investigation and treatment. Screening, a form of secondary STI
prevention, can therefore improve STI detection, facilitate the interruption of STI transmission and
improve control (182), and is a key group- and population-level intervention that is discussed at length
in the literature. Traditionally, screening has largely relied on individuals presenting to clinical settings
(190). However, many populations do not regularly access health care facilities for STI testing, with
barriers including a lack of transportation, concerns about confidentiality, stigma, lack of knowledge
about STIs, etc. The availability of nucleic acid amplification technology (NAAT) and the ability to test
urine and self-collected swabs for chlamydia and gonorrhea, has made the conduct of screening in nonclinical settings more feasible (190). As Johnson et al. (191) assert, a non-clinical STI screening program
is a convenient forum to serve a high-risk population.
There are a number of publications discussing STI screening outreach to specific populations within
established venues in the community, outside of traditional healthcare facilities (e.g., secondary schools,
Family Court, shelters, sports-related venues, bathhouses, etc.). There are also examples of screening
outreach outside of existing venues, such as on the street or in public areas. In a recent review by
Hengel et al. (190) outreach programs were identified in a variety of settings among diverse populations
and participation was found to be particularly high where screening was offered within existing venues
(e.g., community centre, homeless shelter, parenting centre) or a sporting club, rather than on the
street or in public areas within the community.
5.8.1 School-based STI Screening and Treatment Programs
School-based STI screening, coupled with school-based treatment or referral for treatment, has been
studied in a number of settings with encouraging although not uniform results. The rationale for such
programs that take place within the school setting, include that adolescents and young adults are
disproportionately affected by chlamydia and gonorrhea, most chlamydia infections are asymptomatic,
particularly in females, and gonorrhea is typically asymptomatic in males; therefore active screening and
treatment programs are essential in order to prevent complications; adolescents are less likely than
some other age groups to seek or receive preventive health services and STI screening; and the
availability of urine-based nucleic acid amplification tests (NAAT) facilitates testing in non-clinical
settings (192). There were high rates of treatment for students with identified infection, however those
studies that evaluated the impact of school-based screening on STI rates over time produced mixed
results. The resource-intensive nature of such screening programs is consistently recognized.
The Philadelphia Department of Public Health (PDPH), with the support of the School District of
Philadelphia (SDP), established a voluntary high school-based education and screening program to
identify and treat chlamydia and gonorrhea (192). The Philadelphia High School STD Screening Program
(PHSSSP) was initiated in 2003; a description of the program is presented in Appendix D. Of the ~30,000
students who attended the PHSSSP, ~65% submitted specimens adequate for testing (note that this
represents less than 40% of the students enrolled in these grades in the public school system). Five
percent of these tested positive for chlamydia, 0.5% for gonorrhea, and 0.3% for both infections.126
Females had higher prevalence of infections than males (prevalence of chlamydia and gonorrhea were
3.3 and 5.1 times higher, respectively). Treatment was administered to 99.9% of students with infection;
of those treated, 70.3% received treatment at “in-school” treatment sessions, 22.4% at PDPH STI clinics,
with smaller proportions in other venues such as private physicians’ offices. Students treated during
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school treatment sessions received significantly faster intervention, as the median time between testing
and treatment was 5 days shorter for students who were treated during school treatment sessions than
for those treated in other settings (8 days vs. 13 days) (192). The program was felt to be labor-intensive,
but was acceptable to students and staff (192). Information on long-term effect on STI prevalence was
not available. A concern that has been raised regarding urine-based screening for chlamydia and
gonorrhea in non-traditional settings is that screening for other STIs (e.g., HIV and syphilis) may not
occur. In this program, all students with an identified infection were counseled to seek follow up for
comprehensive STI care (192).
A longitudinal school-based program demonstrated that repeated screening and treatment was
associated with a decrease in the prevalence of chlamydia infections, although this was only significant
among male students (193). Cohen et al. (193) conducted a study in three urban public high schools in
Louisiana (n = >2000). All students in grades 9-12 were given the opportunity to be tested for chlamydia
and gonorrhea during three consecutive school years, using urine tests. Students also received
education, counseling and treatment (where needed) with oral single-dose antibiotic therapy. Controls
were five comparable schools (n = 5063). Between 52%-65% of students participated per year. At the
first test, 11.5% of girls and 6.2% of boys were found to be infected with chlamydia, while 2.5% of girls
and 1.2% of boys were infected with gonorrhea; more than 90% of infections were asymptomatic. With
repeated testing, the chlamydia prevalence among boys decreased to half of what was observed in
comparison schools (3.2% vs. 6.4%), while among girls, chlamydia prevalence decreased to a smaller
degree (10.3% vs. 11.9%).
A study by Nsuami & Cohen et al (194), conducted an evaluation over a 3-year period in three high
schools, and found that the prevalence of chlamydia infection among students who were only tested
once was, 6.2% among males and 12.7% among females. Chlamydia infection at first test among
students who tested more than once was 1.8% for males and 7.7% for females. Among students tested
more than once, no significant difference in chlamydia prevalence was associated with repeat
screenings. Incidence rates per 1000 person-months were 4.3 (2.2 among males and 7.1 among
females).
In a study by Low et al. (2013), in a school-based screening program, chlamydia positivity was found to
increase over time (195). A screening and treatment program began during the 1995-1996 academic
year and continued until 2004-2005 in a sample of high schools. Students with positive chlamydia tests
received counseling by nurses or physicians, treatment with a single oral dose of azithromycin (1g), were
asked to attend the city STI clinic for further examination and testing (including HIV testing), and were
asked to refer their sexual partner(s) for assessment. Participation in the screening program ranged
between 32.3%-51.4% depending on the year. Over the entire 10-year period, most students were
tested at least once. The proportion of students tested decreased with the increased number of years
they were registered in their school; 37.7% (females) and 38.6% (males) of students were screened who
were registered for only one year, but this declined to 10.6% (females) and 12.7%% (males) for students
registered for all four years. Note that females who had a positive chlamydia test in a previous screening
were significantly less likely to be tested at subsequent screening opportunities than were those who
had a previous negative result (age-adjusted OR 0.77). There was however a higher odds of subsequent
participation among students with more recent sexual partners. Chlamydia positivity initially declined
slightly in women, and remained stable in men, then in 1998-1999 positivity increased, then was stable
again from 1999-2000 onwards for both genders. The authors observe that it is difficult to sustain repeat
annual screening.
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Summary: School-based STI screening, coupled with school-based treatment or referral for treatment,
has been studied in a number of settings with encouraging although not uniform results. There were
high rates of treatment for students with identified infection and those studies that evaluated the
impact of school-based screening on STI rates over time produced mixed results. The resource-intensive
nature of such screening programs is noted consistently.
5.8.2 Other Studies
Barry et al. (196) found that screening in a school in an area with high STI rates had fairly high
participation (63% of those in attendance), but relatively low STI yield (no students tested positive for
gonorrhea, and 1.3% tested positive for chlamydia although rates varied among students, with higher
rates observed among black female students). The authors questioned whether the higher-risk students
were in fact in attendance at the schools, and given the resource intensive nature of such a program
(each identified case required 63 staff hours), assert that it is important to consider local epidemiology
and whether schools have substantial proportions of students likely at high risk for STIs, before
establishing a school-based program.
Intervention
School-based
STI screening
and treatment
programs
Behavioural
outcomes
 For
facilitating the
treatment of
cases
 For
participation in
screening
program
STI
incidence/prevalence

Contextual considerations and comments
Screening in school-based settings was the subject
of a large body of research. Generally, there are
favourable outcomes related to the treatment of
individuals that are found to have STIs (many of
which are asymptomatic). Rates of participation in
the screening program vary widely. There is also
inconsistency with respect to the impact of the
program on STI rates over time.
5.8.3 STI Screening in School-based Health Centres (Youth Supplemental Review)
School-based health centers (SBHC)a were first established in the United States over 25 years ago to
improve access to care for low socioeconomic children and ensure that school-aged children receive
quality primary health care (197). Services offered by SBHCs include, but are not limited to, health
promotion focusing on reproductive health and STIs. A standard of care in SBHC is to conduct a
behavioral risk assessment on each student and discuss risk behaviors. Depending on state laws, some
SBHC prescribe or dispense contraceptives and provide confidential STI treatment services. Other SBHC
provide only counseling and education and make referrals to local health departments, hospitals, or
community agencies. Newly opened SBHC often begin by providing only education and prevention, and
some eventually evolve to the provision of contraceptive and reproductive services. The values and
preference of the community, school administrators, and parents are key factors. Currently, about 10%
to 18% of visits to SBHC are for reproductive services and the National Assembly for School based Health
Care survey of SBHC revealed that 60% provided STI diagnosis and treatment and 25% of SBHC
dispensed contraception on site. Although most SBHC treat STI among their patient population, several
have developed specific programs to address prevention of STI and promote reproductive health. An
example of such a program, operating within a Florida SBHC serving a predominantly African American
lower socioeconomic neighborhood, is described in Appendix D.
a
It is unclear whether Health Resource Centers (HRC) and School-Based Health Centers (SBHC) are referring to the
same service, or if these are distinct interventions.
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Another term for school-based clinics is Health Resource Centers (HRC). For example, after the School
District of Philadelphia adopted Policy 123 (see Appendix D), they partnered with a family planning
organization in the community and the Philadelphia Department of Public Health to establish HRCs in
nine public high schools. The HRC included a number of services. Students could drop-in for
reproductive health information, condoms and general health referrals, and received counseling on the
importance of abstinence in preventing STIs and pregnancy. Medical services were not offered within
HRCs, but they would refer to nearby health facilities. Each school had slight variations in their HRC
logistics, as per the needs of the school (e.g., only opening during lunch, opening during specific hours
throughout the day, housed in school health clinics or in classroom or office space, etc.). HRC staff
included nurses, psychologists and health educators. The program operates on “passive parental
consent”, which means that parents can prevent their child from receiving condoms through the HRC by
returning a letter sent home by the school principal; in this model, parental consent is not required for
the receipt of counseling or referrals through the centre.
Braun & Provost et al. (198) evaluated an initiative that offered chlamydia screening to a target
population of young females accessing reproductive health services within a SBHC. A number of
strategies were implemented to support screening initiatives. Health fairs, back-to-school nights and
classroom-based health education were implemented to increase awareness and promote students’
utilization of SBHCs. Youth advisory boards were created to allow students to share their perspectives
about their SBHC. Other outreach activities were conducted in partnership with existing student groups,
such as prom-related promotions, sports tournaments, etc. As well, clinical strategies were
implemented to increase screening, such as new screening protocols that required all new sexually
active patients to receive a chlamydia test before receiving further services (from which they could opt
out if desired); a chart flag system using electronic or paper methods, to remind clinicians to screen for
chlamydia irrespective of the reason for their visit, and standing order for chlamydia tests during certain
types of visits (e.g., health education visits and pregnancy tests). Eighty-five percent of the 3392 clients
that received service reported that the SBHC was their only source of reproductive care in the past 12
months. Among those that received care from the SBHC, 89.1% received a chlamydia test (range 71.9%100%). There was 5.6% chlamydia positivity, with highest positivity among African American (12.9%),
Pacific Islander (8.6%) and Asian students (7.6%).
Other authors have demonstrated that STI screening offered through SBHC can result in moderate-tohigh student participation, and STI detection. For example, in a school-wide chlamydia and gonorrhea
screening effort, Salerno et al. (199) found that 69% of students participated in screening and 8.9%
tested positive for a STI.
A number of studies demonstrated that when STI screening is offered in health centers, (not simply
during reproductive health-focused visits but where screening is offered for students presenting for
diverse reasons) moderate to high rates of STI detection can be achieved. Some of these studies were
conducted in high STI prevalence communities. For example, Burstein et al. (200) demonstrated that STI
screening in middle school health centers can detect fairly high rates of STIs among students. One
hundred and seventy female and 43 male students who visited the health center for reasons that were
related to various primary health concerns (e.g., reproductive health, illness/injury etc.), were routinely
asked to provide urine samples for gonorrhea and chlamydia testing. Among female students, 11.4%
tested positive for gonorrhea, and 16.4% tested positive for chlamydia. Among male students, 2.1%
tested positive for chlamydia, and the same proportion tested positive for gonorrhea. The incidence of
gonorrhea was 34.0 cases/1000 person months (95%CI 19.5-67.5), and incidence of chlamydia was 57.5
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cases/1,000 person months (95% CI 35.3-93.8). Joffe et al. (201) supports the utility of SBHC for
screening specifically for young men. Among 1434 students in middle schools and highschools in
Baltimore and Denver, students were offered screening for chlamydia during various types of health
care visits (e.g., athletics physicals, acute care visits, well adolescent visits, etc.). Among asymptomatic
adolescent males, 6.8% tested positive for chlamydia.
One study, by Gaydos et al. (202) examined chlamydia reinfection rates among female adolescents
presenting for rescreening at SBHCs. As there was not a comparison arm for this study, it is difficult to
determine the impact that the presence of the SBHC made on reinfection rates. For the purpose of this
study, chlamydia reinfection was defined as a positive chlamydia nucleic acid amplification test (NAAT)
occurring between 30-365 days after an initial positive result. Over a seven-year period, more than
10,000 female students were screened for chlamydia (unique females in each year, although females
could be screened in more than one year), and the overall prevalence was 18.1% (95% CI 17.4-18.8%),
with a variation from year to year (from 15.1% [13.1-17.1] to 19.5% [17.8-21.2%]). Note that chlamydia
positivity did not decrease over time, as the lowest prevalence was in 1999 and highest in 2002; the
reasons for this are not clear. Among those who tested positive, 46.7% were rescreened. The cumulative
incidence of reinfection was 26.3% (95% CI 23.4-29.2%), and of these individuals, 42.8% had one or
more negative test results between the initial positive test and subsequent positive test. The age group
with the highest risk of reinfection was age 13 years and younger. The authors concluded that their
findings support the importance of frequent screening of adolescents for chlamydia, especially if there
has been a previous infection.
The literature also suggests that students that have access to a SBHC have a greater likelihood of being
screened for a STI than do students without such access. Ethier et al. (203) compared the receipt of
health care, including STI screening, among sexually experienced adolescents that did, and did not, have
access to a SBHC, in 12 California highschools. Although access to a SBHC did not influence the receipt of
reproductive health care or contraceptive use, among females, those who had access to a SBHC did have
a significantly greater likelihood of having been screened for a STI (AOR 2.1, 95% CI 1.08-4.22).
In the Netherlands, Wolfers et al. (204) conducted a cluster RCT to evaluate the impact of offering sexual
health services to students in senior vocational schools, a group reported to be at high risk for STIs. The
intervention, called ROsafe involved educational sessions, an internet-based home assignment and
sexual health services offered at school sites including STI testing and sexual health advice (free,
anonymous, no appointment required). This full multi-component intervention was delivered to the first
experimental group, while the second experimental group received health education only, and the third
group received sexual health services only. The control group did not receive any of these intervention
components. The intervention arm that received the full ROsafe intervention had 29% of students that
had a STI test; this was higher than the other two experimental arms and the control arm (4%). Note
that 1.4% of the study sample tested positive for chlamydia.
Summary: Services offered by SBHCs can include health promotion activities focusing on reproductive
health and STIs. Studies suggest that SBHCs are an effective way to engage youth in STI screening.
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Intervention
School-based
health centers
Behavioural
outcomes

STI incidence/
prevalence

Contextual considerations and comments
SBHCs are important venues for offering screening to
youth in schools, and have demonstrated the ability to
detect high rates of STIs in US studies. One study
demonstrated that a chlamydia screening initiative
engaged a high proportion of SBHC clients, the majority of
whom did not have another source for reproductive
health care. Another study suggests that this is an
important way to engage asymptomatic young men in
screening. High rates of reinfection with chlamydia were
detected through a SBHC in one study, particularly among
younger youth.
The long-term impact of offering STI screening through
SBHCs on STI incidence/prevalence is not certain.
5.8.4 Sport-related Settings
Sport-related settings may encompass members of a sports team or club, or may involve sports venues,
as settings for STI screening. The results from a study by Gold et al. (205) suggest that high recruitment
for STI screening may be achieved through sporting clubs. As part of a STI screening initiative among
young males in four rural football clubs in Australia, more than 90% of eligible players present at the
clubs on the night of the study participated. Among the 80% that had ever had sex, the prevalence of
chlamydia was 3.9%. Despite a high percentage having visited their physician in the past year (78.7%),
and the fact that most were comfortable with the idea of an annual STI screen, few had ever discussed
sex or STIs with their doctor or had a previous STI test.
However, in the United Kingdom (UK), Saunders et al. (206) explored the acceptability of various venues
(medical, recreational and sports locales) as places for young men to access self-collected testing kits for
STI/HIV testing. Among males aged 18-35 years (n =411), there was a high willingness to access selfcollected tests for STIs (85.1%), but there was low acceptability of sporting venues as test pick-up points
(11.7%); although there was greater acceptance among those who actually participated in sports
(53.9%). In this study, the most acceptable pick-up points were healthcare facilities, specifically general
practice (79.9%), genitourinary medicine (GUM) clinics (66.8%) and pharmacies (65.4%).
Intervention
Screening in
sports/sports
team-related
settings
Behavioural
outcomes
 For
promoting
screening
uptake
STI
incidence/prevalence

Contextual considerations and comments
A limited research base was identified on screening
among sports teams/in sports venues. One study in
Australia demonstrated a very high screening
participation, while another study suggests that
there is potentially a greater acceptance of
screening in these venues among those who
actually participate in sports.
Evidence is needed to assess how this impacts on
STI rates over time.
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5.8.5 Occupational Groups
Screening based on occupational group involves offering screening to workers of a particular job
classification. Kourbatova et al. (207) discuss that the national STI control program in the Russian
Federation involves routine, compulsory STI screening based on occupation. Seven percent of the
population are screened through these programs, which focus on syphilis and gonorrhea, and may also
include Trichomoniasis, chlamydia and HIV. Among study participants (n = 1000), the prevalence of
syphilis based on the results of Rapid Plasma Regain (RPR) and Treponema Pallidum Particle
agglutination Assay (TPPA) tests was 1.2%. Market salespeople had a significantly higher prevalence of
syphilis compared with the other three occupational groups studied (food handlers and other food
industry workers, education and health care providers, and hotel and other public utility workers)
combined (4.4% vs. 0.1%). The prevalence of gonorrhea was 0.3%. The authors also examined costeffectiveness, and the incremental cost per case of STI treated was 8409 rubles ($252USD) for syphilis
screening (compared with no screening) with higher incremental costs associated with expanding the
program to include gonorrhea screening.
Intervention
Occupational
group screening
Behavioural
outcomes

STI
incidence/prevalence

Contextual considerations and comments
A single study was found that offered screening
based on occupational groups. Varying rates of
STIs was observed among different groups.
Evidence is needed to assess the impact on STI
rates over time.
5.8.6 Family Court System
Johnson et al.(191) examined the feasibility of using the Family Court System in Philadelphia (which
involves Juvenile Court and Domestic Relations) (208) as a venue for screening adolescents, especially
males, for chlamydia and gonorrhea. The study sample was comprised of adolescents on probation
under the jurisdiction of the Family Court System of Philadelphia. The Family Court STD Screening
Program, which is described in detail in Appendix D, offered education and voluntary non-invasive
screening for chlamydia and gonorrhea. The program was incorporated into the routine probation
intake protocol, and therefore ideally 100% of adolescents would have been offered testing and
counseling, however less than half of these adolescents were offered testing at intake. Over a 2.5 year
period, 2270 adolescents were counseled about STIs, and over 79.6% of these voluntarily submitted a
urine sample for STI testing. Overall, 8.4% were positive for chlamydia and/or gonorrhea (13.9% of
females and 7.0% of females). High rates of treatment were confirmed (93.3% of males and 100% of
females with positive tests).
Intervention
Screening in
family court
system
Behavioural
outcomes
For reaching
the target
population
 For facilitating
access to
treatment
STI
incidence/prevalence

Population and Public Health, Ministry of Health
Contextual considerations and comments
A single study on screening within the family
court system revealed that less than half of the
target population was offered testing at intake,
however there were very high treatment rates.
Evidence is needed to assess the impact on STI
rates over time.
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5.8.7 Prisons
Arriola et al. (209) examined STI screening in five jails in the US. Screening was offered during medical
intake and, in some settings, during HIV prevention education sessions delivered by a community
organization. Over 2000 inmates were tested for chlamydia, 1300 for gonorrhea and 930 for syphilis. Six
percent had chlamydia, 3% had gonorrhea and 2% had syphilis. Among those who tested positive for
any of these STIs, 78% were treated (79% of those testing positive for chlamydia, 66% for gonorrhea and
100% for syphilis); the remainder either declined treatment or were released before being notified of
their results or receiving treatment.
Kahn et al. (210) (2002) examined syphilis screening among arrestees in a jail in Louisiana. Between
1994-1998, 76% of 50,000 arrestees were screened. Screening occurred during the mandatory routine
health assessment of arrestees, completed within 24-hours of arrival. Among those screened, 1.3% were
diagnosed with untreated syphilis and 61% of these received treatment before release, while 4.7% had
previously been treated for syphilis. During this period a decline in syphilis rates was observed among
both arrestees as well as in the wider community making it difficult to draw an association with activities
that were unique to the prison.
Intervention
Behavioural outcomes
Screening in
prisons
For reaching the target
population
 For facilitating access
to treatment
STI incidence/
prevalence

Contextual considerations and comments
Fair screening rates were reported, while the
treatment rates varied. One of the key factors in
treating cases in this setting is that individuals may
be discharged prior to completing STI
investigation and treatment.
This literature is not clear on the impact of
screening on STI incidence/prevalence over time,
although there is some suggestion of moderate
levels of treatment for those who screen positive.
Note that Ariola et al. (2001) outline key
considerations for screening activities in this
setting, and these are presented for information
in Appendix D, without assuming that there is
strong evidence for this screening based on the
included studies.
5.8.8 Shelter Residents
Grimley et al. (211) examined STI testing among adults at three shelters in two US cities (see the
program description in Appendix D). The recruitment rate was very high (96% in one city shelter and
98% in the other). Note that at the time of screening, all study participants reported having no signs or
symptoms of infection. The rate of chlamydia was 15.0% in city B and 6.4% in city A; gonorrhea was 5.0%
and 3.2%; and syphilis was 0.08% and 1.4%, respectively. Treatment rates were high: 89.0% in city A and
94.0% in city B.
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Intervention
Screening in
shelters
Behavioural
outcomes
 For promoting
screening uptake
 For facilitating
access to
treatment
STI
incidence/prevalence

Contextual considerations and comments
In a single study among adults in US shelters,
high screening program participation, as well as
high treatment rates, were reported.
Evidence is needed to assess the impact on STI
rates over time.
5.8.9 STI Testing of Commercial Sex Workers in Outreach Settings
In a study by Chen et al. (212), female sex workers in China were specifically offered free rapid syphilis
testing as part of an outreach program. Over 2800 female sex workers were offered testing and 95%
participated. A positive result was identified in 6.8% of participants, and 75% were willing to attend a STI
clinic for confirmatory diagnostic testing and treatment. Numerous other identified studies examined
screening among sex trade workers, however in these contexts screening was combined with other
interventions and these have been captured in other respective sections within this report.
Intervention
Screening for
commercial sex
workers
Behavioural
outcomes
For
supporting
screening
uptake
 For
facilitating
access to
treatment
STI
incidence/prevalence

Contextual considerations and comments
A single study suggests that outreach supports
screening uptake, and access to diagnostic testing
and treatment. Note that numerous other studies
have included outreach screening for sex trade
workers, as part of a wider program with other
interventions (see report).
Evidence is needed to assess the impact on STI rates
over time.
5.8.10 MSM Sex on Premises Establishments, Saunas, Bathhouses
Lister et al. (213) studied an outreach STI/HIV screening program in men-only saunas in Australia. This
involved a nurse who set up within the sauna and administered screening. One hundred percent of the
men that tested positive obtained their results, whether by telephone, returning to the sauna to speak
with the nurse, receiving results from the health unit, or by email, and all received treatment. The
authors compared this STI/HIV screening program to an anonymous program that had been in operation
previously in Australia in 2001-2002, and had in fact been modified to create the “comprehensive STI
testing clinic” that was evaluated in the study. No explicit rationale was provided for the selection of this
comparison anonymous intervention, although presumably it provided a natural experiment as well as
the opportunity to assess two different approaches so that jurisdictions could decide which approach
they preferred. It was found that the anonymous program contacted more clients per hour (14 vs. 3),
but the STI/HIV program had a significantly higher proportion of men that tested positive for chlamydia
and/or gonorrhea (17% vs. 10.7%), and a higher proportion of those who tested positive obtained their
test results (100% vs. 70%).
Bathhouses may contain nurses that provide traditional in-person STI testing services, however these
initiatives have limitations as they are not accessible for men who visit bathhouses at times when testing
is not occurring, and some men find the procedure to be embarrassing which represents a barrier (214).
Therefore, in a Canadian study, O’Byrne et al. (214) placed chlamydia/gonorrhea urine testing kits in two
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bathhouses in an urban centre. Drop-boxes were used to house the testing kits and also served as a
drop-off point for the completed kits. The study duration was six months and had a relatively small
sample (n = 50). No one tested positive for chlamydia or gonorrhea, however among those who
underwent testing, some did so for the first time, and eight of these individuals underwent further
testing, and these eight were diagnosed with syphilis. It is noteworthy that 60% of the sample that had
accessed the testing kit had not previously accessed STI testing services from a sexual health clinic. As
well, a number of testing kits were taken but not returned.
Ciesielski et al. (215) found that the yield of syphilis detection with a targeted syphilis screening program
among MSM in a variety of non-medical settings (including bathhouses and MSM-oriented bars, as well
as mobile vans) was 0.9% (over 14,000 syphilis tests were performed). This was found despite the fact
that this targeted outreach screening campaign was implemented in seven US cities where there was a
recent outbreak of syphilis among MSM, and despite the fact that many individuals with syphilis had
met their sexual partners in similar venues to where the screening took place (e.g., bathhouses, bars,
etc.). The yield in bathhouses in particular was 1.2%.
Intervention
MSM sex on premises
establishments,
bathhouses, saunas
screening
Behavioural
outcomes
 For facilitating
treatment for
cases
 For
supporting
obtaining results
STI
incidence/prevalence

Contextual considerations and
comments
A few studies in this area suggest that
screening uptake might be supported
through outreach, as might treatment
for individuals that test positive.
Evidence is needed to assess the impact
on STI detection, as well as rates over
time.
5.8.11 Street
Screening conducted in ‘street’ settings is located outside of a fixed venue (e.g., on street corners, in
parks, etc.). Götz et al. (216) conducted a study in the Netherlands involving chlamydia and gonorrhea
testing offered through an outreach STI prevention program, to males and females aged 15-29 years.
Youths, particularly of non-Dutch ethnicity, were approached by outreach workers in three separate
settings: group settings (e.g., projects for Surinamese/Antillean immigrants, Surinamese/Antillean and
African women, teenage school dropouts of all ethnicities); street settings (e.g., street corners, parks
and underground stations); and sessions at vocational training schools. The street setting yielded the
lowest participation (17%), with much higher participation in the other settings (80% in the group
settings, and 73% in the schools).
Intervention
Street-based
screening
Behavioural
outcomes
 For screening
uptake
STI
incidence/prevalence

Contextual considerations and comments
In one study in the Netherlands, screening
was offered in various settings outside of
fixed venues. Screening uptake varied widely,
with the lowest proportion screened in street
corners, parks and underground stations, etc.
Evidence is needed to assess the impact on
STI rates over time.
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5.8.12 Other Studies
Rusch et al. (217) conducted a study in the downtown eastside in Vancouver, BC, assessing a community
health clinic that offered a weekly program for women. One of the appeals of this program was that it
offered a broader range of services (e.g., food and social activities) as well as a place to access health
care, thereby attracting a wider range of individuals from the community. Among the sample of 126
women, 70% had ever traded sex, 80% had used non-injection drugs and 40% used injection drugs.
Seventy-three percent of participants submitted a urine sample for STI testing; there were no positive
gonorrhea results and 2.2% positive chlamydia results (this includes among 2.6% of those who did not
report any sexual activity in the past). This prevalence rate may be reflective of the fact that most
women in the sample were over the age of 35 years, although the authors note that this age is still lower
than might be expected for those involved in sex work.
Bergman et al. (218) evaluated the use of point-of-care (POC) syphilis and HIV tests in Edmonton,
Alberta (AB), a province affected by a syphilis outbreak. Potential benefits of POC tests include the rapid
availability of test results (usually in less than 30 minutes); reducing loss to follow-up as prolonged
waiting periods are not involved; and facilitating immediate treatment. In this study, POC tests were
administered through outreach in various settings (correctional facilities, inpatient addiction facilities,
health centres, inner city drop-in centres, agencies working with sex trade workers, and bathhouses and
bars). These locations were selected in part because they facilitated access to populations that had been
represented in the AB syphilis outbreak (e.g., MSM, sex trade workers, injection drug users (IDUs) and
Aboriginal individuals). These were also settings that already offered routine STI testing. Among 1183
individuals offered POC testing, 81.5% underwent testing for syphilis and/or HIV. Among those tested
for syphilis, 2.8% were positive; and the majority (86%) had been previously treated for syphilis without
evidence of new infection. The remainder, who were new infections, were treated. Acceptance of
testing was fairly high across settings (from 69.6% in community organizations to 91.3% in settings
serving MSM, with >80% of individuals in correctional, inpatient addictions, and health facilities
accepting testing).
Compared to standard laboratory serological testing, the POC tests had a sensitivity of 85.3% (95% CI
68.9 – 95.0) and specificity of 100% (95% CI 99.6-100.0). Note that the authors discuss the need for
caution when using treponemal POC tests among a previously syphilis seropositive population, as this
test cannot distinguish between old and new syphilis infections, and there is a need for some way to
confirm that cases have not been previously treated. In this study, retreatment was avoided because the
testing nurse was able to access the provincial STI database to verify previous syphilis diagnosis and
treatment.
As previously mentioned, Hengel et al. (190) reviewed numerous other outreach screening studies,
including among youth who have left school/at risk of dropping out of school, males attending a drug
treatment facility, and parenting centre and leisure centre attendees. Other target populations included
travelers staying in backpacker accommodation, and settlement dwellers in South Africa. Studies vary in
the proportion of population tested, and the treatment rate.
These outreach screening studies have many unique elements, however some common principles
emerge (see Box 4).
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Box 4: Key elements to consider in STI outreach programs
Know the population being screened; identify key sites and methods for outreach that are appropriate for the
unique context.
An existing venue, or existing group structure (e.g., sports teams), may have advantages for accessing certain
populations. However, studies have also demonstrated important and successful street-based outreach where
appropriate.
For individuals that test positive for selected STI(s) (e.g., chlamydia and gonorrhea), ensure that a process is in
place for subsequent screening for other STIs (i.e., a complete STI screen).
Ensure that there is a protocol for follow-up with individuals who had positive test results but did not access their
results or present for treatment.
5.9
Home-based STI Testing
Home-based testing refers to STI testing that can be conducted within the home, rather than requiring
individuals to present to a health care facility. A selection of studies explored different ways to make
home-based STI testing accessible to target populations. Utilizing the home as a testing venue may avoid
the stigma of attending a STI clinic, and reduce direct interaction with health care providers, thus
encouraging testing among those who would be least likely to seek medical care otherwise (219).
Studies in the United Kingdom (UK) and Denmark demonstrated that mailing samples for testing is
acceptable and cost-effective (219–221). A study in the US demonstrated that mailing vaginal swab
specimens was feasible, and that the validity of diagnostic testing was not affected (221).
Home-based testing may have elements of both micro- and meso-level interventions. While testing is
targeted to the individual, and requires individuals to independently collect and submit their samples for
testing, home-based testing is often implemented through a wider program targeting specific
population(s). For this reason, this topic is addressed in both the micro- and meso-level sections of this
report.
Bloomfield et al. (219) sought to reach a population that was felt to have sub-optimal STI screening
rates. The target population was individuals living in a particular neighbourhood in San Francisco that
had the highest rates of gonorrhea and syphilis in 1999; this neighbourhood is described as being the
“cultural centre” for MSM. Free STI testing kits and surveys were made available at pharmacies and
gyms because the former is an established site for health interventions, and the latter is a known
meeting place for health-focused individuals. Two hundred and nine kits were picked up from these
locations, and 38% were returned by mail, with half arriving within two days. Participants were given a
telephone number to call for results. Individuals with positive results were notified and several
treatment options were offered (within an STI clinic, delivered to them, or picked up at the pharmacy).
Five percent of samples were found to be positive for chlamydia or gonorrhea (approximately 4%
chlamydia and 1% gonorrhea). All individuals chose to have the prescription for treatment telephoned
to the pharmacy where they could pick it up. Some participants expressed concerns about
confidentiality, privacy and safety (56%, 54% and 34% were very concerned about these areas,
respectively). The cost per received sample was about $30, including the cost per kit ($3.86) as well as
testing, advertising and mailing costs (219).
A free home-testing program for chlamydia and gonorrhea called “I Know” was implemented by the Los
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Angeles County Department of Public Health, targeting African American and Latina women (222). A
social marketing campaign was undertaken to encourage women to order home collection kits via
telephone or online. Within the first year of the program, over 2927 kits were ordered and 1619
specimens were returned (1543 that were testable). The online method was much preferred over the
telephone with 96% of testing kit orders placed via a website and 88% of results obtained via the
program website. Note that this testing volume was four times the average volume seen among females
age 12-25 years at the Los Angeles County Public Health STI clinics during the same period. Testing
revealed that 8.5% were positive: 7.9% chlamydia and 1.0% gonorrhea. Eighty-eight percent of those
who tested positive were treated by STI program nurses, 3.8% were referred to other jurisdictions, while
8.4% could not be contacted (222).
Supporting the potential advantage of home-based screening versus screening in traditional health care
facility settings, Graseck, et al. (223) compared home-based screening with clinic-based screening. They
found that home-based users were more likely to complete screening compared to clinic-based users
(56.3% versus 25.0%; RR 2.2, 95% CI 1.7-2.7).
In terms of impact on STI outcomes, some of the data presented in the micro-level interventions section
on chlamydia screening and PID and other morbidity will be revisited here, because these studies
involve home-based STI testing. In the study by Ostergaard, et al. (89) a home sampling (intervention)
group was compared a screening program based on conventional swab sampling performed at a
physician’s office (control) group, in Denmark. At one year, a significantly higher proportion of women in
the control group (4.2%) required treatment for PID compared to 2.1% in the intervention group (p =
0.045).
However, in the study by Andersen, et al. (90) involving a large sample of women and men in Denmark,
an intervention group was offered an opportunity to be tested for chlamydia via a home sample that
they could mail directly to the laboratory, while the control group was the rest of the population living in
the county. After a nine year follow-up period, there were no significant differences between the
intervention group and control group in terms of PID, ectopic pregnancy, infertility, IVF treatment, or
births in women, and in men, there was no significant difference in epididymitis.
Summary: Studies in the United Kingdom (UK) and Denmark demonstrated that mailing samples for
testing is acceptable and cost-effective while a study in the US demonstrated that mailing vaginal swab
specimens was feasible, and that the validity of diagnostic testing was not affected.
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Intervention
Home-based STI
testing
Behavioural
outcomes
 To support
screening uptake
STI incidence/
prevalence

Contextual considerations and comments
Generally favourable in terms of feasibility and
appears to support the uptake of STI testing. One
study found that ordering a testing kit online, and
obtaining results online, were much preferred over
telephone methods. Some studies observed a higher
screening volume with home-based testing, although
it is not clear why and whether this finding (observed
in settings outside of Canada) would be similar in a
Canadian context. There were concerns expressed by
participants in some studies about privacy,
confidentiality and safety, and these would need to
be addressed in any similar intervention.
There is uncertainty regarding the potential impact of
home-based STI testing on STI morbidity over time, as
two studies revealed contradictory findings, with a
large study with a long follow-up period revealing no
differences between home-based screening and a
control condition. Studies were outside of Canada
(including in the US where there may be some
differences in access to healthcare compared to the
publicly-funded Canadian context).
5.10 Internet-based Campaigns and Services for MSM (MSM
Supplemental Review)
As the internet has evolved over the past two decades, MSM have increasingly used the internet to
meet sexual partners. There is an association between use of the internet to meet sexual partners and
an increased number of partners, an increased number of partners known to have HIV, and an increased
in reported anal sex when compared with partners met via other modes (224). McFarlane, et al.(225)
conducted a qualitative study looking at internet-based health promotion and disease control in eight
US cities (Chicago, New York, Miami, Fort Lauderdale, San Francisco, Los Angeles, Houston and Atlanta).
They found that online efforts were generally divided into several categories:
 Partner notification on the internet—the authors noted that the use of e-mail was preferable to
the use of live chat because of the differences in time required for partner finding (one does not
have to stay in a chat room for long periods waiting for partners to log on; other problems
identified include people using multiple, anonymous online personas). Overall, four of the eight
cities reported having some sort of online partner notification system via e-mail in 2004, with
limited evaluation. Some concerns have been reported with issues of privacy.
 Chat room outreach—four of the eight cities in 2004 conducted chat room outreach. This was
usually accomplished by having staff members logging into chat rooms with a user name like
“letstalkaboutsex” or “askmeabouthealth”. “Profiles” were often created explaining their
purpose for visiting chat rooms, the types of questions they could answer, and referral
information for testing and treatment. Chat room staff was generally passive and waited for
questions.
 Online testing—this was piloted in San Francisco (see below).
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

Online banner advertisements—online banner advertisements have been used in advertising
since the early 1990s. These advertisements take up a small proportion of the screen, can be
clicked on, and the user will be transferred to another website. Banner advertisements are sold
by “impressions” or the number of times an advertisement appears on a webpage. When a user
clicks the ad, the buyer of these advertisements usually pay a fee of 5 cents to 10 dollars to the
hosting website. The San Francisco Department of Public Health (SFDPH) conducted an online
banner advertisement campaign that is reviewed below.
Interactive, targeted interventions—these interviews are more interactive than a typical didactic
educational website. Usually, the intervention begins with the participant answering questions
about risk behaviours. The computer program then provides tailored, targeted feedback to the
visitor. One intervention that was developed and tested in the US was the SmartSexQuest (226),
which aimed to increase STI and HIV testing among MSM and increase condom use. Despite
men logging on and reading through the materials, only 15% returned follow-up questionnaires
after 3 months.
Klausner, et al. (227) published a descriptive evaluation of the online efforts of the SFDPH. A website was
created; there was individual online outreach, banner advertisements, chats, an educational site,
message boards, warnings and an online syphilis testing program. During two months in 2002, staff
conducted 57 hours of outreach on three internet sites (AOL, Craigslist and M4M4Sex) resulting in 212
interactions. Thirty-five or 16% redeemed incentive coupons at the municipal STI clinic. There were nine
banner ad campaigns shown over 33 million times on gay.com and AOL, resulting in a 0.1% click-through
rate. There were seven, one-hour chats on gay.com with 10-50 people in the chat room at any one time,
and 15 questions answered per hour. About 840 people participated in seven sessions. The “Ask Dr. K”
site received 100 questions a week.
The SFDPH also piloted an online syphilis testing website (228). Persons could log onto stdtest.org to
obtain a physician-ordered laboratory requisition and a unique identification number. This requisition
could then be taken to any number of local, private laboratories for specimen collection and analysis.
Results were sent to the SFDPH, who then posted the results on the website, along with the unique
identification number. From June 2003-January 2004, there were thousands of visitors to STDTest.org
(described above), but only 140 completed syphilis testing. Of these, six (4.3%) tested positive.
One other study done in the Netherlands also looked at online syphilis testing (229). The authors
developed a website that presented information on syphilis and allowed users to download a referral
letter which they could bring to a laboratory to test for syphilis. Results were available one week after
the blood test. They compared the percentage of syphilis infected men detected online with those at a
local STI clinic during the same time frame. During 15 months, 898 visitors to the website downloaded a
referral letter. Of these, 93 (10%) men tested and 96% of these obtained their test results online.
Through the website, the authors found a significantly higher percentage of men who needed treatment
for syphilis compared with the STI clinic (50% online versus 24% STI clinic, p < 0.01). Of the online users
who tested positive 3 of 10 had never visited the STI clinic before.
InSPOT is a web-based partner notification service, originally developed for MSM with the goal of
helping them notify partners of possible STI exposure (230).The website design was based on extensive
input from key community advisors and on-site testing in San Francisco with samples drawn from the
general population.
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Two sections of inSpot exist:
 Tell Them, in which users choose one of six e-cards, and they type in up to six e-mail addresses
of recipients. They then select an STI from a pull-down menu and can type in a personal
message. They can add their own e-mail address or send the e-card anonymously. When the
recipient clicks on the e-card, they are sent to a page with disease-specific information.
 Get Checked, which is divided into STI information, a map of local testing sites, and links to
online resources.
To ensure privacy, e-mail addresses are not stored. An initial evaluation by Levine, et al. (230) showed
that an average of 750 people visited inSpot.org daily. Fewer than 10 people reported receiving e-cards
in error. Since its launch in 2004, inSPOT has since expanded in three countries, ten cities, and nine US
states. Online, provider and street intercept surveys performed on MSM between March and December
2005 found that 13-26% knew what inSPOT was, with 65-74% saying they would send or would
recommend sending an e-card, if appropriate. Pattern of diseases reported by Levine, et al. (230) found
that 15.4% of e-cards were for gonorrhea, 14.9% were for syphilis, 9.3% were for HIV, 11.6% were for
chlamydia, and 48.8% were for “other” including cervicitis, “crabs”, scabies, hepatitis A, B, and C, LGV,
Molluscum contagiosum, nongonococcal urethritis, Shigella, Trichomoniasis, and “unspecified.”
Kerani, et al. (155) conducted a RCT of inSPOT. They offered enrollment in the trial to 393 MSM who
were diagnosed with chlamydia and/or gonorrhea in a RCT in four arms: inSPOT, patient-delivered
partner therapy (PDPT), combined inSPOT and PDPT, and standard partner management. However, only
75 (19%) enrolled and the rest declined enrollment. Among the 75 enrollees, only 53 completed
baseline and follow-up interviews. The study was halted early due to low enrollment. Among the 27
men assigned to an inSPOT arm, only one used inSPOT to notify more than one partner. There were no
significant differences between partners notified, treated, or tested for syphilis in adjusted analysis
between those assigned to inSPOT and no inSPOT.
Hightow-Weidman, et al. (231) compared a formalized internet partner notification (IPN) and text
messaging service for partner notification (txtPN) in North Carolina with outcomes for the previous year.
They compared the number of IPN and txtPN contacts initiated and their outcomes from July 1, 2011 to
June 30, 2012, with outcomes from January 1, 2010 to December 31, 2010, the year before the
collaboration. They found that 362 IPN contacts were initiated compared with 133 in 2010. Seven new
cases of HIV infection, 11 new cases of syphilis, and 19 known previous HIV-positive persons were
identified. Text messaging for partner notification was used for 29 contacts who did not initially respond
to traditional notification or IPN. Forty-eight percent responded to txtPN in a median time of 57.5
minutes.
An example of an instant messaging/chat room intervention is that of PowerON (232). PowerON is an
organization that provides counselling to MSM online in real time through instant messaging.
Moskowitz, et al. (232) analyzed a sample of 279 transcripts of exchanges between PowerON counselors
and gay.com users. They found that 43% of the instant message sessions discussed information about
HIV/STIs. Risk taking behaviours were addressed in 39% of the sessions. Information about HIV/STIs and
general counselling were given in 23 and 18% of the counselling sessions, respectively. The authors
conclude that the internet can be a medium through which sexual health information to MSM can be
dispersed.
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Muessig, et al. (233) recruited a sample of 22 black MSM and conducted focus groups to inform the
development of phone-based HIV/STI apps. Despite the fact that half the sample group earned less than
$11,000 annually, all participants owned a smart phone, had unlimited texting and many had unlimited
data plans. Themes that emerged were that the phones were integral to their lives and were the
primary means of accessing the internet. Communication was usually done through text messaging and
messaging through social networking sites. Half used their phones to find sex partners, and over half
used their phones to find health information. For an HIV-related app, participants stated they were
looking for user-friendly content about test site locations, information about STIs, information about
symptoms, the risks of drug and alcohol use, safe sex, sexuality and relationships, gay-friendly health
providers and connection to other gay and HIV-positive men.
Blas, et al. (234) conducted an observational, cross sectional study looking at whether online banner
advertisements offering free HIV and syphilis testing in a South American setting would result in more
testing when compared to an online banner advertisement that did not offer free HIV and syphilis
testing. The inclusion of the health incentive increased the frequency of completion of surveys (5.8
versus 3.4%, p < 0.001). Eleven percent of participants who said they had completed the survey offering
free testing visited the STI clinic. Of those who attended the clinic, 6% had already been diagnosed as
having HIV, while 5% tested positive for HIV and 8% tested positive for syphilis. Although in this South
American setting, free incentives advertised online increased STI clinic attendance, it is unclear whether
offering free HIV and syphilis testing in the Canadian setting, where universal health care exists, would
increase STI clinic attendance. However, offering other incentives (free condoms, for example) should be
further investigated.
Summary: While there have been published studies on internet-based campaigns for MSM, most studies
have been observational or provide only descriptive statistics. More rigorous, controlled studies are
needed to determine if the many types of internet campaigns are indeed effective in decreasing STI
rates and improving outcomes.
Intervention
Internet-based
campaigns for
MSM
Behavioural
outcomes

STI incidence/
prevalence

Contextual considerations and comments
While there have been published studies on internet-based
campaigns for MSM, most studies have been observational or
provide only descriptive statistics. More rigorous, controlled
studies are needed to determine if the many types of internet
campaigns are indeed effective in decreasing STI rates and
improving outcomes.
5.11 Online Initiatives to Promote STI Testing for Youth (Youth
Supplemental Review)
In a recent publication, Mann et al. (11) describe the Get Tested Why Not campaign, an initiative of
Ottawa Public Health, that aims to increase access to testing for chlamydia and gonorrhea infection and
access to sexual health information, specifically targeted to youth (age 15-29 years). The campaign
involves a website and text messaging service. A number of key stakeholders and experts were involved
in program development, including a Youth Advisory Committee, College of Physicians and Surgeons of
Ontario, information technology and communication professionals, as well as the development of new
partnerships with private laboratories to ensure participants had an option of testing locales. A number
of unique features that were included in the program are described in Appendix D.
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The campaign was advertised through social media sites such as Twitter and Facebook, as well as
through transit advertising, posters, business cards and condom wallets. The program website allows
users to assess their risk of chlamydia and gonorrhea and recommendations are given related to
whether they should be tested. If a participant is symptomatic, they are advised to see their regular
health care provider or present to Ottawa Public Health’s Sexual Health Centre. A lab requisition form
can be downloaded and printed and samples can be dropped off at any of 26 partner labs in the city. In
an evaluation of this campaign, over a 12-month period there were over 13,000 website hits (82%
unique visitors), and 104 requisitions were submitted for chlamydia and gonorrhea testing. Of the
submitted requisitions, 57% of these were by individuals age 15-29 years, with individuals age 15-19
years comprising 30% of requisitions, and individuals age 20-24 years comprising 45% of requisitions.
Fifty-three percent were male and 47% female. Four asymptomatic chlamydia cases were detected
(3.8% of requisitions), while no gonorrhea cases were detected. Further, among those who completed a
website survey, 53% indicated that they would change their behaviour due to visiting the website (e.g.,
encourage their partner to get tested, increase the frequency of STI testing, use condoms more
frequently).
Woodhall et al. (235) evaluated the use of websites to increase access to free chlamydia tests through
the National Chlamydia Screening Program (NCSP) in England, among 15-24 year old individuals. The
NCSP offers free chlamydia testing and treatment to sexually active individuals under age 25 years. Tests
can be accessed through multiple channels (e.g., general practitioner [GP] offices, pharmacies in the
community, community health and reproductive services, as well as online). For the online option, tests
are ordered through a website and then sent to the requestor via postal mail; the individual then takes a
sample, delivers it to the laboratory, and accesses their results via text message. Multiple websites offer
free testing through the NCSP, and 58 of these sites were evaluated for 2006-2010. Five percent of the
chlamydia tests conducted in the study areas were accessed online, and the number of tests accessed
online increased from <1% of all tests to 6% of all tests during the study period. Despite the fact that
individuals utilizing online testing services were similar to those presenting to general practice or
community sexual and reproductive health services for testing, the proportion of tests that were
positive from the internet sample was higher than tests from general practice and slightly lower than
community sexual and reproductive health services (7.6%, 5.6% and 8.2%, respectively). It appeared that
young males were reached through this service at a higher rate than females, which is important as this
group is described as being difficult to engage with for chlamydia testing. Further, individuals that
accessed the websites came from a wider range of socio-economic backgrounds, whereas the in-person
testing services had a higher proportion of tests among individuals of lower socio-economic status; this
might reflect lower access to private internet services. As well, women that accessed online testing were
more likely to have had more than one sexual partner in the past year and a new sexual partner in the
past three months. Note that the provision of additional health promotion information and
recommendations for accessing other services/follow-up with a health care professional, varied
between sites. This inconsistency was identified as a limitation, as was the geographically based model
of service delivery.
Summary: Online interventions to promote STI testing using websites and text messaging services as
well as advertising using social media have shown promising outcomes related to changes in selfreported sexual behaviour of youth who accessed the information.
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Intervention
Online
initiatives to
promote STI
testing for youth
Behavioural
outcomes

STI
incidence/prevalence

Contextual considerations and comments
In the UK, an intervention that used websites to
promote access to free STI screening through the
national program, found that although the proportion
of tests accessed online increased, it was still far
below more traditional methods of access. It was
found that young men were reached at a higher rate
than women, which may be important for engaging
this group. A study from Ontario indicated that
participants in an intervention involving website and
text messages indicated that just over half they would
change their behaviour as a result of visiting the
website.
5.12 Contact Tracing and Social Networks
Ogilvie et al. (2005) describe the use of a social networking approach during a syphilis epidemic in
Vancouver, BC (236). This epidemic was mainly among heterosexuals, with concentration in the
Downtown East Side, among sex trade workers and their clients, as well as people who use illegal drugs
(236). Traditional methods of contact tracing were difficult to implement (e.g., sex trade workers were
either unable or unwilling [e.g., due to fear] to identify their contacts, as well as other factors). For this
reason, a social networking approach was utilized (see Box 5). Contract tracing was undertaken using
non-traditional methods and a broad group of individuals were identified, which enabled the
construction of a social network. Street nurses with the BC Centre for Disease Control, conducted health
interviews on the street and information was gained over time through multiple interactions. Social
network interviewing cues were used (i.e., location, event, partner lists). A key question used was ‘‘Who
do you think should be tested for syphilis?’’ and the identification of contacts included but was not
limited to sexual partners (236). Observation of the environment at points of social aggregation for sex
trade workers was also conducted in order to identify contacts. Further, peer workers identified
individuals that were particularly hard to reach. Social network maps were used to identify contacts of
cases. Street nurses recommended testing for syphilis and conducted these tests on the street as the
opportunity arose. This study found that using a social network approach facilitated the identification of
a significantly higher proportion of syphilis cases linked to a case, and a significantly higher percentage
of syphilis cases than were identified by the Street Nurse program (14.9% vs. 23.1%) (236).
Box 5: Social networking approach in STI control (236–238)
At the heart of a social network approach is the understanding of how people are connected with each other in a
social framework (238). A social networking-informed approach would involve the documentation of all close
associations of STI-infected individuals (sexual and other types of associations) and calculate the degree. When
social networking is used, contacts are conceptualized broadly, and include close friends, roommates, previous
sexual partners, individuals that the index case might be involved in risky activities with (e.g., drug use),
acquaintances thought to be involved sexually with others in the interviewee's social group, etc. As Rothenberg et
al.(238) describe, all such contacts would be offered testing and follow-up care. Through interviewing the contacts,
and the contacts of the contacts (i.e., “snowball” approach to network sampling), this can reveal the risk for
syphilis within this broad group and determine what subsequent actions to take (e.g., treatment, further elicitation
of contacts, etc.). Interventions are delivered to this network (e.g., education, screening and diagnostic testing,
treatment), and the intent is that STI transmission will eventually be impacted within the community.
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The use of a social network approach during a syphilis epidemic is also reported by Engelgau et al (237).
However, it is not clear from this article whether the same broad approach was used as described in
Ogilvie et al (236). The authors describe the social network approach as utilizing an intensive campaign
of partner notification and cluster investigation among other interventions; however it is not clear
whether multiple interviews over time were utilized. During a 5-6 month campaign, 373 case-patients
had partner notification/cluster investigations, and 11% of their sex partners and 3% of high-risk
associates were found to have syphilis. The cost per case detected was more than double the costs that
were incurred pre-campaign. While more individuals were identified using this intensive partner
notification/cluster investigation approach compared to the pre-campaign period, other interventions
had a greater yield as well. Note that syphilis incidence in the area within which the study was
conducted decreased during the study period, and it is difficult to determine the impact of this as well as
the relative contribution of different aspect(s) of the campaign (237).
Another Canadian example of network analysis is found in a publication by De et al. (239) in Edmonton,
Alberta (AB), where an outbreak of gonorrhea was investigated among neighbouring aboriginal
reservations and industrial towns using a sexual network analysis. The authors state that “sex partners”
were identified, and therefore it is unclear whether the contacts were defined as broadly as they were
by Ogilvie et al. (i.e. including but not limited to sexual partners). In this analysis, 182 network members
were identified, including 107 index cases of gonorrhea and 75 named sexual contacts. A motel bar in a
particular town in the region was confirmed to be the key venue in this outbreak, and examining social
interaction through the bar led to the construction of a network of individuals that allowed for the
linkage of seemingly isolated outbreaks. This study concluded that individuals with the highest
information centrality scores (i.e., central role in their social network) should be the targets of
intervention.
Intervention
Contact tracing using
a social network
approach
Behavioural
outcomes
 For detection
of STI cases
STI
incidence/prevalence

Contextual considerations and comments
Using a social networking approach for
contact tracing has been shown to have
advantages over the traditional ‘one-time
interview’ approach. Evidence from a syphilis
outbreak in Vancouver, BC demonstrated a
comparatively higher proportion of cases
detected through this method. Another study
suggests that increased costs may be a
consideration.
Evidence is needed to assess how this
impacts on STI rates.
5.13 Presumptive Treatment
Presumptive treatment of STIs is defined as treatment for a presumed infection in a person, or a group
of people, at high risk of infection (240). Presumptive treatment for STIs may be given once, or at
repeated intervals in which case it is termed periodic presumptive treatment (PPT) (241–244).
Presumptive treatment/PPT tries to bypass the need to seek treatment, which has particular importance
where STIs are asymptomatic, and among populations where treatment seeking is low. The aim of
presumptive treatment/PPT is to reduce the pool of individuals infected with STIs, and thereby reduce
STI incidence (241–244). Although treatment is provided to individuals, this is discussed as a meso-level
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intervention because the studies described herein involve the delivery of treatment to an entire group
that is defined based on a common factor (e.g., involvement in sex trade work, or incarcerated MSM),
irrespective of individual STI-status.
In the literature, sex trade workers were a key population studied. Presumptive treatment of STIs among
sex workers involves the treatment of curable STIs based on sex workers’ high risk and prevalence of
infection, rather than on signs and symptoms or the results of laboratory tests (241). Control of STI
transmission in commercial sex networks reduces secondary transmission, and has been shown to have
impact at broader population levels (244). Another population studied was incarcerated MSM.
5.13.1 One-time Presumptive Treatment
Wi et al. (245) conducted a study in the Philippines among sex trade workers reached during a onemonth period of increased outreach (n = 1938 out of the estimated 2000-2500 sex workers in the study
area). This study involved the administration of a single round of presumptive treatment (azithromycin
1-g), along with improved outreach to female sex workers (through which presumptive treatment was
administered and condoms were promoted and distributed) and STI screening services. The explicit aim
of the multi-pronged intervention was to quickly reduce the prevalence of chlamydia and gonorrhea
among female sex workers through the provision of presumptive treatment, and to maintain this
reduced prevalence through enhancing preventive and treatment services. STI screening services were
established for two groups of unregistered sex workers: in brothels (BSWs) and on the street (SSWs). No
changes were made to existing screening methods for registered sex workers (RSWs) or guest relations
officers (GROs). The proportion of women in each group that received presumptive treatment at the
two and 10 month follow periods were as follows: 79% and 70% (BSW), 63% and 32% (SSW), 50% and
17% (RSW), and 75%, and 33% (GRO), respectively. STI screening improved considerably for BSW and
SSW (who previously were without access), and therefore they were more likely to receive STI
treatment in the period after receiving presumptive treatment. This study found that among BSWs, the
baseline prevalence of chlamydia and/or gonorrhea declined from 52% to 27% at one month, and 23%
after seven months. Among SSWs, prevalence declined from 41% to 25% at one month and then was
28% at seven months. Among RSWs baseline, one month and seven month prevalence was 36%, 26%
and 34%, respectively; while among GROs the prevalence was 20%, 6%, 24%, respectively. Therefore, all
four groups demonstrated significant chlamydia/gonorrhea decreases at one month, however at six
months the BSWs and SSWs had sustained decreased prevalence, but prevalence had returned to
baseline levels for RSWs and GROs. Considering community-level impact, the prevalence of
chlamydia/gonorrhea among clients of BSWs significantly decreased from 28% to 15% at six months.
Chen et al. (246) describe the mass syphilis screening and treatment of MSM inmates in the Los Angeles
County Men’s Central Jail that are voluntarily segregated from the general population of inmates. During
a syphilis outbreak among MSM, a syphilis control program in this unit was implemented, consisting of
screening, mass prophylactic treatment, high-risk behavior detection, and education. Chlamydia and
gonorrhea screening were also added for new inmates. All inmates were offered a single dose of
azithromycin (1g), irrespective of whether they had participated in screening. Between March-August,
2000, over 800 inmates were screened for syphilis and 5% (n = 38) tested positive; 9 of these cases were
new diagnoses. A high proportion accepted azithromycin (94%). Further, 2% tested positive for
chlamydia and 1% for gonorrhea. The authors note that it was difficult to evaluate the effectiveness of
azithromycin therapy due to the turnover of the inmate population.
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Intervention
Periodic presumptive
treatment
Behavioural
outcomes

STI
incidence/prevalence

Contextual considerations and comments
One-time presumptive treatment was
evaluated in one study among sex trade
workers, and in another study among
incarcerated MSM. The former study found
an initial decreased STI prevalence over time
in all groups offered presumptive treatment,
however this decline was only sustained
among groups that had expanded STI
screening and treatment services. There was
also a reduction in the STI prevalence of the
clients of one group that had expanded STI
services in addition to presumptive
treatment. This suggests that while
presumptive treatment can be effective over
the short-term, other control measures must
be implemented in order to maintain STI
reductions over the long-term. The study in
a prison setting, documented a high
acceptance rate of prophylactic treatment,
but was not able to assess long-term impact
due to turnover within the prison
population.
5.13.2 Periodic Presumptive Treatment (PPT)
A study in South African mining communities involved the administration of PPT (directly observed 1-g
dose of azithromycin) along with prevention education, to female sex workers (n = 407 over 9-months)
(244). A mobile monthly clinic was utilized for the delivery of PPT, examination and counseling. The
baseline prevalence of chlamydia and/or gonorrhea was almost 25%, however at the first monthly
follow-up visit, the prevalence declined to 12.3% (with 69% follow-up). Similarly, at baseline 12.3% of
the women had genital ulcer disease, and this declined to 4.4%. Local miners were also assessed. The
baseline prevalence of chlamydia and/or gonorrhea was 10.9%, which significantly decreased to 6.2% at
the 9-month follow-up assessment; while the prevalence of genital ulcer disease significantly decreased
from 5.8% to 1.3%. Note that the decrease observed in miners in this study was greater than that seen
among miners living distant from the study site.
A systematic review of PPT among sex trade workers concluded that this intervention can reduce the
prevalence of chlamydia, gonorrhea and ulcerative STIs among this population (241). The authors
further note that additional benefits may include an impact on STI and HIV transmission at a population
level. As presumptive treatment strategies are temporary interventions, other control measures are
required in order to maintain reduced prevalence (e.g., condom promotion, ongoing screening and
treatment programs).
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Intervention
Periodic
presumptive
treatment
Behavioural
outcomes

STI incidence/prevalence
Contextual considerations and comments
For long-term impact on
STI rates
A study among female sex workers in South
Africa found that PPT along with prevention
education resulted in declining STI
prevalence among FSW as well as local
miners in the surrounding community. A
systematic review also found a positive
impact on STI prevalence among sex trade
workers, with emphasis that longer-term
strategies are needed to support this shortterm measure.
Contextual considerations include that
studies were conducted among female sex
workers in South Africa and the Philippines,
and incarcerated MSM in the US.
5.14 Targeted Mass Treatment
In the Downtown Eastside in Vancouver, a targeted syphilis mass treatment intervention was
implemented in January-February, 2000, in response to a sexually-transmitted syphilis outbreak
primarily among heterosexual individuals (247,248). This involved the administration of one dose of oral
azithromycin to over 3000 at-risk individuals, as well as utilizing “secondary carry” involving more than
800 individuals taking over 2000 doses to peers and sexual contacts that did not present for treatment.
Although syphilis rates significantly decreased initially up to the six month point, in the aftermath, rates
increased in 2001 to a higher level than expected. Rekart et al. (247) therefore caution against the
routine targeted mass treatment for syphilis.
Rekart et al. (248) also examine the additional interventions offered to those who participated in mass
treatment: education about syphilis, STIs and risk reduction delivered via handouts, poster and oral
communication; condoms (male and female), lubricant, clean needles and syringes; and referral to social
services and health agencies. Outcomes were assessed among mass treatment participants (defined as
having been approached to participate in mass treatment, irrespective of whether they did or not; n =
212) after one-year, with comparison made to eligible non-participants (i.e., living in the DTES during the
period of mass treatment but had not been approached to participate; n = 211). Laboratory results
revealed that there were no significant differences between the diagnosis of syphilis, chlamydia or
gonorrhea between participants and non-participants (syphilis 7% vs. 4%; chlamydia 8% vs. 6%; and
gonorrhea 2% vs. 2%). Further, 47.9% of participants vs. 38.0% of non-participants reported an
increased awareness of syphilis, but this difference was not significant. Compared to the previous year,
mass treatment participants reported significantly decreased intercourse without a condom, decreased
oral sex without a condom and increased condom use by sex workers.
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Intervention
Targeted mass
treatment
Behavioural
outcomes

STI
incidence/prevalence

Contextual considerations and comments
The literature related to syphilis prophylaxis, with
studies conducted in Vancouver, BC, has urged
caution in the administration of mass prophylaxis.
One study provided evidence of positive
behavioural impacts.
5.15 Patient-delivered Partner Therapy (PDPT)
A discussion of PDPT was included in the micro-level interventions section of this report and, as such,
the evidence related to this intervention will not be discussed here nor will an evidence rating be
assigned. Rather, in order to complement the previous discussion of PDPT, Appendix E presents a
discussion of the policy and legal issues related to this intervention.
5.16 Conditional Cash Transfers
Conditional cash transfers operate on the principle of conditionality (i.e., making payments for
contingent, such as engaging in preventive care or attending school). While studies have evaluated the
impact of this intervention on HIV as well as herpes simplex virus 2 (HSV-2) infection, in keeping with the
focus of this review, only literature that focused on bacterial STIs is summarized here.
A RCT was conducted in rural Tanzania with a sample of males and females age 18-30 years (n = 2399)
(249). This study had three arms: low-value cash transfer arm (eligible for up to $30 over the study =
10,000 Tanzanian shillings); high-value cash transfer arm (eligible for up to $60 over the study = 20,000
Tanzanian shillings); and a control arm (no conditional case transfer but otherwise experienced same
study procedures as intervention participants, including counseling and free STI treatment for the
individual and partners who tested positive). Intervention arm participants could receive conditional
cash transfer incentive payments if they tested negative for chlamydia, gonorrhea and trichomonas,
during the testing periods at 4-, 8- and 12-months (if there was a positive test for any one of these STIs,
they were not eligible for the cash transfer). Individuals were able to receive curative treatment and
continue in subsequent rounds. As well, individuals that converted from a baseline negative syphilis (or
HSV-2) test to a positive test at 12-months, were not eligible for the 12-month cash transfer. The cash
transfers were clearly a self-reported motivator for behaviour change, and a gradient was observed. In
the high-value conditional cash transfer group, 59% reported that the money motivated them ‘very
much’ to change their behaviour, and 12.5% reported that it motivated them ‘somewhat’; while these
values were 37.4% and 20.6% in the low-value conditional cash transfer group, respectively. The
combined prevalence of chlamydia, gonorrhea and trichomonas is also combined with Mycoplasma
genitalium, although the presence of the latter infection alone did not preclude the cash transfers,
because the authors stated that there is uncertainty regarding transmission pathways. After adjusting
for a number of variables (e.g., gender, education, age, marital status, socioeconomic status, village and
baseline STI status), at 4- and 8-months, at the 12-month point there was a significantly decreased
combined prevalence for the high cash transfer group compared to the control group, (although there
were not significant differences in the combined prevalence of the four bacterial STIs) (RR 0.73, 95% CI
0.47-0.99), but not for the low cash transfer group (RR 1.06, 95% CI 0.75-1.38).
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Intervention
Conditional cash
transfers
Behavioural
outcomes

STI
incidence/prevalence

Contextual considerations and comments
While there are other studies examining nonbacterial STI outcomes, the one study that
was reviewed that had bacterial STI
outcomes, demonstrated promising results.
After one year, conditional cash transfers
were associated with lower prevalence of four
STIs. Note that this outcome was not
observed during earlier study periods, and a
gradient effect was noted. More research
specifically on bacterial STIs would be helpful
to confirm this finding that was observed in a
rural low-income country setting.
With respect to behavioural change,
participants report motivation to change
behaviour.
5.17 Community Mobilization
Community mobilization is defined as “a capacity-building process through which community
individuals, groups, or organizations plan, carry out, and evaluate activities on a participatory and
sustained basis to improve their health and other needs, either on their own initiative or stimulated by
others” (250). There are a number of studies that explicitly involve community mobilization efforts
among sex trade workers in low- and middle-income countries. These studies generally document a
positive association between these interventions and lower STI rates. Often community mobilization
occurs in conjunction with other program components, such as improved access to STI services and
education in the wider environment to support adoption of recommended behaviour changes. In most
cases, community mobilization is also tied in with policy changes, and these are described in the “macrolevel” section of this report. It is therefore difficult to tease out the relative contribution of each
program element to the observed outcomes; however it is reasonable to assume that mobilization and
empowerment are important elements of efforts to promote and sustain behaviour change within a
community. As health promotion tells us, education/instruction about behaviour change must be
accompanied by empowerment and environmental changes that gives people the tools and support to
make healthier choices.
A study was conducted in 2008 in India that evaluated the impact of a program among female sex
workers involving the following components: community mobilization and peer-mediated outreach (a
participatory mapping and numeration exercise was conducted, then peer-mediated outreach began
which identified the difficulties that sex workers experienced and tried to promote “camaraderie and
kinship” among this community); increased access to and promotion of utilization of sexual health
services, expansion of condom accessibility through social marketing, and increased condom availability
in non-traditional outlets; and creating an enabling environment to support the program (251). Over a
30-month period, STI prevalence significantly decreased: syphilis 25% vs. 12%; chlamydia 11% vs. 5%;
gonorrhea 5% vs. 2%; and Trichomoniasis 33% vs. 14%. Changes were also seen with respect to condom
use: condom use at last sex with occasional clients significantly increased from 65% to 90%, and with
regular partners increased from 7% to 30%.
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The Avahan program was implemented among female sex workers in India (252). This program is the
India AIDS initiative; the objective is to halt and reverse the spread of HIV. This program delivered
preventive services to female sex workers aiming to address determinants of HIV risk (proximal and
distal) and included: peer outreach education; clinical services for managing STIs, condom promotion
and distribution; community mobilization and building an enabling environment. Assessments in round
one (2006) and round two (2009) revealed that significant declines in syphilis, chlamydia and gonorrhea
occurred: syphilis 15.8% vs. 10.8%; chlamydia 8% vs. 6.2%; gonorrhea 7.4% vs. 3.9%. Further, there were
significant increases in the proportion of female sex workers reporting zero unprotected sex acts (76.2%
vs. 94.6%). Condom use with occasional and regular clients were significantly higher among sex workers
exposed to Avahan compared to those that were not.
Intervention
Community
mobilization
Behavioural
outcomes

STI
incidence/prevalence

Contextual considerations and comments
Studies of initiatives in which community
mobilization was a key element, revealed
significant decreases in STIs and risk
behaviours among sex trade workers.
5.17.1 Other Multi-component Interventions
An intervention in Peru called PREVEN combined four components: promotion of condom use for sex
trade workers and the general population; strengthened STI syndromic management by pharmacy
workers; mobile-team outreach for sex trade workers for STI screening and treatment; and periodic
presumptive treatment of female sex workers for Trichomoniasis (253). This multi-component
intervention was evaluated in a RCT, randomized at the level of the community/city, among a large
sample (n = 12,930) of urban male and females age 18-29 years in the general population, and female
sex workers. The outcome of interest was community-level prevalence of chlamydia, gonorrhea, syphilis
and trichomonas. Data was collected at baseline and during the following up period three to four years
later (both surveys and biological samples for STI testing were collected). The change in STI prevalence
among young adults was 1.1% lower among intervention cities compared to control cities, but this
change was not significant (p = 0.096). However, when the data was disaggregated, among young
women there was a significant absolute risk reduction of 2.6% (8.2% vs. 11.0%, p = 0.024) in intervention
cities, and among female sex workers 14.5% had any STI in intervention cities compared to 22.1% in
control cities (7.4% lower, p = 0.023). This significant difference was not reflected among men (4.4% vs.
5.1%), nor was the prevalence of chlamydia among men who had sex with female sex workers in the
past year (7.2% vs. 3.5% in intervention and control cities, respectively, with a RR of 0.68, 95% CI 0.281.68).
Intervention
Other multicomponent
interventions
Behavioural
outcomes

STI incidence/
prevalence

Population and Public Health, Ministry of Health
Contextual considerations and comments
Based on a single study in Peru, a multi-component
intervention (without a formal policy element) produced
encouraging reductions in STIs among some populations
(young women and FSWs) but not other populations. This
division of evidence is somewhat arbitrary because a
number of other interventions reviewed in this evidence
review have multiple components, and are classified in
other sections.
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5.18 MSM-focused Community Partnerships and Events (MSM
Supplemental Review)
In 2003-04, the New York City Department of Health and Mental Hygiene (NYC DOHMH) developed Hot
Shot!, a community-based program held throughout New York City. The program addressed general
MSM health, including STI and HIV screening, vaccinations, cardiovascular health screenings, mental
health, tobacco, and other drug use (254). Among 1634 attendees, 445 persons accessed one or more
service, with four newly diagnosed with syphilis and seven with HIV. The NYC DOHMH developed this
program after extensive consultations with community-based organizations and a local, health
department-initiated coalition known as the Syphilis Advisory Group. Through this project, the NYC
DOHMH was able to reach out to the MSM population, strengthen community partnerships and address
pressing health issues within the MSM community.
The Frontiers Prevention Project (FPP) (255) aimed to empower key populations in India most affected
by HIV. The FPP set out to improve advocacy within these groups, changing policies that affect these
groups, and increasing community awareness. The provision of a complete set of prevention
interventions, aimed at reducing risk behaviours and STI incidence, resulted in a lower HIV incidence
among the key populations. The goal of the project was to ensure an environment in which adequate
services and commodities were available for key populations. For MSM, there was a significant decrease
between baseline and follow-up for syphilis seropositivity (40% to 32% in FPP group versus 34% to 29%
in non-FPP group, p < 0.05).
Summary: There is some evidence to support community-based partnerships and events in case finding
for syphilis.
Intervention
MSM focused
community partnerships
and events
Behavioural
outcomes

STI
incidence/prevalence

Contextual considerations and comments
There is some evidence to support
community-based partnerships and events
in case finding for syphilis.
5.19 Conclusion
The evidence base on the meso-level of interventions is diverse and fairly extensive. Some interventions
are the subject of multiple studies and have a strong body of corroborating evidence, while others are
only the subject of one of two identified studies. This review has revealed that there are multiple
preventive interventions to consider at the levels of groups, communities and institutions.
The STI-related outcomes in the literature were related to sexual behaviours that may have implications
for STI risk (e.g., condom use), other variables such as screening uptake and partner elicitation, and
incidence and prevalence of STIs. While it is of interest to determine morbidity and mortality outcomes,
this data was extremely limited (with no literature discussing mortality, and note that mortality from
bacterial STIs is extremely rare with the exception of congenital syphilis).
An important consideration related to meso-level and macro-level interventions (discussed below), is
the scope of application (e.g., scale and duration). Not all interventions are created equal; for example,
the same intervention implemented over a six month versus a six year period, may have very different
impacts on group or community-level STI-related outcomes. The same can be said for an intervention
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that is implemented among a small versus a large proportion of the target population. A key
determinant of the effectiveness and impact of an intervention on STI incidence/prevalence relates to
the burden of STIs in the wider community. Reducing the incidence/prevalence of STIs at a population
level affects individual risks of acquisition, and interventions that cover only a small group of people may
not result in the same level of impact if STI rates in the wider community are unaffected. Nevertheless,
STIs are a major population health issue, and it is essential that preventive interventions go beyond the
level of individuals and include groups, communities, institutions and policies.
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6.0 MACRO-LEVEL INTERVENTIONS
The aim of this section is to consider the role that policy interventions play in the prevention and control
of sexually transmitted infections (STIs) (256,257). A wide variety of terms are used to describe policy
instruments, including legislation, regulations, acts, resolutions, guidelines, etc. (256).
In the context of STI prevention and control, "STI-specific" policy instruments refer to policies that
impact, almost exclusively, issues relating to STIs, such as technical guidelines for STI screening,
diagnosis and treatment (256). Other policies aim to address broader social, economic or organizational
issues that have an impact on STIs. In fact, such "non-STI-specific" policy interventions may have
important STI-related impact (256). As Casson et al. (258) assert, “laws act as pathways for social
determinants that impact [STI] risk or resilience in multiple ways”.
As with the meso-level interventions, the STI-related outcomes in the macro-level literature were
related to sexual behaviours that may have implications for STI risk, and incidence and prevalence of
STIs. Morbidity and mortality data was not identified.
Application of the rating scale
The evidence rating scale was applied per the criteria identified in the text portion of Figure 2. As
discussed in the meso-level interventions section, the limitation of this approach in this directed, nonsystematic review, is that there were often very few studies (sometimes only one study) of a particular
macro-level intervention, therefore there was not a corroboration of findings. This is particularly
important when the study is as a result of a natural experiment, which will rarely be repeated (as
occurred for a selection of macro-level interventions). This means that corroboration, theoretical
rationale, study features, etc. have to be carefully weighed to arrive at a rating.
6.1
STI-specific Policy with an Evaluation of Impact on STIs
6.1.1 Condom Use Policy
The 100% Condom Use Program (100% CUP) is a policy that has been implemented in multiple low- and
middle-income countries, representing a partnership between public health, law enforcement and
government. It aims to ensure that a condom is used in all commercial sex encounters, and aims to
make this a standard in all facilities so that there is no opportunity to select one commercial sex
establishment over another based on use or non-use of condoms. The 100% CUP is described in
Appendix D. This policy was found to be one of the most discussed in the global health context and has
been studied in multiple jurisdictions. In this review, articles are included that specifically discuss the
100% CUP, and others that discuss this program in combination with other interventions (i.e. community
mobilization).
In Thailand, a government program began in 1989 that had the following components: government
purchase and distribution of enough condoms to protect most of those engaged in commercial sex in
the country (condoms were distributed to sex trade workers at their periodic during periodic STI
examinations); sanctions against commercial sex establishments where condoms were not used
consistently; and a media campaign that “bluntly advised men to use condoms with prostitutes” (259).
Data was reported on five STIs: syphilis, gonorrhea, non-gonococcal urethritis, LGV, and chancroid.
Hanenberg et al. (259) found that the use of condoms in commercial sex increased from 14% to 94%
between 1989-1993 and that cases of these five STIs decreased by 79% in men (259). Note that in men,
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STIs began to slowly decline in 1986 (three years prior to introduction of the 100% CUP), then there was
a steep decline beginning in 1989. This pre-100% CUP decline may be because gonorrhea and chancroid
were slowly decreasing, as these were susceptible to quinolone antibiotics that were introduced in
Thailand in 1986; the other STIs hardly saw minor decreases before 1989. In 1989, there was a decline in
all STIs, with gonorrhea and chancroid declining more than before, and the other three STIs declining
rapidly. Among female sex trade workers, the number of incident STI cases declined by 54%. It is also
noteworthy that a number of new STI clinics opened during this period, thus potentially increasing the
rate of STI detection; this may mean that the decline in STI rates was greater than that observed.
Zhongdan et al. (260) evaluated a 100% CUP demonstration over a 15-month period in a particular area
of China, with the intent to ensure that condoms be used in all commercial sex encounters. The
managers and staff within so-called ‘sex entertainment establishments’ (e.g., karaoke clubs, bars,
hairdressing facilities, restaurants and massage parlors) were informed about the new policy by public
health workers and the police. They were told that if they did not comply with policy, they were at risk
of temporary or permanent closure; other consequences included warnings or fines for non-compliance
with the policy. Condoms were made available and affordable for sex workers in commercial sex
establishments as well as within stores and clinics. Other STI services that were offered included
counseling, education and mobile clinic services. Condom use was monitored by questioning every male
patient seeking STI services at project STI clinics about which sex establishments they visited and
whether they used a condom; this helped to identify non-compliant establishments that then received a
warning. Surveys were also conducted that examined sex worker condom use and sex establishment
owner’s enforcement of the policy.
At baseline, only 60% of sex trade workers had used a condom during their last sexual encounter.
Twenty-eight percent of study participants were diagnosed with at least one STI based on laboratory
testing and clinical examination; 21.8% with chlamydia; 2.9% with gonorrhea; 6.9% with syphilis and
4.9% with genital warts. Post-intervention, condom use increased to 88.5% at 12-months and 94.5% at
15-months. The impact on STI rates post-intervention varied. Chlamydia prevalence initially increased to
30.4% at six months, then declined to 14.5% at 15-months, then increased to 24% at 21-months.
Gonorrhea was not reported, and syphilis counts were 6.5% at baseline, 0% at 12 months and 2.9% at 21
months (there may be questions about accurate measurement). At the six month follow-up, 95% of
commercial sex establishments were in compliance with the policy. The authors conclude that the
available evidence does not clearly reveal program effectiveness. They also note that the SARS crisis,
which occurred at the same time as this study, may have resulted in decreased monitoring of project
activities due to a shift in the workload of public health staff.
Sopheab et al. (261) conducted a survey among female trade sex workers in Cambodia, where a 100%
CUP was implemented in 2001 (requiring brothel-based female sex workers to use condoms with all
clients). Consistent condom use with clients was reported by 80% of sex trade workers, but only 38%
always used condoms with “sweethearts” or casual partners. Being new to sex work was the only factor
significantly associated with "any STI" (OR = 2.1). Prevalence of syphilis was 2.3%; chlamydia 14.4%;
gonorrhea 13.0%; and any STI, 24.4%. Prevalence of each STI in 2005 was significantly lower than in
1996, but essentially the same as the prevalence observed in 2001 (the year of the policy
implementation). New sex trade workers were found to have substantially higher prevalence than those
who had worked in the sex trade for longer. The percent of sex trade workers who used condoms
consistently was high with clients but remained low with non-paying sex partners. Because of the high
turnover of sex trade workers, the prevention needs of new sex trade workers should be determined.
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Summary: The 100% CUP has demonstrated a positive impact in increasing condom uptake among sex
trade workers and client in Thailand, China and Cambodia. Generalization of these findings to a North
American context is inconclusive based on the studies reviewed.
Intervention
100% CUP
Program
Behavioural
outcomes
 For increasing
condom usage
STI
incidence/prevalence

Contextual considerations and comments
The 100% CUP was discussed widely in the
literature, particularly in low- and middleincome countries. Studies have varied in the
demonstration of impact on STI rates and
therefore more research is warranted.
However, this intervention demonstrated a
positive impact in increasing condom uptake
among sex trade workers/clients.
Evidence about the 100% CUP was found in
Thailand, China and Cambodia, with no
studies from North America. As well, the
100% CUP is specifically targeted to sex
trade workers/clients. Application in other
settings is therefore uncertain.
6.1.2 Integrated Policy and Community Mobilization Interventions
Two articles were found that assessed interventions that combined community mobilization and
government policy initiatives. Kerrigan et al. (262) implemented a community solidarity combined with
government policy intervention among female sex workers in one region of the Dominican Republic, and
a community solidarity intervention only in another region, over a one year period. Elements of the
Thailand 100% condom program model were adapted to the Dominican Republic context.
Implementation occurred in commercial sex establishments, and managers at all sites (n = 68 sites)
agreed to participate. There was a significant decrease in the proportion of individuals with one or more
STIs (chlamydia, gonorrhea, Trichomoniasis) in the combined intervention site only (28.8% to 16.3%; OR
0.50, 95%CI 0.32, 0.78). The change in STI prevalence in the site with the community mobilization
intervention only was from 25% to 15.9%, but this change was not significant. Further, there were
significant increases in condom use with regular partners; verbal rejections of encounters that were not
safer sex encounters; and participating sex establishments’ ability to achieve the goal of no STIs in
routine monthly screenings of sex workers. In the site with community mobilization only, there were
significant increases in condom use with new clients.
Kang et al. (263) also examined an integrated intervention (systematic 100% condom promotion
combined with activities in community solidarity, activities to reduce stigma and discrimination,
outreach education to promote risk-related behaviour change and promote health care seeking, etc.) on
HIV/STIs among female sex workers in China. Between 2004 and 2009, the intervention was
implemented in six intervention counties (n = 1157 female sex worker) and compared with 10 control
counties (n = 2169). It is reported that the prevalence of syphilis was 0.17% among the intervention
group and 1.89% among controls (OR 11.1, 95% CI 2.7, 46.1). Further, intervention sites had significantly
higher condom use at last sex with clients and regular partners.
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Intervention
Combined community
mobilization and policy
initiatives
Behavioural
outcomes

STI
incidence/prevalence

Contextual considerations and comments
Studies of combined community
mobilization and policy initiatives revealed
significant decreases in STIs and risk
behaviours.
Studies are in low- and middle-income
countries.
6.1.3 Performance Measures and Private Health Insurance
Burstein et al. (264) examined the new chlamydia screening Health Plan Employer Data and Information
Set (HEDIS) performance measure: a measure to determine the proportion of sexually active female
youth and young adult members of Medicaid and commercial health plans that are tested annually for
chlamydia. Although HEDIS is only a measure to estimate performance, many health plans attempt to
change practices to improve their performance ratings and to improve treatment. The authors therefore
examined the new performance measure’s association with changes in clinical practice, and sought to
evaluate chlamydia screening policies and testing practices and results in response to the HEDIS
chlamydia-screening performance measure.
The authors examined the electronic medical records of female members age 15-26 years enrolled in
the Kaiser Permanente Mid-Atlantic States (KPMAS) health plan, a managed care organization, to
estimate chlamydia testing and positive tests two years before and after introduction of the HEDIS
measures (37,000+ female patients from 1998-1999 and 37,000+ female patients from 2000-2001). They
also interviewed the chiefs of KPMAS departments of obstetrics and gynecology, pediatrics, internal
medicine and family practice, about any departmental practice and policy changes that were
implemented related to the screening of sexually active females age 15-26 years for chlamydia.
All of the specialty departments that provided primary care to youth/young adult female patients
reported developing a specific strategy for increasing chlamydia screening. For example, in the
Obstetrics & Gynecology department, a policy was instituted to routinely collect a chlamydia test when
a pap test was performed, and this was operationalized by placing a chlamydia collection swab next to
the pap test collection materials. The family medicine and internal medicine departments advised health
care providers to perform chlamydia tests at the time of pap tests, and this was delivered at
departmental meetings. In the pediatrics department, in addition to advising providers at departmental
meetings to conduct chlamydia tests at the time of pap tests, this was also communicated through
written memoranda, and provider training was offered as well as operation of a sub-specialty
adolescent health care clinic. However, none of these departments made systems-level changes in
clinical encounter protocols.
While the proportion of females age 15-26 years that were sexually active remained constant over the
four years of analysis (52%), there was a significant increase in the proportion of females tested for
chlamydia (55% to 72%). Testing increased most among the Obstetrics & Gynecology department,
suggesting that their simple clinical practice change made a difference. There was a 10% increase in the
number of female patients identified with chlamydia.
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Although this data is from the US and specifically concerns a private health insurance plan, the issue of
performance measures, and operationalizing performance measures generally, has relevance for the
Canadian context. Performance measures initiatives are active in Canada; one example are the
performance indicators for organized cervical cancer screening programs (related to Papanicolaou [Pap]
test coverage, cytology, system capacity, follow-up and cancer-related outcomes) (265). Performance
indicators provide a means to monitor performance in a particular area, and also facilitate comparisons
between jurisdictions (265). As such, there is the potential for practices to be changed in light of the
establishment of such measures.
Intervention
Performance
measures
Behavioural
outcomes
 To support
screening
STI
incidence/prevalence

Contextual considerations and comments
Evidence from the United States suggests that
a change in performance measures can have
an impact on STI screening, as participating
institutions seek to implement measures to
improve their performance.
The impact on STI rates however is unclear.
6.1.4 Private Health Plan Reimbursement Law
In the 1990s, the US states of Maryland (MD), Georgia (GA) and Tennessee (TN) enacted laws that
required health plans to reimburse for chlamydia screening for the populations at risk. The impact of
these laws of chlamydia screening rates was assessed for GA and TN (MD was excluded due to nonspecificity of the law and insufficient data) (266). The authors extracted monthly chlamydia screening
rates on women within employer-sponsored private insurance plans and compared changes in screening
rates in these two states to 10 southern states. There were increases in screening rates in both GA and
TN after the enactment of the laws, but the data from the other ten states showed similar increases
over the same period; therefore, there was no significant difference.
The application of this finding to the BC context is difficult to assess, given health care system
differences, as well as the finding of no significant difference in screening rates.
Intervention
Health plan
reimbursement law
for STI screening
Behavioural
outcomes
 For impact on
STI screening
rates
STI
incidence/prevalence

Contextual considerations and comments
Significant differences in chlamydia screening
rates among states that did and did not
implement a health plan reimbursement law,
were not identified in a single US study.
6.1.5 Sex Worker Registration
The municipal government of Tijuana, Mexico has a system whereby registration cards are issued to sex
workers through the municipal health department (267). The cost of this registration is $360 per person
per year. There is mandated quarterly STI screening and monthly HIV testing that occurs at the
municipal health department. Sirotin et al. (267) conducted a study among registered female sex
workers (n = 410) to see if registration was associated with health benefits. Forty-four percent of
participants in this study were registered with the municipal health department. The authors found that
registered sex workers were significantly less likely than unregistered sex workers to test positive for
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gonorrhea (4% vs. 12%), syphilis (18% vs. 40%), or any STI (33% vs. 53%), and the prevalence of active
syphilis and chlamydia were similar. But after adjusting for other confounders associated with
registration, registration was not found to be associated with the lower risk for a positive STI test.
However, registered sex workers were found to have significantly fewer sex partners in the past month
(median 70 vs. 145, p<0.001), as well as being significantly less likely to have had a sex partner who had
ever injected drugs (7% vs. 25%, p<0.001).
Intervention
Registration of sex
trade workers with the
municipal health
department
6.2
Behavioural
outcomes

STI
incidence/prevalence

Contextual considerations and comments
In one study of registration of sex workers
in Mexico, registration was not found to be
associated with lower risk of testing
positive for STIs, in an adjusted model.
STI-specific Policy without an Evaluation of Impact on STIs
6.2.1 Screening Legislation
Casson et al. (2002) describe the passage of legislation that guided STI screening efforts within a
jurisdiction (258). While this article provides an interesting perspective on this process, and outlines the
scope of such legislation, an evaluation of impact was not identified through the course of this review.
See Box 6 for the description of Georgia’s Chlamydia Screening Bill (268).
Box 6: Georgia’s Chlamydia screening bill (268)
The challenge: 80% of women infected with chlamydia are asymptomatic.
The process: Georgia’s state epidemiologist obtained federal funding to conduct pilot chlamydia screenings, and it
was found that teenage girls had an incidence of chlamydia as high as 15% in some locations, and concerning rates
of chlamydia were detected in all geographic areas across the state (urban and rural).
The Georgia Legislative Women’s Caucus, along with the American Social Health Association and other women’s
advocacy groups, formed a Georgia STD Coalition. A Study Committee on Infectious Diseases, created as a result of
a Georgia legislature resolution, determined that the cost of chlamydia complications was $51 million per year,
and $59 million for hospitalizations due to chlamydia. This committee recommended that there was a need for the
screening of at-risk populations.
The legislation: In 1998, legislation was filed that required all Georgia insurers to include an annual chlamydia
screening as basic coverage for women under age 30 years. Despite some objections, the Georgia Chlamydia
Screening Insurance legislation became law in July 1998. As well, the state budget included funds for public health
to provide screening in public health clinics for at-risk women who were uninsured.
Evaluation: No evaluation of this legislation was identified in the course of this search.
Intervention
STI screening
legislation
Behavioural
outcomes
0
STI
incidence/prevalence
0
Population and Public Health, Ministry of Health
Contextual considerations and comments
Legislation from the US is described but no
evaluation is found
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6.3
Non-STI-specific Policy with an Evaluation of Impact on STIs
6.3.1 Alcohol Policy
A number of publications have been identified that explore the relationship between various alcoholrelated policies and STI rates, with a negative relationship proposed between interventions that increase
alcohol control/decrease access and STI rates (269–274). A suggested mechanism for this relationship is
that risky sexual practices that increase the risk of STI transmission (e.g., unprotected sex, unplanned
sex, sexual assault and sex with multiple partners) are co-related with alcohol use. As such, policies that
reduce population alcohol consumption and drinking above the Canadian Low-Risk Alcohol Drinking
Guidelines (275) will likely reduce STIs. Alcohol policies include: increased alcohol taxes and alcohol
prices; increased minimum legal drinking age; and “zero-tolerance” laws for drunk driving. Studies also
evaluate density of alcohol outlets. These studies are generally ecological and therefore have limitations
in establishing exposure-outcome relationships at the level of the individual, and in ensuring that other
factors are not responsible for observed changes in STI rates (see Table 4 below).
For example, a study by Cohen et al. (269) involved a longitudinal analysis of alcohol outlets and
gonorrhea in Los Angeles. As a result of the 1992 Civil Unrest, 270 alcohol outlets surrendered their
licenses due to vandalism and arson. This provided a natural experiment to evaluate the impact of
changes in alcohol outlet density on rates of gonorrhea in this region. The authors also note that if it is in
fact the presence of boarded up buildings that signal social disorder and a change in community norms
and tolerance of high-risk behaviour that is related to elevated STI rates, then the STI rates should in fact
increase following the civil unrest. The analysis was at the level of the census tract; individuals that had
been diagnosed with gonorrhea were identified and their addresses were geo-coded and aggregated by
census tract. Age adjustment was performed. The authors found that after the civil unrest, a one-unit
decrease in alcohol outlets per mile of roadway was associated with 21 fewer cases of gonorrhea per
100,000 in affected tracts vs. unaffected tracts (this finding was significant). A general decline in
gonorrhea rates occurred during this time period in Los Angeles, however the decline in the study area
where alcohol outlets were closed was higher. It is acknowledged however that there are many
limitations, as multiple factors operating at the same time may have been responsible for decreased STI
rates (e.g., an enhanced police presence in these neighbourhoods that discouraged high-risk behaviours).
The major findings of these studies are summarized in Table 4 below, many of which are published in
economic journals and use an economics research methodology that is unfamiliar and therefore difficult
to critically appraise with respect to the quality of research methods.
Table 4: Summary of Key Findings in Studies Exploring the Relationship between Alcohol Policy and
STI Rates
Reference
Chesson &
Harrison
(2000)
Alcohol policy element
Alcohol taxes
Carpenter
(2005)
Zero Tolerance drunk
driving laws for
underage individuals
Sen & Luong
(2008)
Higher beer prices in
Canadian provinces
Relationship with STI rates
A $1 increase in the per-gallon liquor tax is associated with a decline in
gonorrhea rates by 2.1%.
A $0.20 per six-pack increase in the beer tax is associated with a
decline in gonorrhea rates by 8.9%
Adoption of a Zero Tolerance Law is associated with a significant
reduction in gonorrhea rates among 15-19 year old white males in
particular (with no effect for older males, or black individuals, and
mixed effects for white females).
Higher beer prices are correlated with a reduction in chlamydia and
gonorrhea rates.
Population and Public Health, Ministry of Health
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Reference
Scribner et al.
(1998)
Alcohol policy element
Alcohol outlet density in
New Orleans
Relationship with STI rates
A 10% increase in off-sale alcohol outlet density accounts for a .8%
increase in gonorrhea rates.
In response to the request for an expansion of the literature review on alcohol policy, an expert at the
BC Ministry of Health provided a list of published and unpublished documents. These have been
identified separately from the primary search, and are discussed below.
Booth et al. (276) conducted a review of the effects of alcohol pricing and promotion on alcohol
consumption and a variety of other outcomes, including impact on STIs, in the UK. This unpublished
document reviewed systematic reviews and meta-analyses. The authors reiterate the rationale for a
postulated relationship in that while alcohol consumption does not itself cause STIs, it may increase the
risk of exposure to a STI through risky sexual behaviour, as well as that alcohol may compromise the
ability of the immune system to fight infections. The authors cite a single systematic review by Cook &
Clark (277). Eight of 11 studies found that “hazardous” alcohol consumption (see below) is associated
with an increased risk of STIs, and the other three studies found no significant association. Of these
three studies that did not find a significant association, the authors reported a number of limitations
including a small sample size in one study and the use of an insensitive measure of STIs in a second
study. However, it is important to note that there were many different measurements of alcohol
consumption, therefore it is difficult to determine which pattern of alcohol consumption is associated
with the highest risk (276). The conclusion is that, based on these eight studies within the systematic
review, alcohol consumption is associated with an increased incidence of STIs. The authors note
however that it is challenging to establish a “consistent mechanism for direct causal effects”, due to the
fact that there may be other explanations for the engagement in risk behaviours other than alcohol
consumption.
Examining the Cook & Clark (277) paper in more detail, the stated objective was to examine the
association between problematic alcohol consumption and STDs. Problem drinking involved “any
specific drinking pattern that has been shown to be associated with harmful clinical or social problems”;
specifically defined as “binge drinking (5+ drinks for men, 4+ drinks for women), high quantity/frequency
(>7 drinks/week for women, >14 drinks/week for men), being drunk or intoxicated, or having alcoholrelated problems or disorders.” Forty-two articles were felt to be eligible for detailed review based on
specified criteria, while 11 of these included specific measures of problem drinking. These 11 articles are
summarized in Table 5 below (note that one of the articles, Cook et al. (278), is not included here
because the only STI reported was herpes simplex virus type 2 [HSV-2] infections).
Population and Public Health, Ministry of Health
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Table 5: Articles Examining the Association between Problematic Alcohol Consumption and STIs,
identified by Cook & Clark (2005)
Reference
Shafer et al.
(1993) (279)
Population and
Setting
Male youth in a youth
detention
center (n = 414).
65% African American
Cross-sectional study
Ericksen &
Trocki (1994)
(280)
Data from the 1990
National Alcohol
Survey (probability
sample of adults in 48
States, men n = 882,
women n = 979).
Details of alcohol and
STI measures
STI
All participants asked
whether they ever had
a STD, and 65% tested
for chlamydia and
gonorrhea (urethral
culture), syphilis
(serology), hepatitis B
(serology), or genital
warts (clinical
examination).
Alcohol
Quantity and
frequency of standard
drinks consumed in
past 3 months.
STI
Survey question:
“have you ever had a
sexually transmitted
(venereal) disease (for
example, syphilis,
gonorrhea, genital
herpes, genital warts,
chlamydia)?”
Alcohol
Alcohol assessment
questions included
binge drinking (Five or
more
drinks in one sitting on
at least a weekly basis
over the past year)
and problem drinking
(having three or more
of eight major
symptoms associated
with alcohol abuse or
dependence).
Population and Public Health, Ministry of Health
Key Findings
Comments
Compared with youth
who did not drink:
Youth reporting daily
drinking (13% of the
sample) significantly
more likely to have a
current or past STD (OR
3.53; 95% CI, 1.61–7.2).
Youth reporting heavy
drinking (>20
drinks/week) had
increased risk of STD (OR
2.23; 95% CI,
1.08–4.62) – this when
controlling for lifetime
number of sexual
partners and low
condom use.
Binge drinking was
associated with
increased risk of STD in
men, which did not
remain significant during
multivariate analysis,
and no increased STI risk
in women.
Having >3 symptoms of
drinking
associated with an
increased risk of STD in
both men and women
and this remained
during multivariate
analysis.
Limitation: Selfreported STD
data was
combined with
lab and clinical
data.
Self-reported
STD data
Cannot
determine
temporal
relationship
between alcohol
consumption
and STD
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Reference
Ellen et al.
(1996) (281)
Population and
Setting
Heterosexual men and
women (n = 1442)
attending
public STD clinics in
three cities in the US.
-61% male
-70% African American
-More than 25%
current users of crack
cocaine.
Details of alcohol and
STI measures
STI
Laboratory and clinical
assessments for
gonorrhea and
syphilis.
Alcohol
Self-report: how often
they were drunk from
alcohol during sex in
the prior 3 months.
Key Findings
Comments
Men who reported
being drunk before sex
were more likely to be
diagnosed with
gonorrhea (OR, 1.14;
95% CI, 1.02–1.29), but
this result did not
remain significant during
remain significant in
multivariate analysis. No
relationship between
being drunk during sex
and syphilis among men,
or for gonorrhea or
syphilis among women.
Limitations: The
alcohol variable
(being drunk
before sex in the
previous three
months) may
lack validity.
Questions about
whether the
sample size was
large enough to
detect a
difference in
syphilis rates,
given that 5% of
the sample had
syphilis.
STI
Trichomonas
identified by pap
smears and baseline
and every 2 years
(average 3.5
screenings per
woman).
Alcohol
Number of drinks per
week (0, 1–9, 10 or
more) and the number
of years of drinking (0,
1–9, 10 or more).
Compared with women
who did not drink at
baseline, the RR of
incident trichomonas
infection was
significantly higher
among women who
drank 1-9 drinks per
week [1.7 (95% CI, 1.30–
2.23)] but not among
those who drank >10
drinks per week [0.69
(95% CI, 0.22–2.15)].
Limitations:
Potentially large
time difference
between
baseline
assessment of
alcohol
consumption
and incident
trichomonas
infection
(detected up to
9 years later).
Uncertain why
trichomonas was
higher among
women who
drank 1-9
drinks/week but
not 10
drinks/week.
Cross-sectional study.
Zhang et al.
(1996) (282)
Women >25 years
who attended cervical
cancer screening
program in China
between 1974-1985 (n
= 16,797).
Cohort study
Population and Public Health, Ministry of Health
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Reference
Chokephaibulkit
et al. (1997)
(283)
Wilson et al.
(1998) (284)
Population and
Setting
Pregnant youth in
Tennessee. Cases had
been diagnosed with
chlamydia infection
(culture) at first
prenatal visit (n = 67);
controls of similar age
and socio-economic
status had first
prenatal visit on same
day, but were not
infected (n = 53).
Case control study
Women from clinical
and community-based
settings in Brooklyn
(1990-1994), n = 677,
232 had HIV.
86% African American.
Cohort study
Miranda et al.
(2000) (285)
Women in prison in
Brazil (n = 121)
Ross-sectional study
Details of alcohol and
STI measures
STI
chlamydia infection
diagnosed by culture.
Alcohol
Questionnaire
assessed for ‘alcohol
abuse’, but details not
provided.
STI
Tested for chlamydial
and gonococcal
infections using
cervical culture, and
trichomonas infection
using vaginal culture
at baseline and every
6 months.
Alcohol
Self-reported: number
of times drank alcohol
per week in a 1-year
period (measured on a
7-point scale ranging
from “never” to “more
than 4 times a day”).
STI
Gonorrhea (cervical
culture), chlamydia
(enzyme-linked
immunosorbent
assay), syphilis
(Venereal Disease
Research Laboratory
[VDRL] screening with
confirmation), and
trichomonas (vaginal
wet mount).
Alcohol
Survey that assessed
whether the woman
had “ever abused
alcohol.”
Population and Public Health, Ministry of Health
Key Findings
Comments
No significant difference
in the prevalence of
alcohol abuse between
cases (33%) and controls
(39%).
Limitations:
Unclear what is
meant by
‘alcohol abuse’.
Sample size may
also have been
small.
When assessing whether
there was an increased
risk of a new STD with
consecutive levels of
alcohol consumption,
the result was not
statistically significant
(RR, 1.09; 95% CI, 0.97–
1.22).
“Ever abusing alcohol”
was significantly
associated with syphilis
infections only (OR, 2.0;
95% CI, 1.1–5.5), but not
with the other STIs.
Limitation:
definition of
alcohol abuse.
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Reference
Population and
Setting
Male and female
emergency
department patients
in Baltimore;
presenting for medical
treatment of any type.
Note that the analysis
was limited to
participants aged 1831 years.
Details of alcohol and
STI measures
STI
Urine sample used to
test for gonorrhea and
chlamydia using ligase
chain reaction.
Alcohol
Four CAGE questions
(a screening test for
alcohol abuse and
dependence).
Miller et al.
(2001) (287)
Aboriginal males and
females aged 12 to 40
years who were seen
at least twice between
1996-1998 for STD
testing at any of nine
public clinics in
Australia (n = 1034).
Thomas et al.
(2001) (288)
Men and women
enlisted in the US
Navy in California (n =
299).
STI
Laboratory testing for
chlamydial and
gonococcal infections
(using a
urine-based
polymerase chain
reaction assay) and
syphilis (serology).
Alcohol
Alcohol abuse was
defined as “binge
drinking or regular
heavy use” according
to Aboriginal health
workers.
STI
chlamydia testing by a
urine-based LCR assay.
Mehta et al.
(2001) (286)
Cross-sectional
Alcohol
Problem drinking was
defined as “consuming
alcohol until you
passed out or
vomited”
within the previous 30
days.
Population and Public Health, Ministry of Health
Key Findings
Comments
There were two alcohol
questions that were
associated with an
increased risk of STD in
men: “ever been
annoyed by others
criticizing your drinking”
and “ever had a drink
first thing in the
morning,” but only the
latter question remained
significant in
multivariate analysis.
None of the alcohol
questions
were associated with
STDs in women.
Persons with alcohol
abuse were significantly
more likely to have an
incident gonococcal
infection (RR, 1.46; P =
0.007), but there was no
significant association
with chlamydial
infections
(RR, 1.18; P = 0.28) or
syphilis (RR, 0.63; P =
0.42).
Limitations:
Questions ask
about “ever”
having alcohol
problems, but
this is related to
“current” STIs.
Limitations:
Validity of
alcohol abuse
measure.
The prevalence of
chlamydia among
women who engaged in
problem drinking,
compared to those who
did not, was 21.4% vs.
4.6% (OR 6.6, 95% CI,
1.6–27.8) after adjusting
for current pregnancy.
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A working paper by Markowitz et al. (289) examined whether alcohol is a causal factor that affects
sexual activity and risky sexual behavior among youth and young adults. Data was derived from the
National Longitudinal Survey of Youth 1997 cohort (NLSY97) (n = 7900) and the biennial Youth Risk
Behavior Surveys (YRBS) (n = 58,000). There was found to be a negative and statistically significant
relationship between beer tax and male gonorrhea rates for both 15-19 and 20-24 year old males. Other
conclusions were that alcohol use appears to have no causal influence in determining whether an
individual has sex, and that alcohol use lowers contraception use (condoms and birth control
specifically) among sexually active individuals.
Grossman et al. (271) examined the relationship between alcohol policies (e.g., beer taxes and statutes
pertaining to alcohol sales and drunk driving) and rates of gonorrhea and AIDS among youth and young
adults. They concluded that higher beer taxes are associated with lower rates of gonorrhea for males.
Blood Alcohol Concentration (BAC) laws (i.e. laws that make it illegal to drive with a BAC higher than a
certain level), and dry counties were found to have no effect. Zero tolerance laws with respect to drunk
driving may also lower the gonorrhea rate among males under the legal drinking age.
Summary: While not demonstrated in all studies, literature on alcohol policies that look at various
consumption and access measures found that alcohol reduction rates are associated with lower STI
rates.
Intervention
Alcohol policy (e.g.,
taxes, zero tolerance
drunk driving laws,
minimum drinking
age, alcohol outlet
density)
Behavioural
outcomes

STI
incidence/prevalence

Contextual considerations and comments
The literature on alcohol policy includes the
examination of multiple measures of reduced
alcohol access or consumption and finds that
measures that involve alcohol reduction are
associated with lower STI rates. This result is not
mirrored in all studies, and the challenges in
establishing causality are recognized, however
there is a well-supported mechanism of
association that has itself received support in the
literature (i.e. the association between alcohol
consumption and risky behaviour), and
corroboration of evidence in a number of studies.
6.3.2 Other Policy
Other ecological studies explore different policy-related variables and STI-rates, such as welfare policy
(290,291). As this review is directed, there may yet be other policy initiatives that affect bacterial STIs
that were not identified using the given search strategy.
6.4
Funding and Fees
6.4.1 STI Clinic Fees
A study by Rietmeijer et al. (292) explored the impact of charging service fees for STI clinic attendance,
on clinic attendance and gonorrhea and chlamydia detection. Although STI clinics often offer services at
no or minimal cost, due to budget challenges a clinic in Denver introduced a clinic fee of $15 for Denver
residents and up to $65 for non-residents. One month after the co-payment introduction, visits fell by
30%. This decline was greatest among women and younger individuals, with a particularly high decline
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among residents from a neighbouring county that had to pay the higher $65 fee. Compared to the
previous year, during the first three quarters of the year following the fee change there were 28.5%
fewer visits (over 3000 fewer visits) to the clinic. Chlamydia diagnosis decreased by 28.1%; women and
individuals under the age of 20 years were disproportionately affected (40% and 42%, respectively).
There were also 38.1% fewer gonorrhea diagnoses. Among MSM, the number of visits decreased by
21%; gonorrhea diagnoses decreased by 40%; while early syphilis diagnoses increased by 8.8% (from 34
to 37 cases). Among individuals of lower socio-economic status (incomes below 100% of the federal
poverty guidelines), the proportion decreased from 60% in the six weeks prior to the co-payment to 29%
in the six weeks after, to 41% (which is still below the level prior to the co-payment). Further, although
there was also a decline in gonorrhea and chlamydia cases by health care providers outside of the clinic
during this same period, it was much smaller than the decline seen at the clinic, and the ratio of cases
reported by the clinic and those reported by other sites, also declined. This suggests that even if there
was a general decline in gonorrhea and chlamydia cases, the introduction of the co-payments at the
Denver clinic had an effect on STI diagnoses.
Intervention
Clinic copayments
Behavioural
outcomes
 For impact on
clinic visits
STI incidence/
prevalence
 For impact on STI
diagnosis
Contextual considerations and comments
Based on a single, well done natural experiment
with strong theoretical rationale, the introduction of
even a modest fee for STI clinic care has been shown
to result in a considerable decline in clinic visits and
impact the diagnosis of STIs.
6.4.2 Federal Funding
Chesson & Owusu-Edusei, Jr (293) sought to examine the relationship between federal funding for
syphilis elimination and syphilis. In 1999, the CDC instituted a national syphilis elimination plan. The
authors examined syphilis incidence data, at the state level, between 1997-2005 and studied the
association between amount of state-level funding and subsequent syphilis rates. They found that
greater amounts of state-level funding for syphilis elimination in a given year were associated with
lower state-level syphilis rates in subsequent years. Note that to test their results, tuberculosis was
substituted for syphilis, and they did not find an impact of syphilis prevention funding on the
tuberculosis rates. This suggests that the association observed between syphilis elimination funding and
reduced syphilis incidence rates was not driven by a correlation between syphilis elimination funding
and other state-level factor(s) that influence communicable disease incidence generally. Therefore the
authors suggest that federally-funded syphilis elimination activities are having an inverse impact on
syphilis rates.
Intervention
Federal funding
for STI elimination
Behavioural
outcomes
N/A
STI incidence/
prevalence

Population and Public Health, Ministry of Health
Contextual considerations and comments
An inverse association was found between the amount
of federal funding for syphilis elimination activities and
the subsequent syphilis rate in later years, at the state
level in a US study. Although this study design is
ecological, it is appropriate for an examination of data
at this level, and well-designed. While this topic would
benefit from additional research to corroborate this
finding, a sound theoretical rationale and study
features, are key factors that influenced this rating.
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6.5
Clinic-based Systems Interventions Focused on Youth (Youth
Supplemental Review)
6.5.1 Clinical Practice Improvement Focused on Youth (Youth Supplemental Review)
Shafer et al. (294) describe a clinical practice improvement intervention that was designed to increase
chlamydia screening among sexually active adolescent females (aged 14-18 years), seen during routine
check-ups in pediatrics clinics, in a particular large Health Maintenance Organization (HMO) in the US. A
RCT was conducted involving the random assignment of 10 pediatric clinics to the clinical practice
improvement intervention (n = 1017 sexually experienced adolescent females) or to a control
intervention (n = 1194). Staff at all sites received a one-hour session that included information about the
epidemiology of chlamydia in adolescents, and the current chlamydia screening and treatment
recommendations. The clinical practice improvement intervention was additionally implemented in the
intervention sites and included engagement, team-building, redesign of clinical practice, and sustaining
the gain (see Appendix D). Over the entire 18-month period, 47% of females in the intervention sites
were screened compared to 17% at control sites; at 16-18 months, the screening rate among
intervention clinics was 0.65 (95% CI 0.53-0.77) compared to 0.21 (95% CI 0.09-0.33) in the control
clinics. Further, the chlamydia infection rate for the intervention clinics was 5.8% compared to 7.6% in
the control sites (test of significance not reported).
6.5.2 Primary Care Systems Intervention Focused on Youth (Youth Supplemental Review)
Ozer et al. (178) evaluated a systems-level intervention involving health provider training and the
integration and utilization of modified screening and charting tools, aimed at increasing primary care
clinicians’ screening and brief counseling of adolescents in a number of areas, including sexual
behaviour. Component one involved training workshops to increase health care providers knowledge,
self-efficacy and skills to conduct preventive services, and was delivered through didactic presentations,
discussion, demonstration and role plays. Component two included the addition of follow-up questions
to a screening questionnaire as well as prompts and cues relevant to the target areas in order to remind
health care providers to screen and deliver brief counseling messages. Two pediatric clinics within a
HMO in California were intervention sites (n = 37 providers), and two clinics served as control sites
where usual care was delivered (n = 39 providers). The screening and counseling behaviours of health
care providers were based on adolescents’ (age 13-17 years) reports collected after well-care visits
(presumed to refer to visits for regular preventive care). Rates of screening and counseling increased
significantly across all areas, including related to sexual behaviour, while significant increases were not
seen in comparison sites. The training component appears to be responsible for most of this increase,
with the addition of the tools not accounting for much additional change. Little detail is provided on the
specific content of the sexual behaviour intervention so as to limit interpretation of these findings for
this review.
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Intervention
Clinic-based
systems
interventions
Behavioural
outcomes
 To support
screening
uptake
STI incidence/
prevalence

Contextual considerations and comments
Data from HMOs in the US indicate that systematic changes
in clinical practice can positively impact STI screening
uptake among target populations on female youth.
A favourable impact on chlamydia infection is suggested in one
study, however without the reporting of a test of significance it
is difficult to know the implications of this result.
Implications for the Canadian context vs. the HMO context, is
uncertain.
6.6
Mass Media Targeting Youth (Youth Supplemental Review)
A selection of studies examined the relationship between various forms of mass media (television,
music, movies, magazines, etc.) (295) as well as STI incidence/prevalence and sexual risk behaviours. The
postulated mechanism for an association is the portrayal of sexual images while rarely portraying the
consequences of sexual risk behavior (295,296). However, what is lacking is literature that evaluates an
intervention limiting mass media consumption on behavioural or biological outcomes.
Wingood et al. (296) conducted a 12 month prospective study to examine the impact of the exposure to
rap music videos on the incidence of STIs (chlamydia, gonorrhea and Trichomoniasis) and health risk
behaviours (multiple sex partners, condom use, and other behaviour such as fighting, arrests, alcohol
and drug use) among African American adolescent females (n = 522). Participants were between 14 and
18 years of age, had been sexually active in the past six months, and lived in lower socio-economic
status neighbourhoods in Alabama. Adolescents were asked to estimate the volume and type of rap
music videos they viewed, and the viewing circumstances (whom they viewed videos with, and where
videos were viewed). Adolescents were tested for the three STIs under study. Over the 12-month
period, 37.6% acquired a new STI, and adolescents that had greater exposure to rap music videos were
significantly more likely to have acquired a new STI compared to those that had less exposure to rap
music videos (AOR – adjusted by parental monitoring and adolescents’ employment status – 1.6 (95% CI
1.1-2.3, p=0.04). As well, 14.8% had sexual intercourse with someone other than their steady partner,
and adolescents with greater music video exposure were significantly more likely to have had multiple
sexual partners (AOR 2.0 (95% CI 1.1-3.4, p = 0.02). Condom use was not found to be significantly
associated with rap music video viewings. As there are different types of rap music videos, data was
collected on the type of rap music videos viewed; 70% of participants viewed a type of video that the
authors report is explicit about sex and violence, however associations between each type of rap music
video and STI incidence was not reported.
Wingood et al. (297) examined the association between exposure to sexually explicit (i.e., X-rated)
movies and African American adolescent females’ sexual health-related attitudes and behaviours, in a
cross-sectional study. Participants were age 14-18 years and sexually active within the past six months.
Media exposures and sexual health attitudes were assessed by survey; interview assessed sexual
behaviours (administered by African American female interviewers in private rooms); and self-collected
vaginal swabs were used to assess STIs (chlamydia, gonorrhea and Trichomoniasis). Almost 30% of
adolescents reported exposure to X-rated movies. Twenty eight percent of the sample had one or more
STIs, with 5% diagnosed with mixed STI infections (chlamydia, gonorrhea and Trichomoniasis prevalence
was 17.5%, 5.2% and 12.9%, respectively). Exposure to X-rated movies was associated with being
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significantly more likely to test positive for chlamydia (AOR – for single-parent family and being
monitored by someone other than one’s mother – 1.7, 95% CI 1.04-2.80, p = 0.03). A number of other
attitudes and sexual risk behaviours were significantly associated with exposure to X-rated movies,
including an increased likelihood of having had multiple sex partners (AOR 2.0 [95% CI 1.09-3.67, p =
0.03], and increased likelihood of not having used contraception in the past six months (AOR 1.5 [95% CI
1.03-2.30]).
Other authors such as L’Engle et al. (295), focused on attitudes (e.g., intentions to be sexually active)
and sexual behaviours rather than STI incidence or prevalence outcomes. Significant associations are
consistently observed between exposure to sexual content in the media and sexual intentions and
sexual activity. For example, among a sample of 1011 Caucasian and African American male and female
adolescents in the US, L’Engle et al. found that media influences accounted for 13% of the variance in
intentions to have sexual intercourse in the near future; 10% of the variance in light sexual activity
(having a crush, dating, being in a private place and kissing); and 8% of the variance in heavy sexual
activity (breast touching, genitalia touching, oral sex and sexual intercourse), after controlling for age,
sex, race and socio-economic status. Note that demographic factors predicted more variance in
intentions to have sexual intercourse than media, parental, school or religion factors. However, media
variables predicted more variance in sexual intentions and activities than did religion and school factors;
more variance in light sexual activity than parent factors and peer factors; while media variables
predicted less variance in sexual intentions than parental and peer factors, and less variance in heavy
sexual activity than peer factors.
Interestingly, the American Academy of Pediatrics has proposed that adolescents’ access to sexually
explicit media should be limited, and offered suggestions for how this might be accomplished. This
includes enforcing the age limit for attending, renting or purchasing X-rated movies, and educating
parents about the effects of viewing sexually explicit media on adolescent sexual health and behaviours.
A media history form that has been developed by the American Academy of Pediatrics can be used to
document and understand media use habits; pediatric visits can be used to provide education about
media use in the home; and health concerns can be co-related with media use (298). It is uncertain
however whether these suggestions have been implemented and evaluated.
Sznitman et al. (299) conducted a study that evaluated the impact of mass media messages on sexual
risk behaviour change among African American adolescent males age 14-17 years (n = 1383). At
baseline, 8.3% of participants tested positive for at least one STI (chlamydia, gonorrhea, Trichomoniasis),
19% reported multiple recent vaginal sex partners and 32% reported unprotected sex (vaginal, oral
and/or anal) in the past 3 months. Two cities in each of two regions were selected; within each region,
one city served as an intervention site and the other as a control site. All adolescents that tested positive
for STI(s) were treated and received risk reduction counseling, however in intervention cities,
adolescents were also exposed to a mass media HIV prevention program. This involved messages on
mass media channels that were popular with African American youth (TV and radio), and took the form
of “mini-dramas” involving African American adolescents resolving situations regarding sexual risk
behaviour and modeling appropriate responses to challenges. High exposure to these advertisements
were confirmed among the target population. This study found that among adolescents that tested
positive for STI(s), those in the control arm reduced their number of vaginal sex partners and
unprotected sex over the first six months, however after six months they returned to their previously
high levels of risk behaviour. Whereas those in the intervention sites that received the mass media
program demonstrated more stable reductions in unprotected sex. This suggests that mass media
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interventions, coupled with other traditional care, may support long-term reductions in sexual risk
behaviour.
Summary: A selection of studies demonstrated an association between exposure to different types of
mass media (e.g., with sexually explicit content) and STI rates and sexual risk behaviours. However, what
is lacking is literature that evaluates an intervention limiting mass media consumption on behavioural or
biological outcomes.
Intervention
Mass media
targeting youth
Behavioural
outcomes

STI
incidence/prevalence

Contextual considerations and comments
An association between exposure to
different types of mass media (e.g., with
sexually explicit content) and STI rates have
been reported in prospective cohort and
cross-sectional studies. There is a plausible
mechanism and corroboration of evidence of
this association.
What is lacking is research evaluating the
impact of interventions that limit
adolescents’ access to sexually explicit
media, and how this impacts STI burden and
sexual risk behaviour.
6.7
Social Marketing and Public Awareness Campaigns for MSM (MSM
Supplemental Review)
In the 1990s and early 2000s, a syphilis epidemic emerged in San Francisco. Data indicated at that time
that the majority affected were MSM (300). As a result, the San Francisco Department of Public Health
conducted a social marketing campaign to increase syphilis testing and awareness among MSM (300).
Social marketing is a research-driven approach to behaviour change and consists of five components:
branding, segmentation, price, placement, and promotion (301). The SFDPH conducted a social
marketing campaign, the Healthy Penis campaign, in collaboration with a San Francisco-based social
marketing firm in response to the syphilis epidemic. The primary campaign message was to deliver the
“get tested” message to MSM. Secondary objectives were to increase awareness about the syphilis
epidemic in MSM and to increase knowledge about syphilis. The campaign was conducted in MSMconcentrated neighborhoods. Humorous cartoon strips using characters like “Healthy Penis” and “Phil
the Sore” were used to promote syphilis testing, to publicize the rise in syphilis rates among MSM, to
provide information on syphilis transmission, symptoms and prevention, and to delineate the
connection between syphilis and HIV. Cartoon strips were initially published in a popular gay Bay Area
publication. Other posters were posted on streets, in bars and commercial sex venues, on bus shelters
and on buses, on palm cards and on banner advertisements on popular internet sites for meeting sex
partners for MSM. Figure 1 in Appendix F depicts an example of the cartoon strip.
To evaluate the campaign, the authors conducted two sets of surveys, one at six months after the
campaign began, and the second 2.5 years after the campaign began. An increasing proportion of
respondents reported syphilis testing in the previous six months by campaign awareness level (CochranArmitage trend test z = -3.303, p = 0.001) for the first evaluation; and z = -2.304, p = 0.02 for the second
evaluation. After controlling for confounders, each increase in campaign awareness level during the first
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evaluation was associated with a 90% increase in likelihood for having tested for syphilis in the past six
months (OR 1.9, 95% CI 1.3-2.9). In the second evaluation, each increase in campaign awareness level
was associated with a 76% increase in syphilis testing (OR 1.76, 95% CI 1.01-3.1). In 2005, after the
campaign, the incidence of early syphilis was lower than in the previous three years, with decreases in
cases among MSM accounting for the drop (data not provided). Although ecological, the authors
surmise that this campaign, along with other San Francisco Public Health Department syphilis
elimination efforts may have contributed to this decrease.
In Seattle and surrounding King County, in response to an increase in syphilis, chlamydia, and gonorrhea
rates among MSM, Seattle Public Health established the “STD/HIV Prevention Task Force” (Task Force)
to examine the health needs of MSM in Seattle and King County (302). The Task Force created a
document entitled, “A Community Manifesto: A New Response to HIV and STDs”. This document had
several objectives:
 To identify and address key sexual behavioural issues
 To promote an ethical framework for consideration and discussion by MSM
 To promote practices to enhance personal and community sexual health for HIV-positive and
HIV-negative MSM
 To incite action so that future generations of gay and bisexual men do not inherit HIV as their
problem.
The manifesto was first placed in both half and whole page formats in two Seattle weekly newspapers in
October 2003. The manifesto was then reprinted weekly in these two publications for three months and
then less frequently until a final publication in March 2004. Two local press conferences were also held
to distribute the manifesto. The King County Executive and Director of Public Health publicly signed the
manifesto to indicate their concern about the increasing risk behaviours and STIs among MSM. The
manifesto was also posted on a website. A total of 136 persons endorsed and signed on to the
manifesto. Seventy responses were submitted via the website. Sixty-seven percent indicated support for
the manifesto, 18% did not support the manifesto and 16% gave no indication of their support. Themes
of the focus group and comments on the website included:
 Responsibility
 Tone—some felt that there was a blaming and shaming tone of the manifesto toward HIV
positive individuals
 Timing—some felt that “the time is well past for this type of message”
 Authorship—some wondered who wrote the manifesto
For those who completed the survey (web-based, mail-in or street-intercept), 84% had heard about the
manifesto. About half of all respondents reported that the manifesto made them think about their
sexual choices and behaviours. Twenty-seven percent indicated they had made changes to their
behaviours. Sixty-one percent strongly agreed or agreed with the manifesto; 19% disagreed or strongly
disagreed with it; 18% was neutral.
Martinez-Donate, et al. (303) conducted a social marketing campaign, “Hombres Sanos” (Healthy Men),
targeted toward Latino heterosexual-identified MSM in a major US city. They developed materials to
change social norms related to condom use and to promote HIV/STI testing. In their materials, they
focused on promoting condom use during sexual encounters with men and featured condom use as a
way to keep same sex practices secret. For example, they developed a poster that showed the shadow
of two men having sex projected against the wall of a public bathroom. Most people not familiar with
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male-to-male sexual encounters in public settings would not notice this poster as the shadow’s shape
was ambiguous enough (Figure 2 in Appendix F). The text included Spanish-language captions, “No one
knows… and with a condom, no one will.” Services offered include a male health exam that screened for
diabetes, hypercholesterolemia and hypertension, in addition to HIV and STI testing.
To evaluate the campaign, the authors conducted cross-sectional surveys every month with samples of
Latino men. Two hundred and sixty men were recruited per survey wave. Men were recruited from
seven “low-risk” venues (workplaces, shopping centres), and five “high-risk” venues (an adult bookstore
and bars and clubs). They found that there were no changes in the prevalence rates of unprotected
sexual practices with females over the previous 60 days. There was a significant increase in the
percentage who reported and demonstrated condom carrying during the campaign (AOR 2.28, 95% CI
1.59-3.27) and post-campaign (AOR 1.62, 95% CI 1.06-2.49), compared with baseline. HIV testing during
the previous six months increased significantly from baseline to post campaign (AOR 3.13, 95% CI 2.064.75). The percentage of heterosexual respondents who knew where to get tested for HIV increased
during the campaign (AOR 1.60, 95% CI 1.26-2.02) and post campaign phases (AOR 1.57, 95% CI 1.182.08). Respondents’ average level of perceived risk for HIV was higher during the campaign (B=0.013;
95% CI 0.04-0.13) and post campaign (B=0.27, 95% CI 0.17-0.37) than during baseline.
Pedrana, et al. (304) conducted a social marketing campaign among Australian MSM to address the rise
in HIV and STI rates. In February 2008, the Victorian AIDS Council/Gay Men’s Health Centre launched the
“Drama Downunder” social marketing campaign. The campaign used mainstream advertising, as well as
gay media and included multiple advertising channels. Other innovative methods for dissemination
include fridge magnets, drink holders and underwear. Campaign-specific events were held. The
campaign used humour extensively and a website was created. Figure 3 in Appendix F depicts a sample
of a campaign poster.
Surveying a convenience sample of 295 MSM, the authors found that campaign awareness was high
(86%). In multivariable logistic regression, awareness of the campaign was independently associated
with having had any STI test within the past 6 months (prevalence ratio 1.5, 95% CI 1.0-2.4). Compared
with the 13 months before the campaign, their data showed significant increasing testing rates for HIV
(RR 1.17 initial period, RR 1.27 continued campaign period), syphilis (RR 1.19 initial period, RR 1.29
continued campaign period) and chlamydia (RR 1.15 initial period, RR 1.28 continued campaign period)
among HIV-negative MSM (all p < 0.01) as compared to baseline.
Finally, Wei, et al. (305) conducted a Cochrane Review looking at RCTs using an interrupted time series
and pretest-posttest design studies (uncontrolled or controlled) that compared social marketing
interventions with no intervention. They found three studies and included it in their final analysis. Their
meta-analysis showed that the campaigns were effective on HIV testing uptake (OR 1.58, 95% CI 1.401.77) but were not effective in increasing STI testing uptake (OR 0.94, 95% CI 0.68-1.28). They also noted
a high risk of bias and a low quality of evidence for the three studies.
Darrow and Biersteker (306) and Guy, et al. (307) were serial cross-sectional pretest-posttest design
studies without a control while Darrow and Biersteker implemented a social marketing campaign in
South Florida. About 800 posters and 173,000 palm cards were distributed in bars, clubs and elsewhere;
119 advertisements were placed in local publications and six billboards were erected. Syphilis alert
banners appeared on three websites and three different public service announcements were created
and scheduled to be broadcast 1770 times on radio or television. Figure 4 in Appendix F depicts some of
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the posters and palm cards used. Risky sexual practices and patterns of recreational drug use did not
change. There were no significant increases in knowledge, clinic visits or testing or treatment for
syphilis.
Guy, et al. (307) conducted the “Check-It-Out” social marketing campaign targeting a broad range of
MSM in Australia. Posters and takeaway cards (Figure 5 in Appendix F) were developed and displayed in
six hotels, four nightclubs, two gyms, five cafes, and 13 sex on premises venues frequented by the MSM
community. Annual behavioural surveys were conducted following the social marketing campaign found
that there was no significant increase in this overall proportion of MSM reporting having an HIV or STI
test in the past 12 months.
Summary: Although various social marketing campaigns have shown promise in uncontrolled studies,
with some studies demonstrating an increase in uptake of STI testing and a reduction of risk behaviours,
the evidence from controlled studies for the use of social marketing campaigns in controlling for
bacterial STIs is not conclusive.
Intervention
Social marketing
campaigns for MSM
6.8
Behavioural
outcomes

STI
incidence/prevalence

Contextual considerations and comments
Although various social marketing campaigns
have shown promise in uncontrolled studies,
the evidence from controlled studies for the
use of social marketing campaigns in
controlling for bacterial STIs is poor. Some
studies have shown an increase in uptake of
STI testing and a reduction of risk behaviours.
No studies were found evaluating the impact
of social marketing campaigns on STI
incidence/prevalence.
CDC and PHAC Guidelines: Special Populations
As previously discussed in the micro-level interventions section, the following is a review of key
guidelines in Canada and the US regarding a variety of special populations. No evaluation was found of
these guidelines in their entirety (i.e. incidence/prevalence of bacterial STIs before and after a
jurisdiction adopts these guidelines). However, many of the interventions discussed in this review, for
which evidence is available, comprise these guidelines.
Intervention
PHAC and CDC
guidelines
Behavioural
outcomes
0
STI
incidence/prevalence
0
Population and Public Health, Ministry of Health
Contextual considerations and comments
No evaluation was found of the impact of
these guidelines on STI rates at the
population level, however there is literature
examining use among health care providers
(discussed below), and these guidelines
consist of interventions that are discussed
throughout this report.
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6.8.1 Pregnant Women
US CDC guidelines suggest women be screened as early as the first prenatal visit for HIV (308), syphilis
(309) hepatitis B surface antigen (HBsAg) (310), and chlamydia (311). In addition, pregnant women who
live in an area with a high prevalence or at risk for gonorrhea should be screened (312). These risk
factors include women under the age of 25 years, a previous gonorrhea infection, other STIs, new or
multiple sex partners, inconsistent condom use, sex trade work, and drug use. If they are found to have
gonococcal infection during the first trimester, they should be retested within 3-6 months, preferably in
the third trimester. Women deemed to be at high risk should also be retested in the third trimester for
the above. US guidelines do not recommend routine testing in asymptomatic pregnant women for
bacterial vaginosis (BV), trichomonas vaginalis, or HSV-2 in asymptomatic pregnant women (113).
Canadian guidelines recommend all pregnant women be screened for HIV, HBsAg, chlamydia and
gonorrhea and syphilis (13). Although Trichomoniasis and BV have been shown to adversely affect
pregnancy outcomes, owing to the increased risk of pre-term birth with treatment, routine screening is
not recommended. Canadian guidelines recommend counselling on the signs and symptoms of HSV
infection, as well as risk reduction behaviours. Routine screening with HSV serology is not routinely
recommended. If a known or serosusceptible pregnant woman is known to have a partner with oral or
genital herpes, it is important to advise abstinence from oral and/or genital sexual contact. For a
pregnant woman with genital warts, Cesarean section is not recommended for reduction of
transmission of HPV to the newborn. This is similar with US CDC recommendations. If a pregnant woman
is acutely infected with HBV or are chronic carriers, they can transmit the virus to the infant. Use of
hepatitis B immunoglobulin (HBIg) and HBV vaccine in the neonate can prevent 95% of cases. The first
dose of HBV vaccine should be administered within 12 hours of birth and HBIg immediately after birth.
The infant should also receive two additional doses at 1 and 6 months. If a pregnant woman has HCV,
they should be referred to specialists who have expertise in the treatment of HCV. Current treatments
are contraindicated in pregnancy for HCV. For women not pregnant, it is recommended that if they have
received ribavirin as part of a combination treatment for HCV infection, they and their partner should
use an effective form of birth control to prevent pregnancy.
6.8.2 Adolescents
US CDC guidelines recommend routine screening for chlamydia and gonorrhea for all sexually active
females aged 25 years and younger is recommended (311,312). Evidence is insufficient to recommend
routine screening for chlamydia in sexually active young men. HIV screening should be discussed with all
adolescents and encouraged for those who are sexually active and/or use injection drugs (313). The
routine screening of adolescents for syphilis, Trichomoniasis, BV, HSV, HPV, hepatitis A (HAV), and HBV
is not recommended (113).
Canadian guidelines do not include a separate chapter on adolescents, but the specific infection
chapters recommend screening for gonorrhea and chlamydia in males and females aged 25 years and
younger (13).
6.8.3 Children
In children (other than neonatally acquired) with STIs, close collaboration between clinicians, and child
protection authorities is essential. Official investigations should be initiated promptly. Gonorrhea,
syphilis, and chlamydia are virtually indicative of sexual contact, and for a young child, of sexual abuse.
In Canada, the law recognizes some minors as having the ability to consent in some situations (13).
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Persons over the age of 14 are recognized as being able to give consent to participate in sexual activities,
unless the activities are taking place in a relationship where one participant has some authority over or
is in a position of trust in relation to the other person, where there is dependence, or where there is
exploitation. A 12 or 13 year old can also consent to engage in sexual activity with someone who is less
than two years older and with whom there is no relationship of trust, authority, dependency, or
exploitation. Children under 12 do not have the legal capacity to consent to any form of sexual activity.
Canadian guidelines recommend children being screened throughout childhood, during routine visits to
health care providers’ offices, for evidence of sexual abuse.
As with US CDC guidelines, Canadian guidelines recommend the direct involvement of experienced
teams or services. The role of the health care provider is not to determine guilt or innocence of the
suspected parties but to:
1. Take a pertinent medical history.
2. Ensure the physical and emotional well-being of the patient.
3. Treat or prevent illness or injury.
4. Accurately record spontaneous disclosure or volunteered information.
5. Obtain and document physical findings consistent with abuse or suspicions of abuse.
6. Inform the child and caregivers about the medical outcome of the investigation.
7. Assist child protection and law enforcement agencies in their investigation.
Forensic specimens should be obtained by professionals trained in these procedures. Chemoprophylaxis
is recommended if:
 The patient presents within 48 hours after an assault.
 It is requested by the parent or guardian (or patient).
 The patient is at high risk for an STI.
Follow-up tests are recommended. All persons named as suspects in child sexual abuse cases should be
evaluated for STI. Chemoprophylaxis may or may not be offered and treatment decision is based on
history, clinical findings, and test results.
6.8.4 Inmates and Persons in Correctional Facilities
US CDC guidelines recommend universal screening of adolescent females for chlamydia and gonorrhea
at intake in juvenile detention facilities (113). CDC guidelines also suggest universal screening of adult
females at intake for chlamydia and gonorrhea up to 35 years of age. This is largely based on the fact
that females in juvenile detention facilities and young women under the age of 35 years have high rates
of chlamydia (314) and gonorrhea (315). For syphilis, they recommend universal screening on the basis
of local area and institutional prevalence of early infectious syphilis. No other comprehensive US
guidelines have been developed.
Canadian guidelines suggest components of STI prevention programs for the general population are also
applicable to the prison population (13). This includes education, voluntary testing and counselling,
distribution of clean needles or bleach, distribution of condoms and drug-dependence treatment.
Partner notification and testing and treatment of recent sexual contacts are important as well.
Correctional Services Canada (CSC), along with the PHAC, has implemented initiatives aimed at
preventing and controlling the transmission of STIs within federal correctional facilities. These include
confidential, voluntary testing for inmates on admission and throughout incarceration, and pre- and
post-test counselling. Serologic testing and also HAV and HBV immunization are offered. Educational
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materials are also provided. CSC also has provided condoms, bleach kits, and a pilot project of tattoo
parlours in six federal prisons. CSC, however, does not provide needle distribution or exchange services
owing to its zero-tolerance policy on drug use in prisons.
Health care providers should take a complete sexual history (PHAC, 2009), including asking about high
risk sexual practices such as receptive and insertive anogenital intercourse, or-anal intercourse,
unprotected sex, sharing of sex toys, receptive manual-anal intercourse, substance use during sex,
tattooing and IDU and other drug use. Canadian guidelines recommend greater use of routine testing for
inmates at risk, including screening for chlamydia, gonorrhea, syphilis, HIV, and HBV. If symptoms are
present, inmates should be tested for HSV. HCV serology should be obtained for those who use injection
drugs, have tattoos or engage in high risk sexual practices. HAV serology should also be obtained for
those at high risk.
6.8.5 Men Who Have Sex with Men
US CDC guidelines recommend that clinicians should assess the STI-related risks for all male patients,
including asking about the sex of sex partners (113). Risk assessment for MSM should be nonjudgmental. Counselling on high-risk activities should be done. Health care providers should also be
familiar with the local community resources available to assist MSM at high risk. Symptoms associated
with common STIs, such as urethral discharge, dysuria, genital and perianal ulcers, lymphadenopathy,
skin rash, and other anorectal symptoms. Routine laboratory testing should include HIV serology, and
syphilis serology. For those who have had insertive intercourse during the preceding year, testing of the
urine using nucleic acid amplification testing (NAAT) for chlamydia and gonorrhea is suggested. For
those who have had receptive anal intercourse during the preceding year, a NAAT test for rectal
infection for chlamydia and gonorrhea is suggested. A NAAT test for pharyngeal infection for gonorrhea
is suggested for those who have had receptive oral intercourse during the preceding year. Testing for
chlamydia pharyngeal infection is not recommended by the US CDC. Screening for HSV-2 with typespecific serology can be considered if infection status is not known. Screening for anal cancer and precancerous lesions in the anus can be considered but the evidence on this practice is limited. STI
screening at frequent intervals of every three to six months can be considered for MSM who have
multiple or anonymous partners, or those who have sex associated with illicit drugs. Testing for HBsAg
should also be considered, and if not infected and not immunized, be immunized for both HBV. If not
immune to HAV, vaccination is also recommended. Routine serologic testing of HCV should also be
considered.
Canadian guidelines also suggest taking an appropriate history and discussing the risks of specific sex
practices (13), including receptive and insertive anogenital intercourse, oral-anal intercourse,
unprotected sex, sharing of sex toys, rectal douching in association with receptive anogenital
intercourse, receptive manual-anal intercourse, anonymous partnering and use of anonymous
partnering venues, substance use accompanying sex, and IDU and substance use. Canadian guidelines
suggest that based on the risk assessment, routine STI screening at all potential sites of infection for
chlamydia, gonorrhea, and syphilis, HIV serology, and HBV and HAV serology (if not previously
immunized, known to be immune, or known to be positive). Asymptomatic screening for HSV and HPV is
not currently recommended.
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6.8.6 Women Who Have Sex with Women
US CDC guidelines state that women who have sex with women (WSW) should not be presumed to be at
low or no risk for STIs based on the gender of their sexual partners (113). CDC guidelines note that there
is paucity of evidence regarding STI risk transmitted by sex between women, but that sexual practices
such as digital-vaginal or digital-anal contact, especially with shared penetrative sex items are a possible
means of transmission of infected cervico-vaginal secretions. While the rate of chlamydia transmission
between women remains unknown, infection can be acquired from past or current male partners. There
have been reports of syphilis transmitted between female partners as well (113). Thus US CDC
guidelines recommend screening for STIs in WSW. Screening for BV, although common among WSW, is
not advised for asymptomatic women, and neither is treatment.
Canadian guidelines suggest that STI-screening for WSW should be based on a detailed risk assessment,
not on assumptions of low risk behaviours (13).
6.8.7 Sex Trade Workers
Sex trade workers may be female, male, or transgender who exchange sexual services for money, food,
or shelter (13). Canadian guidelines focus on the promotion of safer sexual behaviour through female
and male condom availability and education on correct usage, improved negotiating skills and
supportive policies and laws (13). Education, outreach work, accessible services, advocacy, community
development, program coordination and sex worker involvement are all cited by the Canadian
guidelines as best practices. HBV vaccination should be available to all sex trade workers, and HAV
vaccination should be available to those at high risk (male sex trade workers).
Evaluation of sex trade workers includes a routine STI history and physical examination. Women should
undergo a speculum exam and throat and rectal exam, if warranted. History and counselling should
focus on asking about current and past drug use, regular partners, and condom usage with clients and
partners.
6.8.8 Neonates
Vertical transmission of chlamydia and syphilis can occur to the neonate born to mothers infected with
chlamydia or syphilis. Screening of pregnant women for STIs has been discussed above. Hollier and
Workowski (316) conducted a review of the treatment of STIs in pregnancy and the recommendations
presented below are based on their findings.
Syphilis—US CDC guidelines suggest nontreponemal screening during pregnancy at the first prenatal
visit and a repeat test in the third trimester (113). Penicillin G, in benzathine, aqueous procaine, or
aqueous crystalline form, is the drug of choice in all stages of syphilis (316). It is also the only effective
treatment for the prevention of congenital syphilis. Other antibiotics have not been shown to be
effective or have had adverse fetal effects. For penicillin-allergic patients, desensitization therapy should
be considered.
Gonorrhea—Cefixime and ceftriaxone are recommended as treatment for pregnant women diagnosed
with gonorrhea. Untreated infection is associated with septic spontaneous abortion and infection after
induced abortion, preterm delivery, premature rupture of membranes, chorioamnionitis, and
postpartum infection (316). Neonatal infections include ophthalmia neonatorum, scalp abscess or
disseminated disease.
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Chlamydia—Untreated chlamydia infection increases the risk of preterm delivery, premature rupture of
membranes and perinatal mortality (316). Conjunctivitis and pneumonia can also occur to infants born
to mothers with genital chlamydia infection. Treatment for pregnant women consists of azithromycin 1
g in a single dose or amoxicillin 500 mg three times a day for 7 days. Treatment for the neonate
diagnosed with chlamydial conjunctivitis or pneumonia is with oral erythromycin (113).Topical
erythromycin is not effective.
Trichomonas —Trichomonas infection in pregnancy has been associated with preterm premature
rupture of membranes, preterm delivery, and low birth weight infants (316). However, because of an
increased rate of adverse outcomes among those treated for trichomonas in two RCTs (317,318),
screening of asymptomatic women and subsequent treatment is not recommended.
Bacterial vaginosis (BV)—BV during pregnancy may be associated with premature rupture of
membranes, preterm labour, preterm birth, chorioamnionitis, post-abortion endometritis and
postpartum endometritis. Although US guidelines do not recommend universal screening for BV, Hollier
and Workowski (316) note that all symptomatic pregnant women should be tested and treated with oral
metronidazole.
6.8.9 Aboriginal People
Neither the US nor Canadian guidelines address Native American or Aboriginal groups with regard to STI
prevention and control. One article was found by Steenbeek looking at a holistic approach in preventing
STI among First Nations and Inuit adolescents in Canada (319). Steenbeek outlines several strategies to
assist nurses, particularly practitioners of holistic nursing, in delivering health education to Aboriginal
youth on the prevention of STIs. These strategies include participatory action research (PAR), the use of
peer leaders, and the development of self-advocacy skills. PAR is a form of research that involves
collaboration between the researchers and the population being researched, a process by which both
parties educate one another; and a focus on knowledge production that benefits the local community.
PAR therefore, involves the participants in a way that other research might not; the participants “own”
their own data and use it to better their lives. Steenbeek argues for adolescent peer educators in the
area of STI prevention programs. Peer educators can distribute STI-related information, collect accurate
data, program planning, and modify relevant norms and behaviours for youth no longer in school and
street youth. Steenbeek states that studies have shown that health promotion programs need to include
messages delivered by people who share similar life experiences in order for them to be effective.
However, Steenbeek acknowledges that, as of 2004 at least, there is little evidence to support the use of
peer educators among the Aboriginal population. Finally, developing self-advocacy skills among
Aboriginal adolescents is another strategy that may be employed to prevent STIs. Steenbeck defines
self-advocacy as “the ability to seek, evaluate, and use information to promote one’s own health.”
Steenbeck suggests that holistic health nurses can help Aboriginal adolescents become appropriately
assertive by teaching them to ask for information and to make their own decisions about their care.
Role-playing, teaching negotiation skills, and making health education materials accessible can help
adolescents understand their own health problems and to share them with others whom they trust. The
main goal is to allow Aboriginal adolescents take control of their own health. Steenbeck notes that some
other aspects of self-advocacy health promotion programs may include presenting pre-adolescents with
a healthy picture of adulthood, maintaining sexual abstinence, and the physiology of puberty in pubertal
developmental transition. Nurses involved in monitoring their physical development should be aware of
signs of high stress, poor coping, and devaluation of self, especially during periods of transition.
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6.9
CDC and PHAC Guidelines: Interventions
In addition to the reviews and primary research presented in the micro-level interventions section of
this report, the interventions discussed in the CDC and PHAC guidelines are reviewed here. No
jurisdiction-wide evaluation of these guidelines was found during the course of this search.
6.9.1 Counselling
The US CDC guidelines states the US Preventive Services Task Force (USPSTF) recommends high-intensity
behavioural counselling for all sexually active adolescents and for adults at increased risk for STIs and
HIV. This includes, for providers, taking an appropriate sexual history and educating clients and patients
on abstinence, condom use, limiting the number of sexual partners, and modifying sexual practices. This
should be done in a nonjudgmental manner that respects the client’s or patient’s culture, minority
status, language, age, and sexual orientation. Interactive counselling can be effectively used by health
care providers. Extensive training is not required to perform effective risk reduction counselling, but the
quality of counselling is improved when providers are trained. The US CDC has training resources located
on their website (http://www.cdc.gov/std/training/onlinetraining.htm). Other effective behavioural
interventions are also summarized on their website (http://www.effectiveinterventions.org).
Canadian guidelines suggest an 11-step process in preventing, diagnosing, and managing STIs in the
primary care setting (13):
1. Assessing the reason for a consultation
2. Knowing about STI risk factors and epidemiology
3. Performing a brief patient history and STI risk assessment
4. Providing patient-centered education and counselling
5. Performing a physical examination
6. Selecting appropriate screening/testing
7. Diagnosing by syndrome or by organism and post-test counselling
8. Treating
9. Reporting to public health and partner notification
10. Managing co-morbidity and associated risks
11. Following up
In assessing the reason for a consultation, the Canadian guidelines present an algorithm whereby
providers can assess the risk for STIs (Figure 3).
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Figure 3: STI Risk Assessment in a Primary Care Setting
Adapted from the Canadian Guidelines on Sexually Transmitted Infections – January 2010 (Government of Canada, 2010).
The Canadian Guidelines list risk factors that are associated with an increased risk of STIs. They suggest
that the following should be asked, in addition to asking about symptoms of STIs:
 Sexual contact with person(s) known to have an STI
 Sexually active youth under age 25 years
 A new sexual partner or more than two sexual partners in the past year
 Serially monogamous individuals who have one partner at present but who have had a series of
one-partner relationships over time
 No contraception or sole use of non-barrier methods of contraception
 Injection drug use
 Other substance use, especially during sex
 Any individual who is engaging in unsafe sexual practices (sharing sex toys; oral or anal sex; sex
with blood exchange)
 Sex trade workers and their clients
 Exchanging sex for money, drugs, shelter, or food
 Homelessness
 Anonymous sex (internet, bathhouse)
 Victims of sexual abuse
 Previous STI
Common counselling topics that are recommended include advice on serial monogamy, contraceptive
advice, discussion of safer sex for youth contemplating initiation of sexual activity, acceptance of
sexuality, planning prevention (such as buying condoms, seeking testing, limiting alcohol and drug use
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prior to sexual activity), safer sex counselling (modes of transmission, risk of oral, genital and anal sex,
abstinence, mutual monogamy, barrier methods), the proper use of condoms, and motivational
interviewing techniques.
6.9.2 Abstinence
The US CDC recommends abstinence (from oral, vaginal, and anal sex) and the reduction of the number
of sex partners as a way to avoid or reduce the transmission of STIs (12).
Canadian guidelines also recommend discussion of abstinence and mutual monogamy as a component
of safer-sex counselling.
6.9.3 Male Condoms
Male latex condoms, when used consistently and correctly, are highly effective in preventing the
transmission of bacterial STIs, including chlamydia, gonorrhea, syphilis, chancroid, and Trichomoniasis
(12). In Canada, condoms are also regulated by Health Canada and are considered medical devices (320).
6.9.4 Female Condoms
Canadian guidelines note that the female condom, in the form of a polyurethane vaginal pouch is
commercially available and can be used as an alternative barrier form of STI prevention (13). Although
the manufacturer does not recommend it, some have used it for anal intercourse. US CDC guidelines
state that the efficacy for this use is unknown; Canadian guidelines suggest modifications, training, and
research are needed to address possible safety concerns, as there appears to be a higher incidence of
rectal bleeding and slippage in comparison to the male condom.
6.9.5 Topical Microbicides and Spermicides
The US CDC guidelines state that studies looking at non-specific topical microbicides for the prevention
of HIV and STIs have generally shown them to be ineffective (12). Spermicides containing N-9 should not
be used due to the increased risk of acquiring HIV and STIs. Both US and Canadian guidelines also
caution against the use of N-9 lubricated condoms due to the increased risk of HIV and STI acquisition
(12,13). Moreover, both guidelines recommend against the use of N-9 rectally.
6.9.6 Male Circumcision
Although the World Health Organization and the Joint United Nations Programme on HIV/AIDS (UNAIDS)
have recommended that male circumcision be scaled up as an effective intervention for the prevention
of HIV in countries with high HIV prevalence, predominantly heterosexual transmission and low male
circumcision prevalence (321), the US CDC guidelines have not made similar recommendations for the
US. Canadian guidelines have not recommended for or against male circumcision for HIV or STI
prevention in their latest guidelines.
6.9.7 Patient-delivered Partner Therapy (PDPT)
US CDC guidelines recommend that when the index patients indicate that their partner is not likely to
seek evaluation and treatment, PDPT, which is a form of expedited partner therapy (EPT) (12) may be
effective, where legal. EPT is giving treatment without partners seeing a health care provider.
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Canadian guidelines suggest that partner notification may be done by the patient, health care providers,
or public health authorities (13):
 Self- or patient referral: the infected person accepts full responsibility for informing partners of
the possibility of exposure to an STI and for referring them for treatment and management.
 Health care providers/public health referral: with the consent of the infected person, the health
care provider takes responsibility for confidentially notifying partners of the possibility of their
exposure to an STI (no names are ever given, even though in some relationship it may be
obvious as to who the index case is).
 Contract referral: the health care provider negotiates a time frame with the infected person
(usually 24-48 hours) to inform his or her partners of their exposure and to refer them to
appropriate services.
Canadian guidelines also discuss some barriers to partner notification including fear of physical or
emotional abuse from partner notification; fear of losing a partner; feared legal procedures; fear of revictimization on the part of sex crime victims; and anonymous partnering. Public health or health care
provider referral may be the best option for some of these perceived barriers. Canadian guidelines also
discuss in brief EPT and PDPT, but state that these novel methods are still controversial.
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6.10 Evaluation of STI Control Strategies
6.10.1 Evaluation of STI Control Strategies at the Level of Populations
Using the above described directed GoogleTM search, and within the published literature, no studies
were found that evaluated the impact of jurisdiction-wide STI control strategies (e.g., CDC, PHAC, and
provincial STI Control Strategies) and their impact on STI rates. This is not surprising, as such as a study
has a number of epidemiological and methodological challenges. A study of this nature would need to
measure STI rates before and after implementation of an entire region-wide control strategy, finding
some way to control for the almost certain reality that certain components of the strategy will already
be in operation within the region prior to the time of official strategy implementation. Further, to
ensure that another control strategy had not been adopted by the jurisdiction during the same time
period (or if it had, to find some way to control for the effect of this strategy which almost certainly will
have similar interventions). For example, Canada may be signatory to both a Public Health Agency of
Canada strategy and the World Health Organization strategy; further, provinces and territories within
Canada may also have their own strategies. These three strategies will likely have many common
elements and some differences, therefore it would be extremely complex to tease apart the relative
contribution of each strategy to the STI burden within the population.
However, an unpublished document was provided by an expert reviewer that presented an evaluation
of a specific Alberta syphilis prevention campaign (322). This campaign was undertaken in response to a
syphilis outbreak declared in 2007. The Syphilis Prevention Campaign targeted youth and young adults
age 16-24 years, and had two streams: 1) Don’t You Get It (DYGI) and 2) Plenty of Syph (POS). The aim of
both steams was to make individuals more cautious about their sexual behaviours and to encourage
testing if at risk, and included raising doubts that sexual partners may be affected by syphilis. Messages
were disseminated via multiple mediums, including television, radio and online advertisements (CTV,
ComedyNetwork, MTV, MSN, Facebook, etc.); video boards in restaurant/bar bathrooms; and posters in
restaurants/bars. Evaluation data was collected through a 10-item public survey in eight communities
across the province, primarily in bars as well as on the street (n = 996), and STI clinic nurse/manager
interviews.
Eighty-nine percent of respondents recalled seeing or hearing at least one of the advertising
components used in the campaign. There were some differences in the particular component(s) that
respondents remembered hearing or seeing when disaggregated by age, gender and geographic
location. Seventy-six percent of participants reported receiving the messages that a person could have
syphilis and not know it, and 75% knew that syphilis may not have visible symptoms. Approximately half
shared the information that they had learned from the information they learned through the campaign
(with individuals age 25-39 years being most likely to share information, and individuals over age 50
years being least likely). Among respondents that had seen/heard/visited campaign resources, the
majority did not feel that the information in the advertisements/websites made them wonder whether
they might be at risk of having syphilis (“not at all” [59%]), while 29% reported “a little” and 12%
reported “a lot”. The youngest ages (age 16-17 years) were the most likely to indicate that the
information made them wonder either “a little” (40%) or “a lot” (30%) whether they might be at risk of
having syphilis. Sixty-seven percent stated that they would be very likely to get tested if they felt they
were at risk of having syphilis, while 17% reported “somewhat likely” and 17% reported being
“somewhat likely”. Seventy-seven percent reported that they would know where to get tested if they
felt at risk of having syphilis, with a general increase with age (excepting the oldest category age 60 and
older). One-third reported still needing information about syphilis.
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Interestingly, the STI clinic nurses observed that, beginning from the launch of the campaign, there was
an increased volume in the number of people visiting STI clinics, increased numbers requesting STI
testing, and increased number of individuals requesting syphilis testing and/or confirming that STI
testing included syphilis testing. The information from the provincial laboratories also reported
increased STI testing during the campaign. Information from provincial lab labs also indicated increased
testing of STIs during the campaign.
6.10.2 Evaluation of STI Control Strategies or Guidelines at the Institutional Level
Three studies from the US were identified that explored health provider adherence to CDC treatment
guidelines, and factors associated with adherence. These studies do not evaluate the relative impact on
the presence of guidelines on STI rates however.
Swails et al. (2014) conducted a case-control study that examined adherence to the CDC treatment
guidelines among health care providers in Massachusetts (323). Data was collected by the
Massachusetts Department of Public Health Division of STD Prevention, who called providers that
ordered gonococcal tests that tested positive. These providers were asked to complete a case report
form that included identification of the treatment given. It was found that 96% were treated according
to the CDC guidelines (at that time), while 4% were not. A number of factors were found to be
significantly associated with non-adherence, although the confidence intervals were very wide: patient
penicillin or cephalosporin allergy (AOR], 8.7; 95% CI 2.6–29); private offices and health maintenance
organization (HMO) practices (AOR 16; 95% CI, 1.6–155) compared with family planning/STD clinics; and
non–high-incidence rate cities (AOR 4.3; 95% CI, 1.8–11).
In a study in Philadelphia, the Department of Public Health sent notice (via Health Alert) to local health
care providers that emphasized the preferred treatment for gonorrhea (stimulated by increasing
resistance to cephalosporins that, in 2012, led to the CDC no longer recommending cefixime and instead
recommending dual treatment with ceftriaxone plus either azithromycin or doxycycline, as first-line
treatment) (324). After this, the Department of Public Health’s STD Control Program began active
treatment surveillance for all reported gonorrhea cases, and was able to determine treatment in 92% of
the cases. It was found that 92% were given the recommended treatment, while 8% were not. Health
care providers that diagnosed two or less gonorrhea cases were more likely to treat with therapy that
was not recommended.
Hogben, Wimberly & Moore (2007) evaluated the disseminated of the CDC Control and Prevention
Sexually Transmitted Disease Treatment Guidelines, however the impact of the use of these guidelines
on STI rates is uncertain (325). Among a sample of physicians in the Atlanta area that treated patients
with STIs, 56% had a copy of the guidelines and 26% knew how to access them (among physicians who
did not treat STIs, these proportions were 25% and 30%, respectively). Half of those who had copies of
the guidelines had accessed them from the internet.
Two studies in Australia, and one study in London, evaluated the impact of introducing STI screening
guidelines/strategies. In an Australian sexual health centre, an audit was performed to examine STI
testing rates before and after the introduction of guidelines that recommended regular STI screening of
MSM (326). It was found that there was a significant increase in testing rates for most STI tests after the
guidelines, and in 2002 61% of MSM had all recommended tests within the past year.
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One study that did evaluate the impact of introducing a guideline on STI screening specifically, was
authored by Lister et al. and introduced in the section examining electronic technologies in a clinic
setting (183). Therefore, this intervention encompasses both the guideline itself, and the electronic
reminder to implement the guideline in practice. As discussed, there was a significant increase in rectal
chlamydia testing, and a significant reduction in pharyngeal chlamydia and gonorrhea testing. There was
no change about the proportion of tests that were positive. In another study in London, a HIV unit
introduced a strategy of regular serological screening for syphilis during routine follow up care. This
strategy was evaluated in the second year after it was introduced, and it was found that 90% of
individuals with a surrogate marker of having had routine follow-up blood work, done also had syphilis
serology done. There was a higher syphilis rate in those treated after the strategy was introduced
compared to those treated in the year prior (7.3 per 1000 patient years [95% CI 5.2-9.9] vs. 2.8 per 1000
patient years [95% CI 1.8-4.9).
Intervention
STI Control Strategies
and Guidelines
Behavioural
outcomes

STI
incidence/prevalence
0
Contextual considerations and comments
There is evidence of a positive impact of
guidelines on the uptake of STI screening in
studies from Australia and the UK, and some
positive impacts on knowledge from a
syphilis prevention campaign in Alberta.
Data from the US does reveal that
adherence to CDC STI treatment guidelines
seems quite high.
No evaluation of jurisdiction wide control
strategies or treatment guidelines for impact
on subsequent STI rates was found.
6.11 Conclusion
The literature on macro-level interventions, although comparatively smaller than the micro- and mesolevel literature base, contained a wide variety of policy-related interventions. It is important to note that
these interventions involved both STI-specific and non-STI specific policy, demonstrating that STIs can be
influenced by a range of factors within the environments of individuals, families and communities
(including policies related to condom use, alcohol, health care performance measures, national-level
funding, financial factors at the level of local institutions, etc.). As such, STI Control Strategies for
jurisdictions must take into account this broad milieu.
As with meso-level interventions, scale and duration are key factors to consider when evaluating macrolevel interventions. In addition, the availability of appropriate population-level measurement data (or
lack thereof) can determine what can be learned about the true impact of both meso- and macro-level
interventions. In this respect, the existence of a population-based survey that collects both behavioural
and biological outcome data is a tremendous asset.
There has been no evidence of the evaluation of STI control strategies at a population heath and or
institution level. An evaluation of these types of strategies would likely be very complex given the
various components of each strategy and how these impact the STI burden within the population.
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Although this review has identified a number of promising interventions at the meso- and macro-levels,
there is limited evaluative data that assesses both sexual behaviour and STI incidence/prevalence or
morbidity, and specifically, limited evaluative data from BC. As such, a rating of “warrants further
research” (particularly regarding biological outcomes) is associated with a number of these
interventions, and may continue to be even if they are well-designed and implemented and potentially
effective. There is the concern that effectiveness may not be able to be adequately measured in the
absence of appropriate data. What is needed in order to evaluate many meso- and macro-level
interventions, is a population-based survey that can validate changes in behaviour as well as biological
outcomes (e.g., STI incidence/prevalence, morbidity. As such, the existence of such a survey in the BCcontext, that includes self-reported behavioural and STI data, which is ideally linked to objective
biological data, would be highly advantageous to the future evaluation of programs and interventions
delivered to populations within the province.
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7.0 STI CONTROL STRATEGIES
7.1
World Health Organization
The aim of the WHO strategy is to provide an overview of STI prevention and control interventions from
a global perspective; however, many of the described activities are relevant to developed countries as
well.
Organization: World Health Organization (327)
Title: Global strategy for the prevention and control of sexually transmitted diseases: 2006-2015- Breaking the
chain of transmission.
Date of publication: 2007
Purpose/objectives: Provides a global framework for the prevention and control of sexually transmitted
infections, outlining essential elements of an effective response to the burden of infection and provides
information on key issues.
Target audience: National managers for managers for sexual and reproductive health programs; public- and
private-sector health-care providers; health ministers, policy-makers; international agencies and NGO partners;
donors.
Transmission dynamics
Understanding transmission dynamics helps in the design of STI intervention and control strategies.
According to transmission dynamics, the distribution and transmission characteristics of an STI change
over time and within/between subpopulations. Figure 4 shows a simplified description of the
relationship between subpopulations.
Figure 4: Transmission Dynamics of Sexually Transmitted Infections at the Population Level
Source: WHO. 2007. Global strategy for the prevention and control of sexually transmitted infections 2006-2015 (327)
Prevention and control interventions
STI prevention and control interventions and programs need to take into account transmission dynamics
described above. Other considerations when planning STI prevention and control programs include:
 vulnerable populations;
 behaviours or circumstances which place these populations at risk;
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

best methods to disrupt or break chains of transmission; and
how to prioritize, scale up, and sustain interventions.
Vulnerable populations
STI control and prevention strategies need to target individuals belonging to high-risk populations:
 Sex workers and their clients who have sex with regular partners;
 mobile populations;
 men who have sex with men;
 men who have sex with men and who also have sex with women;
 substance users, especially those engaged in trade of sex for drugs;
 incarcerated persons, especially juveniles;
 refugees (internal and external) and displaced persons;
 members of uniformed services, including military and police;
 tourists and recreational sex tourists; and
 victims of sexual and gender-based violence.
Adolescents need special consideration as they are at higher risk of acquiring STIs. Contributing factors
to higher risk include lack of information, skills, health-care and support during the years of sexual
development.
Promoting healthy sexual behaviour
The WHO strategy recommends providing individuals with accurate and explicit information on safer
sex, such as proper use of condoms; the importance of abstinence and the delay in onset of sexual
activity; keeping one sexual partner; and reducing multiple sexual partners.
Health education
Health education about STIs should include:
 promoting voluntary testing and counseling of both infected and uninfected people;
 encouraging individuals to openly discuss STIs and sexual behaviour with their sexual partners.
Providing condoms and other barrier methods
The WHO Strategy recommends the use of the male latex condom, and recognizes it as the single, most
effective technology available to reduce STIs.
Delivering prevention and care
According to the WHO strategy, the goal of delivering care for people with STIs is to prevent long-term
complications in those already infected and to prevent the spread of infection to their uninfected
partners, fetus, or neonate.
STI prevention and control programs should promote accessible, acceptable, and effective interventions.
Treatment should be prompt when an STI is diagnosed or suspected.
Strategies for prevention and care of STIs
Components of an effective STI prevention and control strategy prevention and control program should
include:
 Correct diagnosis by syndrome or laboratory diagnosis. Laboratory testing may not always be
convenient; waiting for results may delay treatment. Syndromic diagnosis/management is
recommended for patients presenting with consistently recognizable signs and symptoms.
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




Case finding. As STIs are often asymptomatic, WHO recommends case-finding for patients who
seek care for non STI-related reasons.
Notification and treatment of sexual partners. The WHO strategy recommends treating the
sexual partners of index patients in whom STIs have been diagnosed and treated;
Age-appropriate education and counseling to reduce or prevent further risk-taking behavior;
Providing effective treatment; and
Promoting and providing condoms with clear instructions.
Scaling up
The WHO strategy recommends scaling up small-scale prevention or pilot programs, effective in small or
limited geographical areas or populations, in order to have impact on a wider scale.
Improving information for policy and program development
 Surveillance
Recommended surveillance strategies include disaggregated case-reporting by age and sex;
assessing and monitoring STI prevalence in defined populations; monitoring anti-microbial
resistance; assessment of etiology of infections. Data should be collected for patient care,
program design and monitoring, and advocacy/resource allocation.
 Monitoring and evaluation
Progress of STI intervention and prevention programs needs to be monitored and evaluated in
order to make sure that program activities are effective. Monitoring of programs ensure that
programs are performed as planned; are on time and within budgeted resources; and determine
whether the activities are producing the expected outcome or impact
 Integration with other programs and partners
STI prevention and control activities should be integrated into other relevant public health
programs, thereby widening the coverage of interventions of the respective programs.
 Laboratory support
Effective STI control strategies require adequate laboratory support, such as defining clear
laboratory guidelines; strengthening of laboratories at national and regional levels; and where
feasible, at local levels. Figure 5 describes roles and responsibilities of laboratories at these
different levels of service.
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Figure 5: Roles and Responsibilities of Laboratories at National, Regional, and Local Levels
Source: WHO. 2007. Global strategy for the prevention and control of sexually transmitted infections 2006-2015 (327)
Priority components for immediate action
The WHO strategy recommends that strategies be implemented for which there is sufficient evidence
for impact and feasibility. The WHO strategy identifies two levels of priorities. Priority 1 activities (Table
6a) are those which have already been implemented with only modest additional human and financial
resources, but may need “scaling up” for maximum usefulness at the national level. Priority 2 activities
(Table 6b) require significantly more resources, and should be implemented when these resources
become available.
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Table 6a: Summary of Priority 1 Activities for Immediate Implementation
Priority 1 Activities
1. Build on success. Scale
up of services for
diagnosis and treatment
of sexually-transmitted
infections (use
syndromic management
where diagnostic
resources are limited).
2.
Control congenital
syphilis as a step
towards elimination.
Indicators
1(a). Proportion of primary point-of-care
sites providing comprehensive case
management for symptomatic infections.
1(b). Proportion of pregnant women with
sexually-transmitted infections at selected
healthy facilities who are appropriately
diagnosed, treated, and counselled
according to national guidelines.
2. Proportion of pregnant women aged
15-24 years attending antenatal clinics
with a positive serology for syphilis.
3.
Scale-up sexuallytransmitted infection
prevention strategies
and programmes for
HIV-positive persons.
3. Proportion of HIV-positive patients with
sexually-transmitted infections who are
given comprehensive care including advice
on condom use and partner notification.
4.
Upgrade surveillance of
sexually-transmitted
infections within the
context of secondgeneration HIV
surveillance.
5.
Control bacterial genital
ulcer disease.
6.
Build on success.
Implement targeted
interventions in highrisk and vulnerable
populations.
4(a). Number of prevalence studies
regularly conducted (at sentinel sites or in
sentinel populations) every three to five
years.
4(b). Annual incidence of reported
sexually-transmitted infections (syndromic
or etiological reporting).
5(a). Proportion of confirmed cases of
bacterial genital ulcer disease among
patients with genital ulcerative diseases.
5(b). Percentage of pregnant women aged
15-24 years attending antenatal clinics
with a positive serology for syphilis.
6(a). Health needs identified and national
plans for control of sexually-transmitted
infections, including HIV, for key high-risk
and vulnerable populations developed and
implemented.
6(b). Proportion of young people (aged
15-24 years) with infections that were
detected during diagnostic testing for
sexually-transmitted infections.
National-level Targets
1(a). 90% of primary point-of-care
sites provide comprehensive care
for people with sexuallytransmitted infections by 2015.
1(b). By 2015, 90% of women and
men with sexually-transmitted
infections at health-care facilities
are appropriately diagnosed,
treated, and counselled.
2(a). More than 90% of first-time
antenatal clinic attendees aged 1524 years screened for syphilis.
2(b). More than 90% of women
seropositive for syphilis treated
adequately by 2015.
3(a). Strategies and guidelines on
interventions for HIV-positive
patients with sexually-transmitted
infections in place by 2010.
3(b). 90% of primary point-of-care
sites provide effective care to HIVinfected patients with sexuallytransmitted infections.
4(a). At least two rounds of
prevalence surveys conducted by
2015.
4(b). Routine reporting of sexuallytransmitted infections established
and sustained over five consecutive
years by 2015.
5(a). Zero cases of chancroid
identified in patients with genital
ulcer disease by 2015.
5(b). Less than 2% of positive
syphilis serology among antenatal
clinic attendees aged 15-24 years.
6(a). By 2010, health needs,
policies, legislation, and regulation
reviewed; plans in place and
appropriately selected countryspecific targeted interventions
implemented.
6(b). At least two rounds of
prevalence surveys conducted
among groups with high-risk
behavior and among young people
by 2015.
Source: WHO. 2007. Global strategy for the prevention & control of sexually transmitted infections 2006-2015 (327)
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Table 6b: Summary of Priority 2 Activities to be Implemented when Resources are Available
Priority 2 Activities
Implement ageappropriate
comprehensive sexual
health education and
services.
Indicators
7. Percentage of schools with at least one
teacher who can provide life-skills-based
education about prevention of HIV and
other sexually-transmitted infections.
2.
Promote partner
treatment and prevention
of reinfection.
8(a). Proportion of patients with sexuallytransmitted infections whose partners(s)
are referred for treatment.
3.
Support roll-out of
effective vaccines (against
hepatitis B and human
papillomavirus and,
potentially, herpes simplex
type 2 infections).
9(a). Policy and plans for universal
vaccination against hepatitis B.
1.
4.
Facilitate development and
implementation of
universal opt-out voluntary
counselling and testing for
HIV among patients with
sexually-transmitted
infections.
9(b). Plans and policy reviews and
strategies for use of human
papillomavirus and potential herpes
simplex virus type 2 vaccines.
10. Proportion of patients assessed for
sexually-transmitted infections who are
routinely counselled and offered
confidential testing for HIV.
National-level Targets
7(a). Review of policies and
development of age-appropriate
training and information materials
for schools completed by 2007.
7(b). Increased number of
teachers trained in participatory
life-skills-based HIV education that
includes other sexuallytransmitted infections by 2015.
8(a). Plans and support materials
for partner notification developed,
and health-care provider training
in place by 2010.
8(b). The proportion of patients
who bring in, or provide treatment
to, their partners doubled by
2010.
9(a). Plans in place regarding
vaccination against hepatitis B and
human papillomavirus infection by
2008.
9(b). Pilot vaccination programs
initiated and scaling up in progress
by 2010.
10(a). HIV testing and counselling
available in all setting providing
care for people with sexuallytransmitted infections by 2015.
10(b). The proportion of patients
with sexually-transmitted
infections who receive voluntary
counselling and testing for HIV
doubled.
Source: WHO. 2007. Global strategy for the prevention and control of sexually transmitted infections 2006-2015 (327)
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7.2
England Department of Health
The framework recommends that STI intervention programs target populations at highest risk of
infection, and recommends providing people with accurate, non-biased sexual health education and
information, so that they will make informed and responsible choices.
Organization: England Department of Health (328)
Title: A framework for sexual health improvement in England
Date of publication: March 2013
Purpose/objectives: The purpose of the document is to provide an evidence base that helps improve the sexual
health of the whole population.
Target audience: Health Services Chief Executives, Medical Directors, Directors of Public Health, Directors of
Nursing.
Prevention across the life course
Individuals require age-appropriate education, information and support to promote life-long sexual
health, including STI prevention and control.
Key principles for best practices in sexual health
The framework identifies the following key principles as best practice for wider sexual health, including
STI prevention and control.






Prevention
Behaviour change. Health education must be combined with prevention interventions based on
behaviour-change theory.
Leadership
Elected health officials, health directors, etc., play a strong role in developing local sexual health
policy. Leaders should work together with community organizations and private businesses to
improve local sexual health.
Wider determinants of sexual health
Sexual health is linked to other key factors contributing to health and wellbeing, such as alcohol
and substance misuse; smoking; obesity; mental health; and violence (especially gender-based
violence). The framework recommends that efforts should be combined in addressing these
wider factors, rather than individually addressing each one.
Needs of vulnerable groups
The framework recommends that services and interventions be targeted at vulnerable groups
who are at high risk of poor sexual health.
STI prevention
The framework recommends condoms as the best way for sexually active people of any age to
avoid an STI. Other STI prevention services include providing open access services offering
efficient and confidential testing, treatment, and partner notification.
Surveillance
Accurate STI surveillance is essential for identifying and treating members of high-risk groups,
service planning, and for monitoring the effects of interventions.
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7.3
European Centre for Disease Prevention and Control
Chlamydia control in Europe, despite having a primary focus on chlamydia prevention and control
strategies, was included in this review since chlamydia is the most common bacterial STI. The prevention
and control strategies for chlamydia are applicable to other STIs.
Organization: European Centre for Disease Prevention and Control (329)
Title: Chlamydia control in Europe
Date of publication: 2009
Purpose/objectives: Guidance to about national strategies for chlamydia control in Europe; provides a framework
for developing, implementing or improving national chlamydia control in Europe.
Target audience: Developers of health policy in Europe
Essential control activities
The guidelines identify the following range of activities required for chlamydia control:
 primary prevention which includes sexual health and relationship education, focusing on young
adults;
 promotion of safer sex and condom use;
 effective diagnosis and treatment of infection;
 effective identification and treatment of partners of infected individuals; and
 active case-finding to treat and identify asymptomatic cases.
Developing chlamydia control strategies

A step-by-step strategy for chlamydia control
Chlamydia Control in Europe, suggests using a step-based approach when planning a chlamydia
control program (Table 7). The goal is to make sure that patient management infrastructure and
quality controls are in place prior to introducing community-based intervention such as
screening. Each step is graded with a letter, (A to D), according to levels of evidence associated
with each intervention.
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Table 7: Suggested Step-based Approach to Developing a Chlamydia Control Program
Source: Chlamydia control in Europe, 2009 (329)
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7.4
Department of Health and Ageing, Commonwealth of Australia
Organization: Department of health and ageing, Commonwealth of Australia (330)
Title: Second National Sexually Transmissible Infections Strategy 2010-2013
Date of publication: 2010
Purpose/objectives: To reduce the transmission of and morbidity and mortality caused by bacterial STIs and to
minimize the personal and social impact of the infections.
Target audience: Health directors/professionals responsible for health policy development, clinicians, professional
and community organizations
Guiding principles
The guiding principles behind Second National Sexually Transmissible Infections Strategy are:
 STIs can be prevented by adopting and maintaining protective behaviours. Before healthy
behaviours can be applied, education and prevention programs need to be in place.
 The framework for effective STI prevention and control activities is provided by the Ottawa
Charter for Health Promotion, which respects the human rights of vulnerable, marginalized
populations.
 Harm reduction is an important measure in preventing transmission.
 Cooperative consultation needs to underpin effective partnerships between governments,
communities, researchers, and health professionals.
Priority action areas
The strategy identifies chlamydia, gonorrhea, syphilis, and trichomonas infection as the highest priority
STI infections.
Variables affecting spread of STIs:
 risk of transmission;
 number of at-risk sexual partners of an individual; and
 period of infectiousness of a specific STI.
Elements of a comprehensive approach to STI control:
 health promotion and prevention;
 early intervention and partner notification;
 access to clinical care and support;
 surveillance and research.
Health promotion and prevention
STI prevention and control requires engaging the broader community and educating people about STIs
and their consequences.
Young people
The strategy recommends school-based sex education, focusing on risk-taking behaviours among young
people. Peer education and social marketing are also identified as effective tools in the prevention of
STIs.
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Aboriginal populations
STI prevention and control activities need to be delivered in the cultural context of Aboriginal people
when addressing this population’s health needs.
Men who have sex with men
The strategy recommends peer-based prevention and control activities.
Sex workers
The strategy recommends peer-based prevention and control activities, as well as understanding the
importance of workplace safety and marginalization among this group.
Tools for prevention
The strategy recommends water-based lubricants and condoms as the primary tool for the prevention of
STI transmission.
Partner notification
The strategy recommends urgent notification of an infected person’s partners in order to stop the chain
of transmission.
Clinical management
The use of other qualified and trained health care professionals, such as nurses, is recommended for
diagnosing and treatment of STIs. Individuals should be offered diagnostic services during their health
visits as part of preexisting programs, such as prenatal or well-person visits.
7.5
Manitoba Health/Public Health, Communicable Disease Control
Unit
Organization: Manitoba Health/Public Health, Communicable Disease Control Unit (331)
Title: Provincial sexual transmitted diseases control strategy
Date of publication: 2001
Purpose/objectives: To provide provincial leadership in the prevention of the spread of sexually transmitted
diseases; to reduce burden of STD morbidity in Manitoba by focusing on the needs of vulnerable populations.
Target audience: Government, regional health authorities, community groups
Sexually transmitted diseases prevention goals
 Condom use
Proper use of latex condoms generally blocks the transmission of most STIs during penetrative
sexual intercourse and/or oral sexual activity. Despite condom use having increased, and being
perceived as socially responsible, there are still sub-populations inconsistently using condoms,
especially young people aged 15-24 years.
 Screening and testing
Since a timely diagnosis of STIs, especially chlamydial infections, is essential for early treatment
and partner notification, the strategy recommends urine-based chlamydia testing for youth
aged 15-24 years.
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

Sexually transmitted diseases among adolescents
Serial monogamy, the usual pattern for sexual relationships among 15-24 year olds, has been
identified as a barrier to condom use, since young individuals claim that knowing their partners’
sexual history precludes them from using condoms. The strategy encourages young people to
either abstain from sex or use a latex condom.
Core groups
The guidelines identify “core groups” as being transient individuals living in urban areas;
individuals with high rates of sex partner change; and drug use. Research on STI prevention and
control must focus on identifying these core groups, and their social and sexual dynamics.
Group-specific screening may be more effective than aggressive contact tracing if a core group
can be identified geographically.
Prevention efforts
 Primary prevention
The strategy’s focus is on harm reduction, versus abstinence from high-risk behaviors, since
abstinence may not be a realistic goal for some individuals and communities. It is recommended
that parents, teachers, youth care workers, medical professionals, outreach personnel and peers
be involved in helping individuals choose lower-risk behaviours.
Sexual activity
Primary prevention strategies identified by the strategy include:
 targeting high-risk risk groups with culture and age appropriate education;
 individual and group behavioural interventions;
 peer education;
 community-based outreach;
 sexual health promotion materials in remote and or small communities;
 provincial sexual health phone lines/Websites.
Injection Drug Users (IDU)
The strategy recommends prevention interventions for IDU because of the STI risks associated
with injecting cocaine:
 needle distribution and exchange, and safe injection sites;
 safe disposal sites for used injection equipment;
 non-prosecution of personal users;
 involvement of pharmacies with needle exchange and sales; and
 public media campaigns.
School-based prevention
The strategy recommends that school-based STI prevention activities be implemented since
sexual norms are set during adolescence. Recommended interventions include:
 using peer counselors and educators;
 information that is age-appropriate and clear;
 ensuring that the audience understands risk associated with sexual behaviours;
 addressing social and media influences
 teaching interpersonal skills that focus on harm reduction; and
 allowing sufficient classroom time per school year.
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Prison-based interventions
The strategy recognizes that providing STI prevention and control activities in prisons can be a
challenge, since these interventions must occur in the context a security environment.
Research
The strategy recommends that the medical community be involved in research activities that
support STI control.

Secondary Prevention
Screening programs
The strategy recommends:
 the screening of core groups for STIs;
 standardization of education for health care professionals providing pre- and post-test
counseling;
 increased accessibility to testing;
 allowing qualified non-physician health care professionals, such as public health nurses
to order the appropriate tests; and
 testing for gonorrhea and chlamydial using nucleic amplification testing. Urine testing
could decrease psychological and physical barriers and increase access to testing.
Contact tracing
The strategy recommends contact tracing as an important means of identifying and treating new
cases of STIs. Contact tracing can prevent reinfection of the treated partner, control antimicrobial resistance, and encourage timely treatment. The strategy views contact tracing as an
important method of identifying members of core groups of infected individuals, allowing the
identification of sexual networks.
Surveillance
The strategy support strong STI surveillance activities, supported by dedicated resources and
mandatory reporting.

Tertiary Prevention
Access to treatment
The strategy identifies both barriers to accessing timely and effective treatment of STIs as well
as supportive factors. Barriers include:
 concerns regarding treatment competence by physicians;
 concerns about stigmatization;
 lack of coordination and sharing of information between service providers and the
community;
 lack of treatment support programs;
 lack of adequately funded programs;
 lack of appropriate time to implement programs.
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Supportive factors which have potential to enhance effective and timely treatment of STIs
include:
 consultation with infected and affected people regarding service delivery;
 consulting First Nations communities regarding prevention, detection, and intervention
services;
 integration of community-based services;
 changing stigma of needle exchange/condom distribution;
 “one-stop shopping” for harm reduction services;
 addressing conflicting policies, e.g., prisons and needle distribution;
 working with, not against, community groups and/or leaders.
Adherence to treatment
The strategy considers adherence to a particular treatment regimen to be dependent on several
behaviours. Some of the factors that the strategy states have a positive effect on adherence to
treatment regimens include:
 high self-efficacy;
 patient's belief in the medications;
 supportive social and community environments;
 fewer medications to take per day; and
 ability to take medication at home.
Prevention strategies and disease phase
The strategy suggests a phase-specific approach to STI prevention and control, which is
population specific and differentiates between the general population (maintenance networks)
and core groups (spread networks). The approach is summarized in Figure 6.
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Figure 6: Two-pronged Phase-appropriate STI Prevention and Control Strategy
Source: Manitoba’s Provincial Sexually Transmitted Diseases Control Strategy (August 2001) (331)
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APPENDIX A: SUMMARY OF DATABASE SEARCH RESULTS
Youth
Database(s): Ovid MEDLINE® In-Process & Other Non-Indexed Citations and Ovid MEDLINE® 1945Present
Search Strategy:
#
Searches
Results
1
youth.mp. or Adolescent/
1572736
2
Chlamydia Infections/ or Chlamydia/
13986
3
Gonorrhea/
11625
4
Syphilis/
15858
5
Lymphogranuloma Venereum/
1215
6
Sexually Transmitted Diseases, Bacterial/ or sexually transmitted
3171
infection.mp.
7
Primary Prevention/
13637
8
Secondary Prevention/
1739
9
Tertiary Prevention
80
10 Health Promotion/
50756
11 Harm Reduction
1480
12 2 or 3 or 4 or 5 or 6
41231
13 7 or 8 or 9 or 10 or 11
65612
14 1 and 12 and 13
107
Database: EMBASE
Search Strategy:
#
Searches
1
youth.mp. or Adolescent/
2
Chlamydia Infections/ or Chlamydia/
3
Gonorrhea/
4
Syphilis/
5
Lymphogranuloma Venereum/
6
Sexually Transmitted Diseases, Bacterial/ or sexually transmitted
infection.mp.
7
Primary Prevention/
8
Secondary Prevention/
9
Tertiary Prevention
10 Health Promotion/
11 Harm Reduction
12 2 or 3 or 4 or 5 or 6
13 7 or 8 or 9 or 10 or 11
14 1 and 12 and 13
Population and Public Health, Ministry of Health
Results
1312448
16939
13692
23381
1404
36802
25810
15040
43526
70090
2603
76914
148657
483
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Database: All EBM Reviews
Search Strategy:
#
Searches
1
youth.mp. or Adolescent/
2
Chlamydia Infections/ or Chlamydia/
3
Gonorrhea/
4
Syphilis/
5
Lymphogranuloma Venereum/
6
Sexually Transmitted Diseases, Bacterial/ or sexually transmitted
infection.mp.
7
Primary Prevention/
8
Secondary Prevention/
9
Tertiary Prevention
10 Health Promotion/
11 Harm Reduction
12 2 or 3 or 4 or 5 or 6
13 7 or 8 or 9 or 10 or 11
14 1 and 12 and 13
Results
75443
452
390
77
8
200
571
156
1
2887
63
965
3613
10
Database: Health and Psychosocial Instruments
No results were found
MSM
Search results using Ovid Medline.
1
Chlamydia Infections/ or Chlamydia/ or Chlamydia trachomatis
2
Gonorrhea/
3
Syphilis/
4
Lymphogranuloma venereum/
5
Sexually Transmitted Diseases, Bacterial/
6
Sexually transmitted infections.mp
7
1 or 2 or 3 or 4 or 5 or 6
8
Tertiary Prevention/ or Secondary Prevention/ or Primary Prevention/ or
prevention.mp
9
Health Promotion/
10 Harm Reduction/
11 8 or 9 or 10
12 Control.mp? or Communicable Disease Control/
13 11 or 12
14 Homosexuality, Male/ or men who have sex with men.mp
15 7 and 11 and 13 and 14
16 Limit 15 to English language
Search results using Ovid EMBASE
1
Chlamydia Infections/ or Chlamydia/ or Chlamydia trachomatis
2
Gonorrhea/
3
Syphilis/
Population and Public Health, Ministry of Health
18328
12178
16644
1299
899
5977
49340
403362
54805
1644
449416
2078158
2425817
11763
368
358
25951
15129
25050
Page 134
Core Public Health Functions for BC: Evidence Review
Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
4
5
6
7
8
9
10
11
12
13
14
15
16
Lymphogranuloma Venereum/
Sexually Transmitted Diseases, Bacterial/
Sexually transmitted infections.mp
1 or 2 or 3 or 4 or 5 or 6
Tertiary Prevention/ or Secondary Prevention/ or Primary Prevention/ or
prevention.mp
Health Promotion/
Harm Reduction/
8 or 9 or 10
Control.mp or Communicable Disease Control/
11 or 12
Homosexuality, Male/ or men who have sex with men.mp
7 and 11 and 13 and 14
Limit 15 to English language
Search results using Ovid EBM Reviews.
1
Chlamydia Infections/ or Chlamydia/ or Chlamydia trachomatis
2
Gonorrhea/
3
Syphilis/
4
Lymphogranuloma Venereum/
5
Sexually Transmitted Diseases, Bacterial/
6
Sexually transmitted infections.mp
7
1 or 2 or 3 or 4 or 5 or 6
8
Tertiary Prevention/ or Secondary Prevention/ or Primary Prevention/ or
prevention.mp
9
Health Promotion/
10 Harm Reduction/
11 8 or 9 or 10
12 Control.mp or Communicable Disease Control/
13 11 or 12
14 Homosexuality, Male/ or men who have sex with men.mp
15 7 and 11 and 13 and 14
16 Limit 15 to English language
Search using Ovid Health and Psychosocial Instruments
1
Chlamydia Infections/ or Chlamydia/ or Chlamydia trachomatis
2
Gonorrhea/
3
Syphilis/
4
Lymphogranuloma Venereum/
5
Sexually Transmitted Diseases, Bacterial/
6
Sexually transmitted infections.mp
7
1 or 2 or 3 or 4 or 5 or 6
8
Tertiary Prevention/ or Secondary Prevention/ or Primary Prevention/ or
prevention.mp
9
Health Promotion/
10 Harm Reduction/
Population and Public Health, Ministry of Health
1491
36381
6817
87555
716949
69346
2547
774503
2553605
3176766
5835
727
709
524
390
77
8
22
316
1149
46633
2887
63
48938
145193
172559
309
32
32
0
0
0
0
0
22
22
0
0
0
Page 135
Core Public Health Functions for BC: Evidence Review
Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
11
12
13
14
15
16
8 or 9 or 10
Control.mp or Communicable Disease Control/
11 or 12
Homosexuality, Male/ or men who have sex with men.mp
7 and 11 and 13 and 14
Limit 15 to English language
Population and Public Health, Ministry of Health
1830
4859
6547
65
0
0
Page 136
Core Public Health Functions for BC: Evidence Review
Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
APPENDIX B: SUMMARY OF REVIEWED STUDIES
MICRO-LEVEL INTERVENTIONS ACROSS POPULATIONS – Randomized Controlled Trials
Paper
Country
Intervention
Boyer, et al.
(2005)
US
Cognitive-behavioural
intervention on
preventing STIs and
unintended
pregnancies.
Population and Public Health, Ministry of Health
Population
Follow-up rate
Decreased risktaking behaviour
during study
Behavioural Interventions
Female marine
At first followNR
recruits
up, 80.8%. At
second followup, 64%.
Effect on STI risk
Notes
A higher proportion
of the control group
had a postintervention STI or
unintended
pregnancy (OR 1.41,
95% CI 1.01-1.98).
Among participants
with no history of
STIs or pregnancy
but who engaged in
risky sexual
behaviours, the
control group was
more likely to
acquire an STI (OR
3.24, 95% CI 1.746.03).
Page 137
Core Public Health Functions for BC: Evidence Review
Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
Paper
Country
Intervention
Population
Follow-up rate
Chacko, et
al. (2010)
US
Client-centered
motivational
behavioural
intervention to
promote seeking of
STI check-ups.
Young women
For intervention
group: 70% at 6
months, 61% at
12 months.
For standard
care group: 82%
at 6 months,
68% at 12
months
Champion
and Collins
(2011)
US
Cognitive behavioural
intervention versus
enhanced
counselling.
Abused ethnic
minority
adolescent
women
93% at 6 months
and 94% at 12
months
Population and Public Health, Ministry of Health
Decreased risktaking behaviour
during study
No significant
differences
between groups on
client-initiated
clinic visits in
response to 7 highrisk behaviours,
consistent condom
use or movement
along the stages of
change obtained at
baseline.
NR
Effect on STI risk
Notes
No effect on
number of
chlamydia and
gonorrhea episodes.
Intervention group
had fewer infections
at 0-6 months (0
versus 6.6%), 6-12
months (3.6 versus
7.8%) and 0-12
months (4.8 versus
13.2%), all p < 0.01
The intervention is
grounded in
knowledge of the
target
populations’
behaviours and
culture. The great
cost of saying “no”
to unsafe sex—the
loss of a partner—
may be greater
than the risk of
acquiring STIs,
even HIV.
Page 138
Core Public Health Functions for BC: Evidence Review
Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
Paper
Country
Intervention
Population
Follow-up rate
Crosby, et
al. (2009)
US
Brief, clinic-based
safer sex program
administered by a lay
health adviser.
Young African
American men
newly
diagnosed with
an STI
At 3 months,
74.1%.
Population and Public Health, Ministry of Health
Decreased risktaking behaviour
during study
Those receiving the
intervention were
more likely to
report using
condoms during
last sexual
intercourse (72.4%
versus 53.9%, p =
0.008). They also
reported fewer
sexual partners
(2.06 versus 4.15, p
> 0.001) and fewer
acts of unprotected
sex (12.3 versus
29.4, p = 0.045).
Effect on STI risk
Notes
Those receiving the
intervention were
less likely to acquire
subsequent STIs
(50.4% versus
31.9%, p = 0.002).
Page 139
Core Public Health Functions for BC: Evidence Review
Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
Paper
Country
Intervention
Population
Follow-up rate
DiClemente,
et al. (2004)
US
Behavioural
intervention to
reduce risk
behaviours, HIV, STIs,
and pregnancy. Four,
4 hour group sessions
were given
emphasizing ethnic
and gender pride, HIV
knowledge,
communication,
condom use skills and
healthy relationships.
African
American girls
aged 14-18
years.
At 6 months,
90%. At 12
months, 87.3%.
Population and Public Health, Ministry of Health
Decreased risktaking behaviour
during study
Participants in the
intervention arm
reported using
condoms more
consistently in the
30 days preceding
the six month
assessment (75.3%
in intervention
versus 58.2% in
control) and the 12
month assessment
(73.3% versus
56.5%). Over the
12 month period,
adjusted OR was
2.01, 95% CI (1.283.17). They also
reported more
consistent condom
use in the 6
months preceding
the 6 month (61.3
versus 42.6%) and
12 month
assessments
(58.1% versus
45.3%) and over
the entire period
(AOR 2.30, 95% CI
1.51-3.50).
Effect on STI risk
Notes
Chlamydia
infections were
reduced OR 0.17,
95% CI 0.03-0.92
over 12 months.
There were no
significant
differences in
gonorrhea or
trichomonas
infections, although
there was a trend
toward lower rates
in the intervention
group.
Page 140
Core Public Health Functions for BC: Evidence Review
Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
Paper
Country
Intervention
Population
Follow-up rate
Feldblum, et
al. (2005)
Madagascar
Female sex
workers
At 6 months,
89% in peer only.
At 6 months,
92% in peer +
clinic.
Grimley, et
al. (2009)
US
Peer education
supplemented by
individual risk
reduction counselling
by a clinician versus
condom promotion
by peer educators
only.
Brief face-to-face
behavioural
intervention.
Mostly African
American
At 6 months,
75% and 58% of
the intervention,
and comparison
group returned,
respectively.
Population and Public Health, Ministry of Health
Decreased risktaking behaviour
during study
OR for reported
condom use was
1.4 (95% CI 1.1 to
1.8).
In the intervention
group, 32%
reported consistent
condom use versus
23% in the
comparison group
(p = 0.03).
Effect on STI risk
Notes
OR for chlamydia,
gonorrhea,
Trichomoniasis and
aggregate STI were
0.7 (0.4-1.0), 0.7
(0.5-1.0), 0.8 (0.61.2) and 0.7 (0.50.9), respectively.
The combined
gonorrhea and
chlamydia incidence
declined to 6% in
the intervention
group versus 13% in
the comparison
group (p = 0.04).
Page 141
Core Public Health Functions for BC: Evidence Review
Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
Paper
Country
Intervention
Population
Follow-up rate
GuilamoRamos, et
al. (2010)
US
Parent-based
intervention
delivered to mothers
in a pediatric clinic as
they waited for their
child to complete a
physical examination.
Latino and
African
American youth.
94.6% at nine
months.
Population and Public Health, Ministry of Health
Decreased risktaking behaviour
during study
They found
statistically
significant reduced
rates of
transitioning to
sexual activity and
frequency of sexual
intercourse at ninemonth follow-up in
the control versus
intervention group
(22.2 versus 6.8%,
p < 0.05). Sexual
activity increased
from 6 to 22% for
young adults in the
“standard of care”
control group, but
remained at 6%
among young
adults in the
intervention
condition at nine
month follow-up.
Effect on STI risk
Notes
NR
Page 142
Core Public Health Functions for BC: Evidence Review
Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
Paper
Country
Intervention
Population
Follow-up rate
Harvey, et
al. (2009)
US
Health behaviour
change model
Heterosexual
couples
At three months,
83% for women,
79% of men. At 6
months, 77.7%
of women (men
were not
followed-up at
six months).
Population and Public Health, Ministry of Health
Decreased risktaking behaviour
during study
No significant
intervention effect
found among
couples at three
months or among
women at six
months.
Effect on STI risk
Notes
NR
Participants in the
intervention
condition
participated in
three weekly
sessions, each
lasting 2.5 hours.
At each session,
facilitators
provided
information and
involved
participants in
discussions to
address key
individual and
relationship
factors that
influence
increased use of
condoms. There
were other
activities on skillbased activities.
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Core Public Health Functions for BC: Evidence Review
Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
Paper
Country
Intervention
Population
Follow-up rate
James, et al.
(1998)
UK
Individually focused
counselling and skills
training intervention,
including written
materials, to receive
written materials
only, or control.
Patients at a
genitourinary
clinic.
At 4 months,
51%
Jemmott, et
al. (2005)
US
Skill-based HIV/STI
risk-reduction
intervention
African
American and
Latino
adolescent girls
At 12 months,
88.6%.
Population and Public Health, Ministry of Health
Decreased risktaking behaviour
during study
Intervention
subjects were
significantly more
likely than controls
to report carrying
condoms when
anticipating sexual
intercourse with
new partner (p <
0.05). There were
no significant
effects on levels of
knowledge about
correct condom
use, attitudes to
condoms, selfreported condom
use or incidence of
STI.
Skills-intervention
participants
reported less
unprotected sex at
12 months (mean
[SE], 2.27 versus
4.04 [0.81 versus
0.80], p = 0.03),
fewer sexual
partners (0.91
versus 1.04 [0.05
versus 0.05], p =
0.04).
Effect on STI risk
Notes
NR
Skills-intervention
participants were
less likely to test
positive for STI
(10.5% versus 18.2%
[2.9 versus 2.8%], p
= 0.05).
Page 144
Core Public Health Functions for BC: Evidence Review
Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
Paper
Country
Intervention
Population
Follow-up rate
Jemmott, et
al. (2007)
US
Brief HIV/STI risk
reduction
intervention
African
American
women
Return rates
were 91.8%,
90.2%, and
86.9% at three,
six and 12-month
follow-ups,
respectively.
Kalichman,
et al (1999)
US
A three hour
behavioural skills
building intervention
that educated
women about the
female condom,
motivating female
condom use, and
building behavioural
skills relevant to the
female condom.
African
American
women
At one month,
93%. At three
months, 90%.
Population and Public Health, Ministry of Health
Decreased risktaking behaviour
during study
Those in the skillbuilding
interventions
reported less
unprotected sexual
intercourse
(Cohen’s d[d] =
0.23, p = 0.02),
reported a greater
proportion of
protected sex (d =
0.21, p = 0.05).
Those who
received the
intervention used
the female condom
to a greater extent
than did the
control group.
Effect on STI risk
Notes
Intervention
participants were
less likely to test
positive for an STI
than control
participants (d =
0.20, p = 0.03).
NR
Page 145
Core Public Health Functions for BC: Evidence Review
Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
Paper
Country
Intervention
Population
Follow-up rate
Kamali, et
al. (2003)
Uganda
Behavioural and STI
interventions
Rural Uganda
Median followup 3.6 years per
person (cluster
randomized trial)
Kamb, et al.
(1998)
US
There were 2
interactive HIV/STD
counselling
interventions with
didactic prevention
messages typical of
current practice
Heterosexual,
HIV-negative
patients aged 14
years or older
At three months,
71%, at six
months, 70%, at
9 months, 64%,
and at 12
months, 66%.
Population and Public Health, Ministry of Health
Decreased risktaking behaviour
during study
NR
At three and six
month follow-up
visits, self-reported
condom use was
100% higher in
both the enhanced
counselling and
brief counselling
arms compared
with those in the
didactic messages
arm.
Effect on STI risk
Notes
Incidence of active
syphilis and
prevalence of
gonorrhea were
lower in the
behavioural and STI
intervention group
than in the control
group (incidence RR
for syphilis 0.52,
95% CI 0.27 – 0.98;
prevalence ratio for
gonorrhea, 0.25,
95% CI 0.10-0.64)
At 12-month followup, 20% fewer
participants in each
counselling
intervention had
new STIs compared
with those in the
didactic messages
arm (p = 0.008).
Page 146
Core Public Health Functions for BC: Evidence Review
Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
Paper
Country
Intervention
Population
Follow-up rate
Krauss, et
al. (2000)
US
Brief one session
intervention
Female partners
of male
injection drug
users
At 7 week
follow-up,
81.1%.
Marion, et
al. (2009)
US
A nurse practitioner
directed, culturally
specific, intensive
intervention
African
American
women having
past STIs
Metcalfe, et
al. (2005)
US
HIV testing and
counselling in 1 visit
with standard HIV
testing and
counselling in 2 visits.
15-39 year old
STI clinic
patients in 3 US
cities.
For intervention,
at visit 2: 63%, at
visit 3: 53%, at
visit 4: 48%. For
control, at visit 2:
76%, at visit 3:
69%, at visit 4,
58%.
99% of the rapidtest group and
69.4% of the
standard-test
group.
Population and Public Health, Ministry of Health
Decreased risktaking behaviour
during study
A higher
proportion of
women who took
pre-test
assessment
reported consistent
safer sex (66.7%)
versus those who
did not (55.6%).
The adjusted odds
ratio was 0.22 (95%
CI 0.06-0.78).
Among women
who did not take
pre-tests, 76.9%
reported consistent
safer sex versus
33.3% in the
pamphlet group.
NR
Effect on STI risk
Behaviours were
similar between
groups.
STI was acquired by
19.1% of the rapid
group and 17.1% of
the standard group
(RR1.11, 95% CI
0.96-1.29).
Notes
NR
At 15 months, the
probability of an
intervention
participant having
an STI was 20% less
than a control
participant.
Page 147
Core Public Health Functions for BC: Evidence Review
Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
Paper
Country
Intervention
Population
Follow-up rate
MorrisonBeedy, et al.
(2013)
US
Sexual risk-reduction
intervention,
supplemented with
post-intervention
booster sessions
Low-income,
urban, teenage
girls
For intervention:
84% at three
months, 86% at
6 months, 76%
at 12 months.
For control: 84%
at three months,
82% at 6
months, and 76%
at 12 months.
Patterson,
et al. (2008)
Mexico
Brief behavioural
intervention to
promote condom use
Female sex
workers
At 6 months,
81.6%
Population and Public Health, Ministry of Health
Decreased risktaking behaviour
during study
Those receiving the
sexual riskreduction
intervention
showed decreases
in total episodes of
vaginal sex and all
follow-ups, the
number of
unprotected
vaginal sex acts at
three and 12
months, and total
number of sex
partners at six
months.
Effect on STI risk
Notes
NR
The intervention
provided HIV
information,
increased
readiness to
reduce risk
behaviours, and
instructed,
modeled, and
allowed girls to
practice
interpersonal and
self-management
skills facilitating
sexual risk
reduction and
condom use. The
intervention
addressed the
concerns of girls.
The control group
consisted of
general health
promotion topics.
There were
increases in the
number and
percentage of
protected sex acts
and decreases in
the number of
unprotected sex
acts with clients (p
< 0.05).
Cumulative STI
incidence in the
intervention versus
control groups was
13.8 versus 24.92
per 100 personyears (p = 0.034), a
40% decline.
Page 148
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Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
Paper
Country
Intervention
Population
Follow-up rate
Peipert, et
al. (2008)
US
Transtheoretical
model-tailored expert
system intervention
General
population
At 24 months,
61% in
intervention
arm, 67% in
control arm.
Proude and
D’Este
115
(2004)
Australia
Brief intervention
Young adults
aged 18-25
years
68% returned
follow-up
questionnaires.
Scholes, et
al. (2003)
US
Theory-based
tailored minimal selfhelp intervention
Women aged
18-24 years
For the control
group, at 3
months: 87%,
and at six
months: 85%.
For the self-help
group, at three
months: 91%
and at six
months: 88%.
Population and Public Health, Ministry of Health
Decreased risktaking behaviour
during study
Intervention group
participants were
more likely to
report use of dual
contraceptive
methods during
follow-up (adjusted
hazard ratio, 1.7,
95% CI 1.09-2.66).
Self-reported
behaviour did not
change
significantly.
Intervention group
reported
significantly more
condom use overall
(AOR 1.86, 95% CI
1.32-2.65) and with
recent primary
partners (OR 1.97,
95% CI 1.37-2.86).
They also reported
using condoms for
a higher proportion
of intercourse
episodes, carried
condoms,
discussed condoms
with partners, and
had higher selfefficacy to use
condoms with
primary partners.
Effect on STI risk
Notes
No difference in
rates of STI.
NR
NR
Page 149
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Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
Paper
Country
Intervention
Population
Follow-up rate
Senn, et al.
(2011)
Switzerland
The two different
intervention arms
were: motivational
brief intervention (BI)
and provision of
condoms.
Travelers aged
18-44 years who
traveled
without their
regular sexual
partner
Shain, et al.
(1999)
US
Three small-group
sessions of 3-4 hours
each designed to help
women recognize
personal
susceptibility, commit
to changing their
behaviour and
acquire necessary
skills.
Mexican
American and
African
American
females with
non-viral STIs.
BI + condom
distribution
group: 66% at
two years.
Condom
distribution
group: 67% at
two years.
Standard
consultation:
66% at two
years.
At six months,
82%. At 12
months, 89%.
Population and Public Health, Ministry of Health
Decreased risktaking behaviour
during study
There was no
significant
difference among
the groups in terms
of condom use.
Effect on STI risk
NR
During first six
months, rates of
subsequent
infection versus
control group was
11.3 versus 17.2% (p
= 0.05). During the
second 6 months,
rates of infection
were 9.1 versus
17.7%, p = 0.008.
Over the entire 12
months, rates of
infection were 16.8
versus 26.9%, p =
0.004.
Notes
NR
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Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
Paper
Country
Intervention
Population
Follow-up rate
Shain, et al.
(2004)
US
Standard and
enhanced (addition
of optional support
groups) gender- and
culture-specific small
group behavioural
interventions
Hispanic
American and
African
American
women
Retention rate
was 91%.
Population and Public Health, Ministry of Health
Decreased risktaking behaviour
during study
NR
Effect on STI risk
Notes
Adjusted infection
rates were higher in
controls than in the
enhanced in year 1,
year 2, and
cumulatively (26.8
versus 15.4% (p =
0.004, 23.1 versus
14.8% p < 0.03, 39.8
versus 23.7%, p <
0.001 respectively)
and in the standard
arm (26.8 versus
15.7%, p = 0.006;
23.1 versus 14.7%, p
= 0.03, 39.8 versus
26.2% p < 0.008,
respectively).
Page 151
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Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
Paper
Country
Intervention
Population
Follow-up rate
Strathdee,
et al. (2013)
Mexico
Brief combination
interventions
Female sex
workers who
inject drugs
97% had at least
one follow-up
visit over 12
months.
Thurman, et
al. (2008)
US
Sexual Awareness For
Everyone (SAFE)
behavioural
intervention
Adolescents and
adults who were
African- or
MexicanAmerican who
had been
diagnosed with
an STI
Intervention
participation
rates were 92%
for at least one
session, 82% for
at least two
sessions, and
79% for all
sessions.
Population and Public Health, Ministry of Health
Decreased risktaking behaviour
during study
NR
Effect on STI risk
Notes
aRR for group B 0.88
(95% CI 0.40-1.94),
group C 0.38 (95%
CI 0.16-0.89), group
D 0.37 (95% CI 0.160.89), relative to
group A. HIV/STI
incidence decreased
by over 50% in the
interactive sex
intervention
compared to
didactic.
Group A: Didactic
injection risk
intervention and
didactic sexual risk
intervention
Group B:
Interactive
injection risk
intervention and
didactic sexual risk
intervention
Group C:
Interactive sexual
risk intervention
and didactic
injection risk
intervention
Group D:
interactive
injection risk
intervention and
interactive sexual
risk intervention.
Adults and teens
randomized to
SAFE intervention
had significant
decreases in highrisk sexual
behaviours.
Teens in SAFE
intervention had
lower incidence of
gonorrhea and
chlamydia at 0 to 6
months and
cumulatively (52%,
p = 0.04; 39%, p =
0.04).
Page 152
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Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
Paper
Country
Intervention
Population
Follow-up rate
Trent, et al.
(2010)
US
Brief behavioural
intervention provided
at the time of
diagnosis of pelvic
inflammatory disease
(PID)
Adolescents
aged 15 to 21
years with mild
to moderate
PID.
Intervention
group at 2
weeks: 59%.
Control group at
2 weeks: 63%.
Warner, et
al. (2008)
US
Brief STI prevention
messages in a video
shown in a high
volume clinical
setting
Attendees of a
publicly funded
STI clinic.
96% of patients
analyzed.
Wingood, et
al. (2004)
US
Behavioural
intervention
emphasizing gender
pride, maintaining
current and
identifying new
network members,
HIV transmission
knowledge,
communication and
condom use skills,
and healthy
relationships.
Women with
HIV in Alabama
and Georgia.
At six months,
92.6%. At 12
months, 85.2%
Population and Public Health, Ministry of Health
Decreased risktaking behaviour
during study
The intervention
groups had higher
rates of 72-hour
follow-up (32
versus 16%) and
partner treatment
(71 versus 53%), p
= 0.1. There were
no differences in
medication
completion, sexual
abstinence or
partner
notification.
NR
Women in the
intervention
reported fewer
episodes of
unprotected
vaginal intercourse
(1.8 versus 2.5, p =
0.022), were less
likely to report
never using
condoms (OR =
0.27, p = 0.008).
Effect on STI risk
Notes
NR
Patients assigned to
intervention had
significantly fewer
STIs compared with
control (hazard
ratio, 0.91, 95% CI
0.84-0.99)
Women in the
intervention group
had a lower
incidence of
chlamydia and
gonorrhea (OR =
0.19, p = 0.006).
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Country
Intervention
Population
Follow-up rate
Wingood, et
al. (2013)
US
Two 4-hour HIV
intervention sessions
based on Social
Cognitive Theory and
the Theory of Gender
and Power were
given.
African
American
women
72.9% at six
months and
74.7% at 12
months
Witte, et al.
(2011)
Mongolia
Enhanced
behavioural
intervention. Three
groups: a
relationship-based
HIV sexual risk
reduction
intervention (HIVSSR); the same
intervention plus
motivational
interviewing(+MI); a
control condition
focused on wellness
promotion (WC).
Female sex
workers in
Mongolia
For HIV-SSR
group: 71.4% at
two weeks,
67.4% at three
months, 67.4%
at six months.
For +MI group:
81.0% at 2
weeks, 79.3% at
three months;
81.0% at six
months.
For WC group:
72.9% at two
weeks, 72.9% at
three months,
84.8% at six
months.
Population and Public Health, Ministry of Health
Decreased risktaking behaviour
during study
Participants in the
HIV intervention,
relative to the
health promotion
intervention had
lower risk of
concurrent male
sex partners (OR
0.55, 95% CI 0.370.83).
There were
decreases among
all groups in
unprotected sex
and number of sex
acts with clients,
but the betweengroup differences
were not
significant.
Effect on STI risk
Notes
Participants in the
HIV intervention,
relative to the
health promotion
intervention had
lower risk of nonviral incident STI
(OR 0.62, 95% CI
0.40-0.96).
NR
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Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
Paper
Country
Intervention
Population
Andersen,
et al. (2011)
Denmark
Home sampling for
chlamydia
trachomatis
General
population
(men and
women)
Graseck, et
al. (2010)
US
Home-based
screening versus
clinic-based screening
Women using
long-acting
reversible
contraceptive
methods
(previously
enrolled in the
CHOICE
project).
Population and Public Health, Ministry of Health
Follow-up rate
Decreased risktaking behaviour
during study
Screening to prevent PID
100%
N/A
(populationbased health
registers)
For home-based
screening, 56%
completed
screening. For
clinic-based
screening 33%
completed
screening.
Home-based users
were more likely to
complete screening
compared to clinicbased (56.3%
versus 25.0%).
Effect on STI risk
Notes
No significant
differences between
the intervention and
control group for
PID, ectopic
pregnancy,
infertility, IVF
treatment, births or,
for men,
epididymitis.
NR
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Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
Paper
Country
Intervention
Population
Follow-up rate
Oakeshott,
et al. (2010)
UK
Chlamydia screening
and treating
Female college
students
94% at 12
months
Ostergaard,
et al. (2000)
Denmark
Home versus
conventional
sampling for
chlamydia
trachomatis
Females in
Denmark
N/A
Scholes, et
al. (1996)
US
Scholes, et
al. (2006)
US
Screening for
chlamydia
trachomatis to
prevent PID.
Chart prompts to
screen for chlamydia.
Women in a
large health
maintenance
organization
Women aged
14-25
At 12 months,
51.1% of
intervention
group, and
58.5% in control
group.
At 12 months,
76%
N/A (clinics were
randomized)
No significant
effect on testing
Population and Public Health, Ministry of Health
Decreased risktaking behaviour
during study
NR
N/A
Effect on STI risk
Notes
Incidence of PID in
screened women
was 1.3% compared
with 1.9% in
controls (RR 0.65,
95% CI 0.34-1.22).
Seven of 74 control
women who tested
positive for
chlamydia. Most
episodes of PID
occurred in women
who tested negative
for chlamydia at
baseline.
2.1% of women in
the intervention
group, and 4.2% in
the control group
had been treated
for PID (p = 0.045).
RR 0.44 (95% CI
0.20-0.90)
There is evidence
to suggest that
screening for
chlamydia at
baseline reduces
risk of PID, but
may be
overstated.
NR
Page 156
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Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
Paper
Country
Intervention
Walker, et
al. (2010)
Australia
Computer reminders
for chlamydia
screening in general
practice
Fontanet, et
al. (1998)
Thailand
Feldblum, et
al. (2001)
Kenya
Female condoms
when clients refuse
male condoms.
Establishments
randomized to two
groups-one where
only male condoms
were available and
another where male
and female condoms
were available.
Cluster randomized
trial; six intervention
sites received male
and female condoms;
the other sites only
male condoms.
Population and Public Health, Ministry of Health
Population
Decreased risktaking behaviour
during study
General
Cluster
Testing increased
population
randomized trial; from 8.3% to 12.2%
100% of control
in the intervention
clinics and 94%
group and from
of intervention
8.8% to 10.6% in
clinics.
the control group,
both p < 0.01.
Overall the
intervention group
had a 27% (OR 1.3,
95% CI 1.1-1.4)
greater increase in
testing.
Male condoms – No RCTs Reviewed
Female sex
workers
Rural Kenya
Follow-up rate
Female condoms
100% (cluster
randomized trial)
100% (cluster
randomized trial)
Effect on STI risk
Notes
NR
There was a 17%,
non-significant
reduction in
unprotected sex
acts in the
male/female
condom group.
There was a 24%,
non-significant
reduction in the
weighted geometric
mean incidence of
STIs in the sex
establishments of
the male/female
condom group.
Consistent female
condom use was
reported by 11 and
7% of intervention
site women at six
and 12 months.
There was no
significant
difference in STI
prevalence between
the two sites.
Page 157
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Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
Paper
Country
Intervention
Population
Steiner, et
al. (2006)
Jamaica
Standard clinic
condom, or a choice
of 4 different
condoms
Men with
urethral
discharge
Ramjee, et
al. (2008)
Southern
Africa
Cervical diaphragm
with lubricant gel
with condoms versus
condoms alone
Women
Choice group,
62% at
completion.
Control group,
59% at
completion.
Cervical diaphragms
Over 93%
Cutler, et al.
(1977)
?
Use of conceptrol
Women
Topical microbicides
?
Population and Public Health, Ministry of Health
Follow-up rate
Decreased risktaking behaviour
during study
No significant
difference in
condom usage
Effect on STI risk
Notes
No significant
difference in first
incidence of
chlamydia,
gonorrhea, or
Trichomoniasis
No significant
difference in the
rate of acquisition
of chlamydia or
gonorrhea.
NR
There was a
“marked degree of
protection against
reinfection with
gonorrhea in
women who used it
for 6 months after
presenting with
infection”.
Article not
available.
Page 158
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Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
Paper
Country
Intervention
Population
Follow-up rate
Kreiss, et al.
(1992)
Kenya
N-9
Women
At completion,
84%
Louv, et al.
(1988)
US
N-9
Women using
reliable forms of
birth control
At 6 months,
78%.
Population and Public Health, Ministry of Health
Decreased risktaking behaviour
during study
NR
NR
Effect on STI risk
Notes
There was a
reduced risk of
gonococcal cervicitis
(RR 0.4, p < 0.0001)
but an increased
risk of genital ulcers
(RR 3.3, p < 0.0001)
and vulvitis (RR 3.3,
p < 0.0001). There
was also a trend
toward increased in
HIV seroconversion
that was not
significant (RR 1.7,
95% CI 0.9-3.0).
Women assigned to
the N-9 group were
less likely to
become infected
with gonorrhea (RR
0.75, 90% CI, 0.580.96) and chlamydia
(RR 0.79, 90% CI
0.64-0.97).
Page 159
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Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
Paper
Country
Intervention
Population
Follow-up rate
Niruthisard,
et al. (1992)
Thailand
N-9
High-risk
women
76% in the N-9
group, and 75%
in the placebo
group
Rendon, et
119
al. (1980)
?
Suppository forms of
phenylmercuric
acetate, N-9, and
placebo
Women
56%
Population and Public Health, Ministry of Health
Decreased risktaking behaviour
during study
NR
NR
Effect on STI risk
For all cervical
infection, RR 0.75
(95% CI, 0.5-1.1). In
women who used N9 for more than 75%
of their coital acts,
the infection rate
was reduced by 40%
(95% CI, 0.3-1.0).
However the rate of
symptomatic
irritation was
increased by 70%
among N-9 users
(95% CI, 1.1-2.6).
Gonorrhea was
diagnosed in 2 of 24
women using
phenylmercuric
acetate, 4 of 24
using N-9, and 8 of
29 using placebo.
These results were
significant.
Notes
Article not
available
Page 160
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Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
Paper
Country
Intervention
Population
Follow-up rate
Richardson,
et al. (2001)
Kenya
N-9
Female sex
workers
At 12 months,
69% in the N-9
group, and 61%
in the placebo
group.
Roddy, et al.
(1998)
Cameroon
N-9
Female sex
workers
At completion,
90%
NR
Roddy, et al.
(2002)
Cameroon
N-9 versus condoms
Female sex
workers
For the control
(condoms)
group, 99%. For
the gel and
condoms group,
99%.
NR
Population and Public Health, Ministry of Health
Decreased risktaking behaviour
during study
NR
Effect on STI risk
Notes
There was a
significantly higher
incidence of
gonorrhea in the N9 group than in the
placebo group (RR
1.8, 95% CI 1.0-3.1).
No significant
differences were
observed for the
other STIs.
There were no
significant
differences in the
rate of new HIV,
gonorrhea or
chlamydia infection.
The RR for
gonococcal infection
in the gel group
versus the condom
group was 1.5 (95%
CI, 1.0-2.3) and 1.0
for chlamydia (95%
CI 0.7-1.4).
Page 161
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Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
Paper
Country
Intervention
Population
Follow-up rate
Rosenberg,
et al. (1987)
Thailand
Contraceptive sponge
High-risk Thai
women
36% in the
sponge group,
34% in the nonuser group
Van
Damme, et
al. (2008)
Three
African and
two Indian
sites
Cellulose sulfate
Women
In cellulose
sulfate group,
98%. In the
placebo group,
98%.
Mehta, et
al. (2009)
Kenya
Male circumcision
Population and Public Health, Ministry of Health
Male circumcision
Men aged 18-24 95.4% tested for
years
the 3 infections
during follow-up.
Decreased risktaking behaviour
during study
NR
NR
NR
Effect on STI risk
There were lower
risks of infection
with chlamydia and
gonorrhea (RR 0.67,
95% CI 0.42-1.07; RR
0.31, 95% CI 0.160.60), but higher
rates of Candida (RR
2.76, 95% CI, 0.967.98).
No significant
effects were found
on the rates of
gonorrhea and
chlamydia.
Notes
Trial stopped early
The incidence of
STIs did not differ by
circumcision status.
Page 162
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Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
Paper
Country
Intervention
Population
Follow-up rate
SobngwiTambekou,
et al. (2009)
South Africa
Male circumcision
Men aged 18-24
years
33% in both
groups
Tobias, et
al. (2009)
Uganda
Male circumcision
HIV negative
uncircumcised
males aged 1549 years
For the
intervention
group: at 12
months, 97.6%;
at 24 months,
88.7%. For the
control group: at
12 months,
91.9%; at 24
months, 88.7%.
Population and Public Health, Ministry of Health
Decreased risktaking behaviour
during study
NR
NR
Effect on STI risk
Notes
There were no
significant
differences in the
two groups on the
prevalence of
gonorrhea or
chlamydia or
trichomonas. But
there was a trend
toward reduced risk
of acquisition of
these STIs. The ORs
for gonorrhea,
chlamydia, and
trichomonas are
0.97 (p = 0.84), 0.58,
(p = 0.065) and 0.54
(p = 0.062),
respectively.
No significant
differences in the
incidence of syphilis
(HR 1.10, 95% CI
0.75-1.65).
Page 163
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Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
Paper
Country
Cameron, et
al. (2009)
UK
Golden, et
al. (2005)
US
Intervention
Decreased riskEffect on STI risk
taking behaviour
during study
Patient-delivered partner therapy and other forms of expedited partner therapy
PDPT versus PTK
Women testing
45% at 12
NR
There was no
(partners send in
positive for
months
significant
urine for testing)
chlamydia at a
difference in
versus standard
genitourinary
reinfection of
patient referral
medicine, family
chlamydia between
planning, and
PDPT versus patient
termination of
referral, PTK versus
pregnancy
patient referral or
clinics.
PDPT versus PTK.
Expedited partner
General
For intervention, NR
EPT was more
therapy (EPT)population
68% completed
effective than
participants in the
study. For
standard referral of
EPT group had the
control group,
partners in reducing
option to give
68% completed
persistent or
medications to their
study.
recurrent infection
sex partners or if they
among patients with
preferred, have study
gonorrhea (3 versus
staff members
11%, p = 0.01) and
contact partners and
chlamydia (11
provide them with
versus 13%, p =
medication without
0.17).
an exam.
Population and Public Health, Ministry of Health
Population
Follow-up rate
Notes
Page 164
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Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
Paper
Country
Intervention
Population
Follow-up rate
Kerani, et al.
(2011)
US
PDPT and inSPOT, a
web-based partner
notification service.
Four arms: inSPOT,
PDPT, combined
inSPOT and PDPT and
standard partner
management.
Men who have
sex with men
with chlamydia
and/or
gonorrhea.
Of the 75
enrollees, 71%
completed
baseline and
follow-up
interviews.
Population and Public Health, Ministry of Health
Decreased risktaking behaviour
during study
The number of
partners treated
per original patient
was 2.33 in the
PDPT arm and 1.52
in the non-PDPT
arms. PDPT
assignment
increased the mean
number of partners
treated per original
patient by 54%
(ratio of means
1.54, 95% CI, 1.012.34).
Effect on STI risk
Notes
NR
Page 165
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Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
Paper
Country
Intervention
Population
Follow-up rate
Kissinger, et
al. (2005)
US
Three arms: PDPT,
booklet-enhanced
partner referral, or
standard partner
referral
Men with a
diagnosis of
urethritis at a
public STI clinic.
Most (95%)
were African
American.
37.5% agreed for
follow-up
testing.
Kissinger, et
al. (2006)
US
PDPT. Those with
trichomonas were
given treatment to
give to their partner.
Women
attending a
family planning
clinic who were
culture positive
and treated for
trichomonas.
89% returned for
one follow-up
visit.
Population and Public Health, Ministry of Health
Decreased risktaking behaviour
during study
Men in the PDPT
arm were more
likely than men in
the BEPR and PR
arms to report
having seen their
partners, having
talked to their
partners about the
infection, having
given the
intervention to
their partners, and
having been told by
their partners that
the antibiotic
treatment had
been taken (55.8%,
45.6%, 35.0%,
respectively; p <
0.001).
The percentage of
women reporting
that their partners
were treated was
similar for PDPT
but significantly
lower for booklet
enhanced partner
referral compared
to standard partner
referral.
Effect on STI risk
Notes
Among those
tested, men in the
PDPT and BEPR
arms were less likely
than those in the PR
arm to test positive
for chlamydia
and/or gonorrhea
(23.0%, 14.3%, and
42.7%, respectively;
p < 0.001).
Those tested were
similar to those
not tested with
regard to the
study variables
measured.
NR
Page 166
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Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
Paper
Country
Intervention
Population
Follow-up rate
Low, et al.
(2006)
UK
Partner notification
at the general
practice immediately
after diagnosis by
trained practice
nurses with
telephone follow-up
by a health advisor or
referral to a specialist
health advisor at a
genitourinary
medicine clinic.
General
population
Intervention
group: 73.6%
Control group:
75%
Lyng and
Christensen
(1981)
NR
Single dose tinidazole
to sexual partner or
placebo to sexual
partner for patients
with positive
trichomonal cultures.
NR
89%
Population and Public Health, Ministry of Health
Decreased risktaking behaviour
during study
A total of 65.3% of
participants
receiving practice
nurse led partner
notification had at
least one partner
treated compared
with 52.9% of
those referred to a
genitourinary
medicine clinic
(Risk difference
12.4%, 95% CI 1.8% to 26.5%).
NR
Effect on STI risk
Notes
NR
Conclusion is that
practice based
partner
notification by
trained nurses is
at least as
effective as
referral to
specialist health
advisor at
genitourinary
medicine clinic.
Relapse rate with
tinadazole-treated
partner was 5.1%
and with placebotreated partner was
23.7% (p = 0.01).
Thus there is a 78%
reduction in the
relapse rate.
Page 167
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Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
Paper
Country
Intervention
Population
Follow-up rate
Nuwaha, et
al. (2001)
Uganda
Patient-based partner
referral (PBPR)
compared with
patient-delivered
partner medication
(PDPM)
Patients
attending an STI
clinic in
Kampala,
Uganda
NR
Schillinger,
et al. (2003)
US
PDPT with
azithromycin by
females with
chlamydia to male
sex partners
General
population
A total of 81%
returned for at
least one followup visit.
Population and Public Health, Ministry of Health
Decreased risktaking behaviour
during study
For women, in the
PDPM group, 86 of
103 partners were
treated, compared
with 23 of 104
partners in the
PBPR group (RR
4.55, 95% CI 2.927.08, p < 0.001).
For casual partners,
18 of 51 were
reported treated in
the PDPM group,
compared with
only 3/45 partners
in the PBPR group
(RR 1.43, 95% CI
1.40-2.65; p <
0.01).
NR
Effect on STI risk
Notes
NR
Risk of reinfection
was 20% lower
among women in
the PDPT arm (12%)
than among those in
the self-referral arm
(15%). This was not
statistically
significant (OR 0.80,
95% CI 0.62-1.05).
Page 168
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Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
Paper
Country
Intervention
Population
Follow-up rate
Schwebke
and
Desmond
(2010)
US
Self-referral of
partners (PR),
patient-delivered
partner therapy
therapy (PDPT) or
public health disease
intervention (DIS)
locating partners and
delivering
medications in the
field.
Females and
partners
diagnosed with
Trichomoniasis
40% at 3 months
Decreased risktaking behaviour
during study
NR
Effect on STI risk
Notes
No significant
difference in
repeated infection
rates when PDPT or
DIS were compared
to the reference of
PR. However, when
PDPT was compared
to DIS or PR/DIS
combined at one
month, the PDPT
group had lower
repeat infection rate
(5.8 versus 15% and
5.8 versus 12.5%,
respectively).
MICRO-LEVEL INTERVENTIONS ACROSS POPULATIONS – Non-RCTs
Paper
Country
Intervention
Population
In-iw, et al.
(2012)
US
Health
education
counselling
Adolescents
Laughon, et
al. (2011)
US
Brief nursing
intervention
Battered
women
Population and Public Health, Ministry of Health
Study type
Decreased risktaking behaviour
during study
Behavioural interventions
Retrospective
NR
cohort study
Pre-post
intervention
Number of safer
sex behaviours
increased from
baseline to
follow-up,
although not
statistically
significant.
Effect on STI risk
Those having health education
counselling were less likely to
having recurrent STI (adjusted
OR 2.24, p = 0.041).
N/A
Notes
The authors note a
small sample, lack of
a control group and
no randomization in
this study, although
the intervention
shows promise.
Page 169
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Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
Paper
Country
Intervention
Population
Study type
Ulibarri, et
al. (2012)
Mexico
Brief
behavioural
intervention
promoting
condom use
Female sex
workers
Pre-post
intervention
Ahmed, et
al. (2001)
Uganda
Male condom
General
Ugandan
Cohort
Crosby, et
al. (2003)
US
Male condoms
African
American
females
aged 14-18
years
Cohort/Survey
N/A
Ness, et al.
(2004)
US
Male condom
use
African
American
females
Cohort study
NR
Population and Public Health, Ministry of Health
Decreased risktaking behaviour
during study
The intervention
decreased the
mean number of
sex acts with
clients, and the
mean number of
sex acts with
clients in the
following month
(86.6 to 77.4, and
32.3 to 14.5,
respectively).
Male condom
N/A
Effect on STI risk
Notes
NR
Consistent condom use
reduced syphilis (OR 0.71, 95%
CI 0.53-0.94),
gonorrhea/chlamydia (OR
0.50, 95% CI 0.25-0.97).
The RR for non-consistent
condom use, compared with
consistent condom use for
acquiring chlamydia,
gonorrhea, or Trichomoniasis
was 1.69 (95% CI, 1.16-2.46).
RR of 0.5 (95% CI 0.3-0.9) for
consistent condom users.
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Country
Intervention
Population
Study type
Sanchez, et
al. (2004)
Peru
Male condoms
Female sex
workers
Cohort/survey
Dokkum, et
al. (2012)
Netherlands
Gold, et al.
(2011)
Australia
Text messaging
(SMS)
reminders for
chlamydia
screening
Text messaging
for sexual
health
promotion
Population and Public Health, Ministry of Health
General
population
aged 16 to
29 years
General
population
aged 16-29
years
Decreased risktaking behaviour
during study
NR
New Technologies
Pre-post
N/A
intervention
Pre-post
intervention
N/A
Effect on STI risk
Notes
Reported consistent condom
use is associated with a
statistically significant 62%
reduction in risk of acquiring
gonorrhea and 26% reduction
in risk of acquiring chlamydia.
Proportion of invitees
returning a sample increased
significantly from 10 to 14%
after email/SMS reminders.
Increase in knowledge (p <
0.01) and STI testing (p < 0.05)
over time in both males and
females.
Eighteen percent
withdrew from
receiving the text
messages and only
40% completed the
follow-up survey.
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Country
Intervention
Population
Study type
Ehlman, et
al. (2010)
US
Internet-based
Partner
Notification
(IPN) program
for early
syphilis
infections
General
population
who met sex
partners
online
Crosssectional
Jones, et al.
(2012)
US
Facebook site
that addresses
the signs,
symptoms,
treatment,
screening and
prevention of
chlamydia
infection
Young adults
aged 15 to
24 years.
Descriptive
pilot study
Population and Public Health, Ministry of Health
Decreased risktaking behaviour
during study
N/A
Effect on STI risk
Notes
From 361 early syphilis
patients, a total of 888 sex
partners were investigated, of
which 381 (43%) were via IPN.
IPN led to an 8% increase in
the overall number of syphilis
patients with at least one
treated sex partner, 26% more
sex partners being medically
examined, and treated if
necessary, and 83% more sex
partners notified of their STI
exposure.
The authors used the
US CDC Disease
Investigation
Specialist disposition
codes. If patient with
syphilis only provided
internet-locating
information for
partner, the partner
was sent an email.
(Email was also used
if partner could not
be notified using
traditional means.)
There was a 23%
self-reported
increase in
condom
utilization.
There was a 54% reduction in
positive chlamydia cases
among 15-17 year olds.
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Paper
Country
Intervention
Population
Gottlieb, et
al. (2013)
US
Screening and
treating
chlamydia
trachomatis
genital
infection to
prevent PID
Young
women
Hollier and
Workowski
(2005)
US
Treatment of
STI in
pregnancy
Pregnant
women
Obiero, et
al. (2012)
Multinational
Topical
microbicides
Population and Public Health, Ministry of Health
General
population
Study type
Decreased risktaking behaviour
during study
Screening
Systematic
N/A
review
Effect on STI risk
Notes
N/A
Review
N/A
Authors conclude that
data from RCTs offer
evidence that
chlamydia screening
and treatment is an
important and useful
intervention to
reduce the risk of PID
among young women.
However, the
magnitude of the
benefit may have
been overestimated.
This is a review
looking at the
diagnosis and
treatment of various
STIs in pregnancy to
prevent vertical
transmission.
N/A
Topical microbicides
Systematic
NR
review
There was no evidence of an
effect of any microbicide on
the acquisition of gonorrhea,
syphilis, condyloma
cuminatum, trichomonisasis or
HPV.
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Country
Intervention
Stephens,
et al.
(2009)
US
Patientdelivered
partner
therapy
Steenbeck
(2004)
Canada
Health
promotion
Population
Decreased riskEffect on STI risk
taking behaviour
during study
Partner notification and patient-delivered partner therapy
General
Program
NR
Adjusted RR was 0.99 (95% CI,
population
evaluation
0.86-1.14) for chlamydia
reinfection and 0.90 (95% CI,
0.72-1.11) for gonococcal
reinfection.
Aboriginal
youth
Study type
Aboriginal
Review
NR
NR
Notes
This paper outlines
three strategies in STI
prevention that
holistic health nurses
can use.
MESO- LEVEL INTERVENTIONS ACROSS POPULATIONS
Paper
Population
NIMH Collaborative
HIV/STD prevention
Trial Group (2010)
High-risk populations
in China, India, Peru,
Russia and Zimbabwe
Chin et al. (2012)
Adolescents
Jemmott et al.
(2007)
African American
Women
Population and Public Health, Ministry of Health
Intervention
Results
Social diffusion
Community Popular Opinion
No significant differences in chlamydia incidence were found between
Leader (C-POL) intervention
intervention and control venues in any of the four countries, nor for
trichomonas incidence in women in any of the three countries. Significantly
decreased rates of HSV-2 among the intervention venues in China (average
difference -1.26, p=0.012 across venues) and Russia (-1.50, p = 0.016) but
this was not observed in the other three countries (note however that there
were a low number of incident cases of HSV-2 in most countries).
Comparison of gonorrhea and syphilis between intervention and control
venues were not performed due to low incidence rates in all countries.
Note that there were high response rates (84.4% at 12-months and 82.0% at
24-months for interviews, and 74% for HIV/STD testing at baseline, 12- and
24-months).
Group education:
Meta-analysis demonstrated that comprehensive risk-reduction.
-risk reduction
interventions resulted in 31% of STI prevalence (risk ratio [RR] = 0.69)
-abstinence
Conclusions could not be drawn re: abstinence education.
“Sister-to-Sister: The Black
Individual and group skill-building arms in RCT had lower likelihood of
Women’s Health Project”
testing positive for a STD than control participants at 12 months.
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Population
Cohen et al. (1999)
High school students
Nsuami & Cohen
(2000)
High school students
Low et al. (2013)
High school students
Steen et al. (2000)
Female sex workers
and miners in South
African mining
community
Ramos et al. (2006)
Sex workers in the
Philippines
Population and Public Health, Ministry of Health
Intervention
Results
Outreach – screening
School-based screening
With repeated testing, the chlamydia prevalence among boys significantly
decreased to half of what was observed in comparison schools (3.2% vs.
6.4%), while among girls, chlamydia prevalence decreased to a smaller
degree and was not significant (10.3% vs. 11.9%).
School-based screening
Chlamydia infection at first test among students who tested more than once
was 1.8% for males and 7.7% for females. Among students tested more than
once, no significant difference in chlamydia prevalence was associated with
repeat screenings. Incidence rates per 1000 person-months were 4.3 (2.2,
males; 7.1, females).
School-based screening
Chlamydia positivity initially declines slightly in women, and remained stable
in men, then in 1998-1999 positivity increased, then was stable again from
1999-2000 onwards for both genders.
Presumptive treatment
Presumptive treatment
Baseline prevalence of chlamydia and/or gonorrhea was ~25%. At the first
monthly follow-up visit, prevalence declined to 12.3% (69% follow-up).
At baseline 12.3% of the women had genital ulcer disease, and this declined
to 4.4%.
Among miners, baseline prevalence of chlamydia and/or gonorrhea was
10.9%, which significantly decreased to 6.2% at the 9-month follow-up
assessment; while the prevalence of genital ulcer disease significantly
decreased from 5.8% to 1.3%.
Presumptive treatment
PT for BSW (brothel-based sex workers) and SSW (street): BSW baseline
prevalence of chlamydia and/or gonorrhea 52%, which decreased to 27% at
one month post-presumptive treatment, and 23% after seven months.
Among SSWs, the baseline prevalence was 41% and this decreased to 25% at
one month and then was 28% at seven months.
No PT for RSW (registered) and guest relations officers (GRO): RSWs
baseline, one month and seven month prevalence was 36%, 26% and 34%,
respectively; while among GROs the proportions were 20%, 6%, 24%,
respectively.
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Rekart et al. (2003)
Population
Primarily heterosexual
outbreak in DTES,
Vancouver
Rekart et al. (2005)
De Walque et al.
225
(2012)
Males and females
age 18-30 years in
largely rural villages in
Tanzania.
Intervention
Mass targeted syphilis
treatment
Results
Syphilis rates significantly decreased up to the six month point, rates
increased in 2001 to a higher level than expected.
At one year, no significant differences between the diagnosis of syphilis,
gonorrhea or chlamydia between participants (approached to participate in
mass treatment, irrespective of whether they did or not) and nonparticipants (syphilis 7% vs. 4%; chlamydia 8% vs. 6%; and gonorrhea 2% vs.
2%).
Conditional cash transfers
Intervention arm 1: High
After controlling for numerous demographic variables as well as baseline STI
conditional cash transfers
status, compared to the control group, although there were not significant
Intervention arm 2: Low
differences in the combined prevalence of the four bacterial STIs at 4- and 8conditional cash transfers
months, at the 12-month point there was a significantly decreased
Control: no cash transfers
combined prevalence for the high cash transfer group (RR 0.73, 95% CI 0.470.99), but not for the low cash transfer group (1.06 (95% CI 0.75-1.38).
Outcome: combined
prevalence of chlamydia,
gonorrhea, trichomonas and
Mycoplasma genitalium, by
objective testing.
MACRO-LEVEL INTERVENTIONS ACROSS POPULATIONS
Paper
Population
Hanenberg et al.
(1994)
Zhongdan et al.
(2008)
Sex trade workers and male clients in
Thailand
Sex trade workers in China
Sopheah et al.
(2008)
Sex trade workers in Cambodia
Population and Public Health, Ministry of Health
Intervention
100% Condom Use Program
100% CUP
100% CUP
100% CUP
Results
Cases of the five major STIs decreased by 79% in men.
Chlamydia prevalence initially increased to 30.4% at 6months, then declined to 14.5% at 15-months, then
increased to 24 % at 21-months. Gonorrhea was not
reported, and syphilis counts were very low [11/170
(6.5%) at baseline; 0/85 at 12 months and 3/102 (2.9%)
at 21 months).
Prevalence of each STI in 2005 was significantly lower
than in 1996, but essentially the same as prevalence
observed in 2001 (year of the policy implementation).
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Population
Reza-Paul et al.
(2008)
Female sex workers in India
Mainkar et al.
(2000)
Female sex workers in India
Kerrigan et al.
(2006)
Kang et al. (2013)
Sirotin et al.
(2010)
Intervention
Community mobilization
Community mobilization and peermediated outreach, increased
access to and promotion of
utilization of sexual health services,
and creating enabling environment
to support the program.
Avahan program
Results
STI prevalence significantly decreased: syphilis 25% vs.
12%; chlamydia 11% vs. 5%; gonorrhea 5% vs. 2%; and
trichomonas 33% vs. 14%.
Significant declines in syphilis, chlamydia and gonorrhea
occurred: syphilis 15.8% to 10.8%; chlamydia 8% to 6.2%;
gonorrhea7.4% to 3.9%.
Community mobilization and policy integrated interventions
Female sex workers in Dominican
Community solidarity combined
Significant decrease in the proportion of individuals with
Republic
with elements of the Thailand 100% one or more STIs (gonorrhea, Trichomoniasis, chlamydia)
CUP adapted to Dominican
in the combined intervention site only (28.8% to 16.3%;
Republic context
OR 0.50, 95%CI 0.32,0.78). Change in STI prevalence in
the site with the community mobilization intervention
only was from 25.% to 15.9%, but this change was nonsignificant.
Female sex workers in China
100% condom promotion,
Prevalence of syphilis 0.17% among the intervention
community solidarity, activities to
group vs. 1.89% among control group (OR 11.1, 95% CI
reduce stigma and discrimination,
2.7, 46.1).
outreach education to promote
risk-related behaviour change and
promote health care seeking, etc.
Sex trade workers
Population and Public Health, Ministry of Health
Sex trade workers registration
Registration
Registered sex workers were significantly less likely than
unregistered sex workers to test positive for gonorrhea
(4% vs. 12%), syphilis (18% vs. 40%), or any STI (33% vs.
53%); but the prevalence of active syphilis and chlamydia
were similar. But after adjusting for other cofounders
associated with registration, registration was not found
to be associated with the lower risk for a positive STI test.
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Population
Chesson &
Harrison (2000)
Carpenter (2005)
Sen & Luong
(2008)
Scribner et al.
(1998)
Cohen et al.
(2006)
Shafer et al.
(1993)
Youth and young adults
Residents of LA neighbourhood postcivil unrest
Male youth in a youth detention
center (n = 414).
65% African American
Cross-sectional study
Population and Public Health, Ministry of Health
Intervention
Alcohol policy
Alcohol taxes
Zero Tolerance drunk driving laws
for underage individuals
Higher beer prices in Canadian
provinces
Alcohol outlet density in New
Orleans
Alcohol units closure post-civil
unrest
STI
All participants asked whether they
ever had a STD, and 65% tested for
chlamydia and gonorrhea (urethral
culture), syphilis (serology),
hepatitis B (serology), or genital
warts (clinical examination).
Alcohol
Quantity and frequency of standard
drinks consumed in past 3 months.
Results
$1 increase in the per-gallon liquor tax is associated with
a decline in gonorrhea rates by 2.1%.
A $0.20 per six-pack increase in the beer tax is associated
with a decline in gonorrhea rates by 8.9%.
Adoption of a Zero Tolerance Law is associated with a
significant reduction in gonorrhea rates among 15-19
year old white males in particular (with no effect for
older males, or black individuals, and mixed effects for
white females).
Higher beer prices are correlated with a reduction in
chlamydia and gonorrhea rates.
A 10% increase in off-sale alcohol outlet density accounts
for a .8% increase in gonorrhea rates.
After the 1992 civil unrest in LA, one unit decrease in
alcohol outlets per mile of roadway was associated with
21 fewer cases of gonorrhea per 100,000 in affected
tracts vs. unaffected tracts.
Compared with youth who did not drink:
Youth reporting daily drinking (13% of the sample)
significantly more likely to have a current or past STD (OR
3.53; 95% CI, 1.61–7.2).
Youth reporting heavy drinking (>20 drinks/week) had
increased risk of STD (OR 2.23; 95% CI, 1.08–4.62) – this
when controlling for lifetime number of sexual partners
and low condom use.
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Erickson & Trocki
(1994)
Population
Data from the 1990 National Alcohol
Survey (probability sample of adults in
48 States, men n = 882, women n =
979).
Ellen et al. (1996)
Heterosexual men and women (n =
1442) attending
public STD clinics in three cities in the
US.
-61% male
-70% African American
-More than 25% current users of crack
cocaine.
Zhang et al.
(1996)
Cross-sectional study.
Women >25 years who attended
cervical cancer screening program in
China between 1974-1985 (n =
16,797).
Cohort study
Population and Public Health, Ministry of Health
Intervention
STI
Survey question: “have you ever
had a sexually transmitted
(venereal) disease (for example,
syphilis, gonorrhea, genital herpes,
genital warts, chlamydia)?”
Alcohol
Alcohol assessment questions
included binge drinking (5 or more
drinks in 1 sitting on at least a
weekly basis over the past year)
and problem drinking (having 3 or
more of 8 major symptoms
associated with alcohol abuse or
dependence).
STI
Laboratory and clinical assessments
for gonorrhea and syphilis.
Alcohol
Self-report: how often they were
drunk from alcohol during sex in
the prior 3 months.
Results
Binge drinking was associated with increased risk of STD
in men, which did not remain significant during
multivariate analysis, and no increased STI risk in women.
Having >3 symptoms of drinking associated with an
increased risk of STD in both men and women and this
remained during multivariate analysis.
STI
Trichomonas identified by Pap
smears and baseline and every 2
years (average 3.5 screenings per
woman).
Alcohol
Number of drinks per week (0, 1–9,
10 or more) and the number of
years of drinking (0, 1–9, 10 or
more).
Compared with women who did not drink at baseline, the
RR of incident trichomonas infection was significantly
higher among women who drank 1-9 drinks per week
[1.7 (95% CI, 1.30–2.23)] but not among those who drank
>10 drinks per week [0.69 (95% CI, 0.22–2.15)].
Men who reported being drunk before sex were more
likely to be diagnosed with gonorrhea (OR, 1.14; 95% CI,
1.02–1.29), but this result did not remain significant
during remain significant in multivariate analysis. No
relationship between being drunk during sex and syphilis
among men, or for gonorrhea or syphilis among women.
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Chokephaibulkit
et al. (1997)
Wilson et al.
(1998)
Population
Pregnant youth in Tennessee. Cases
had been diagnosed with chlamydia
infection (culture) at first prenatal visit
(n = 67); controls of similar age and
socio-economic status had first
prenatal visit on same day, but were
not infected (n = 53).
Case control study
Women from clinical and communitybased settings in Brooklyn (19901994), n = 677.
232 had HIV.
86% African American.
Intervention
STI
Chlamydia infection diagnosed by
culture.
Results
No significant difference in the prevalence of alcohol
abuse between cases (33%) and controls (39%).
Alcohol
Questionnaire assessed for ‘alcohol
abuse’, but details not provided.
STI
Tested for chlamydial and
gonococcal infections using cervical
culture, and trichomonas infection
using vaginal culture at baseline
and every 6 months.
When assessing whether there was an increased risk of a
new STD with consecutive levels of alcohol consumption,
the result was not statistically significant
(RR, 1.09; 95% CI, 0.97–1.22).
Cohort study
Miranda et al.
(2000)
Women in prison in Brazil (n = 121)
Ross-sectional study
Population and Public Health, Ministry of Health
Alcohol
Self-reported: number of times
drank alcohol per week in a 1-year
period (measured on a 7-point
scale ranging from “never” to
“more than 4 times a day”).
STI
Gonorrhea (cervical culture),
chlamydia (enzyme-linked
immunosorbent assay), syphilis
(Venereal Disease Research
Laboratory [VDRL] screening with
confirmation), and trichomonas
(vaginal wet mount).
Alcohol
Survey that assessed whether the
woman had “ever abused alcohol.”
“Ever abusing alcohol” was significantly associated with
syphilis infections only (OR, 2.0; 95% CI, 1.1–5.5), but not
with the other STIs.
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Mehta et al.
(2001)
Population
Male and female emergency
department patients in Baltimore;
presenting for medical treatment of
any type. Note that the analysis was
limited to participants aged 18-31
years.
Miller et al.
(2001)
Aboriginal males and females aged 12
to 40 years who were seen at least
twice between 1996-1998 for STD
testing at any of 9
public clinics in Australia (n = 1034).
Thomas et al.
(2001)
Men and women enlisted in the US
Navy in California (n = 299).
Intervention
STI
Urine sample used to test for
gonorrhea and chlamydia using
ligase chain reaction
(LCR).
Alcohol
4 CAGE questions (a screening test
for alcohol abuse and dependence).
STI
Laboratory testing for chlamydial
and gonococcal infections (using a
urine-based polymerase chain
reaction assay) and syphilis
(serology).
Alcohol
Alcohol abuse was defined as
“binge drinking or regular heavy
use” according to Aboriginal health
workers.
STI
Chlamydia testing by a urine-based
LCR assay.
Cross-sectional
Reitmeijer et al.
(2005)
Denver neighbourhood residents and
non-residents
Population and Public Health, Ministry of Health
Alcohol
Problem drinking was defined as
“consuming alcohol until you
passed out or vomited”
within the previous 30 days.
Fees and funding
Co-payments (clinic fee $15 for
residents and up to $65 for nonresidents).
Results
There were two alcohol questions that were associated
with an increased risk of STD in men: “ever been annoyed
by others criticizing your drinking” and “ever had a drink
first thing in the morning,” but only the latter question
remained significant in multivariate analysis. None of the
alcohol questions were associated with STDs in women.
Persons with alcohol abuse were significantly more likely
to have an incident gonococcal
infection (RR, 1.46; P = 0.007), but there was no
significant association with chlamydial infections
(RR, 1.18; P = 0.28) or syphilis (RR, 0.63; P = 0.42).
The prevalence of chlamydia among women who
engaged in problem drinking, compared to those who did
not, was 21.4% vs. 4.6% (OR 6.6, 95% CI, 1.6–27.8) after
adjusting for current pregnancy.
In addition to decreased clinic visits, chlamydia diagnosis
decreased by 28.1% (women and individuals under the
age of 20 years were disproportionately affected [40%
and 42%, respectively]). 38.1% fewer gonorrhea
diagnosis. Among MSM, gonorrhea diagnosis decreased
by 40%, while early syphilis diagnoses increased by 8.8%
(from 34 to 37 cases).
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Chesson &
Owusu-Edusei, Jr
(2008)
Population
Residents of US states
Intervention
Federal funding for STI elimination
Results
Greater amounts of state-level funding for syphilis
elimination in a given year were associated with lower
state-level syphilis rates in subsequent years.
INTERVENTIONS FOR YOUTH
Paper
Crosby et al.
31
(2003)
Population
Sexually active African American female
youth age 14-18 years (n = 217) from lowincome neighbourhoods. Youth that tested
positive at baseline for a STI were treated.
Population and Public Health, Ministry of Health
Methods
Parental monitoring
Prospective cohort study – 18-month
period. STIs (gonorrhea, chlamydia and
trichomonas) identified through selfcollected vaginal swab specimens.
STIs tested at baseline, and three
subsequent points during the study
period: 6-, 12- and 18-months.
Parental monitoring assessment through
questionnaire with Likert scale, asking:
how often parents/parental figures knew
were they were when they were not at
home or at school; and how often
parents knew whom they were with
when not at home or school.
Adjustment for baseline STI prevalence.
Results
Youth that perceived that parental monitoring was
infrequent at baseline were significantly more likely
to acquire chlamydia (AOR 1.8 [95% CI, 1.01-3.21])
or Trichomoniasis (AOR 2.4 [95% CI 1.22-4.87])
compared to youth that perceived greater levels of
monitoring. During 18-month follow-up, youth that
perceived that parental monitoring was infrequent
were significantly more likely to test positive for a
STI (AOR 2.1 [95% CI 1.16-3.74]).
Association only, no intervention.
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Paper
Crosby et al.
(2002)44
Population
Pregnant African American females age 1420 years that were sexually active in the past
2 months, in an urban area in the southern
US
Downs et al.
(2004)72
Adolescent girls in an urban setting (n = 300)
Østergaard
et al. (2000)
64
Highschool students; intervention group (n =
867), control group (n = 833).
Population and Public Health, Ministry of Health
Methods
Sexual risk behaviours were assessed
through interview.
Perceived family support was assessed
by survey, and included questions about
the receipt of emotional support, family
efforts to help, and being able to talk
about problems.
Mother-daughter communication was
assessed by survey, and included
questions about having discussions
about sex, prevention of HIV/AIDS, and
prevention of STIs.
STI history was assessed by survey. Urine
samples were collected for STI testing.
Electronic technologies
RCT
Intervention: Interactive video
Control condition 1: The same content in
book form
Control condition 2: Brochures
These 3 initiatives delivered at baseline,
plus booster sessions at 1, 3 and 6
months.
Home-based testing
Intervention group: tested for chlamydia
by home sampling.
Control group: tested in a physician’s
office.
Results
At baseline, 51.2% of participants reported a past
STI; 45% of these participants reported being
treated for a STI within the past 6 months. Only less
frequent mother-daughter communication about
the prevention of AIDS was associated with selfreported STIs, as was not residing with a family
member/relative. Low perceived family support
was not found to be significant, nor was less
frequent communication about STI prevention or
less frequent discussion about sex.
Adolescents in the intervention arm were
significantly less likely to report having been
diagnosed with a STI. Chlamydia diagnostic tests
(PCR assay of chlamydia trachomatis)
demonstrated a non-significant trend in this
direction.
At one year, 2.9% of the intervention group had
new chlamydial infection, compared to 6.6% of the
control group (p = 0.026). Significantly fewer
women in the intervention group reported being
treated for PID compared to the control group
(2.1% vs. 4.2%, p = 0.045).
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Paper
Cook et al.
(2007)63
Østergaard
et al. (1998)
67
Lonczak et
al. (2002)24
Population
Females age 15-24 years who had a recent
STI (chlamydia, gonorrhea or Trichomoniasis)
or had certain risk factors including age <20
years, African American, monthly douching,
>1 sexual partner in the past year or living in
a neighbourhood with higher chlamydia
rates (n = 403); 70% of the sample was
African American.
Results
71% of the intervention group returned at least one
home test, and 10% of tests were positive for
chlamydia and/or gonorrhea. Although significantly
more chlamydia and gonorrhea tests overall were
completed per year by the home testing group
(1.94 vs. 1.41 test per women-year, p <0.001), and
more specifically asymptomatic tests (1.18 vs. 0.7
tests per woman-year, p<0.001), there was no
significant difference in the incidence rate of STIs
detected overall (20.4 vs. 24.1 infections per 100
woman-years, p = 0.28) as well as when
disaggregated for chlamydia or gonorrhea.
17 highschools in Denmark
RCT
Intervention arm had significantly higher testing
Intervention arm: home sampling
rates: females - 93.4% tested vs. 7.6% in the control
Control arm: usual testing (i.e., students
arm (p < 0.001); males - 97.3% vs.1.6% (p < 0.001).
were offered testing at their doctors or
Among females, 4.6% chlamydia positivity vs. 0.6%
at the local clinic)
in control group (p <0.001). Among males,
chlamydia positivity was 2.5% vs. 0.4% (p < 0.05). A
significantly higher proportion of participants in the
control arm reported symptoms.
Multi-component interventions – children, parents and teachers
Elementary school students, teachers and
Intervention: Seattle Social Development A significant difference in STI diagnosis was not
parents
Project implemented during elementary
found overall, but after controlling for poverty,
school.
there was a significant difference among African
Evaluation at age 21 years.
Americans in the intervention versus control arms:
7% vs. 34% reported being diagnosed with a STI in
their lifetime (OR 0.11, p < 0.01) or a difference of
27%. For non-African Americans, this difference
was 3%.
Population and Public Health, Ministry of Health
Methods
RCT (the Detection Acceptability
Intervention for STDs in Youth [DAISY]
study).
Intervention group: home testing kit for
testing at 6, 12 and 18 months. Samples
were mailed directly to the laboratory.
Comparison group: postcard invitation to
attend a medical clinic for testing during
the same intervals.
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Paper
Population
Gaydos et
46
al. (2008)
Female adolescents presenting for
rescreening at SBHCs (10,000+ over 7-years)
Shafer et al.
30
(2002)
Sexually active adolescent females (age 1418 years), seen during routine check-ups in
pediatrics clinics, in a HMO in the US
Population and Public Health, Ministry of Health
Methods
School-based health centers
Chlamydia testing offered within SBHCs
(middle and highschools).
RCT - random assignment of 10 pediatric
clinics to the clinical practice
improvement intervention (n = 1017
sexually experienced adolescent females)
or to a control intervention (n = 1194).
Control arm: one-hour session that
included information about the
epidemiology of chlamydia in
adolescents, and the current chlamydia
screening and treatment
recommendations.
Intervention arm: same, but additionally
the clinical practice improvement
intervention was implemented that
included engagement, team-building,
redesign of clinical practice, and
sustaining the gain.
Results
Overall chlamydia prevalence was 18.1% (95% CI
17.4-18.8%), with a variation from year to year
(from 15.1% [13.1-17.1] to 19.5% [17.8-21.2%]).
Chlamydia positivity did not decrease over time.
Among those who tested positive, 46.7% were
rescreened. The cumulative incidence of reinfection
was 26.3% (95% CI 23.4-29.2%), and of these
individuals, 42.8% had one or more negative tests
results in between the initial positive test and
subsequent positive test. The age group with the
highest risk of reinfection was age 13 years and
younger.
Over an 18-month period, 47% of females in the
intervention sites were screened compared to 17%
at control sites; at 16-18 months, the screening rate
among intervention clinics was 0.65 (95% CI 0.530.77) compared to 0.21 (95% CI 0.09-0.33) in the
control clinics. Chlamydia infection rate for the
intervention clinics was 5.8% compared to 7.6% in
the control sites (test of significance not reported).
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Population
Wingood et
53
al. (2003)
African American adolescent females (n =
522) between 14 and 18 years of age, had
been sexually active in the past six months,
and lived in lower socio-economic status
neighbourhoods in Alabama.
Wingood et
54
al. (2001)
African American females age 14-18 years
and sexually active within the past six
months.
Population and Public Health, Ministry of Health
Methods
Mass media
12-month prospective study to examine
the impact of the exposure to rap music
videos on the incidence of STIs
(chlamydia, gonorrhea and
Trichomoniasis) and health risk
behaviours.
Cross-sectional study examining the
association between exposure to
sexually explicit (i.e., X-rated) movies and
STIs, sexual health-related attitudes and
behaviours.
Results
37.6% acquired a new STI, and adolescents that had
greater exposure to rap music videos were
significantly more likely to have acquired a new STI
compared to those that had less exposure to rap
music videos (AOR 1.6 (95% CI 1.1-2.3, p=0.04).
Association only. No intervention.
~30% reported exposure to X-rated movies, and
28% had >1 STI with 5% diagnosed with mixed STI
infections. Chlamydia, gonorrhea and
Trichomoniasis prevalence was 17.5%, 5.2% and
12.9%, respectively. Exposure to X-rated movies
was associated with being significantly more likely
to test positive for chlamydia (AOR 1.7 (95% CI
1.04-2.80, p = 0.03).
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INTERVENTIONS FOR MSM
Paper
Country
Population
Methods
Behavioural Interventions
Behavioural interventions
Systematic
review
European
Centre for
Disease
Prevention and
Control (ECDC),
2009
Herbst, et al.
(2005)
Europe
Multinational
Behavioural interventions
Systematic
review
Johnson, et al.
(2008)
Multinational
Behavioural interventions
Systematic
review
Population and Public Health, Ministry of Health
Results
The authors found four studies that looked at
unprotected anal intercourse (UAI) as an
outcome. For behavioural outcomes, two studies
found no significant differences. The other four
found RR of 0.47-0.86.
One study found a RR of 1.66 (95% CI 1.00-2.74).
Overall interventions were associated with a
significant decrease in unprotected anal
intercourse (OR 0.77, 95% CI 0.65-0.92), reduction
in number of sexual partners (OR = 0.85, 95% CI
0.61-0.94), and a significant increase in condom
use during anal intercourse (OR 1.61, 95% CI 1.162.22).
Interventions that were successful were based on
theoretical models, including interpersonal skills
training, and incorporated several delivery
methods and were delivered over multiple
sessions.
They found 44 studies evaluating 58 interventions
with a total of 18,585 participants. Forty
interventions that compared to minimal or no HIV
prevention intervention reduced occasions for
UAI by 27% (95% CI 15-37%). The other 18
interventions reduced UAI by 17% when
compared with other standard therapies (95% CI
5-27%).
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Paper
Country
Wilson, et al.
(2011)
Australia
Blank, et al.
(2005)
US
Gutierrez, et al.
(2010)
India
Population
Methods
Chemoprophylaxis for syphilis
Chemoprophylaxis for syphilis
Mixed-methods
Community Partnerships and Events
The New York City Department of Health and
Descriptive
Mental Hygiene developed Hot Shot! to address
general MSM health issues, including STI.
The Frontiers Prevention Project (FPP) aimed to
Two crossempower the key populations in India most
sectional surveys
affected by HIV. The FPP set out to improve
advocacy within these groups, changing policies
that affect these groups, and increasing
community awareness. The provision of a
complete set of prevention interventions, aiming
to reduce risk behaviours and STI incidence,
resulted in a lower HIV incidence among the key
populations. The goal of the project was to ensure
an environment in which adequate services and
commodities were available for key populations.
Population and Public Health, Ministry of Health
Results
They surveyed 2095 gay men; 52.7% of them
(95% CI 50.6-54.8%) indicated that they would be
very likely or slightly likely to use
chemoprophylaxis to reduce their chances of
acquiring syphilis. When told it would help reduce
infections in the gay community, that number
rose to 75.8% (95% CI 74.0-77.6%). Their
mathematical model showed that this could
reduce the number of syphilis cases by 50% after
12 months of use and 85% after 10 years.
Of 1634 attendees, 445 persons accessed one or
more service; 4 were newly diagnosed with
syphilis and seven with HIV.
For MSM, there was a significant decrease
between baseline and follow-up for syphilis
seropositivity (40% to 32% in FPP group versus
34% to 29% in non-FPP group, p < 0.05).
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Country
Population
Methods
Results
Male circumcision
Templeton, et
al. (2010)
Multinational
Male circumcision
Systematic
review
Wiysonge, et al.
(2011)
Multinational
Male circumcision
Systematic
review
Blas, et al.
(2007)
Peru
Internet-based marketing campaigns
Online banner advertisements offering free HIV
Observational,
and syphilis testing
cross sectional
Population and Public Health, Ministry of Health
For bacterial STIs, they found six studies looking
at the association between circumcision and STIs
in MSM. For gonorrhea and chlamydia, two
studies found no significant association between
circumcision status and urethral gonorrhea or
chlamydia.
For syphilis outcomes, 8 pooled studies showed
no significant association between male
circumcision and syphilis.
The inclusion of the health incentive increased
the frequency of completion of surveys (5.8
versus 3.4%, p < 0.001). Eleven percent of
participants who said they had completed the
survey offering free testing visited the STI clinic.
Of those who attended the clinic, 6% had already
been diagnosed as having HIV, while 5% tested
positive for HIV. Eight percent tested positive for
syphilis.
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Paper
Klausner, et al.
(2004)
Country
US
Population
Internet-based prevention intervention-website
was created, there was individual online outreach,
banner advertisements, chats, an educational site,
message boards, warnings and an online syphilis
testing program.
Methods
Descriptive
Koekenbier, et
al. (2008)
Netherlands
Online-mediated syphilis testing
Cohort study
Levine, et al.
(2005)
US
Online syphilis testing
Descriptive
McFarlane, et
al. (2005)
US
Internet-based health promotion and disease
control
Review of
programs in
eight cities;
qualitative
Population and Public Health, Ministry of Health
Results
During two months in 2002, staff conducted 57
hours of outreach on three internet sites;
resulting in 212 interactions: AOL, Craigslist and
M4M4Sex. Thirty-five or 16% redeemed incentive
coupons at the municipal STI clinic. There were 9
banner ad campaigns shown over 33 million times
on gay.com and AOL, resulting in a 0.1% clickthrough rate. There were 7 one-hour chats on
gay.com with 10-50 people in the chat room at
any one time, and 15 questions answered per
hour. About 840 people participated in 7 sessions.
The “Ask Dr. K” site receives 100 questions a
week. From June 2003-January 2004, there were
thousands of visitors to STDTest.org, but only 140
completed syphilis testing. Of these, six (4.3%)
tested positive.
During 15 months, 898 visitors to the website
downloaded a referral letter. Of these, 93 (10%)
men tested and 96% of these obtained their test
results online. Through the website, the authors
found a significantly higher percentage of men
who needed treatment for syphilis compared with
the STI clinic (50% online vs. 24% STI clinic, p <
0.01). Of the online users who tested positive 3 of
10 had never visited the STI clinic before.
During the first year 218 tests were performed
and 13 had reactive serology. Six were diagnosed
with a new syphilis infection.
Authors looked at eight cities in the US (Chicago,
New York, Miami, Fort Lauderdale, San Francisco,
Los Angeles, Houston and Atlanta). Public health
officials were contacted for interviews regarding
local, online efforts to implement disease control
and health promotion strategies.
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Paper
Moskowitz, et
al. (2008)
Country
US
Population
Use of instant messaging counselling
Methods
Descriptive
Muessig, et al.
(2013)
US
Mobile phone apps
Qualitative
Population and Public Health, Ministry of Health
Results
About 43% of the instant message sessions
discussed information about HIV/STIs. Risk taking
behaviours were addressed in 39% of the
sessions. Information about HIV/STIs and general
counselling were given in 23 and 18% of the
counselling sessions, respectively.
Authors recruited a sample of 22 black MSM.
Despite the fact that half the sample earned less
than $11,000 annually, all participants owned
smart phones and had unlimited texting and
many had unlimited data plans. Themes that
emerged were that the phones were integral to
their lives and were the primary means of
accessing the internet. Communication was
usually done through text messaging and
messaging through social networking sites. Half
used their phones to find sex partners, and over
half used their phones to find health information.
For an HIV-related app, participants stated they
were looking for user-friendly content about test
site locations, information about STIs, information
about symptoms, the risks of drug and alcohol
use, safe sex, sexuality and relationships, gayfriendly health providers and connection to other
gay and HIV-positive men.
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Paper
Country
Population
Methods
Chesson, et al.
(2013)
US
STI Screening
Rectal screening for chlamydia and gonorrhea
Sexton, et al.
(2013)
US
Self-screening
RCT
Tuli, et al.
(2009)
US
Screening among MSM inmates
Mathematical
modeling
Vriend, et al.
(2013)
Netherlands
Anorectal chlamydia screening in care at HIV
treatment centers
Mathematical
model
Population and Public Health, Ministry of Health
Mathematical
model
Results
The authors looked at two different models—a
base case, in which only benefits to those
screened were included; and a dynamic version,
in which the population impacts were also looked
at. The cost per quality-adjusted life year gained
through screening MSM for rectal chlamydia and
gonorrhea was $16,300 in the static version of the
model and the cost per quality adjusted life year
gained was less than $0, meaning the measure
was cost-saving.
Self-administered testing was significantly better
at identifying pharyngeal gonorrhea (discordant
3%) and rectal gonorrhea (discordant 2.9%) (p <
0.01) and had results similar to provider
administered testing for pharyngeal chlamydia
(discordant 0.5%) and rectal chlamydia
(discordant 1.1%).
Modeling suggests that a screening, treatment
and condom provision intervention for inmates
can be cost saving for incarcerated MSM who
have sex before incarceration and no condom
use, and for incarcerated MSM who have sex
before incarceration and condom use by 20% of
screened inmates. For inmates who have no sex,
the net cost would be almost $180,000.
There will be cost savings by routine once yearly
chlamydia screening of MSM in care at HIV
treatment centres if these patients do not seek
care elsewhere.
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Paper
Country
Ahrens, et al.
(2006)
US
Katzman, et al.
(2007)
US
Population
Methods
Social Marketing Campaigns
Healthy penis campaign
Cross-sectional
survey
A “Community Manifesto” to appeal to control
HIV/STIs among the MSM community
Population and Public Health, Ministry of Health
Cross sectional
survey
Results
An increasing proportion of respondents reported
syphilis testing in the previous six months by
campaign awareness level (Cochran-Armitage
trend test z = -3.303, p = 0.001) for the first
evaluation; and z = -2.304, p = 0.02 for the second
evaluation. After controlling for confounders,
each increase in campaign awareness level during
the first evaluation was associated with a 90%
increase in likelihood for having tested for syphilis
in the past six months (OR 1.9, 95% CI 1.3-2.9). In
the second evaluation, each increase in campaign
awareness level was associated with a 76%
increase in syphilis testing (OR 1.76, 95% CI 1.013.1).
Ecologically, the incidence of early syphilis was
lower than in the previous three years (data not
provided).
For those who completed the survey (web-based,
mail-in or street-intercept), 84% had heard about
the manifesto. About half of all respondents
reported that the manifesto made them think
about their sexual choices and behaviours.
Twenty-seven percent indicated they had made
changes to their behaviours. Sixty-one percent
strongly agreed or agreed with the manifesto;
19% disagreed or strongly disagreed with it; 18%
was neutral.
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Paper
MartinezDonate, et al.
(2010)
Country
US
Population
Hombres Sanos; social marketing campaign for
heterosexually identified Latino MSM
Methods
Before-after
Pedrana, et al.
(2012)
Australia
Social marketing campaign
Before-after
Population and Public Health, Ministry of Health
Results
There were no changes in the prevalence rates of
unprotected sexual practices with females over
the previous 60 days. There was a significant
increase in the percentage who reported and
demonstrated condom carrying during the
campaign (AOR 2.28, 95% CI 1.59-3.27) and postcampaign (AOR 1.62, 95% CI 1.06-2.49), compared
with baseline. HIV testing during the previous six
months increased significantly from baseline to
post-campaign (AOR 3.13, 95% CI 2.06-4.75). The
percentage of heterosexual respondent who
knew where to get tested for HIV increased at the
campaign (AOR 1.60, 95% CI 1.26-2.02) and postcampaign phases (AOR 1.57, 95% CI 1.18-2.08).
Respondents’ average level of perceived risk for
HIV was higher during the campaign (B=0.013;
95% CI 0.04-0.13) and post-campaign (B=0.27,
95% CI 0.17-0.37) than during baseline.
Surveying a convenience sample of 295 MSM, the
authors found that campaign awareness was high
(86%). In multivariable logistic regression,
awareness of the campaign was independently
associated with having had any STI test within the
past 6 months (prevalence ratio 1.5, 95% CI 1.02.4). Compared with the 13 months before the
campaign, their data showed significant
increasing testing rates for HIV (RR 1.17 initial
period, RR 1.27 continued campaign period),
syphilis (RR 1.19 initial period, RR 1.29 continued
campaign period) and chlamydia (RR 1.15 initial
period, RR 1.28 continued campaign period)
among HIV-negative MSM (all p < 0.01).
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Paper
Wei, et al.
(2013)
Country
Multinational
Population
Social marketing
Population and Public Health, Ministry of Health
Methods
Systematic
review
Results
They found three studies and included it in their
final analysis (Darrow and Biersteker, 2008; Guy,
2009; McOwan 2002). Their meta-analysis
showed that the campaigns were effective on HIV
testing uptake (OR 1.58, 95% CI 1.40-1.77) but
were not effective in increasing STI testing uptake
(OR 0.94, 95% CI 0.68-1.28). They also noted a
high risk of bias and a low quality of evidence for
the three studies.
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APPENDIX C: SUMMARY OF EVIDENCE RATINGS
MICRO-LEVEL INTERVENTIONS – ACROSS POPULATIONS
Intervention
Behavioural
outcomes

STI incidence/
prevalence





Peer education


Cognitive-behavioural
interventions
Brief behavioural
interventions




Screening and treating
for STI to prevent PID
Male condoms
N/A

N/A

Female condoms
N/A

Cervical diaphragms
N/A

Topical spermicides
N/A

General behavioural
interventions and risk
reduction counselling
Behavioural
interventions stressing
ethnic pride and skillbuilding
Small group sessions
Population and Public Health, Ministry of Health
Contextual considerations and comments
Results of trials looking at general behavioural interventions have been mixed. There is some
evidence to support implementation of this strategy in limited settings but further studies should
be done evaluating the impact of this intervention on a wider scale.
Behavioural interventions stressing ethnic pride and skill-building have been shown to be
effective in African- and Latino-American populations.
Small group support sessions have shown to positively affect risk behaviours and reduce the risk
of STIs in African- and Latino-American women.
Peer education sessions have been shown to be effective in reducing STI rates and increasing
condom usage among female sex workers in developing nations.
There is some evidence that cognitive-behavioural interventions can help reduce the risk of STIs
and improve health behaviours.
There is evidence that cognitive-behavioural interventions can help reduce the risk of STIs and
improve health behaviours. Many of these studies were done in African- and Latino-American
populations and young adults.
RCTs have shown a decreased risk of PID in those screened for chlamydia in studies in developed
nations, but the benefits of screening may be overstated.
Male condoms have been shown to be highly effective in preventing the transmission of STIs.
Studies have been done in a variety of settings in North America and in developing nations.
Although the female condom, as a technology, is effective as a mechanical barrier to viruses and
semen, poor uptake of the female condom and cost limit its recommendation for wide
dissemination. However, it should be noted that there is a lack of safety data on usage during
anal intercourse.
The use of diaphragms for STI prevention is as effective as male condoms, as a technology.
However, poor uptake may limit its recommendation for wide dissemination.
Topical spermicides have not been shown to be effective in reducing the transmission of STI, and
in fact may facilitate the transmission of STI, especially in the case of N-9.
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Intervention
Topical microbicides
Behavioural
outcomes
N/A
STI incidence/
prevalence

Male circumcision
N/A

Patient referral
N/A

Contact slips
N/A

Provider referral
N/A

PDPT
N/A

Contextual considerations and comments
Topical tenofovir has shown promise in preventing the transmission of HIV only. More research
is needed into whether other microbicides is effective in preventing STI acquisition.
There is evidence to suggest that male circumcision is effective in preventing transmission of STI
but most studies were done in developing nations with high HIV prevalence. Limited evidence
exists for a wide policy of recommending male circumcision in developed nations. Accordingly,
the US CDC and Canadian guidelines have not recommended for or against this strategy in
developed nations.
Patient referral is generally less effective than provider referral and PDPT.
More research is warranted into whether contact slips can be used as a partner notification
technique.
Although provider referral has shown some promise, more research is needed before this
strategy can be recommended.
PDPT has been shown in multiple studies, including randomized controlled trials, particularly in
chlamydia and gonorrhea, to reduce reinfection rates. Some caution, however, should be
exercised given that gonorrhea is becoming a multi-drug resistant organism and may require
parenteral treatment. PDPT should only be implemented for chlamydia in the heterosexual
population. For MSM, because there is a higher risk for HIV infection, PDPT may only be
cautiously offered, if at all, to ensure appropriate testing and counselling.
MESO-LEVEL INTERVENTIONS – ACROSS POPULATIONS
Intervention
Group education – risk
reduction
Behavioural
outcomes

STI incidence/
prevalence

Contextual considerations and comments
Group education involving risk reduction has been shown to be effective in impacting STI rates in
some, but not all, studies.
This intervention has also been shown to impact sexual risk behaviour outcomes in some, but
not all, studies.
Population and Public Health, Ministry of Health
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Intervention
Behavioural
outcomes

STI incidence/
prevalence

Skill building in group
education


Community opinion
leaders


Group education abstinence
Contextual considerations and comments
Group education with an abstinence message has revealed a positive impact on sexual initiation
in a recent study. However a meta-analysis suggests that conclusions cannot be drawn and some
other studies have not found an impact.
Impact on STI rates is uncertain based on the reviewed literature.
As a general principle, in group education, beyond just providing information, skill-building is an
important element. Both individual-and group-level skill building interventions have contributed
to decreased STI rates and risky sexual behaviour.
Community opinion leaders, based on diffusion of innovation theory, are postulated to influence
community norms. A large, randomized, multi-site study did not demonstrate reduced STI
incidence, yet a comprehensive comparison intervention may have made it difficult to detect a
difference.
Evidence related to sexual risk behaviour was also not conclusive.
Peer mentors within a
social network


Contact tracing using a
social network approach
 For
detection of
STI cases

Electronic technologies
in STI clinic settings
 To support
testing STI
screening,
diagnosis, retesting

A small study suggests a beneficial effect on reducing HIV/STI-related stigma.
The single identified study (RCT) on the topic of a peer mentor operating within their social
network, revealed encouraging reductions of risky sexual behaviour.
However impact on STI rates is uncertain.
Using a social networking approach for contact tracing has been shown to have advantages over
the traditional ‘one-time interview’ approach. Evidence from a syphilis outbreak in Vancouver
demonstrated a comparatively higher proportion of cases detected through this method.
Another study suggests that increased costs may be a consideration.
Evidence is needed to assess how this impacts on STI rates.
The evidence is supportive of electronic technologies, sometimes in conjunction with another
intervention (such as the introduction of guidelines, or intensive DIS follow-up) being effective in
improving various outcomes related to STI diagnosis and follow-up care (e.g., STI screening,
timely follow-up post-diagnosis, rescreening).
Impact on STI rates over time is uncertain.
Population and Public Health, Ministry of Health
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Intervention
Behavioural
outcomes
 To support
partner
elicitation
STI incidence/
prevalence

Syphilis testing during
routine HIV monitoring
 To support
syphilis
detection

Male clinics


Mobile clinics
 To support
screening
uptake

School-based STI
screening and treatment
programs
 For
facilitating
the
treatment of
cases
 For
participation
in screening
program

Disease Intervention
Specialists (DIS) within a
clinic setting
Population and Public Health, Ministry of Health
Contextual considerations and comments
Limited study suggests a positive impact on partner elicitation.
Research on the impact of DIS on STI rates is needed. (Note that there is also a study of a
combined DIS and electronic technologies intervention that demonstrates promising results).
Including routine syphilis testing with every blood test that is collected as part of HIV monitoring
resulted in a significant increase in early syphilis detection, among HIV-positive MSM in an
Australian study.
Impact on STI rates is uncertain.
Male health clinics are suggested as an important way to promote male access to STI care. The
limited study identified on this topic reported positive impact on STI knowledge and suggests
positive impacts on sexual risk behaviour, however impact on STI detection and STI rates is not
reported.
A single study revealed mobile clinics as a feasible and acceptable way to reach community
members and test for STIs. Note that general health services were also offered in order to
decrease stigma.
Impact on STI rates over time is not examined.
Screening in school-based settings was the subject of a large body of research. Generally, there is
favourable outcomes related to the treatment of individuals that are found to have STIs (many of
which are asymptomatic). Rates of participation in the screening program vary widely. There is
also inconsistency with respect to the impact of the program on STI rates over time.
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Intervention
Behavioural
outcomes
 For
promoting
screening
uptake
STI incidence/
prevalence

Occupational group
screening


Evidence is needed to assess how this impacts on STI rates over time.
A single study was found that offered screening based on occupational groups. Varying rates of
STIs was observed among different groups.
Screening in family
court system
For
reaching the
target
population
 For
facilitating
access to
treatment
For
reaching the
target
population
 For
facilitating
access to
treatment

Evidence is needed to assess the impact on STI rates over time.
A single study on screening within the family court system revealed that less than half of the
target population was offered testing at intake, however there were very high treatment rates.
Screening in
sports/sports teamrelated settings
Screening in prisons
Contextual considerations and comments
A limited research base was identified on screening among sports teams/in sports venues. One
study in Australia demonstrated a very high screening participation, while another study
suggests that there is potentially a greater acceptance of screening in these venues among those
who actually participate in sports.
Evidence is needed to assess the impact on STI rates over time.

Population and Public Health, Ministry of Health
Fair screening rates were reported, while the treatment rates varied. One of the key factors in
treating cases in this setting is that individuals may be discharged prior to completing STI
investigation and treatment.
This literature is not clear on the impact of screening on STI incidence/prevalence over time.
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Intervention
Screening in shelters
Screening for
commercial sex workers
MSM sex on premises
establishments,
bathhouses, saunas
screening
Street-based screening
Behavioural
outcomes
 For
promoting
screening
uptake
 For
facilitating
access to
treatment
For
supporting
screening
uptake
 For
facilitating
access to
treatment
 For
facilitating
treatment for
cases
 For
supporting
obtaining
results
 For
screening
uptake
STI incidence/
prevalence

Contextual considerations and comments
In a single study among adults in US shelters, high screening program participation, as well as
high treatment rates, were reported.
Evidence is needed to assess the impact on STI rates over time.

A single study suggests that outreach supports screening uptake, and access to diagnostic testing
and treatment. Note that numerous other studies have included outreach screening for sex
trade workers, as part of a wider program with other interventions (see report).
Evidence is needed to assess the impact on STI rates over time.

A few studies in this area suggest that screening uptake might be supported through outreach,
as might treatment for individuals that test positive.
Evidence is needed to assess the impact on STI detection, as well as rates over time.

In one study in the Netherlands, screening was offered in various settings outside of fixed
venues. Screening uptake varied widely, with the lowest proportion screened in street corners,
parks and underground stations, etc.
Evidence is needed to assess the impact on STI rates over time.
Population and Public Health, Ministry of Health
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Intervention
Home-based STI testing
Behavioural
outcomes
 To support
screening
uptake
STI incidence/
prevalence

Presumptive treatment


Periodic presumptive
treatment

For longterm impact
on STI rates
Targeted mass
treatment
Community mobilization




Population and Public Health, Ministry of Health
Contextual considerations and comments
Generally favourable in terms of feasibility and appears to support the uptake of STI testing. One
study found that ordering a testing kit online, and obtaining results online, were much preferred
over telephone methods. Some studies observed a higher screening volume with home-based
testing, although it is not clear why and whether this finding (observed in settings outside of
Canada) would be similar in a Canadian context. There were concerns expressed by participants
in some studies about privacy, confidentiality and safety, and these would need to be addressed
in any similar intervention.
There is uncertainty regarding the potential impact of home-based STI testing on STI morbidity
over time, as two studies revealed contradictory findings, with a large study with a long followup period revealing no differences between home-based screening and a control condition.
One-time presumptive treatment was evaluated in one study among sex trade workers, and in
another study among incarcerated MSM. The former study found an initial decreased STI
prevalence over time in all groups offered presumptive treatment, however this decline was only
sustained among groups that had expanded STI screening and treatment services. There was also
a reduction in the STI prevalence of the clients of one group that had expanded STI services in
addition to presumptive treatment. This suggests that while presumptive treatment can be
effective over the short-term, other control measures must be implemented in order to maintain
STI reductions over the long-term. The study in a prison setting, documented a high acceptance
rate of prophylactic treatment, but was not able to assess long-term impact due to turnover
within the prison population.
A study among female sex workers in South Africa found that PPT along with prevention
education resulted in declining STI prevalence among FSW as well as local miners in the
surrounding community. A systematic review also found a positive impact on STI prevalence
among sex trade workers, with emphasis that longer-term strategies are needed to support this
short-term measure.
The literature related to syphilis prophylaxis in BC, has urged caution in the administration of
mass prophylaxis.
Studies of initiatives in which community mobilization was a key element, revealed significant
decreases in STIs and risk behaviours among sex trade workers.
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Intervention
Other multi-component
interventions
Conditional cash
transfers
Behavioural
outcomes

STI incidence/
prevalence



Contextual considerations and comments
Based on a single study in Peru, a multi-component intervention (without a formal policy
element) produced encouraging reductions in STIs among some populations (young women and
FSWs) but not other populations. This division of evidence is somewhat arbitrary because a
number of other interventions reviewed in this evidence review have multiple components, and
are classified in other sections.
While there are other studies examining non-bacterial STI outcomes, the one study that was
reviewed that had bacterial STI outcomes, demonstrated promising results. After 1-year,
conditional cash transfers were associated with lower prevalence of four STIs. Note that this
outcome was not observed during earlier study periods, and a gradient effect was noted. More
research specifically on bacterial STIs would be helpful to confirm this finding that was observed
in a rural low-income country setting.
With respect to behavioural change, participants report motivation to change behaviour.
MACRO-LEVEL INTERVENTIONS – ACROSS POPULATIONS
Intervention
Performance measures
100% CUP Program
Combined community
mobilization and policy
initiatives
Behavioural
outcomes
 To support
screening
STI incidence/
prevalence

 For
increasing
condom
usage



Population and Public Health, Ministry of Health
Contextual considerations and comments
Evidence from the United States suggests that a change in performance measures can have an
impact on STI screening, as participating institutions seek to implement measures to improve
their performance.
The impact on STI rates however is unclear.
The 100% CUP was discussed widely in the literature, particularly in low- and middle-income
countries. Studies have varied in the demonstration of impact on STI rates and therefore more
research is warranted.
However, this intervention has demonstrated a positive impact in increasing condom uptake
among sex trade workers/clients.
Studies of combined community mobilization and policy initiatives revealed significant decreases
in STIs and risk behaviours.
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Intervention
Behavioural
outcomes
 For impact
on STI
screening
rates
0

STI incidence/
prevalence

Contextual considerations and comments
0

Registration of sex trade
workers with the
municipal health
department
Clinic co-payments


Legislation is described but no evaluation is found.
The literature on alcohol policy includes the examination of multiple measures of reduced
alcohol access or consumption and finds that measures that involve alcohol reduction are
associated with lower STI rates. This result is not mirrored in all studies, and the challenges in
establishing causality are recognized, however there is a well-supported mechanism of
association that has itself received support in the literature (i.e., the association between alcohol
consumption and risky behaviour), and corroboration of evidence in a number of studies.
In one study of registration of sex workers in Mexico, registration was not found to be associated
with lower risk of testing positive for STIs, in an adjusted model.
For impact
on clinic visits
Federal funding for STI
elimination
N/A
For impact
on STI
diagnosis

PHAC and CDC
Guidelines
0
0
Health plan
reimbursement law for
STI screening
STI screening legislation
Alcohol policy (e.g.,
taxes, zero tolerance
drunk driving laws,
minimum drinking age,
alcohol outlet density)
Population and Public Health, Ministry of Health
Significant differences in chlamydia screening rates among states that did and did not implement
a health plan reimbursement law, were not identified in a single US study.
Based on a single well done natural experiment with strong theoretical rationale, the
introduction of even a modest fee for STI clinic care has been shown to result in a considerable
decline in clinic visits and impact the diagnosis of STIs.
An inverse association was found between the amount of federal funding for syphilis elimination
activities and the subsequent syphilis rate in later years, at the state level in a US study. Although
this study design is ecological, it is appropriate for an examination of data at this level, and welldesigned. While this topic would benefit from additional research to corroborate this finding, a
sound theoretical rationale and study features, are key factors that influenced this rating.
No evaluation was found of the impact of these guidelines on STI rates at the population level,
however there is literature examining use among health care providers (discussed below), and
these guidelines consist of interventions that are discussed throughout this report.
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Intervention
STI Control Strategies
and Guidelines
Behavioural
outcomes

STI incidence/
prevalence
0
Contextual considerations and comments
There is evidence of a positive impact of guidelines on the uptake of STI screening in studies from
Australia and the UK, and some positive impacts on knowledge from a syphilis prevention
campaign in Alberta.
Data from the US does reveal that adherence to CDC STI treatment guidelines seems quite high.
No evaluation of jurisdiction wide control strategies or treatment guidelines for impact on
subsequent STI rates was found.
MICRO-LEVEL INTERVENTIONS – YOUTH
Intervention
Behavioural
outcomes
STI incidence/
prevalence
Contextual considerations and comments
Computer-based
education and skill
building behavioural
intervention for youth


Online interventions
(general or multiple
interventions)


Note that the review of this study is intended to complement the previous discussion of
individual-level behavioural interventions, and not stand on its own. This particular computerbased program that combined education and skill-building, had some positive behavioural
outcomes (while others did not differ from traditional print-based materials) as well as lower
rates of self-reported STIs. However, objective STI data is uncertain.
Systematic review/meta-analysis data suggests that “new digital media/interactive computerbased” interventions, can have a positive impact on behavioural outcomes.
Determining impact on STI rates would benefit from further research.
Home-based STI testing
For
promoting
testing and
STI detection

Acceptance is high among youth.
Although not all studies have found a differential impact on STI detection, the bulk of the
evidence suggests that home-based STI testing has advantages over traditional face-toface/clinic testing in promoting testing uptake among youth, as well as detecting STIs.
MESO-LEVEL INTERVENTIONS – YOUTH
Intervention
Behavioural
outcomes
STI incidence/
prevalence
Population and Public Health, Ministry of Health
Contextual considerations and comments
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Intervention
Behavioural
outcomes

STI incidence/
prevalence

Worksite based
programming for
parents


Multi-component
approaches targeting
children/younger youth


Parental monitoring
Multi-component
approach targeting
youth in highschool


Peer education alone
and combined with
outreach screening in
partnership with a faithbased organization


Population and Public Health, Ministry of Health
Contextual considerations and comments
An association between parental monitoring and sexual risk behaviours has been
consistently identified, and in one prospective cohort study, an association between
parental monitoring and STI incidence was identified. What is lacking is literature evaluating
a parental monitoring intervention.
A single identified study examining a workplace-based program for parents of adolescent
children, and demonstrated positive impact on parent-child communication about sexual
behaviour, but it is uncertain how this impacts subsequent adolescent sexual behaviour and STI
rates.
Interventions delivered to target populations of children/young youth, varied in their
components and scope (e.g., involvement of parents and teachers, community service
elements). However, the studies in this area all suggest that the period of children/early
adolescence is an important time for STI prevention interventions can reduce sexual risk
behaviour over the long-term. These studies also highlight the importance of the social and
community context for youth.
Impact on STI incidence/prevalence was only assessed in one study, and a significant difference
was only found among African American individuals. Further study is warranted.
Similarly to the multi-component school-based interventions delivered to younger students,
along with their teachers and parents, a multi-component intervention among highschool
students had numerous positive impacts on sexual risk behaviour. In this single study however,
the intervention did not seem to impact sexual initiation, but did decrease sexual risk
behaviours.
Impact on STI incidence/prevalence is uncertain.
Peer education alone demonstrated improvements in STI-related knowledge and undergoing STI
testing. This was expanded to include outreach screening, in partnership with a faith-based
organization, which demonstrated further positive impact in engaging youth in STI screening.
Impact on STI incidence/prevalence warrants further research.
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Intervention
School-based health
centers
Online initiatives to
promote STI testing
Behavioural
outcomes


STI incidence/
prevalence


Contextual considerations and comments
SBHCs are important venues for offering screening to youth in schools, and have demonstrated
the ability to detect high rates of STIs in US studies. One study demonstrated that a chlamydia
screening initiative engaged a high proportion of SBHC clients, the majority of whom did not
have another source for reproductive health care. Another study suggests that this is an
important way to engage asymptomatic young men in screening. Further, high rates of
reinfection with chlamydia were detected through a SBHC in one study, particularly among
younger youth.
The long-term impact of offering STI screening through SBHCs on STI incidence/prevalence is not
certain.
In the UK, an intervention that used websites to promote access to free STI screening through
the national program, found that although the proportion of tests accessed online increased, it
was still far below more traditional methods of access. It was found that young men were
reached at a higher rate than women, which may be important for engaging this group. A study
from Ontario indicated that participants in an intervention involving website and text messages,
indicated that just over half they would change their behaviour as a result of visiting the website.
MACRO-LEVEL INTERVENTIONS – YOUTH
Intervention
Clinic-based
systems
interventions
Behavioural
outcomes
 To support
screening uptake
STI incidence/
prevalence

Contextual considerations and comments
Data from HMOs in the US indicate that systematic changes in clinical practice can positively
impact STI screening uptake among target populations on female youth.
A favourable impact on chlamydia infection is suggested in one study, however without the
reporting of a test of significance it is difficult to know the implications of this result.
Implications for the Canadian context vs. the HMO context, is uncertain.
Population and Public Health, Ministry of Health
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Intervention
Mass media
Behavioural
outcomes

STI incidence/
prevalence

Contextual considerations and comments
An association between exposure to different types of mass media (e.g., with sexually explicit
content) and STI rates have been reported in prospective cohort and cross-sectional studies.
There is a plausible mechanism and corroboration of evidence of this association.
What is lacking is research evaluating the impact of interventions that limit adolescents’ access
to sexually explicit media, and how this impacts STI burden and sexual risk behaviour.
MICRO-LEVEL INTERVENTIONS – MSM
Intervention
Behavioural
outcomes

STI incidence/
prevalence

Chemoprophylaxis
for syphilis


Male circumcision


Self-screening
N/A

Universal anorectal
screening for
chlamydia and
gonorrhea
N/A

Behavioural
interventions for
MSM
Population and Public Health, Ministry of Health
Contextual considerations and comments
There is evidence to suggest that behavioural interventions are effective in reducing sexual risk
behaviours among MSM.
However, there is a paucity of data for effectiveness in reducing STI and HIV transmission risk.
Interventions that were found to be most effective are those based on theoretical models,
interpersonal skills training, with multiple delivery methods, and a focus on the adverse effects
of risky sexual behaviour and HIV/STI infections.
One mixed-methods study has shown acceptability among gay men to use chemoprophylaxis to
reduce the transmission of syphilis. Running this through a model shows the potential to reduce
syphilis transmission rates by 85% over 10 years. More research is needed to demonstrate that
this would be an effective intervention, especially balanced against the risks of antibiotic
treatment.
There is very limited evidence to support male circumcision in the prevention of bacterial STIs.
The quality of evidence is low; hence randomized trials of MSM in the prevention of both HIV
and STIs are warranted.
While one study showed some promise in self-screening, limitations in the control group mean
that this strategy cannot yet be recommended. More research is needed.
There is evidence for once yearly universal anorectal screening for chlamydia and gonorrhea
among MSM. This recommendation rests on the fact that three studies have shown this to be
cost-savings and the fact that selective screening based on history may miss many infections.
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MESO-LEVEL INTERVENTIONS – MSM
Intervention
Community
partnerships and
events
Internet-based
campaigns
Behavioural
outcomes

STI incidence/
prevalence

Contextual considerations and comments


While there have been published studies on internet-based campaigns for MSM, most studies
have been observational or provide only descriptive statistics. More rigorous, controlled studies
are needed to determine if the many types of internet campaigns are indeed effective in
decreasing STI rates and improving outcomes.
STI incidence/
prevalence

Contextual considerations and comments
There is some evidence to support community-based partnerships and events in case finding for
syphilis.
MACRO-LEVEL INTERVENTIONS – MSM
Intervention
Social marketing
campaigns
Behavioural
outcomes

Population and Public Health, Ministry of Health
Although various social marketing campaigns have shown promise in uncontrolled studies, the
evidence from controlled studies for the use of social marketing campaigns in controlling for
bacterial STIs is poor. Some studies have shown an increase in uptake of STI testing and a
reduction of risk behaviours. No studies were found evaluating the impact of social marketing
campaigns on STI incidence/prevalence.
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APPENDIX D: DESCRIPTIONS OF SELECTED INTERVENTIONS
Box 1: Philadelphia High School STD Screening Program (PHSSSP)
Letters were sent to parents and guardians of students in advance of the PHSSSP implementation, describing the
risks of chlamydia and gonorrhea infections, high rates of infection in Philadelphia, and nature of the voluntary
screening program. The letter encouraged parents to discuss the problem of STDs with their children, but parental
consent was not required in accordance with regulations in Pennsylvania.
The Philadelphia Public Health Department (PDPH) staff worked with school administrators to set up the program
in each high school. Groups of approximately 60 students attended an educational and screening session, led by
specially trained disease intervention specialists and STD educators. The 25-minute interactive educational portion
included an overview of common STDs and risk factors for STDs with an emphasis on chlamydia and gonorrhea.
During the sessions, it was emphasized that screening was voluntary and confidential, and that free and
confidential treatment would be made available for those who tested positive. Screening was available for all
students who attended the educational sessions, however the importance of screening for those who had ever
engaged in sexual intercourse was emphasized.
Each high school's sessions were planned to ensure that each student was scheduled to attend a session for one
period during the school day; some students were missed because of absence or truancy. Sessions were held at
each school over five months.
Every student was given a testing kit, consisting of a brown paper bag with: 1) a form to be completed by the
students (name, date of birth, address, phone number, ethnicity, preferred method for contact by PDPH staff, and
a self-selected secret code); 2) a urine collection cup; and 3) a card with a PDPH telephone number to call for test
results. Students were asked to provide urine specimens if they wanted to be tested. Small groups of students
(equal to the number of stalls in the bathrooms), were accompanied to the bathrooms by PDPH staff who collected
kits as students exited (irrespective of whether a urine specimen was provided). Specimens were tested for
chlamydia and gonorrhea using NAAT at the PDPH Public Health Laboratory.
Students who phoned PDPH were given their test results after confirmation of their secret code. Students with
positive test results were informed when PDPH staff would be at their school to provide treatment, were
instructed to abstain from sex until completing treatment, and were encouraged to ensure that their partners
received treatment. Those with partners in the same school were told that partners could come to ‘in-school’
treatment sessions. The staff at each school established ways to ensure that attendance at treatment sessions
would be confidential. When students with positive test results attended ‘in-school’ treatment sessions, a PDPH
clinician provided a single-dose observed therapy (1 g azithromycin orally for the treatment of chlamydia and/or
400 mg cefixime orally for the treatment of gonorrhea). Students with allergy or other contraindications were
referred to a public health center or to their physician for treatment. Students who received treatment within the
school or at PDPH clinics received STD risk avoidance counselling, were referred for complete STD and HIV testing,
and given referral cards listing PDPH clinics for their sexual partners. Students with symptoms of PID or
epididymitis were treated and referred for immediate evaluation.
For students with positive tests that did not call for their results, PDPH staff tried to confidentially inform them
about the treatment session at their school. Students that did not attend the school treatment sessions were
actively followed by PDPH and offered assistance (including with transportation) to attend a PDPH clinic or other
healthcare provider of their choice. Staff then followed up with the healthcare providers to ensure that
appropriate treatment had been given.
Population and Public Health, Ministry of Health
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Box 2: Family Court STD Screening Program
The Family Court is responsible for adjudicating all cases of delinquency among juveniles in Philadelphia. The
Screening Program began in April 2004 through a collaborative effort between the Philadelphia Department of
Public Health, Sexually Transmitted Disease (STD) Control Program, and the Family Court of Philadelphia. It was
designed to offer all youth under Court-ordered supervision, who had been adjudicated delinquent and placed on
probation, an opportunity to receive a confidential screening for chlamydia and gonorrhea using urine samples. It
seems appropriate for STD screening of youth because most of the youth already provide urine for drug testing; as
well, probation officers can provide current addresses to help assure treatment when necessary. Note that
adolescents adjudicated delinquent in Family Court are released and return to their communities; therefore, if
they have a STI infection and do not receive treatment, there is a risk of continuing infection spread.
Before the program started, input was sought from the Offices of the Public Defender and the District Attorney.
Potential barriers to program implementation were addressed. These included concerns about confidentiality of
testing and test results, self-incrimination by adolescents, and possible bias by the court if positive results are
known.
Directly after the Family Court hearing and intake into the probation system, youth were directed by probation
officers to the STD screening office (staffed by one full time public health employee) in the Family Court building
where they were offered confidential STD screening. Participation was voluntary. In Pennsylvania, parental
consent is not required for STD testing, diagnosis, or treatment of minors. If recent testing could not be
documented through public health records, the adolescent was given a brief educational/motivational
presentation and then asked to permit a portion of the urine specimen collected for required drug testing to also
be tested for chlamydia and gonorrhea. Adolescents were asked to select a secret code that would allow them to
access their results by telephone 1 week from the testing date by calling an identified public health number.
Participants who telephoned public health were given their test results after confirmation of their secret code,
and, if necessary, directed to a medical facility for treatment. Treatment was provided through the public health
STD clinics and included antibiotic therapy, risk reduction counselling, testing for other STDs as appropriate
(including HIV), referral for other services as needed, and partner referral counselling. All adolescents who tested
positive were followed-up by Disease Intervention Specialist staff to confirm that treatment had been received or
arrange for treatment.
Box 3: Shelter-based screening program
Adult shelter clients were taken to a private room within the shelter for an interview, and asked to provide urine,
blood and oral fluid samples for STI/HIV testing (chlamydia, gonorrhea, syphilis and HIV). Testing was free and
confidential, however participants were informed that positive results would be reported to the State Department
of Health. Pre- and post-test counselling was provided. Participants were asked to access their test results by
returning to the shelter where they were screened after one week. Participants who tested positive for chlamydia
or gonorrhea were treated on-site at the shelter in a private location by a project nurse (1 g azithromycin single
oral dose for CT, 400 mg ofloxacin single oral dose for gonorrhea). Individuals with infection were instructed to
inform their partners and abstain from sexual intercourse until their sexual partners had completed treatment.
Those who tested positive for either syphilis or HIV were taken to the local health department by project staff for
treatment, partner notification, and follow-up care.
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Box 4: Description of the 100 % Condom Use Program (100% CUP)
The 100% Condom Use Program began in Thailand in 1989 and has been implemented in Cambodia, Philippines,
Vietnam, China, Myanmar, Mongolia and Laos PDR, with variations in program components between countries. It
is a collaborative program between local authorities (health services, police, public security, local governor or
government office) and all sex entertainment establishments (owners, managers and sex trade workers) that aims
to reduce the sexual transmission of HIV and STIs by ensuring that condoms are used during commercial sex. The
program aims to promote the use of condoms 100% of the time in 100% of risky sexual relations in 100% of the sex
entertainment establishments in a large geographic area, whether a town, district, province or whole country. The
main characteristic of the program is the empowerment of sex trade workers to be able to assert “No condom –
No sex” in sex work. The intent is that there is no choice but to use condoms because all sex establishments will
have the same rule “No condom – No sex”.
Box 5: Description of the CHAT intervention
The CHAT intervention curriculum defines a Peer Mentor as someone who has meaningful conversations with
partners, friends, and other people in their social network. The intervention emphasized that the main difference
between this program and their usual conversations was that as Peer Mentors in the CHAT program, they used a
specific set of communication skills to engage in meaningful conversations about HIV and STI risk reduction. The
four communication skills, which also represent the intervention’s acronym, (CHAT) are: 1) Choose the right time
and place; 2) Hear what the person is saying; 3) Ask Questions; and 4) Talk with respect.
Box 6: The ImPACT intervention
The ImPACT intervention includes a 22-minute video containing footage about the importance of parental
monitoring and adolescent risk and protective behaviours through interviews, parent-youth conversations, youthto-youth discussions, as well as demonstrations and communication/negotiation. The key messages in the video
included the importance of monitoring youth (i.e., know where they are, whom they are with, and what they are
doing); talking with youth about sex before they begin to have sex or engage in other risky behaviours; being
aware that parents and youth should know how to use a condom; emphasizing self-protection including
abstinence and the use of both condoms and other forms of contraceptives; and emphasizing that drug and
alcohol use has risks and can lead to risky sexual behaviours.
After the video was played for the parent-youth dyad in their home by project staff, the parent and youth were
asked to role-play a vignette, with prompts; demonstrate the proper use of a condom on a plastic model; and then
review the key points in the video and repeat the role play to try and incorporate the messages from the video.
Finally, parents were given a copy of the video along with written material that reviewed the key messages.
Box 7: Draw the Line/Respect the Line program
The Draw the Line/Respect the Line Program is a 20-session curriculum, intended to help students to develop their
personal sexual limits and practice skills needed to keep those limits, even when challenged.
The program was implemented in grades 6, 7 and 8 classrooms, and was intended to be delivered over a threeth
year period and have a cumulative effect (i.e., later lessons built on principles learned in earlier lessons). The 6
grade curriculum featured limit setting and refusal skills in situations that were not related to sex (e.g., pressure to
th
use drugs, lie or steal). The 7 grade curriculum addressed personal limits related to sexual intercourse, and using
skills to maintain person limits and respect the limits of others (e.g., identifying risky situations and refusal skills).
th
The 7 grade curriculum also discussed the consequences of unplanned sexual intercourse, including STIs and
th
pregnancy. The 8 grade curriculum included presentations from a speaker that was living with HIV,
demonstration of condom use, and practice of refusal skills in a dating situation.
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The program was interactive and used different ways of delivering information (e.g., small group discussions, largegroup discussions, skill practice in pairs or small groups, stories, etc.).
The curriculum was designed to be appropriate for diverse ethnic groups. Further, as the sample was comprised of
60% Latino participants, the curriculum included key concepts that were important in the Latino culture. As well,
all program materials were provided in English and Spanish.
The program curriculum was delivered by trained health educators, and taught during a specific period at each
school.
Box 8: Safer Choices program
Safer Choices, a program implemented among students in grades nine and 10, has five components:
1) School organization: A School Health Promotion Council involves representation from teachers, students,
parents, administrators and community representatives.
2) Curriculum and staff development: Teachers are trained to deliver the classroom curriculum, involving 10
sessions at each of the grade nine and 10 levels (20 total sessions).
3) Peer resources and school environment: A Safer Choices club or team hosts activities that are implemented
throughout the school.
4) Parent education: Includes parent newsletters, student-parent homework activities, tips on talking to youth
about STIs, and other activities for parents.
5) School-community linkages: To increase students’ familiarity with the support services in the community, and to
increase their access to these services (e.g., homework assignments to learn about local services, resource guides,
presentations by individuals who are living with HIV, etc.).
Box 9: Clinical Practice Improvement Intervention
The clinical practice improvement intervention involved four steps:
1) Engage: Enlist the involvement of HMO leadership by presenting evidence showing that there is a gap between
the current situation and chlamydia screening best practice.
2) Team Building: Individuals that were particularly interested in adolescent health were identified by the research
time and chiefs of staff in the pediatric departments, and these individuals would comprise the adolescent care
team that would champion the project (i.e., nurses, administrators, medical assistants and medical practitioners).
They completed a workshop focused on skill building in group processes, implementation of a change model (plando-study-act) and developed a practice toolkit consisting of customized clinic flowcharts, exit polls and the Why to
Pee! (Y2P) campaign materials. The Y2P targets adolescent girls and attempts to raise awareness and interest in
screening.
3) Redesign clinical practice: The adolescent care team met monthly to review data on chlamydia screening rates
and notes from charts to discuss barriers to screening and strategies to overcome these, and to assess
improvements in screening rates. Note that all of the sites felt that the most effective way to accomplish screening
was to implement a universal urine specimen collection from all adolescents at the time of registration.
Practitioners subsequently determined which adolescents were sexually active, and these specimens were sent for
testing. Adolescents with positive results were contacted and received treatment. Attempts were also made to
treat partners.
4) Sustain the gain: Monitoring progress was achieved through the development of performance indicators (i.e.,
number of visits and chlamydia screening rates).
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Box 10: Example of a Florida SBHC program
Funding and Staff
This SBHC is funded by the county hospital through a half-penny sales tax. The staff includes a nurse practitioner
(NP), registered nurse (RN), social worker, and a receptionist and medical records clerk.
Parental consent
Enrolment requires notarized parental consent. The SBHC has a notary on site and parents often come in to sign
the consent form.
Scope of services (including but not limited to STI-related services)
A range of health services are offered, including: treatment of minor illness and injury; health promotion;
laboratory services; family planning; STI-HIV testing; and mental health counselling.
Every student that presents to the SBHC is asked to complete a behavioural risk assessment tool; this tool was
modeled after the Guidelines for Adolescent Preventive Services, developed by the American Medical Association.
In addition, the SBHC uses a unique “group” physical model. This is conducted on specific days by medical students
from the local medical school along with SBHC primary care providers. Students begin the program by attending
seminars, which may include topics on diet, exercise, STI, healthy lifestyles, and self-esteem. One station highlights
the various programs offered by the SBHC and health education materials are available on health-related topics.
Students process through various stations including height and weight, vital signs, vision, blood work, individual
physical examinations, and risk assessments.
STI-specific services
Two broad components:
1) Primary health care, including testing and treatment of STI/HIV, and mental health counselling.
2) Engaging students in prevention programs through a peer mentoring program, STI/HIV website, classroom
teaching and community involvement.
The SBHC promotes abstinence first and supports safer sex for adolescents that do not choose abstinence.
Risk assessments conducted through the group assessment process described previously, identifies students at risk
for STI/HIV. These students are asked to make appointments with the SBHC for follow-up services. It appears that
students can also attend the SBHC on their own initiative and receive services.
Peer-educators: The SBHC staff directs and supervises the peer educators in conjunction with adolescent
volunteers. Approximately 50 candidates each year are recruited to be peer educators. They learn about the
program by word of mouth, referrals, and classroom presentations and from other peer educators. Students are
required to participate in 8 hours of training and testing to prepare them to become peer educators. These trained
peer educators lead school activities, which include classroom sessions on STI-HIV, community health resources,
communication and negotiation skills to say “no,” and safer sex strategies. At these sessions, participants are given
a pretest and posttest questionnaire on the subject matter discussed to provide feedback to peer educators on the
effectiveness of their teaching. Data from the questionnaires are then used to improve strategies and methods.
Peer educators meet regularly to develop new programs and activities, which may include health fairs, speaking at
school assemblies, and participating in walk-a-thons in the community. These activities are ways the peer
educators get their messages out about abstinence, safer sex, and prevention of STI beyond the classroom setting.
Website: The website is interactive and student friendly and contains information on the SBHC; basic information
on gonorrhea, chlamydia, syphilis, herpes, hepatitis, venereal warts, and HIV-AIDS; statistics on the incidence and
prevalence of STI-HIV-AIDS; and links students to different websites to get additional information on STI, safe sex,
condom use, and other important health topics. The website also has an HIV-AIDS quiz, with true and false
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questions, such as “The first system that HIV-AIDS attacks to weaken the body is your nervous system,” or “On
September 3, 2002, the first cure was found for HIV.” Teachers are involved with the website and encourage its
use. To encourage widespread use of the website, contests are held throughout the year. Those students who
answer the most questions correctly about STI-HIV treatment and prevention receive prizes. Another component
of the website is a section on “Ask the Expert,” where students are linked to answers to questions on such teenage
issues as: What is acne? What causes bad breath? What is ringworm? In 2004, approximately 2000 high school
teenagers accessed the website. Each year, new students are enrolled in the program for continual updating and
maintenance of the website. This program runs parallel to the peer education program and compliments the
program.
Classroom education: Workshops include self-esteem workshops to improve students' self-concept. The social
worker goes into classrooms on a regular basis to provide education on various topics, such as STI-HIV prevention,
self-esteem, stress management, and other mental health subjects.
Box 11: Policy 123
Policy 123, which was adopted in 1991 by the Board of Education for the School District of Philadelphia, is a
package of interventions designed to reduce rates of STIs, HIV and pregnancy among youth. The three strategies of
this policy are:
1) “To direct schools to develop instruction that promotes ‘healthy habits and moral values regarding human
sexuality’ and to convey that ‘abstinence is the most effective way of preventing pregnancy, STIs and HIV’”.
2) To authorize education for staff, outreach directed at parents and the development of partnerships with health
care providers in the community.
3) To recommend that the school district be involved in initiatives that maximize condom access and create a pilot
program (phased-in) of condom availability in schools that have grades 9-12.
Box 12: Features of the Get Tested Why Not program, Ottawa Public
Health
Website features:
-Mapping function, allowing for ready identification of the nearest laboratory using Google maps.
-A floating “hide” button that users can select to quickly leave the website if there are concerns about privacy.
-A scrolling text marquee that contains information about sexual health.
Text/SMS service:
Users can text an automatic system that will provide information about sexual health and local resources. Available
24 hours per day.
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Box 13: Challenges related to STI screening in prison and suggested
solutions
Challenge
Inmates may initially decline testing but then want to be
tested at a later time.
Inmates may be released prior to testing results being
available, thereby missing the opportunity for treatment.
Safety and security are the priority, therefore where there
are lockdowns, shift changes, and processing of certain
inmates, the daily screening and treatment activities may
be affected. This may make it difficult to identify the total
number of inmates that can be offered screening.
Population and Public Health, Ministry of Health
Suggestion
Offer screening at various points during an inmate’s
time in prison.
Contract with laboratories that can return results
quickly.
Establish a process for community follow-up for
inmates that are released before being notified of
positive test result(s). Establish a process for notifying
inmates and offering this community follow-up.
Careful tracking and ensuring that data is correct and
comprehensive.
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APPENDIX E: PATIENT-DELIVERED PARTNER THERAPY (PDPT)– THE
POLICY AND LEGAL ENVIRONMENT
Hodge et al. (332) discuss expedited partner therapy (EPT), the delivery of medications or prescriptions
by persons living with a STI to their sexual partners without prior clinical assessment of those partners.
Clinicians provide patients with sufficient medication directly or via prescription, for them and their
partners and encourage patients to have their partners seek clinical assessment (332). The CDC
evaluated EPT studies and concluded that EPT is a “useful option” to promote partner treatment,
particularly for male partners of women with chlamydia infection or gonorrhea; and in 2006, the CDC
recommended EPT as an option for certain populations with specific conditions (333) (334).
The benefits and concerns related to PDPT/EPT include (332) (335):
Benefits:
 Treatment of hard-to-reach partners who may not otherwise receive treatment.
 Treatment of partners as the same time as the patient, which can avoid reinfection; there is
evidence that not treating both partners when one presents with gonorrhea and chlamydia is
associated with an increased risk of PID in females, and risk of reinfection of the index case.
Concerns:
 Potential for missed morbidity in partners who are treated without being assessed clinically
(e.g., partners may have concurrent STIs or PID or other sequelae that is missed because they
are not examined).
 Lost opportunity to counsel sexual partners about risk reduction, and to in turn refer their other
partners for assessment and treatment.
 Legal questions about providing medications or prescriptions to individuals that the clinician has
not personally assessed or established a physician-patient relationship (this consideration
potentially applies to other health care professionals as well, such as Nurse Practitioners or
Advanced Practice Outpost Nurses).
In a survey of state boards of medicine and pharmacy in the US, Golden et al. (2005) found that 88% of
boards felt that EPT was illegal or of “uncertain” legality. This was partly due to the fact that the legal
issues had not been addressed (336).
Health care providers do not usually provide prescription medications to non-patients; this helps to
ensure that individuals do not gain access to medications they do not need or that could be dangerous
to them. However, there are exceptions to this that are done in an attempt to ensuring that safe and
effective medications are made available to people who need them (332):
 Physicians providing prescription medications to children or elderly patients through parents or
caregivers.
 Spouses given medications.
 Medications for people with mental disabilities may be distributed through court-appointed
guardians.
 Public health practitioners provide flu vaccines without an extensive clinical evaluation.
 In response to outbreaks of meningococcal meningitis in hospitals, hospital staff and their family
members may be provided antibiotics without being personally assessed. This may apply to
other settings as well.
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Hodge et al. (2008) determined that, at the time of their review, 3/4 of states or territories in the U.S.
either expressly permit EPT or do not expressly prohibit EPT (see Figure 1) (332).
Figure 1: Map Depicting the Legal Status of EPT across the U.S.
Reference: Hodge et al. (2008) (332)
EPT is legally permissible in 12 jurisdictions because their laws or governing authorities expressly allow
the practice of EPT. Examples of excerpts from these jurisdictions are presented in the table below.
Examples of different EPT regulations in different jurisdictions (332)
Jurisdiction
California
Source
Statutory law
Tennessee
Board of medical
examiners
Colorado
Board of medical
examiners
Administrative
code
Nevada
Excerpt
A physician in California may “provide prescription antibiotic drugs to [a]
patient’s sexual partner[s]. . . without examination of that patient’s
partner[s]” for treating chlamydia, gonorrhea, or other STDs (337).
Promulgated administrative rules allowing EPT for the ““effective and safe
treatment to partners of patients infected with [chlamydia infection] who
for various reasons may not otherwise receive appropriate treatment.”
(338)
Board of medical examiners recommended EPT in response to the
compelling need for partners to receive treatment (339).
Adopted the CDC’s STD treatment guidelines which include EPT (240).
In 28 jurisdictions, EPT is legally potentially allowable; this conclusion was reached because the laws
within these jurisdictions may allow EPT, subject to specific interpretations or inconsistent or ambiguous
provisions, or there are policy statements supporting EPT, or regulations adopting current STD
treatment guidelines that support EPT (332). In 13 jurisdictions, EPT is probably precluded (332).
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The Canadian context
In Ontario, the College of Physicians and Surgeons of Ontario (CPSO) medication prescribing policy,
under the heading “Physician Patient Relationship”, states:
“Exceptions
The circumstances in which physicians are permitted to prescribe without a prior assessment of the
patient can include:
Prescribing for the sexual partner of a patient with a sexually transmitted infection (STI) who, in the
physician’s determination, would not otherwise receive treatment and where there is a risk of further
transmission of the STI…” (340)
In Ontario, the Provincial Infectious Diseases Advisory Committee (PIDAC), a multidisciplinary scientific
advisory body who provide advice to the Chief Medical Officer of Health, offered the following
recommendations regarding PDPT (335):
“12.1 Patient-Delivered Partner Therapy (PDPT) should be considered as an option for difficult to reach
contacts of chlamydia or gonorrhea when usual contact tracing methods are unsuccessful [IA] Evidence is
available only from studies of heterosexual men and women.
 PDPT must be used with caution in populations at high risk for HIV and syphilis
 Patient information sheets must be included in PDPT…”
The official position on PDPT in the BC environment was not identified through the online search used
for this evidence review. An additional search, beyond that specified in the methodology, was
conducted to search for relevant documents, including:



Search terms in GoogleTM:
o “College of Registered Nurses of British Columbia Patient-Delivered Partner Therapy for
STI”
o “College of Physicians and Surgeons of British Columbia Patient-Delivered Partner
Therapy for STI”
The websites of both organizations were searched using the terms “patient-delivered partner
therapy”.
Title-based search of CPSBC “guidelines” and “laws” sections, with full review of any documents
that seemed likely to contain this information (e.g.,
“Prescribing Practices, Countersigning Prescriptions and Internet Prescribing”).
This search did not identify any results; however, this information may be contained in codes or policies
that were not available through the aforementioned search. A dedicated search of the policies of these
Colleges would likely be more fruitful.
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APPENDIX F: EXAMPLES OF SOCIAL MARKETING CAMPAIGNS
Figure 1: A cartoon strip from the Healthy Penis campaign.
Adapted from Ahrens, et al. (2006). Permission to reproduce not required.
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Figure 2: Sample of a poster in the Hombres Sanos campaign.
Adapted from Martinez-Donate, et al. (2010). Permission to reproduce granted by The Sheridan Press.
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Figure 3: An example of a Drama Downunder campaign poster.
Adapted from Pedrana, et al. (2012). Permission to reproduce granted by Wolters Kluwer Health.
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Figure 4: A sample of social marketing campaign materials from Darrow and Biersteker (2008).
Permission to reproduce granted by The Sheridan Press.
Figure 5: An example of a poster from the “Check-It-Out” campaign.
Adapted from Guy, et al. (2009). Permission to reproduce by BMJ Publishing Group Ltd.
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APPENDIX G: RECOMMENDED KNOWLEDGE MOBILIZATION PARTNERS
This appendix was created by the BC Ministry of Health after the bacterial STI prevention interventions were identified and rated. It lists all
interventions that had a two star rating in biological and/or behavioural outcomes. In the absence of a population-based sexual health survey,
some promising and effective interventions did not achieve two star or higher ratings. Such STI prevention interventions were added following
consultation with BCCDC subject matter experts who ranked the interventions as important to consider for programming based on provincial
epidemiology, current context and/or currently emerging trends.
To effectively tackle bacterial STI in the province, action is required across the social determinants of health and needs to involve all levels of
government as well as the not-for-profit and private sectors (341). Maximizing effective approaches to preventing and addressing STIs among
British Columbians, but particularly young adults and MSM, must engage the public systems they use – this includes the health system, the
education system (through the Ministry of Education), the social development system (such as through the Ministry for Children and Family
Development, or the Ministry of Social Development/Social Innovation), the criminal justice system (through the Ministry of Justice), and
partners in civil society. Accordingly, this table lays out the highly rated or promising interventions, and identifies the potential public systems
and partners (termed knowledge mobilization partners) that have a role to play in implementing strategies aligned with the evidence.
Leadership in multiple sectors will be crucial to achieving meaningful and sustainable outcomes.
The knowledge mobilization partners suggested are not exhaustive, but highlight the opportunities for leadership and types of collaboration
required within the health system and beyond to effectively prevent STIs. Three distinct categorizations are provided. Some are mostly within
the scope of BC’s health-authorities, including both regional and the Provincial Health Services Authority (PHSA). Regional health authorities
would include organizations such as Providence HealthCare. These would also include BC Centres for Excellence in HIV/AIDs, and BC Centre for
Excellence in Women’s Health. In some cases, implementation may best be undertaken in partnership with the First Nations Health Authority
(343).b Additionally, there are interventions that require partnership among multiple health sector partners, and interventions that require
health sector collaboration with other sectors comprising civil society.
The role and work of the Ministry of Health, regional health authorities, the Provincial Health Services Authority and the First Nations Health
Authority, are articulated in the Ministry of Health 2014/15 - 2016/17 Service Plan (342).
b
The First Nations Health Authority (FNHA) in BC assumed the programs, services, and responsibilities formerly handled by Health Canada's First Nations Inuit Health Branch –
Pacific Region in 2013. Their vision is to “transform the health and well-being of BC's First Nations and Aboriginal people by dramatically changing healthcare for the better”.
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The term 'health sector’ encompasses all organizations (that perform services) whose primary function is to prevent illness, promote well-being,
and treat disease. This extends from public health programs, contracted agencies, and community organizations to the more familiar “bricksand-mortar” hospitals and specialist services.
Notes:
For micro-level interventions, regional health authorities, PHSA and BCCDC programs would offer these mostly through clinical programs such as
the Oak Tree Clinic, or BCCDC STI clinic locations/outreach, regional STI or primary care clinics, etc.
Community based organizations for this purpose are those that are often contracted by health authorities or other agencies to better reach and
engage people into care and other social services.
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Micro-Level Interventions
Intervention
STI/HIV Prevention Counselling and
Behavioural Interventions, including:
1) General behavioural interventions and
risk reduction counselling
2) Behavioural interventions stressing
ethnic pride and skill-building
3) Behavioural interventions for MSM
4) Cognitive-behavioural interventions
5) Brief behavioural interventions
Population and Public Health, Ministry of Health
Implementation
Primary knowledge mobilization partners
Falls within health authority scope and
mandate in collaboration with health system
and community partners.

Falls within health authority scope and
mandate in collaboration with health system
and community partners who support ethnocultural populations.

Falls within health authority scope and
mandate in collaboration with health system
and community partners who support MSM
populations.
Falls within scope and mandate of health
authorities in collaboration with health
system and community partners.
Falls within scope and mandate of health
authorities in collaboration with health
system and community partners.













Regional health authorities and
PHSA/BCCDC
Independent health care providers
Community-based organizations
Regional health authorities and
PHSA/BCCDC (for example, the Chee
Mamuk program)
Independent health care providers
Community-based organizations
supporting ethno-cultural populations
Regional health authorities and
PHSA/BCCDC
Independent health care provider
Community-based organizations
supporting MSM
Regional health authorities and
PHSA/BCCDC
Independent health care providers
Community-based organizations
Regional health authorities and
PHSA/BCCDC
Independent health care providers
Community-based organizations
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Intervention
Small group sessions
Implementation
Requires collaboration among the health
system, community partners, and partners
outside the health system.
Peer education
Requires collaboration among the health
system, community partners, and partners
outside the health system.
Online interventions targeting youth (general
or multiple interventions)
Falls within scope and mandate of health
authorities, but requires collaboration with
health system, community partners and
partners outside the health system.
Population and Public Health, Ministry of Health
Primary knowledge mobilization partners
 Regional health authorities and
PHSA/BCCDC
 Independent health care providers
 Community-based organizations
 Workplace health/labour sector
 Ministry of Education
 Ministry of Children and Family
Development
 Regional health authorities and
PHSA/BCCDC
 Community-based organizations
 Workplace health/labour sector
 Ministry of Education
 Ministry of Children and Family
Development
 Regional health authorities and
PHSA/BCCDC
 Community-based organizations
 Workplace health/labour sector
 Ministry of Education
 Ministry of Children and Family
Development
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Intervention
Innovative STI Screening programs, including:
1. Home-based STI screening for youth
2. Self-screening for MSM
Use of male condoms
Patient-Delivered Partner Therapy
Population and Public Health, Ministry of Health
Implementation
Primary knowledge mobilization partners
Falls within scope and mandate of health
authorities and individual care providers, but
requires collaboration with health system and
community partners.
Requires home testing kits to be approved for
sale in Canada.

Falls within scope and mandate of health
authorities, but requires collaboration with
health system and community partners.
Requires home testing kits to be approved for
sale in Canada
Falls within scope and mandate of health
authorities, but requires collaboration with
health system and community partners, and
partners outside the health system.

Falls within scope and mandate of health
authorities in collaboration with relevant
independent health care providers and
professional colleges.













Public Health Microbiology and
Reference Laboratory/BCCDC
Independent health care providers
Community-based organizations
Health system and industry partners
Public Health Microbiology and
Reference Laboratory/BCCDC
Community-based organizations
Health system and industry partners
Regional health authorities and
PHSA/BCCDC
Independent health care providers
Community-based organizations
Workplace health/labour sector
Ministry of Education
Ministry of Children and Family
Development
Regional health authorities and
PHSA/BCCDC
Independent health care providers
Community-based organizations
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Meso-Level Interventions
Intervention
Social Diffusion, including:
1) Community opinion leadersc
2) Peer mentors within a social
network
c
Implementation
Primary Knowledge Mobilization Partner(s)
Requires collaboration among the health system,
community partners.


Community-based organizations
Regional health authorities and
PHSA/BCCDC (for example, through
outreach with immigrant
populations)
Requires collaboration among the health system,
community partners, and partners outside the
health system.

Regional health authorities and
PHSA/BCCDC
Independent health care providers
Community-based organizations
Workplace health/labour sector
Ministry of Education
Ministry of Children and Family
Development





Listed as a stand-alone intervention, but meant to be an integral component of any community-based work.
Population and Public Health, Ministry of Health
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Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
Intervention
Group Education, including:
1) Risk reduction
2) Skill building in group education
Population and Public Health, Ministry of Health
Implementation
Primary Knowledge Mobilization Partner(s)
Requires collaboration among the health system,
including community partners, and partners
outside the health system.

Requires collaboration among the health system,
including community partners, and partners
outside the health system.











Regional health authorities and
PHSA/BCCDC
Independent health care providers
Community-based organizations
Ministry of Justice
Ministry of Education
Ministry of Children and Family
Development
Regional health authorities and
PHSA/BCCDC
Independent health care providers
Community-based organizations
Ministry of Justice
Ministry of Education
Ministry of Children and Family
Development
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Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
Intervention
Clinic-based Interventions, including:
1) Disease Intervention Specialists
(DIS)
Implementation
Falls within scope and mandate of health
authorities in collaboration with relevant
independent health care providers and others in
the health system.
Primary Knowledge Mobilization Partner(s)



2) Electronic technologies in STI clinics,
including active use of electronic
medical records, reminders, and
other software to promote care
Falls within scope and mandate of health
authorities in collaboration with relevant
independent health care providers.
3) Syphilis testing during routine HIV
monitoring
Falls within scope and mandate of health
authorities, including laboratories, in collaboration
with community partners who may provide HIV
testing, and with relevant independent health care
providers.

Falls within scope and mandate of health
authorities in collaboration with community
partners who support men, and relevant
independent health care providers.

Falls within scope and mandate of health
authorities in collaboration with community
partners who provide mobile services, and relevant
independent health care providers.

4) Male clinics
5) Mobile clinics
Population and Public Health, Ministry of Health







Regional health authorities and
PHSA/BCCDC
Independent health care providers
Regional health authorities and
PHSA/BCCDC
Independent health care providers
Regional health authorities and
PHSA/BCCDC
Independent health care providers
Community-based partners
Regional health authorities and
PHSA/BCCDC
Independent health care providers
Community-based partners
Regional health authorities and
PHSA/BCCDC
Independent health care providers
Community-based partners
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Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
Intervention
Venue or Group-based Screening Outreach:
1) School-based STI screening and
treatment programs
2) School-based health centers
3) Screening in prisons
4) Screening in shelters
5) Screening for commercial sex workers
Population and Public Health, Ministry of Health
Implementation
Primary Knowledge Mobilization Partner(s)
Falls within scope and mandate of health
authorities, but requires collaboration with health
system and community partners, and partners
outside the health system.

Falls within scope and mandate of health
authorities, but requires collaboration with health
system and community partners, and partners
outside the health system.

Requires collaboration with health system and
community partners, and partners outside the
health system
Falls within scope and mandate of health
authorities, but requires collaboration with
community partners.
Falls within scope and mandate of health
authorities, but requires collaboration community
partners.














Regional health authorities and
PHSA/BCCDC
Independent health care providers
Community-based organizations
Ministry of Education
Regional health authorities and
PHSA/BCCDC
Independent health care providers
Community-based organizations
Ministry of Education
Regional health authorities and
PHSA/BCCDC
Independent health care providers
Community-based organizations
Ministry of Justice
Regional health authorities and
PHSA/BCCDC
Community-based organizations
Regional health authorities and
PHSA/BCCDC
Community-based organizations
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Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
Intervention
6) Screening at MSM sex-on-premises
establishments, bathhouses, saunas
Implementation
Falls within scope and mandate of health
authorities, but requires collaboration with
community partners.
7) Home-based STI testing
Falls within scope and mandate of health
authorities, but requires collaboration.
Requires kits to be approved for sale in Canada.

Requires collaboration with health system and
community partners.

Internet-based promotional campaigns and
services to increase STI testing:
1) for MSM
Primary Knowledge Mobilization Partner(s)
 Regional health authorities and
PHSA/BCCDC
 Community-based organizations



2) For youth
Contact tracing using a social network
approach
Periodic presumptive treatment
Population and Public Health, Ministry of Health
Requires collaboration among the health system,
including community partners, and partners
outside the health system.
Falls within scope and mandate of health
authorities in collaboration with relevant
independent health care providers and community
partners.
Falls within scope and mandate of health
authorities in collaboration with relevant
independent health care providers.








Regional health authorities and
PHSA/BCCDC
Community-based organizations
Health system and industry partners
Regional health authorities and
PHSA/BCCDC
Community-based organizations
who support MSM
Regional health authorities and
PHSA/BCCDC
Community-based organizations
who support youth
Ministry of Education
Regional health authorities and
PHSA/BCCDC
Community-based organizations
Independent health care providers
Regional health authorities and
PHSA/BCCDC
Independent health care providers
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Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
Intervention
Community mobilization
Implementation
Requires collaboration among the health system,
including community partners.
Primary Knowledge Mobilization Partner(s)
 Regional health authorities and
PHSA/BCCDC
 Community-based organizations
Macro-Level Interventions
Intervention
STI-specific policy with an evaluation of
impact, including:
1) 100% CUP Program
Implementation
Requires collaboration among the health system,
and partners outside the health system.
Primary Knowledge Mobilization Partner(s)




2) Combined community mobilization Requires collaboration among the health system,
and policy initiatives
including community partners.



3) Performance measures
Falls within the scope and mandate of the Ministry
of Health as well as health authorities, but requires
collaboration among multiple health system
partners.
Population and Public Health, Ministry of Health


Regional health authorities and
PHSA/BCCDC
Independent health care providers
Community-based organizations
Ministry of Justice
Regional health authorities and
PHSA/BCCDC
Community-based organizations
Ministry of Health
Regional health authorities and
PHSA/BCCDC
Community-based organizations
Ministry of Health
Ministry of Justice
Ministry of Education
Ministry of Children and Family
Development
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Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
Intervention
Clinic-based systems interventions
Mass media Campaigns:
1) targeting youth
Implementation
Falls within scope and mandate of health
authorities in collaboration with relevant
independent health care providers.
Requires collaboration among the health system
and community partners, and partners outside the
health sector.
Primary Knowledge Mobilization Partner(s)
 Regional health authorities and
PHSA/BCCDC
 Community-based organizations




2) Social marketing campaigns for
MSM
Population and Public Health, Ministry of Health
Requires collaboration among the health system,
including community partners who support MSM.



Regional health authorities and
PHSA/BCCDC
Independent health care providers
Community-based organizations that
support youth
Ministry of Education
Regional health authorities and
PHSA/BCCDC
Independent health care providers
Community-based organizations that
support MSM
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Prevention of Sexually Transmitted Infections, with a Focus on Bacterial Sexually Transmitted Infections
ABBREVIATIONS AND ACRONYMS
CDC:
DIS:
EPT:
GUM:
FSW:
MSM:
NAAT:
PCR:
PDPT:
PHAC:
PID:
PN:
PPT:
RCT:
SBHC:
SMS:
STD:
STI:
WHO:
United States Centers for Disease Control and Prevention
Disease intervention specialist
Expedited Partner Therapy
Genitourinary medicine clinic
Female sex trade worker
Men who have sex with men
Nucleic acid amplification test
Polymerase chain reaction
Patient-delivered partner therapy
Public Health Agency of Canada
Pelvic inflammatory disease
Partner notification
Presumptive periodic treatment
Randomized controlled trial
School-based health centers
Short messaging service
Sexually transmitted disease
Sexually transmitted infection
World Health Organization
Population and Public Health, Ministry of Health
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