STDs and HIV

Implications for Counseling

Throughout the HIV epidemic, and in fact for decades, prevention of STDs has generally been overlooked, as more attention has been given to medical diagnosis and treatment of STDs than to changing behaviors.

There are compelling reasons for HIV test counselors to discuss STDs with clients. Because both HIV and other STDs are sexually transmitted, prevention messages for both are similar. By hearing clients' STD histories, HIV test counselors can learn about attitudes related to HIV, such as the client's views of sexuality, sexual behavior, risk reduction and being infected with STDs. Some clients may have given little thought to HIV, but have extensive experience with STDs. Or, they may have extensive HIV knowledge, but little knowledge of other STDs.

This section presents STD-related issues that are relevant to the HIV test counseling session, including behavioral risks and the health implications of STDs. In addition, the section responds to concerns of clients with or without STDs, as well as to young people, who are disproportionately affected by STDs.

The following are key points for HIV test counselors to discuss with clients.

• By engaging in safer sex, clients can protect themselves from infection or reinfection with both HIV and other STDs. When a client does not see his or her HIV-related risk as significant enough to warrant behavior change, present information about the risk of other diseases that may result from these behaviors. For someone who shows little concern about HIV because its debilitating effects may not be felt for years, state that many STDs can have immediate and damaging effects.
• The occurrence or recurrence of an STD along with a repeated negative HIV test result does not mean a person is not susceptible to HIV infection. In fact, multiple STD episodes are a clear warning that a person is engaging in high-risk behaviors for HIV infection.
• STDs can make a person more susceptible to HIV infection. And, STDs put strain on the body's immune system, making it more susceptible to other infections and less able to defend against them.
• People who have contacted STDs through injection drug use may not see their risk for HIV infection through sexual behavior. For instance, someone infected with hepatitis B virus (HBV) through infection drug use may perceive his or her drug use as risky, but feel he or she can engage in unprotected sex without being infected.

Sexual Behaviors and STDs

After learning the behaviors clients practice or desire to practice, describe to them the specific diseases that may be transmitted through these behaviors. For instance, clients who engage in oral sex without a condom are not only putting themselves at risk for HIV infection, but also for gonorrhea, syphilis, chlamydia, herpes and hepatitis B infections. Remember that there are behaviors, such as rimming, also know as oral-anal sex, that some client may not consider a high risk or HIV infection, but which definitely put a person at high risk for other STDs, including parasites and hepatitis B virus.

Responding to STD Infection

STD testing is important for anyone who has symptoms of an STD or anyone who has had unsafe sex with someone with an STD. Symptoms may not develop for extended periods after infection, but STDs can progress in the absence of symptoms. Symptoms generally occur sooner after infection for men than for women. Laboratory testing can detect most STDs in the absence of symptoms.

Many times, even with symptoms, people disregard STDs. Not wishing to acknowledge an infection, they avoid examining the genital area. They may even notice a skin lesion, but believe it is not a problem that needs immediate attention. For this reason, urge clients who think they are infected with, or have symptoms of, and STD to visit an STD clinic or their primary care provider. Talk to these clients about the complications of untreated STDs as well as the risk of future infections. State that STDs respond best to treatment before symptoms develop, and they generally worsen and become more infectious when untreated.

Clarify myths about STDs. For instance, clients may believe incorrectly that good personal hygiene, or a "clean" appearance, is a sign that someone is free of STDs.

In counseling clients with no STD history, support them for any steps they have taken to avoid STDs. If these clients appear to have little STD knowledge, make sure they understand that HIV is not the only disease that can be transmitted sexually, and that other STDs are serious unto themselves and can make a person more susceptible to HIV infection.

Clients with an STD History

Clients with an STD history have, in most cases, engaged in behaviors that have placed them at risk for HIV infection, and they may be several times more likely than other clients to become infected with HIV. Counselors may feel their efforts to repeat information to clients with extensive STD histories are futile. However, counselors have a unique, and perhaps "last chance" opportunity to offer assistance before these clients become infected with HIV.

Recognize that a person with a history of STDs may never have received thorough or effective counseling. Ask clients about their previous counseling and how effective they believe it has been in helping them understand and change risk behaviors. Through the HIV test counseling session, the client may, for the first time, see his or her STDs as a warning sign, and may perceive the need to change behaviors and even ask for help in doing so.

Many people with a history of STDs may not have strong feelings about the dangers of HIV. They may know from their personal experience that STDs can cause pain, but they may not realize these STDs can be life-threatening.

Explain that, even without HIV infection, repeated episodes of STDs can have debilitating and far-reaching effects. STDs can destroy organs, break down tissue, make it difficult for a women to become pregnant, and increase risk for other diseases. For instance, venereal warts for women and genital warts for men can increase risks for certain cancers.

Stress the importance of following the full course of treatment for STDs even if symptoms of disease have cleared. Failure to follow the full treatment course can allow disease to recur and lead to bouts with drug-resistant STDs.

After taking an STD history, ask the client to describe his or her risk behaviors and the context in which they occurred. Ask how the client feels about the safety of those behaviors, and how he or she felt when STDs were detected or diagnosed. Hearing this, the counselor may be able to identify a client's motivation to avoid STDs in the future and assist in developing skills to avoid risky behaviors.

Be prepared for a variety of factors that may lead clients to state they do not wish or feel able to change behaviors. These include rationalizations about unsafe sex, denial bout the safety of specific behaviors, and compulsive sexual behavior, in which a person may feel compelled to have sex and unable to control sexual desires.

Some clients may believe that if they engage in significant amounts of sex with many partners, they deserve or expect STD infections. Clients with an STD history may be especially vulnerable to fatalistic feeling about HIV infection, and they may express that being infected with HIV is inevitable and beyond their control.

Unsafe sex may be such a significant part of a person's life that he or she may not be able to imagine life without unsafe sex. Empathize with the client's position, and help him or her see that no matter how distant safer sex may seem, it is possible. Empower the client to see that he or she can have control over behaviors and becoming infected. Ask the client if there was ever a time he or she did not need to engage in unsafe sex, and, if so, explore the feelings of that time, including feelings of self-esteem.

Clients who have had thorough counseling previously, yet are unable to change sexual practices, may respond to direct statements about their risks. For instance, it may be appropriate to state: "You've had several counseling sessions. Your behaviors continue to put you at risk for a life-threatening disease. Are there things we can talk about doing that might help you change your behavior? Do you want to change?"

Some people with STDs may avoid taking responsibility for actions that leads to STD infection. They may view partners as responsible for the STD. This may lead clients to avoid reducing their risk in the future. Such clients may also decline to notify partners of their STD. Inform people with STDs that they are legally liable if they transmit that disease to another person. And, people who fail to use protective devices, such as condoms, have a legal obligation to inform prospective partners of their STDs. [Editor's Note: The last two statements apply to California residents; they may or may not be applicable to other states.]

STDs and Clients with HIV

Make clients aware that people with HIV are more susceptible to infection with other STDs. In addition, STDs are faster-acting and their effects on the immune system more threatening for people with HIV. Provide this information in both pre- and post-test counseling.

For clients who test HIV positive, recommend medical intervention and STD screening. Stress the importance of avoiding unsafe sex not only to avoid reinfection with HIV or infecting others, but also to avoid other STDs.

A Counselor's Perspective

"Clients often feel they have no control over being infected with STDs. I can help these clients begin to see that it is possible to have control, and they can take steps to regain it."

Young People

Be sensitive to differences between younger and older people. Be careful to avoid messages that may be conveyed as "sex negative." These can be particularly alienating for young people who may feel their sexuality and independence are being questioned by test counselors who are generally older.

Young people may believe STDs are to be expected from healthy sexual expression. They are often less willing to acknowledge risks for infection or the seriousness of disease. Because young people may have heard fewer prevention messages, they may need to have them repeated more often. Or, they may need to use new information to refocus attitudes and behaviors.

Be aware of the unique dynamics of sexual and emotional relationships of young people. Because of their relative inexperience in relationships, young people may not be certain what they desire from relationships. In addition, relationships may be shorter-lasting for young people than for older people, yet feelings in the relationship may be experienced as being especially intense. Because sexual and emotional intimacy develop quickly, people may soon find themselves feeling comfortable engaging in unsafe sex.

Often for young people, engaging in sex is not considered a result of a decision or choice, but rather as something that is necessary. In some cases, experiences or relationships of young people may consist of rape, incest or other forced sexual or violent behavior.

Talk with young people about the meaning of making choices consciously. Help them understand their rights and responsibil- ities in making their own choices, as well as the benefits that come from giving thought to the decision-making process and slowing down to do so. Ask clients what they perceive their choices to be and which choices they wish to make. Ask young people if they are aware of what they want from sex partners or relationships. If they are, they may be better able to define their choices.

A Counselor's Perspective

I get frustrated when clients say that STDs are only a nuisance for them. I have to then be patient and explain the severity of STDs, and their relationship to HIV infection.

Referrals

To determine appropriate referrals, first ask the client what he or she needs regarding STDs. Understand that clients may be resistant to visiting public STD clinics. In addition, clients may fear that at clinics they will be thoroughly quizzed on their sexual histories and that their sexual partners will be notified. Listen to a client's concerns and address them.

Provide telephone numbers and addresses of local STD clinics, and, if possible, the names of clinic staff. Also, let clients know they can visit personal physicians for STD care. Contact and become familiar with referrals.

For clients who feel unable to change sexual behavior to reduce their STD risks and who report a pattern of compulsive and self-destructive sexual "acting out," ask if they are interested in gaining help to avoid these behaviors. If so, provide referrals to 12-step recovery programs such as Sex and Love Addicts Anonymous or Sex Addicts Anonymous. These programs are found in phone directories in most larger cities.

In addition, offer referrals to therapists trained in dealing with behaviors related to sexual compulsion. Be aware that clients often are most receptive to behavior change intervention and more likely to follow up on referrals at the time they are experiencing symptoms of disease.