Counselling

STI/RTI basics
Chapter 4. STI/RTI education and counselling

Counselling

Health care providers have an important role to play in supporting women and men to adopt effective prevention strategies. Counselling is a more in-depth process than health education and requires more time. Because of this, in busy clinics it may make sense to have a person specifically assigned to counsel patients. Such a person may provide other services, such as voluntary HIV counselling and testing. Effective counselling must deal with issues of risk and vulnerability (Box 4.5).

Box 4.5. Elements of effective counselling

Try to understand how a person�s situation may increase risk and vulnerability. Understand that there may be circumstances in a person�s life that are difficult to change (for example, alcohol use, sex work for survival) and that may make safer sex difficult.

Provide information. Give patients clear and accurate information on risky behaviours, the dangers of STI, and specific ways to protect themselves.

Identify barriers. What keeps someone from changing behaviour? Is it personal views, lack of information, or social restraints such as the need to please a partner? Which of these can be changed and how?

Help people find the motivation to reduce their risk. People often change behaviour as a result of personal experience. Meeting someone who has HIV/AIDS, hearing about a family member or friend who is infertile due to an STI/RTI, or learning that a partner has an infection are all experiences that can motivate someone to change behaviour.

Establish goals for risk reduction. Set up short- and long-term goals that the patient thinks are realistic.

Offer real skills. Teach negotiation skills, demonstrate how to use condoms, and conduct role-playing conversations.

Offer choices. People need to feel that they have choices and can make their own decisions. Discuss substitute behaviours that are less risky.

Plan for setbacks. Rehearse how to deal with a difficult situation (for example, the husband becomes angry or refuses to use condoms).

Messages should be adapted to be relevant for each person or couple. Finding the right balance between reliable prevention of pregnancy and prevention of STI (dual protection) for each client requires a flexible approach to counselling on the part of the health care provider.

Preventing pregnancy may be the main concern for young, single clients who may be unaware of their risk of STI (see Box 4.6). Education about STI risk may increase motivation to use condoms for dual protection, or to delay onset of sexual activity.
Women and men in their early reproductive years�whether or not they are currently using contraception�are often concerned about their future ability to have children. Emphasizing the importance of STI prevention in maintaining family health and fertility may be effective motivation.
Pregnant women and their partners who are concerned about maintaining a healthy pregnancy can be motivated to prevent infection to reduce the risk of congenital infection.
Pregnancy prevention is not an issue for some people. A woman who has undergone tubal ligation, is postmenopausal or currently pregnant may still be at risk of STI and require advice on prevention.

Box 4.6. Special considerations for counselling young people

Counselling young people may take more time.
Young people must feel confident that their privacy and confidentiality will be respected.
Try to establish whether the young person has someone to discuss her/his problems with.
Be sensitive to the possibility of sexual violence or coercion. Sex with much older partners may be more likely to be coerced and may carry a higher risk of HIV or STI.
Make sure the young person understands normal sexual development, and how pregnancy occurs.
Make sure the young person understands that it is possible to say "no" to sex.
Discuss issues related to drug and/or alcohol use and sexual risk-taking.
It may be useful to involve peers in education.
Check that the adolescent can afford any medicines necessary to treat an RTI and will be able to take the full course of treatment. Young people are particularly likely to stop or interrupt treatment if they experience unexpected side-effects.
Ensure follow-up is offered at convenient times.

Thinking about risk and vulnerability

Few people are able simply to accept information about what is good for them and make the necessary changes in their lives. Health care providers should be aware of situations and behaviour that influence STI risk and vulnerability, and take a realistic approach to behaviour change. Risk and vulnerability are influenced by behaviour as well as by other factors, such as age and gender, the place where one lives and works, and the larger social, cultural and economic environment, which may be beyond the person�s power to change. Migrant workers who are separated from their families for long periods of time may have risky sex because they are lonely; poor people often have poor access to health care services; and some women and men are forced to sell or trade sex in order to survive or support their families.

An understanding of these factors permits a realistic approach to counselling that takes into account circumstances in a person�s life that may be difficult to change. Knowledge of risk can also help with decisions about RTI management (Table 4.2).

Table 4.2. How individual risk may influence reproductive health decisions and STI/RTI prevention, detection and management

	High risk	Low risk
Contraceptive choice (Chapter 6)	Women with multiple sexual partners should use condoms alone, or in addition to another contraceptive method.	Dual protection may not be needed for couples in a stable mutually monogamous relationship.
RTI detection	Priority for STI screening (where available) should be people with multiple partners or other risk. Women over 35 should be given priority for cervical cancer screening because they are at higher risk.	Apart from syphilis testing in pregnancy, asymptomatic patients without obvious risk do not need to be screened for STI.
RTI management (Chapter 8)	An adolescent with vaginal discharge, whose boyfriend has a discharge, should receive additional treatment for cervical infection, and counselling on partner treatment and STI prevention.	A woman with vaginal discharge who is monogamous and has a stable family life is probably at low risk for STI and should be treated for the common vaginal infections (see Flowchart 1 in Chapter 8).
Counselling (Chapter 4)	Counselling should address specific risk behaviours.	Women with no apparent risk do not require lengthy counselling (and may not welcome it).
Partner treatment (Chapter 8)	Decisions about partner treatment should be made in the context of the couple�s situation. If one partner has had other sexual partners, or travels away from home often, it may be safer to treat both partners for STI even when symptoms are unclear.	Many RTIs do not require partner treatment because they are not sexually transmitted. If in doubt, approach the issue of partner notification carefully and let the patient decide.

Unfortunately, there is no foolproof way to evaluate a person�s risk. Table 4.3 may help providers manage patients, using their clinical skills and knowledge of the community, and the patient�s own assessment in thinking about risk. By addressing real issues, patients may be able to find solutions that will work for them.

Table 4.3. Factors to consider in assessing risk

Prevalence of STI in the community or social network	STI prevalence is often higher among: sex workers, clients of sex workers and partners of either; people who engage in risky sexual behaviour for money, gifts or favours. These people may not consider themselves sex workers or at risk; migrant workers and other people in occupations that involve frequent travel and separation from family; adolescents and young adults.
Information collected from patient	Increased exposure may be suggested by a patient: having multiple sexual partners; having a recent new sexual partner; having a partner with STI symptoms.
Provider judgement	Health care providers can use their clinical judgement and knowledge of the community, together with the above factors, to evaluate risk.
Patient thinks she may be at risk	Sometimes it is difficult to ask intimate questions about risk behaviour, or patients may be reluctant to answer them. In such cases, it may be useful simply to ask the patient whether she thinks she may be at risk for STI. Asking about risk may open the door to more questions and discussion, or a woman may simply acknowledge being at risk even when she declines to discuss the details.

Supporting behaviour change

Whatever their situation, patients need information about STI/RTI, behaviours that increase risk and how to avoid them. They also need support and encouragement in negotiating safer sex, including condom use.

Health care providers can use their counselling skills to support women and men to agree on adopting safer sex behaviour that meets their needs. Box 4.7 gives some pointers that may be useful in helping patients negotiate safer sex.

Box 4.7. Negotiating for safer sex

Negotiating for safer sex is similar to negotiating for other things that we need. Thinking about how to negotiate successfully in other areas will help. A way to begin is for one person to decide what she or he wants, and what she or he is willing to offer in return.

Focus on safety

In negotiating for safer sex, the focus should be on safety, not lack of trust or blame or punishment. It is easier to reach agreement about safety because both people benefit from it.

Use other people as examples

Knowledge that others are practising safer sex can make it easier to start.

Ask for help if you need it

Inviting another trusted person to help discuss safer sex with a partner may make it easier.

Condom negotiation is one example. Box 4.8 suggests some responses to common objections that partners may raise when asked to use condoms.

Box 4.8 Help women with condom negotiation skills

If he says:	Try saying:
It will not feel as good�	It may feel different, but it will still feel good. Here let me show you. You can last even longer and then we will both feel good!
I do not have any diseases!	I do not think I have any, either. But one of us could and not know it.
You are already using family planning!	I would like to use it anyway. One of us might have an infection from before that we did not know about.
Just this once without a condom�	It only takes one time without protection to get an STI or HIV/AIDS. And I am not ready to be pregnant.
Condoms are for prostitutes. Why do you want to use one?	Condoms are for everyone who wants to protect themselves.
	NO CONDOM, NO SEX!
Do what you can to make sure that you both enjoy having sex with a condom. That way, it may be easier to get him to use one the next time.

Counselling patients about �risks� and �protection� can easily sound negative, especially to adolescents and others who may feel confused or guilty about their sexuality. Health care providers should strive to maintain a positive attitude and emphasize the benefits of enjoying a healthy sex life while protecting health and fertility. The next section looks at ways of getting these messages across in the community and within reproductive health clinic settings.

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	Department of Reproductive Health and Research (RHR), World Health Organization Sexually transmitted and other reproductive tract infections A guide to essential practice	Preface/Full text PDF About the guide Abbreviations Glossary