Family Practitioners and Sexually Transmitted Diseases

The family practitioner's role has traditionally been to maintain 
health with periodic examinations and to restore health in times of illness and injuries. Today. 
family practitioners are expected to play a more proactive role by assessing unexpressed patient 
needs. This new approach focuses on global knowledge of the patient, including lifestyle and 
workplace history. When assessing sexually transmitted diseases (STDs) in particular, it is 
important for the family practitioner to recognize the association of morality issues and to 
counsel without being judgemental. Primary prevention of STDs is aimed at reducing or 
eliminating risks before exposure occurs. and includes counselling on safe sex, condom use. 
substance abuse, needle/syringe use, and consideration of hepatitis B immunization and 
universal screening of pregnant women for hepatitis B surface antigen. Secondary prevention 
refers to the recognition and elimination (if possible) of an STD after exposure and includes 
early disease detection, adequate STD treatments, screening, human immunodeficiency virus 
testing with pre- and post test counselling, epidemiological treatment of patient contacts, and 
hepatitis B prophylaxis by passive or active immunization. Tertiary prevention is aimed at 
limiting disease progression or reversing damage, but such measures are usually quite 
expensive and of limited value. Assessment of risks for hepatitis B virus infection should 
include lifestyle indices such as sexual preference, sexual expression, number of partners and 
alcohol/drug consumption. Prostitutes, street youth and sexually abused individuals should 
be considered at high risk for hepatitis B virus infection. Counselling about hepatitis B virus 
infection involves risk evaluation, patient education, evaluation of immune status to hepatitis 
B virus and discussions about vaccine needs and availability.

wide epidemic of sexually transm itted diseas es (STDs). Not having been able to resolve the gonorrh ea and chlamydia problems. we are entering the era of viral STDs. For mos t viral STDs there is chronicity. no curative treatment and the threat of oncogenicity. Family practitioners have been vital players in major breakth roughs in p reventive medicine. For exam ple. without help from family practitioners . such significant declines in the prevalences of tu berculosis. cervical cancer and cardiovascular dis ease could not have been achieved . Similarly. family practition ers s h ould be regarded as key mem bers of the health professional team in the figh t against STDs.
Family practi tioners are involved in many areas of the Canadian h ealth care system. from clinic a nd hospital s ettings to. more recently. the workplace and school. Th eir roles have centred on maintaining health by timely periodic examinations and screening for disease before complications . a nd on restori ng health in times of illness and injuries. Family practitioners· roles today are changing. however. as they are expected to be proactive , especially in the field of STDs. The new approach is cen tred on acquiri ng a global knowledge of the patient. which includes lifestyle and workplace issu es. In addition. family practitioners must attempt to assess the unexpressed needs of patien ts (1).
STDs remain a p uzzle for many general practitioners. General practitioners have ranked diagnos ing STDs fifth on a list of 24 primary care and health care problems. according to a study in Quebec by Leclere et al (2). Since STDs are linked to morality issu es and taboos. il is of the u tmost importance that family practitioners recognize the 28A implications of their own personal val u es clashing with those of some STD patien ts. Family practitioners should a ttempt to elimi nate or reduce patient risks related to sex and drugs with edu cation and co unselling. not wi th judgemental remarks .

PRIMARY PREVENTION
Primary preven tion is achieved by redu cing or eliminating exposure or by heigh tening defence mechanisms against the agen t of disease . Family practitioners are responsible for ·safe sex· cou nselling and should know the appropriate colloquial sexual expressions. They should teach patients how to recognize the risks of STDs in sexual partners and discuss how to negotiate protection. Safe sex counselling shou ld include a thorough questionnaire about sexual preference. sexual expressions, numbers of partn ers and. when n ecessary or appropriate. commercial sex and sexual abu se (3). Street youth and persons with out known addresses should be identifi ed as they are a particularly vulnerable group . Use of condoms should be discussed with respect to the best type (eg, latex) or brand to buy, how to prevent b reakage or. if the patient does not use th em. why not. Substance abuse should be discussed as it tends to decrease preventive behaviour. Fu rthermore. referral for detoxification and / or ed ucation about access to clean injection material dramatically decreases human imm unodeficiency vi rus (HIV) seroconversio n in intravenous drug users (4).
Hepatitis B vaccination is very importan t since it achieves over 9 5% protection in hepa ti tis 13 virus-exposed s u bjects (5). Over one-half of acu te hepatitis B vi rus infections are sexually transmitted (about 25% heterosexually, 33% h omosexually). Vaccination of sexu a lly active person s is persons is associated with a ben eficial cost/ benefit ratio, even at today's cost (6). Universal screening of pregnant women for hepatitis B surface a ntigen and active and passive vaccination of their offspring (recommended by the National Advisory Comm ittee on Immunization) are also of great public h ealth benefit . Family practitioners play an important role in educating and implementing universal precautions in h ealth care settings, to prevent infections due not only to h uman immunodeficiency virus (HIV) (fewer than 1 %). but also those due to hepatitis B vims (approximately 30%) and others (7) .

SECONDARY PREVENTION
Secondary prevention involves elimination of the agent of disease after ex-posure but before com plications. Early disease recognition by both patien t a nd physician is very important since many STDs manifest clinicaliy for only brief periods before symptoms disappear despite persisten ce of the disease agent. Adequate STD treatment is a lso important s ince exposure to inadequate dosages may increas e the risk of resistance against antimicrobials and increase subclinical disease in patients. Consequently. these patients may contin ue spreadin g the in adequ ately treated STDs to former or new sexu al partners in the false belief that they have been cured.
It is a lso advisable to screen patients in whom infection is suspected and to treat ·ep idemiologically' contacts of proven index cases . even without confirm ation test results (3). HIV testing with p re-and post test cou nselling is also important not only to discover HIV carriers but also to commun icate risk reduction messages (3). Hepatitis B virus post exposure prophylaxis for sexual, n onsexual and parenteral contact is feas ible with passive and /or active vaccination (8 ). Post exposure prophylaxis is more effective if given s oon after contact. Appropriate management of contacts should be outlined in a policy for whi,h adequate education would be required.

TERTIARY PREVENTION
Tertiary prevention is aimed at limiting disease progression or reversing damage due to disease. A strategy s uch as in vitro fertilization for infertility arisin~ from dilamydtal salpingitis is quite expensive and of limited efficacy: fewer than 10% of in vitro fertilization cycles produce a live birth (9); it could thus cost m ore than $60,000 per live birth (based on actualized costs from American studies [1 01). Zidovudine (AZf). on the other hand. reduces the evolution of HIV infection b u t costs from $2000 lo $8000 per year of trea tment and is in no

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Family practitioners and STDs way curative. Acyclovir can p reven t resurgence of herpes simplex virus infection but can cost from $30 per episodic treatment to $ 1200 a year for suppressive therapy. Interferon alpha-2b h as been shown to stop hepatitis B virus replication in hepatic cells of ch ronic carriers and can cost over $12,000 per patient treated. Compared to primary prevention. tertiary prevention is not very cost effective: treatment of one carrier of h epatitis B virus with in terferon alpha-2b would cos t the same as administering hepatitis B vin1s vaccinations to a. group of 120 people.

COUNSELLING ABOUT HEPATITIS B VIRUS
Identification of STD risk is frequently n ot considered in a medical h istory. Hepatitis B virus risk can be determined with good workplace and STD risks assessment and social indices reconnaissance. Since the general population and the average patient know little about hepatitis B vims compared to HIV or syph ilis, education about hepatitis B vi rus infection is crucial (1 1). Edu cational material about h epatitis B virus is available through the Canadian Liver Fou ndation. various provincial health agen cies a n d dmg companies. Patient consent for hepatitis B virus vaccination must be based on prior d iscussions with a family practitioner on the benet1ts, potential side effects and limitations of the vaccine. In addition. prevaccination evaluation of immune status by appropriate serological testing may be warranted for individuals suspected of exposure. Patien ts with limited fmancial resources. for whom accessibility might be a concern, should be informed of the availability of public health vaccin ation pro· grams.
Since the target populations and costs for hepatitis B virus immunization would be similar lo those for HIV immunization. hepatitis B virus immunization represents a unique pu blic health opportunity for in-field practice before an HIV vaccine becomes available (6).
In conclusion. family practitioners are obligated to take a proactive role in the treatment and prevention of STDs. Procrastination by family practitioners and public health authorities in implementing hepatitis B virus immun ization programs will prove costly to the health care system and patients.