STIs Trainers' Manual

STIs TRAINERS' MANUAL

Welcome Message Dear SCORAngels, I am extremely excited to be presenting to you IFMSA-Egypt's first ever Sexually Transmitted Infections (STIs) Trainers' Manual.

The current rise of STIs is a serious public health concern that requires immediate attention. However, due to the stigma surrounding the topic and the many misconceptions held by the community, it is still a neglected issue.

Therefore, this year, we decided to shed more light on STIs as a whole and worked on educating SCORAngels and medical students about STIs and sexual health through workshops and campaigns.

This manual comes as a step to further strengthen and streamline our educative efforts about STIs and to help all SCORA trainers to efficiently design and deliver workshops and sessions raising awareness about STIs. I would like to thank Miss Mirna Hussein, the SWG coordinator and every single contributor to this manual. If it wasn't for their efforts and hard work over the past few months, this manual wouldn't have come to light.

With this said, I hope you find the manual useful and I wish you great sessions and learning experiences wherever you are !

Yours, Shaimaa Adel IFMSA-Egypt NORA 2020-2021

Manual Team

SWG Coordinators

Radwa Torky

National WAC Coordinator

Esraa Rashad

Nada Saeed

Mirna Hussein

SWG Co-Coordinator

SWG Members Salma Rashwan

Mohammed Fathy Mashally

Reem El-Emam

Mariam Azzam

Enas Elshabrawy

About the Manual: This training manual is intended for all SRHR advocates in IFMSAEgypt intending to conduct sessions for medical students, paramedical students, and the general public.

The contents of this training manual are focusing on spreading sex positivity, empowering people to understand their body, symptoms, and open sex-positive conversations.

The scope of discussion is limited to conducting awareness sessions on stigmas surrounding STIs and not training people to self-diagnose or diagnose others.

The facilitator should preferably attend IFMSA-Egypt’s STIs and Sexual Health TOT and should be acquainted with adult learning principles and basics of behavioral change as well as familiarity with anti-stigma training and activities.

It is preferable for the facilitator to read through and understand the entire training manual including going over the resources before using the manual to conduct sessions; thus they would become aware of how the chapters build upon each other and retain all relevant information.

The manual includes recommendations for activities as well as pictures that the manual SWG that would help facilitate the sessions or even full workshops.

Table of Contents Page 6

Research and Statistics

Page 14

Anatomy and Physiology

Page 27

Syndromic Case Management

Page 35

History Taking and Examination

Page 46 Counselling And Partner Management

Page 58 Protection

Research and Statistics

Definition of STIs STDs vs STIs STDs vs Venereal Diseases Modes of Transmission STIs Situation in Egypt Statistics Related to STIs

Definition of STIs They are infections that are passed from one person to another through sexual contact. The contact is usually vaginal, oral, and anal sex. But sometimes they can spread through other intimate physical contacts, like herpes and HPV, are spread by skin-to-skin contact and other STIs like gonorrhea and syphilis can be passed from infected mother to her baby during pregnancy or breastfeeding. Also, some people can be infected via the use of IV drug needles.

STDs vs. STIs

A lot of people think that the two terms are the same because they are often used interchangeably even though they’re different terms.

STIs mean sexually transmitted infections and it’s the first leading step to the disease. The causative organism has entered the body, but with no apparent symptoms.

STDs mean sexually transmitted diseases and the word "disease " suggests that the person has a medical problem with obvious signs and symptoms. The causative organism has affected the body's normal functions and processes.

Simply put, all STDs begin with STIs. However, not all STIs become STDs.

STIs vs Venereal Diseases The classic definition of venereal disease is a disease only transmitted by sexual intercourse and caused by microorganisms that survive on the skin or mucous membrane or via semen and vaginal secretions during intercourse. The term is now out of date because of changing social conditions and has been replaced by the term STI which is caused by several ways not only through sexual intercourse.

Modes of Transmission Although the sexual route is the main mode of transmission of STIs, there are other modes such as through contact with infected blood and vertical transmission from mother to child.

Sexual Transmission Anal Sex

Vaginal Sex

Blood Products & Tissue Transfer

Oral Sex

During Pregnancy

Mother to Child During Childbirth

STIs Situation in Egypt Little work has been done to evaluate the magnitude of this problem in Egypt. A study was conducted by Ain Shams University (Ali et. al) between October 1993 and April 1995, and examined 95 cases. To date, it is the only study conducted in Egypt that examined both males and females.

Another study conducted by Al-Azhar University in Cairo, Assiyut, and Damietta in 2020 yielded similar results. However, the study only examined married female patients.

Global Statistics Related to STIs Source: WHO

More than 1 million STIs are acquired each day

Each year, there are an estimated 376 million new infections with 1 of 4 STIs.

More than 500 million people are estimated to have genital infections with the herpes simplex virus (HSV) .

More than 290 million women have a human papillomavirus (HPV) infection .

An estimated 240 million people are living with chronic hepatitis B globally.

HPV infection causes 570,000 cases of cervical cancer and over 300,000 cervical cancer deaths each year.

Over 350,000 adverse birth outcomes including 200,000 stillbirths and newborn deaths, have been attributed to syphilis.

Activities Activity 1: Guess which one is the STI, STD or venereal disease Goals

After the activity, the participants will differentiate between 3 terms: STIs, STDs and venereal disease and know when to use each term.

Materials

Sticky notes, markers and flipchart

Methodology

The trainer will give each participant a sticky note containing information about STIs or STDs or venereal diseases and each one has to match the sticky note with one of the three choices written on a flipchart

Expected time

10 minutes

Activity 2: Which sentence do you think describes the mode of transmission?

Goals

Giving accurate information about the mode of transmission of STIs.

Materials

Cards with facts & myths written on it

Methodology

The trainer asks the participants to stand in a circle and will say facts & myths about mode of transmission, if it is a fact , raise your hand and if it is not, don’t move

Expected time

10 minutes

Activity 3: Guess on the scale Goals

To assess how aware the participants are of the statistics

Materials

Paper & sticky notes (cut to thin pieces)

Methodology

Statements that include statistics will be written each on a paper except the numbers will be written as a range or scale. Participants will stick their sticky notes on the scale where they think the true answer is. Later each statement is discussed and the true numbers are revealed.

Expected time

5 minutes

Activity 4: Choose the right answer Goals

Assess the background of the participants regarding STIs

Materials

Powerpoint

Methodology

Statements that include the statistics will be displayed missing a word/ number (the name of the organism, the period of time, the statistic...etc) along with choices. Participants will guess the right answer. Works physically or online

Expected time

15 minutes

Sample Statements Activity 2: 1. Some STIs can be acquired through skin-to-skin contact 2. Using condoms can lower your risk of acquiring an STI 3. Anyone can get an STI 4. You can get some STIs more than once 5. You cannot get STIs from oral sex

Activity 3 1. Number of people who acquire STIs everyday worldwide (1 million) 2. Number of people who have genital infections with the herpes simplex virus (HSV) (500 million) 3. Number of cases of cervical cancer caused by HPV (570,000)

Activity 4 1. Each ____, there are an estimated 376 million new infections with 1 of 4 STIs: ____, gonorrhea, ____, and trichomoniasis.

2. More than 500 ____ people are estimated to have genital infections with the herpes simplex virus (HSV) .

3. More than 290 million ____ have a human papillomavirus (HPV) infection .

4. ____ pregnant women were infected with syphilis in 2016.

References 1. https://www.who.int/news-room/fact-sheets/detail/sexuallytransmitted-infections-(stis) 2. https://www.healthline.com/health/healthy-sex/sti-vs-std 3. https://www.cdc.gov/std/statistics/prevalence-incidence-cost2020.htm 4. https://www.who.int/news-room/feature-stories/detail/fourcurable-sexually-transmitted-infections---all-you-need-to-know 5. https://www.mayoclinic.org/diseases-conditions/sexuallytransmitted-diseases-stds/symptoms-causes/syc-20351240 6. https://www.who.int/reproductivehealth/curable-stis/en/ 7. https://www.medicinenet.com/venereal_disease/definition.htm 8. https://pubmed.ncbi.nlm.nih.gov/17214196/ 9. https://aimj.journals.ekb.eg/article_123155.html

Anatomy and Physiology

Normal Female Genital Discharge Causes of Abnormal Vaginal Discharge Normal Male Discharge Modes of Transmission of STIs General Symptoms of STIs Comparing Different STIs High Risk Behaviors for STI Transmission Reasons for High Risk Behaviors Short and Long-Term Consequences Complications

Normal Female Genital Discharge Vaginal discharges are commonly normal for most women.

They are secretions from glands in the vagina and cervix.

They keep the vagina clean and healthy. The amount, odor and color vary from one woman to another. It also changes during the menstrual cycle. These are the possible variations in the vaginal discharge:

source: PristynCare.com

Causes of Abnormal Vaginal Discharge 1-Infective Bacterial vaginosis (Most common cause ) Candida 2-Non-infective Physiological Others ( polyps, foreign bodies, malignancies, allergies,) 3-Sexually transmitted Chlamydia Gonorrhea Trichomonas vaginalis

Normal Male Discharge Male discharges are less common and frequent than female discharges. It's any foreign substance that comes from the urethra and appears on the tip of the penis.

There are 3 normal male discharges: Pre-ejaculate It’s a clear and mucoid fluid secreted during sexual arousal. It’s secreted from Cowper's glands. It’s usually secreted in small amounts, evidence shows that pre-ejacuate could contain few sperm cells that may cause pregnancy. It can transmit STIs as HIV and chlamydia.

Ejaculate It’s a white, cloudy, and sticky substance secreted during orgasm. It contains sperms (1%) and other fluids secreted by the prostate, and other glands

Smegma It’s a cheesy white fluid secreted by small glands on the glans in uncircumcised men.

Any other discharge is considered abnormal and should be examined by a doctor

Modes of Transmission of STIs

Sexually

Vertical

Direct Contact

The organisms present in semen or vaginal secretions. A person with an STI can pass it to others through contact with genitals, mouth, rectum, or body fluids. This includes contact through vaginal sex, anal sex, or oral sex.

Certain STIs — such as gonorrhoea, chlamydia, HIV, and syphilis — can be passed from an infected mother to her child during pregnancy, delivery, or in milk. STIs in infants can cause serious problems or even death.

Certain STIs -such as herpes and syphilis- can be transmitted through direct contact with the lesion.

Transfusions

Some STIs like HIV, HBV, HCV, syphilis can be transmitted by transfusion with whole blood, plasma, clotting factors, and cellular fractions of blood.

Contaminated Needles

Transmission can occur by inoculation with contaminated needles or syringes among drug users or accidentally if a contaminated needle punctures the skin of a health care worker.

General Symptoms of STIs Pain or burning during urination.

Unusual discharge from the penis or anus.

Abnormal vaginal discharge or bleeding.

Burning or itching in the vaginal area.

Pain during sexual intercourse.

Bumps and sores around genitals or anus.

Pain in the pelvic or abdominal region.

Warts around genitals or anus, sometimes in the mouth or throat but it is very rare.

Nonspecific symptoms include chills – fever – tiredness – rashes – weight loss.

Comparison between STIs Infection

Organ Common Transmission Affected symptoms

Penis Vagina Chlamydia Anus Throat Eye (rare)

Semen Pre-ejaculate Vaginal fluid Anal fluid

IP

Test

No Urine symptoms 2-6 Pain during weeks and\or Swap urination

Abnormal discharge

Infection

HPV

Organ Common Transmission Affected Symptoms Penis Vagina Anus Genital area Mouth (rare) Eye (rare)

Penis Gonorrh Vagina ea Anus

Throat Eye (rare)

HBV

Blood

Skin to skin contact

Semen Pre-ejaculate Vaginal fluid Anal fluid

Blood Semen Pre-ejaculate Vaginal fluid

IP

Test

No symptoms Weeks Visual Painless to exam bumps on years

skin

No symptoms Symptoms Urine 2-7 on penis and\or days Pain during Swap

urination

Abnormal discharge

No symptoms Nausea Loss of 6-22 Appetite Blood weeks Fever

Stomach ache ,Jaundice

Infection

Syphilis

Trichom onas sis

Herpes simplex virus

Organ Common Transmission Affected Symptoms Penis Vagina Anus Genital area Throat Skin

Penis Vagina

Penis Vagina Anus Genital area Mouth

Skin to skin contact

Semen Pre-ejaculate Vaginal fluid

Skin to skin contact

IP

Test

No 3 symptoms days - Swab Painless or 3 sore month blood Non-itchy s rash

No symptoms Pain during urination Abnormal vaginal discharge

No symptoms Itching. burning, or tingling sensation Painful sores or blisters

Urine 5-28 and\or days Swap

2-21 days

Swap or blood

Infection

HIV

Organ Common Transmission Affected symptoms

Blood

Blood Semen Pre-ejaculate Vaginal fluid

IP

Test

No symptoms 2-4 Blood Flu-like weeks symptoms

Headache Muscle ache

High risk behaviors for STIs transmission Unprotected sex (oral, vaginal, anal) without a male or female condom.

Starting sexual activity at a young age.

Having multiple sex partners.

Having a partner who has multiple sex partners Having sex with a partner who injects or has ever injected drugs.

Sex trade work.

Reasons for high-risk behavior People may have high-risk behavior because they may not: Know a lot about STIs and how they are transmitted.

Talk about safer sex practices with partners.

Be prepared or don't understand how to use protection.

Be aware of symptoms of STIs. Seek medical care for STI testing or treatment.

Have access to treatment or be able to afford it.

May use alcohol and drugs that impair their judgment and make unsafe sex more likely.

Short and long term consequences of STIs Getting tested for an STI is imperative because if they are not detected early on, there are many risks involved such as: Spreading it to other people Infertility Risking pregnancy Risk of getting HIV Risk of complications

STIs complications Some of the complications that one can develop from an untreated STI are: Pelvic inflammatory disease and infertility by Chlamydia and Gonorrhoea.

Meningitis and bladder issues by Genital herpes.

Liver cancer and cirrhosis by Hepatitis B. Reduced life expectancy by HIV Cervical and rectal cancer by HPV. Dementia, heart, brain, eyes, kidneys, and bones damage, blindness

by Syphilis.

source: Healthline.com

Activities Activity 1. (Anatomy and physiology: Comparison between STIs)

Goal

Materials

Methodology

Expected time

At the end of this activity, participants will gain more knowledge about causative organisms, modes of transmission, treatment, Incubation period, and common symptoms of STIs

Flipcharts, papers, markers, tape 1. Prepare 8 flipcharts (the number depends on the number of STIs mentioned in the session), each with a brief information related to the disease, Missing different words to be completed by the participants. Put flipcharts on the wall with enough space in between.

2. Write the words each on a paper, then put all papers on a table in the middle of the room 3. Divide the participants into small groups 4. Assign each group to a certain disease 5. The first group to complete the chart is the winner 6. Reflect on each disease and discuss it with the participants.

45 minutes

Activity 2: Anatomy and physiology: Genital discharge)

Goal Materials

At the end of this activity, participants will be able to differentiate between normal and abnormal genital discharges for both male & female. laptop, Showscreen

Methodology Watch the videos then reflect on them.

Expected time

30 minutes

Frequently Asked Questions (FAQs) Q1. Can an STI be mistaken for a UTI? UTIs share symptoms similar to STIs and are misdiagnosed more often than you think. According to the American Society for Microbiology, 64% of patients with an (STI) were actually diagnosed as having a UTI instead.

Q2. The difference between an STD and a UTI? They both have several symptoms in common including pain or burning with urination. UTI’s often have a frequent or urgent need to urinate, a feeling of incomplete bladder emptying, and cloudy, dark, or strange-smelling urine. However, STDs can have additional symptoms that are not present with a UTI that include: Pain during intercourse Genital blisters, sores, or rashes Sore throat Nausea Fever Spotting between periods

References 1. https://www.who.int/news-room/feature-stories/detail/fourcurable-sexually-transmitted-infections---all-you-need-to-know 2. https://www.mayoclinic.org/diseases-conditions/sexuallytransmitted-diseases-stds/symptoms-causes/syc-20351240 3. https://www.healthline.com/health/sexually-transmitteddiseases/symptoms 4. https://www.nhs.uk/conditions/sexually-transmitted-infectionsstis/ 5. http://naco.gov.in/sites/default/files/STI%20Counsellor%20Refr esher%20Training%20Trainee%20Handout.pdf 6. https://www.webmd.com/women/guide/vaginal-dischargewhats-abnormal#1 7. -https://familydoctor.org/condition/vaginal-discharge/? adfree=true 8. https://www.issm.info/sexual-health-qa/what-is-pre-ejaculateor-precum/ 9. https://playsafe.health.nsw.gov.au/2015/02/05/peniledischarge/ 10. https://www.justthefacts.co.nz/do-i-have-stis-sexuallytransmitted-infections/sexually-transmitted-infections-stimyths-and-facts 11. Facilitator’s note: make sure the words are easy to figure out; to avoid consuming much time and energy.

12. Male discharge: https://www.youtube.com/watch? v=0S_8I51V8iI 13. Female discharge: https://www.youtube.com/watch? v=CFlp8FbU7BE

Syndromic Case Management

Defining Syndromic Case Management Components Pros and Cons Comparing Classical Approaches to STI Management How to Use a Flowchart

Effective management of STI is one of the cornerstones of STI control, as it prevents the development of complications and decreases the spread of these diseases in the community.

However, diagnosis of STI is a challenge in many settings. It places constraints on time, resources, costs and access to treatment.

Consequently, a syndrome-based approach was developed to overcome these challenges and offer a cost-effective type for STIs cases management.

Defining Syndromic Case Management It is a type of management that is based on syndromic diagnosis and treatment: The main STIs are classified by clinical syndromes — a combination of symptoms a patient complains of, and signs identified during the clinical examination. An STI syndrome is identified and then treated with combination therapy for the majority or most serious organisms responsible for producing a syndrome. The syndromic approach enables healthcare providers to make a diagnosis within a short time without special skills and sophisticated laboratory tests.

Algorithms or flow charts are used to guide healthcare workers through the correct identification and treatment of an STIassociated syndrome. They also offer a package of comprehensive care from history taking, examination, to counseling/education on risk reduction and partner notification and treatment.

Components History taking Physical examination Treatment based on syndromic diagnosis.

Patient education including information on: compliance nature of infection importance of partner notification and treatment therefore risk reduction and prevention of further STI transmission HIV risk perception and assessment Counselling for STIs and HIV testing Condom promotion Partner management Clinical follow up

Pros and Cons of Syndromic Case Management Pros Highly sensitive Treatment is given at first visit Avoids expensive laboratory tests Can be implemented at primary care level Problem-orientated High rates of cure

Cons Over-diagnosis and overtreatment Cannot be used on asymptomatic individuals Does not address the issue of poor treatment-seeking behavior Accuracy of algorithms vary among symptoms

Comparing Classical Approaches to STI Management Etiological Diagnosis

Process

Using the lab to identify the causative agent.

Clinical Diagnosis Using clinical experience to identify the causative agent.

Pros

Avoids over treatment Conforms to traditional clinical training Satisfies patients who feel not properly attended to Can be extended as screening for the asymptomatics

Saves time for patients Reduces laboratory expenses

Cons

Requires skilled personnel and consistent supplies Treatment does not begin until results are available It is time-consuming and expensive Testing facilities are not available at the primary level

Requires high clinical acumen Most STIs cause similar symptoms Mixed infections are common and failure to treat may lead to serious complications Doesn’t identify asymptomatic STIs

How to Use a Flowchart A flowchart is a diagrammatic map that guides you through a series of decisions and actions you need to make. Each decision or action is enclosed in a box, with one or two routes leading out of it to another box, with another decision or action.

Each flowchart is made up of a series of three sorts of steps: The clinical problem (the patient’s presenting symptom at the top). This is the starting point

A decision to make, usually by answering "yes" or "no" to a question An action to take: what you need to do (different boxes suggest treatment, education and condom promotion, etc, and patient referral if necessary).

Yes Start

Step

Action

End

Action

End

Decision No

Challenges in STI Control Integration of STI prevention and care in reproductive health services and in HIV/AIDS control programs.

The changing epidemiology of STI. Mobilizing policy, priority setting, capacity building, and multisectoral approaches.

Activities Activity 1: The House with the 4 Doors Goals

Allow the participants to brainstorm and conclude that syndromic case management is the best STIs management.

Materials

Flip chart, markers

Methodology

Audience will be divided into 3 groups, each group will discuss a way of STIs management (syndromic case management, etiological diagnosis, clinical diagnosis). The discussion will include 4 doors; the concept door, the advantage door, the disadvantage door, & the opinion door.

Each group will be given a paper of flip chart to represent their house & a marker to write the discussion of the 4 doors. Later they will present their house for the other 2 groups and try to prove their house is the best. It can work both online ( by dividing them into rooms) or physical (by dividing them into groups).

Expected time

15 minutes (5 for group discussion, 10 for presentation)

Activity 2: Small pieces and a Big picture.

Goals

Allow participants to highlight the main steps of flow chart used in syndromic case management.

Materials

Flip chart, markers

Methodology

Steps of the flowchart are written on small papers and then the participants are asked to arrange them in the correct order to complete the big picture of syndromic case management flowcharts.

Expected time

10 minutes

Frequently Asked Questions (FAQs) Q1. Is the syndromic approach scientific?

Yes. It is based on a wide range of epidemiological studies in both the industrialized and developing world. This case management approach has been used and adapted in more than 20 countries throughout the world.

Validation studies have compared syndromic and laboratory diagnosis to assess the accuracy of syndromic diagnosis and found their results to be similar.

Q2. Wouldn’t it be better to treat the patient first for the most common cause and then, if the symptoms do not improve, treat for a second cause?

Many patients required to return to a health center for treatment do not do so. They may even seek treatment elsewhere. If the first course of treatment is not effective, the patient may continue to transmit the STI – at best for a few days but at worst for years.

Q3. Can the syndromic approach result in a waste of drugs because patients are being over-treated?

Over-treatment in syndromic management could be said to be a waste when patients are treated for a syndromic cause which is not the cause of the discharge. This includes, for example, treatment for gonorrhea and/or chlamydial infection as the causes of vaginal discharge in areas where they are not the predominant cause.

Q4. How much training should healthcare workers receive in order to use the syndromic approach?

Healthcare workers should be trained enough to be able to use the management flowcharts and know how to take proper sexual history as this type of management depends completely on history and observations.

References

1. http://apps.who.int/iris/bitstream/handle/10665/43275/92415934 07_mod2_eng.pdf;jsessionid=B19B61C27D5E4C1DBA84246840C8 9894?sequence=3 2. https://asq.org/quality-resources/flowchart 3. https://www.smartdraw.com/flowchart/ 4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1744836/pdf/v080 p00174.pdf 5. https://drive.google.com/drive/folders/14xidywrDIMSsKv26Hv52YXT-JEbz-_h?usp=sharing

History Taking & Examination

Safe Clinical Environment Sexual History Communication Skills Ethics Mistakes During History Taking The Importance of STI Tests Testing Recommendations How to Examine Sensitive Areas

Taking proper sexual history from adults and adolescents helps in the screening for high-risk sexual behaviors, identification of sexual problems such as sexually transmitted infections (STIs), provision of information, and support to patients.

Discussing sexuality with a provider may be uncomfortable at any age, so a good doctor must assure his patients, provide them with a safe space, and establish trust .

Safe Clinical Environment 1. Creating a welcoming safe clinical environment for all patients

should begin at registration.

2. Establishing your patient’s name and pronouns, as well as their sexual orientation and gender identity, are important in medical care.

3. Some patients may not be comfortable talking about their sexual history, sex partners, or sexual practices. Some patients may have experienced abuse or trauma in their lives or while in a medical setting. All clinicians need to apply patientcentered, sensitive care to all interactions.

4. Some patients may be experiencing intimate partner violence and seeking care for medical health concerns could be their only opportunity to access safe resources. Try to put patients at ease and be prepared to link patients to needed resources. Let them know that taking a sexual history is an important part of regular medical care.

Sexual History First, the doctor should greet the patient, Introduce themself, gain consent to speak with or examine the patient and describe what they will do. Should they wish to take notes as they proceed, they should ask the patients permission to do so. The doctor must explain to the patient that the questions aren’t an intrusion in his relationships but, they are to help them provide the best healthcare.

To further guide the dialogue with the patient, the 5 “Ps” may be a useful way to help you remember the major aspects of sexual history.

Partners The number, gender, new, and risk factors of patient’s sex partners

Past History of STIs Symptoms, STIs testing, and partner's STI history

Pregnancy Intention

Contraception use and wanting to have (more) children, when, and prevention until when

Practices Sex practices like types of sex, drug use, or masturbation

Protection from STIs Abstinence, or not having sex, number of sex partners, condom use, the patient’s perception of their own risk and their partner’s risk, and STI testing.

By the end of the interview session, the patient may have come up with information or questions that they were not ready to discuss earlier.

Ask your patient about a history of trauma, sexual abuse, or violence, as these are common, and patients may benefit from additional care.

Also consider asking about sexual functioning, including pleasure and performance, and referring for care, as indicated.

For patients at risk for STIs, be certain to encourage testing and give positive feedback about prevention methods that the patient is willing or able to use .

Communication Skills The language and communications skills are very important in the process of taking a sexual history, so there are some instructions that should be followed: 1-Appropriate greeting and maintaining eye contact are important to establish a good rapport between the doctor and the patient.

2-Patients are often vague or use euphemisms if embarrassed.

Listen and watch to ensure you have understood and whether you need to ask further questions to confirm. Use open questions to initiate the consultation, clarifying with closed questions if required.

3- Pay attention to the patient’s Facial expressions, body movement, posture, gestures, eye contact, in addition to loudness or tone of voice.

4-Do not make assumptions; use neutral terms such as 'person' or 'partner' (rather than 'boy/girlfriend', 'wife/husband') until you have confirmed an individual's sexual orientation and relationship status.

Do not ask whether individuals are married or not; rather, ask how many partners they have had.

5-If discussing sexual behaviors, ensure that the patient understands any medical terminology you may use and that you understand their slang terms. Some patients prefer doctors to use colloquial terms to discuss sex; others would find this off-putting.

There should be a capacity to accommodate and communicate with those whose first language is not Arabic.

Ethics First, being serious is a key requirement, because it can build up trust to ensure good cooperation for a complete and accurate sexual history. Doctors should be patient and attentive when listening to the patients.

Second, respect for the patient’s privacy is an important act of professionalism. The environment should be welcoming and comfortable but private and isolated.

Companions may prevent the patient from telling some personal information so the doctor must see the patient alone.

Third, Patients should be assured of confidentiality which can only be broken in exceptional circumstances when it is in the patient's or public's interest.

Fourth, the doctor should take consent before doing anything.

Fifth, the doctor must only ask for the information he needs and if the patient didn't come with a complaint related directly to sex, the doctor can check if the patients will be comfortable to discuss their sexual concerns after explaining to the patient why he is asking these questions

Sixth, All patients should be treated equally, regardless of their personal differences, Discriminating against patients for any reason is strictly prohibited

Mistakes during History Taking Although the doctors are aware of the ethics of taking history and they know to what extent taking a sexual history is a sensitive process, they can still make mistakes that can lead the patient to feel bad or uncomfortable during the consultation like: 1 .Having the consultation in front of parents or partners makes the patient uncomfortable.

2. Not minimizing note taking especially in the sensitive questions that include private information.

3. Assuming a patient’s gender identity, sexual orientation, and sexual behaviors and judging them for it.

4. Using leading questions instead of open-ended questions to give the patient the chance to express his complaint freely.

5. Interrupting the patients instead of listening to them carefully for the sake of reaching an accurate diagnosis.

The Importance of STI Tests 1. Plenty of STIs are asymptomatic, with mild symptoms, or mistaken for other infections.

2. Without testing, people infected with STIs might spread the infection to others.

3. STIs may lead to serious health complications.

Testing Recommendations Each STI has a specific diagnostic test. Tests may be part of a routine health screening or ordered when a patient has signs and symptoms related to an STI. STIs screening is recommended for those at high risk. This includes people: With an STI-infected partner With multiple sex partners Having unsafe sex Using IV drugs Homosexuals & bisexuals Generally speaking, Everyone aged from 13 to 64 should be tested for HIV at least once, based on risk level. People practicing unsafe sex, IV drug users, people with multiple sex partners, and homosexuals should have regular STI testing.

How to Examine Sensitive Areas 1. Consent must be given voluntarily and freely by the patient.

Do not pressure them into getting the exam.

2. Thoroughly explain the procedure and its purpose to the patient before obtaining their consent.

3. Provide the patient with privacy to dress and undress.

4. Provide drapes and gowns that allow for adequate coverage of the body during the exam.

5. Only expose the parts of the body that need to be examined and leave them uncovered for the shortest time necessary.

6. If the patient withdraws their consent, the physician must stop the examination.

Activities

Activity 1: Guess the questions asked during taking sexual history Goals

Make the participants aware about the right way for taking sexual history.

Materials

Sticky notes, markers and flipchart

Methodology

Expected time

Trainer gives the participants sticky notes and asks them to write examples of questions they think the doctor will ask during taking sexual history, then they will put the sticky notes on a flipchart and the trainer takes a sample of the sticky notes and starts to discuss them with the participants.

Works physically.

20 minutes

Activity 2: Comparison between the right and wrong way for taking sexual history Goals

Materials Methodology

Expected time

Make the participants know the ethics of taking sexual history and how to treat the patient without judgement.

Papers and markers for writing the 2 scenarios Trainer chooses 6 participants and divides them into 2 teams, each team consists of 3, one is a doctor, one is a patient and one is a nurse. Each team will be given a scenario, one scenario is the right way for taking history and the other scenario is the wrong way, after that the trainer will reflect on the two scenarios and tell the audience the ethics and the right way for taking sexual history.

30 minutes

Sample Statements Activity 1: 1. At this point in the visit I generally ask some questions regarding your sexual life. Will that be ok?

2. Do you have any questions or concerns about your sexual health?

3. Do you and your partner(s) discuss STI prevention?

4. Have you been diagnosed with an STI in the past? When? Did you get treatment?

Frequently Asked Questions (FAQs) Q1 . What if the patient refused to disclose information?

Confidentiality between the doctor and the patient mustn’t be broken. If the patient refuses to disclose information, the reasons should be considered and respected. Yet, if another patient or healthcare provider is at risk of infection, the doctor would inform the patient that disclosure is necessary and obligatory.

Q2.If the patient refused to get examined, what should the doctor do?

Consent is a must for an STI examination. The doctor should make sure that the patient fully understands the importance and procedures of the test, the consequences of his refusal, and the complications of the suspected disease.

Q3. Is the gender of the examiner important to the patient or not?

Yes, sometimes. New research suggests that “female physicians were more likely to see female patients, had longer visit durations and were more likely to perform female prevention procedures and make some follow-up arrangements and referrals.”

Q4. What if a family member asks how the patient is doing?

Confidentiality shouldn’t be broken. Ethically, the doctor shouldn’t share any information about the patient’s health with anyone without the patient’s consent.

Q5. What are the cases in which confidentiality can be breached?

1- Concern for the safety of other people 2- Legal requirements to report certain conditions or circumstances

Q6. Who should get tested?

All sexually active people are at risk for STIs, yet not every person needs testing for STIs. STIs screening is recommended for those at high risk; due to age, gender, health history, number of sexual partners, and sexual orientation. This includes people: with an STIinfected partner, with multiple sex partners, having unsafe sex, and using IV drugs. In addition to homosexuals & bisexuals.

Q7. When to take an STI test?

If your sexual history and current signs and symptoms suggest that you have a sexually transmitted disease (STD) or a sexually transmitted infection (STI), laboratory tests can identify the cause and detect coinfections you might also have.

Q8- What are the types of STIs tests?

Blood tests. HIV, syphilis Urine samples.

Fluid samples. For open genital sores

References 1. https://patient.info/doctor/sexual-history-taking 2. https://link.springer.com/chapter/10.1007/978-981-13-7677-1_35 3. https://siecus.org/wp-content/uploads/2018/07/1.7-Taking-ASexual-History.pdf#page3 4. https://www.aafp.org/dam/AAFP/documents/patient_care/sti/hop s19-sti-script.pdf 5. https://labtestsonline.org/std-testing 6. https://www.cdc.gov/std/treatment/sexualhistory.pdf 7. https://assets.publishing.service.gov.uk/government/uploads/syst em/uploads/attachment_data/file/138296/dh_103653__1_.pdf 8. https://health.uoregon.edu/sensitive-exam

Counselling & Partner Management

What is Counselling?

Importance of Counselling Effective Counselling Helps People to...

Barriers of Effective Counselling Skills and Attitudes Counselling Process Harm Reduction Breaching Confidentiality Partner Management Partner Notification Partner Notification Prerequisites Types of Partner Notification

What is Counselling?

Counselling is a collaborative confidential process of professional assistance and guidance which helps clients in resolving personal or psychological problems.

Importance Counselling is an effective tool to help people learn about their sexuality and STIs. Many people feel embarrassed or ashamed to talk about such topics. So, they usually seek a friend or a relative who may not give them the right information or the emotional support they need. A good counsellor will diminish their fears, guilt, and anger and give them the necessary information.

Effective Counselling Helps People to: 1. Clearly understand their situation and all its aspects 2. Cope better with the situation 3. Choose the best option that suits their needs, feelings, and values 4. Make decisions and take full responsibility for them 5. Develop new skills to deal with life and sexuality in particular

Barriers of Effective Counselling Barriers related to the client Social stigma Fear of treatment Fear of emotions Anticipated Utility and Risk

Barriers Related to the Counsellor Controlling instead of encouraging Judging Moralizing and preaching Labelling and making assumptions Unwarranted reassurance Not accepting the client’s feelings

10 Rules for Skills and Attitudes The counsellor’s attitude is extremely important especially in matters related to sexuality and STIs. This is because of the sensitivity and stigma related to these topics. A counsellor should be able to create a safe space for the clients to talk openly about their feelings and issues. This could be achieved by: 1.Showing respect to the clients’ feelings, values, and problems 2.Understanding their resources, knowledge and strength to deal with their problems.

3.Not judging, being warm and easy to talk to, and using words of empathy, not sympathy.

4.Being open and modest to learn from them.

5.Being sensitive to inequality between both genders and how this may affect their sexual health.

6. Being trustworthy and confidential about clients’ information.

7. Taking informed consent before any procedure 8. Knowing your limits i.e knowing when to refer a client.

9. Listening actively to them and taking notice of the change in their body language.

10. Taking permission before taking notes and not doing it while they’re talking.

Counselling Process

Closure or ending Ongoing support Defining roles Building rapport and boundaries

STIs Harm Reduction: Harm reduction is a strategy directed toward individuals or groups that aims to reduce the harms associated with certain behaviours, it was developed initially for adults with substance abuse problems for whom abstinence was not feasible. In recent years, harm reduction has been successfully applied to sexual health education in an attempt to reduce both teen pregnancies and sexually transmitted diseases, including HIV. There are several possible approaches to risky behaviours:

Discourage the behaviour (ie, stopping the behaviour

completely); Encourage individuals to reduce the behaviour Provide them with information aimed at reducing the harmful consequences of the behaviour when it occurs

Breaching Confidentiality: Medical ethics principles stress respect, beneficence, and justice; however, STIs cases stretch our concept of these principles.

Although confidentiality is an essential part of the physicianpatient relationship, there are situations that may justify breaching confidentiality: 1. There is abuse of a vulnerable person, such as a child or older person 2. There is public health risk, such as with communicable disease 3. The patient is a substantial danger to himself/herself or to others.

Partner Management

Partner Notification for STIs has been recommended as an important step to help interrupt transmission of infections, prevent potential re-infection, and prevent complications.

However, there are obstacles. Patients may not inform their sex partners out of fear, embarrassment, or unawareness of the importance of doing so. In resource-poor settings, it is usually impractical for notification to be done by the health sector.

Partner Notification Partner notification should be considered whenever an STI is diagnosed to enable earlier diagnosis for partners, motivate behavior change in patients and partners, and reduce the burden of disease in communities. Partner notification also offers an important opportunity for identifying asymptomatic persons, particularly women, at an early stage and prior to the development of complications.

Partner notification ensures success in limiting STIs transmission by: Treating all sexual partners (at least within the previous three months) of the patient.

Treating the partners for the same STI (and any additional ones found) as in the index patient.

Partner Notification Prerequisites: It must observe the principles of confidentiality and non compulsion.

Particular care should be taken to observe human rights and respect the dignity of the individual.

It should be voluntary and non-coercive.

The necessary support and counselling needs should be provided.

The aftermath of partner notification may require other services to be available to provide support and counselling. This can be done through collaborative institutions offering such services or by training existing health workers to meet this need .

Types of Partner Notification There are 3 main types of partner notification; the suitability of partner notification types will depend on the choice and circumstances of the index patient: 1. Patient referral: The index patient takes responsibility for informing their sexual partner(s) of their possible exposure to an STI and for referring them to services. Patients may personally inform their partner(s) of the risk of infection, accompany partner(s) to a healthcare facility, or simply hand over a contact card from the service where they are diagnosed.

2. Provider referral: The provider (service) takes responsibility for informing sexual partner(s) of the index patient of their possible exposure to an STI. This requires healthcare professionals to obtain from the index patient the names of sexual partners along with other identifying information. It is usually not successful if it is perceived to threaten patient confidentiality.

3. Contract referral: The provider (service) makes a contract with the index patient that the index patient will contact their sexual partners within a certain time period. Provider referral is carried out if the index patient fails to do this.

Activities

Activity 1: Roleplay

Goals

Giving participants the creative freedom and letting them think of the best way to act and what to say to get their point across to others all while having fun

Materials

Markers, paper

Methodology

The trainers will come up with some scenarios for acting out like (two partners discussing STIs and counseling, or a counselor and a patent, or a counselor and a patient's partner, two random people with one supports counseling and the other is against it) and the participants will be selected randomly and given the main point/theme to memorize and act for the rest of the group with the freedom to change and improvise

Expected time 15-20 minutes

Activity 2: Cases stimulation

Goals

the stimulation aims at testing what they have learned in the session and how will they use it to apply to the case if they were in their shoes and will also give them a sense of

Materials Methodology

markers papers the trainers will come up with some controversial cases about partner management and how to handle difficult situation and uncooperative patients and the participants will be divided into groups with he number of cases and each will be given a case to discuss and say what would they do if they were in their position and if they think the person in the case behaved correctly or faulty

Expected time 10-15 minutes

Activity 3: What is counselling: Counselling in one word

Goals

At the end of this activity, participants will be able to 1. define counselling 2. Understand how people have different opinions about counselling based on their personal experience and beliefs.

Materials Methodology

Flip chart, markers, sticky notes Give each participant a sticky note Ask the participants to describe counselling in one word, write it down on the sticky note, and stick it on the flipchart.

Read all sticky notes and discuss the definition with the participants.

Expected time 30 mins Activity 4: Counselling skills: Active listening skills

Goals Materials Methodology

At the end of this activity, participants will be able to listen actively and communicate non judgmentally.

-

Divide the participants into pairs, one speaker and one responder.

For 2 mins, Ask each pair to make a conversation; in which one conversate and the other responds with “yes, but…”

Repeat the same but the response will be “yes, and…”

Ask the participants to compare their feelings at both times.

Expected time 20 mins Suggested questions to ask

which approach you felt more comfortable with as a listener/speaker? In counselling, what do you think is the best approach?

Activity 5: Counselling: Partner involvement

Goals

At the end of this activity, participants will be able to understand the importance of partner management and how to do it.

Materials Methodology Expected time Resources

laptop, Showscreen Watch the videos then reflect on them.

30 mins Including partner in counselling: https://www.youtube.com/watch? v=P66JrB4VV5A How to tell your partner you have an STD? https://www.youtube.com/watch? v=xxV7CiE2Bwc

Frequently Asked Questions (FAQs) Q1. Why should I risk my reputation and get tested?

No one is far from getting infected by an STI, and reputation has nothing to do with getting infected or being ill. Consequently, getting tested can help find an infection early or when you have no symptoms. This is important so that:

You can get treatment and avoid long-term problems and spreading the infection to others.

You can tell your sex partner(s) so they can be treated and can avoid spreading the infection.

If you're pregnant, an STI test can find an infection so you don't spread the infection to your newborn.

Q2. How is premarital and prenatal testing and counseling helpful?

Premarital & prenatal testing help detect STIs which can help prevent the transmission to the partner or the babies.

Moreover, premarital STIs counselling and testing is a necessity because these infections may remain dormant and asymptomatic for months or even years in carriers without showing any symptoms, and getting married without knowing that will expose the partner and babies to the risk of acquiring infection.

Q3. What should I do if I suspect that my partner is unfaithful?

The two partners should get tested for sexually transmitted diseases at the earliest opportunity.

It's best to be direct and honest.

Allow the conversation to proceed naturally.

Don't push your partner to make decisions about sex or your relationship right away.

Encourage your partner to ask questions.

Keep in mind that some STDs don’t always show up right away.

It’s possible that you or your partner got the STD in a previous relationship without even knowing it.

Talk about the STARS: STIs status, Turn-ons, Avoids, Relationship intentions, and Safer sex etiquitte.

References 1. https://www.ippf.org/sites/default/files/counsellingforstihivprev entioninsrhsettings.pdf 2. http://helid.digicollection.org/en/d/Js2660e/6.4.html 3. http://naco.gov.in/sites/default/files/STI%20Counsellor%20Refr esher%20Training%20Trainee%20Handout.pdf 4. https://iris.wpro.who.int/bitstream/handle/10665.1/11368/929 0610557_eng.pdf 5. https://thefarmrehab.com/common-barriers-to-counseling/ 6. https://data.unaids.org/publications/irc-pub04/una97-6_en.pdf 7. https://www.unaids.org/sites/default/files/media_asset/stdcont roltu_en_0.pdf 8. https://ssha.info/wp-content/uploads/ssha-guidance-onpartner-notification-aug-2015.pdf

STIs Protection Behavioral Approaches Prevention and Vaccination Condom Negotiation STIs Egyptian Control Strategy Ways to Get STIs Without Having Sex Re-Testing

Behavioral Approaches Abstinence and the maintenance of a mutually monogamous relationship with an uninfected partner decrease the risk for all STIs. Always practice safe sex – use a condom correctly and consistently or abstain from intercourse. If engaging in oral sex, use a male condom or dental dam.

Drinking heavily or taking mind-altering drugs will impair judgement and inhibitions during a sexual encounter, increasing the risk of making unsafe choices like not using a condom.

If you have engaged in risky sexual activities or suspect that you may have an STI, visit a healthcare provider immediately. If the results confirm that you have an STI, inform all your sex partners and encourage them to seek testing and medical attention.

Prevention There are several ways to avoid or reduce your risk of sexually transmitted diseases (STDs) or sexually transmitted infections (STIs).

Abstain: The most effective way to avoid STIs is to abstain from sex.

Stay with one uninfected partner: Another reliable way of avoiding STIs is to stay in a long-term mutually monogamous relationship in which both people have sex only with each other and neither partner is infected.

Get vaccinated: Getting vaccinated early, before sexual exposure, is also effective in preventing certain types of STIs. Vaccines are available to prevent HPV, hepatitis A and hepatitis B.

Use condoms and dental dams consistently and correctly: use a new latex condom or dental dam for each sex act, whether oral, vaginal or anal.

Don't drink alcohol excessively or use drugs: If you're under the influence, you're more likely to take sexual risks.

Communicate: Before any serious sexual contact, communicate with your partner about practicing safer sex. Be sure you specifically agree on what activities will and won't be OK. Consider male circumcision: There's evidence that male circumcision can help reduce a man's risk of acquiring HIV from a woman by as much as 60%. Male circumcision may also help prevent transmission of genital HPV and genital herpes.

Consider pre-exposure prophylaxis (PrEP): The Food and Drug Administration (FDA) has approved the use of the combination drugs to reduce the risk of sexually transmitted HIV infection in people who are at very high risk.

Avoid sharing towels or underclothing.

Wash before and after intercourse.

Condom Negotiation What’s condom negotiation?

It is the process by which individuals in a sexual relationship decide whether to use a male condom during sex.

Tips for communicating with your partner Try and talk to them about the benefits to both of you of having safe sex, such as protection against STIs and preventing pregnancy. Fun Fact: If used correctly, condoms are 98% effective in preventing STIs and unplanned pregnancy.

If either partner are unsure about how to use condoms, they should learn how to use one before engaging in sexual intercourse.

Once they reach an agreement to use condoms, they should plan ahead and make sure they have them handy when the time comes.

Remember that it is everyone’s responsibility to buy or carry condoms on them. Don’t assume that it’s the partner’s job or expect them to buy them.

Always use condoms with a water-based lubricant to avoid the condom breaking.

What if the other partner refuses?

The woman is the one who is at risk of pregnancy, so she is often perceived as responsible for contraception.

The male condom offers an opportunity for men to take part in this responsibility.

Proper use of condoms and other protective methods Steps for Use of Male Condom Reasons for Non Compliance with Condom Use Dislike of condoms Problems of condom accessibility, availability or affordability Difficulty raising the subject of condom use in a relationship or negotiating its use Unfamiliarity with the condom and its us

Ways to Increase Condom Use Educate the patient about the advantages of condom use Ensure that a patient is familiar with the appearance, the texture and the correct use of a condom Educate the patient about where to obtain quality condoms Make helpful suggestions on how the patient can negotiate its use in a way that is appropriate for a particular relationship

STIs Egyptian Control Strategy Currently the Egyptian Ministry of Health exerting tremendous efforts to standardize quality service in the prevention and treatment of STIs, activities including: The establishment and strengthening of the National HIV/STIs Surveillance plan and system.

Production and validation of National Guidelines for STIs case management.

Production of STIs training manual for healthcare professionals including contents about communication, counseling, advocacy, and management of with STIs/HIV Establishment of Pilot STIs Clinics: – Cairo Skin and STIs Hospital (El Hod El Marsoud) and Alexandria Skin and STIs Clinic (Mina El Basal).

Training and recruitment of qualified healthcare providers.

Several trials for the introduction of syndromic approach for the management of STIs

Protection vs contraception Using condoms or dental dams during sex.

Condoms are the only way that helps prevent both pregnancy and most STDs by acting as a barrier.

Using contraceptive forms are specific in that they are used for the purpose of preventing sperm from reaching a female’s egg These methods include oral

Dental dams help only in the prevention of STDs. lamp or sheepskin condoms are not effective in preventing STDs.

contraceptive pills, intrauterine devices (IUDs), tubal ligation, hysterectomy, vasectomy , barrier methods (condoms, diaphragms), and spermicides.

Ways to Get STIs Without Having Sex Kissing: IOral Herpes, also known as the Herpes Simplex Virus Type 1 (HSV-1), can be spread by contact with an active sore.

Oral sex should also be avoided when a cold sore is present, in order to prevent contracting HSV-1 in the genital area.

Oral sex: Chlamydia and Gonorrhoea are amongst the STIs most commonly passed through oral sex to the throat. Syphilis and Genital Herpes can also be passed through contact with a blister or sore in the genital area.

Sharing toothbrushes, razors or needles: Bloodborne infections can be spread by sharing objects which can cut the skin with someone who is infected. This includes HIV, Hepatitis B and Hepatitis C. Blood transfusion Contaminated food: Hepatitis A can be spread through contaminated food or water and then passed to others through anal sex (contact with infected faeces). This is more common in developing countries with poor sanitation.

Skin-on-skin contact: HPV, which can cause Genital Warts, can be transmitted through physical contact with a wart. Syphilis is usually passed through direct contact with a Chancre or sore (the first stage of infection).

Re-testing Reinfections are common due to transmission by either an untreated prior partner or an infected new partner. Thus, retesting is recommended for earlier treatment which can prevent complications and further transmission. For healthcare providers, retesting, regardless of the results, provides the opportunity to rediscuss STIs prevention with patients.

It is recommended that anyone who tested positive for chlamydia or gonorrhoea and any female who tested positive for trichomoniasis be retested three months after treatment.

Activities Activity 1: Rapid fire round

Goal

Try to test the participants knowledge on different subjects related to the topic of protection and also giving them the new information in a fun active way and also keeping them engaged and energised

Materials

Flash cards, stop watch, markers, tracking sheets Try to test the participants knowledge on different subjects related to the topic of protection and also giving them the new information in a fun active way and also keeping them engaged and energised

Methodology

Expected time 10-15 minutes

Activity 2: Group discussion

Goal

Deliver the point of importance of condoms in STIs protection in an unconventional way

Materials Methodology

Visual aids Asking people what they know about condoms, their importance and the correct way to use them then showing them a video explaining the best way to use it after taking their inputs

Expected time 10 - 15 minutes Activity 3: Pick your corner game

Goal

Raise a topic of discussion and controversy to see the different opinions of participants on certain protective methods and correcting their faulted believes

Materials Methodology

Markers, papers The room is divided into three parts. Each part holds a group ( absolute protectionintermediate protection- no protection at all) and each person will be handed a piece of paper with the method of protection and according to what they see fit they will stand in the corner they think is right. After everyone is standing they will be asked to reveal what was the method they got and why he picked that corner and other participants will be allowed to comment too

Expected time 5-10 minutes

Activity 4: Story telling

Goal Materials Methodology

Participants gain perspective on the impacts of negative sexual experiences and stigma Pen and paper, suitable background music perhaps The trainers will come up with stories on different subjects as condom negotiation, pre marital testing, HIV stigma, etc. And the participants will be asked to close their eyes while listening to the stories and imagine being a part of it then asking them about their feelings and thoughts after and what they relate with and what they would've done differently.

Expected time 20 minutes

Frequently Asked Questions (FAQs) Q1. Why should I get retested?

Reinfections are common due to transmission by either an untreated prior partner or an infected new partner. Thus, retesting is recommended for earlier treatment which can prevent complications and further transmission.

Q2. Are condoms 100% effective in preventing STIs? Condoms are believed to be 98% effective to prevent STIs. In addition to using condoms, knowing your partner's sexual history and regularly testing will help protect you from STIs.

Q3. What is the most effective way of preventing sexually transmitted infections?

Abstinence from sex is the most effective way to prevent STIs. Yet, if you're sexually active, the correct use of male latex condoms is a highly effective method to reduce the risk of STI. It must be used every time you have anal, vaginal, or oral sex.

Q4. What can I do to reduce my risk of getting an STD? There are several ways for STI protection such as: 1. Abstinence from sex 2. Correct and consistent use of condoms 3. Monogamous relationships 4. Vaccination 5. Male circumcision 6. Not sharing needles, towels, or clothes

Q5. Can HIV be transmitted through kissing or touching?

.

Casual contact such as kissing and touching does not transmit HIV. Yet CDC recommended not to engage in an open-mouth (French) kissing, though the risk is very low, with a person living with HIV while having dental problems. This is mainly to avoid the potential contact with blood.

Q6. Should I only get tested when I have a new partner?

No. While testing regularly for STIs should be part of every sexually-active adult, that’s not the case with most people.

Doctors recommend testing regularly every 6 months and after 3 months of a sexual encounter\relationship.

References 1. https://www.mayoclinic.org/diseases-conditions/sexuallytransmitted-diseases-stds/diagnosis-treatment/drc-20351246 2. https://www.webmd.com/sex-relationships/understandingstds-prevention 3. https://www.mayoclinic.org/diseases-conditions/sexuallytransmitted-diseases-stds/symptoms-causes/syc-20351240 4. https://www.tandfonline.com/doi/abs/10.1080/00224499.2013 .868861?journalCode=hjsr20 5. https://www.getthefacts.health.wa.gov.au/fun-stuff/letstalk/inline-content/tips-for-negotiating-condom-use 6. https://www.ippf.org/blogs/condom-negotiation 7. https://urgentcareomaha.com/uti-or-std-how-to-tell-thedifference/ 8. https://physiciansimmediatecare.com/uti-or-std/ 9. https://www.aafp.org/about/policies/all/prevention-sti.html 10. https://www.iamat.org/country/egypt/risk/sexuallytransmitted-infections 11. https://www.researchgate.net/publication/264974882_Sexually _Transmitted_Infections_The_Egyptian_situation_with_special_e mphasis_on_HIVAIDS 12. https://www.stdcheck.com/blog/difference-betweenprotection-birth-control-and-contraception/ 13. https://www.who.int/news-room/fact-sheets/detail/sexuallytransmitted-infections-(stis) 14. https://drive.google.com/file/d/1EunIXc5sj5Exi1J_pXzeAjxmVrsmfUp/view?usp=sharing