Brazilian Protocol for Sexually Transmitted infections 2020: approaching sexually active individuals

Abstract This article aims to present concepts and clinical practices recommended to approach people with active sex life. These concepts are an integral part of the recommendations of the Clinical Protocol and Therapeutic Guidelines for Comprehensive Care for People with Sexually Transmitted Infections (STI), published by the Ministry of Health of Brazil in 2020. The article proposes a comprehensive approach to sexuality for health promotion. It presents significant aspects of the communication process that must develop, without prejudice and judgment, focusing on sexual and reproductive health. It also highlights relevant points about the exercise of sexuality at specific stages of life, recommending assessment of risks and vulnerabilities and screening for STI and condom use. In this way, it is possible to contribute to exercise their sexuality fully, responsibly, and safely.


INTRODUCTION
Sexual and reproductive rights are considered fundamental, together with the rights to life, food, health, housing, and education for the complete exercise of citizenship 4 .The right of individuals and couples of all sexual orientations to have their sexual health preserved is recognized.Sexual health is defined as the physical, emotional, mental, and social wellbeing associated with the exercise of sexuality and not just the lack of sexual infections, disorders, or diseases 5 .It is considered an essential component for promoting human development 6 .It implies the exercise of safe and healthy sexual experiences without coercion, discrimination, or violence 7 .Finally, sex is understood as one of the essential dimensions of sexuality, not limited to genitality or reproduction 8 .

2/7 BRAZILIAN PROTOCOL FOR SEXUALLY TRANSMITTED INFECTIOUS 2020
Guidelines for approach to sexuality by healthcare staff Set a routine of questions to all users on sexuality (dialog on sex and sexual practices).
Develop your style, observing a respectful association.Avoid previous judgments.Do not assume preconceived notions (unless you ask, there is no way of knowing someone's sexual orientation, behaviors, practices or gender identity).
Respect the patient's limits (non-verbal language).Observe for any discomfort and reformulate the questions or briefly explain why you are making this questions, in case the patient seems offended or reluctant in answering.

Monitor and restrain your reactions (non-verbal languages).
Say the same questions are made to everyone (protocol procedure), regardless of sex, age, profession or marital status.
Use neutral and inclusive terms (for example, "partner" instead of "boyfriend", "girlfriend", "husband", or "wife") and make questions in a non-judgmental way.
When servicing a transexual person, ask how they want to be called or identified.Offer support to the current gender identity, even if the anatomy does not correspond to such exactness.

FIGURE 1:
General guidelines for approach to sexuality by healthcare staff.

COMMUNICATION IN THE APPROACH TO SEXUAL HEALTH
The communication process plays a significant role in the improvement of the professional-patient relationship and, as a consequence, for the adherence to the recommendations and treatment 9 .Health professionals can be unprepared and feel embarrassed when it comes to approaching patients regarding STI and sexuality 10 .The offer of adequate training could minimize such embarrassment and contribute to qualifying such professionals' performance, aiming to make them familiar with the different concepts of gender, sexual orientation, and identity.
Health services must promote environments favorable to the dialog and embrace the different dimensions of the exercise of sexuality by sexually active individuals.We recommend a gradual approach, advancing from general aspects to the most specific ones 11 .Adequate approach to sexuality must encompass guidelines on prevention and identification of risk factors and vulnerabilities, sexual practices, and behaviors that favor STI contamination.
To establish an association of trust, we need a clear and transparent approach, adequate to receptivity and the life context of the persons, which must be recognized as active individuals in the care process 10 .All services must favor the development of autonomy of the subjects for identifying solutions to their demands.The approach must take place free from prejudiced attitudes, labels, and stigmatization, understanding sexuality as part of the culture and the historical, social, and life context of each individual 4 .
We recommend to the professional to assure that the person is comfortable to talk about such themes, informing them that those are questions made routinely in the healthcare service, regardless of sex, sexual orientation, age, professional activity, and marital status.Emphasis should be placed on the secrecy and confidentiality of information 12,13 General guidelines on communication can be found in Figure 1.
Telemedicine has currently been gaining ground in disclosing information, promotion and prevention, expanding the scope of healthcare services, especially in a continental country with regions that are hard to reach.Useful communication techniques in servicing people with STI are also needed in telemedicine 14 .For this reason, it is necessary to incorporate its use in the service to people with STI, respecting the ethical limits and current recommendations regarding data storage, handling and transmission, as well as confidentiality, privacy and the guarantee of professional secrecy 15 .

SEXUALITY IN SPECIFIC LIFE STAGES
Adolescence is a period of significant biological, psychological and social transformations.Physical alterations, social interactions and the awakening of new interests reflect fast and profound changes that characterize this life stage.The way adolescents express and live sexuality is influenced by the quality of emotional and affective associations experienced with relevant people in childhood, integration with peers, transformation arising from growth and development, the start of reproductive capacity, beliefs, moral patterns, myths, and taboos, as well as the traditions of the family or society in which they are inserted 16 .
In this stage, values, attitudes, habits, and behaviors are being formed, transformed, and consolidated, making adolescents more vulnerable, mainly because parents or guardians, school, and even health staff tend not to approach the aspects regarding the exercise of sexuality.Therefore, many times adolescents start their sexual lives without due orientation 17 .
Healthcare services can play a fundamental role, disclosing to adolescents information contributing to the awakening of a healthy sexual life and prevention of STI and unintended pregnancy.Such orientation must be based on dialog, allowing for autonomy and responsible attitudes 18 .The approach must comply with confidentiality and privacy principles, indispensable for trust and respect between adolescents and health professionals 19 .It also must take place from the point of view of comprehensive care, providing access to different technologies associated with combined prevention 16 .
During gestation, sexual relations do not pose a risk to pregnancy, except in unique obstetric situations (membrane rupture, cervical Suggestions for questions to be made by healthcare staff to sexually active people

Sexual health
"I am going to ask some questions on sexual health.As sexual health is important for general health, I always question patients on that.If it is all right for you, I will ask some questions on sexual matters now.Before starting, ask if the person have any questions or concerns regarding your sexual health that would like to discuss?" Identification "How do you consider yourself (sexual orientation)?Homosexual (gay, lesbian), heterosexual, bisexual, other, do you not know?""What is your gender identity?Men, women, transexual men, transexual woman, transvestite, other?" "With which sex were you designated when born, how are you registered in your birth certificate?"

Partners
"Have you ever had sexual relations?"If so: "How many sexual partners did you have last year?"(or another period, according to clinical examination to be carried out in medical appointment).
"Did you have sexual relations with men, women or both?" "Over the last three months, did you have sexual relations with somebody you did not know or had just known?" "Have ever been forced or pressed to have sexual relations?"

Sexual practices
"Over the last three months, what kinds of sex did you have?Anal?Vaginal?Oral?Receptive (bottom), penetrative (top), both (bottom and top)?" "Did you or your partner use alcohol or drugs when having sex?" "Have you ever exchanged sex for drugs or money?"

History of sexually transmitted infections
"Have you ever had a sexually transmitted infection?"If so: "Which?Where was the infection?When was it?Did you treat it?Did your partner get treated?""Have you ever being tested for HIV, syphilis, hepatitis B/C?"If so: "How long ago did this test happen?What was the result?"

Protection
"What do you do to protect yourself from sexually transmitted infections, including HIV?" "When do you use protection?With which partners?" "Have you been vaccinated for hepatitis B? Hepatitis A? HPV?" Family planning "Do you wish to have (other) children?"If so: "How many children would you like to have?When would you like to have a child?What are you and your partner doing to prevent pregnancy by now?"If no: "Are you doing something to prevent pregnancy?"(Make sure to make the same questions for transsexual people that still have female reproductive organs).

FIGURE 2:
Routine service questions for assessment of the risk of sexually transmitted infections.
insufficiency, short cervix, or premature delivery).However, we should not ignore the possibility of a pregnant woman getting an STI that harms the gestation's prognosis, or vertically transmitting the disease.For this reason, healthcare staff must approach routine questions associated with the sexual health of pregnant women and their sexual partners and offer HIV, syphilis, and hepatitis B and C tests in prenatal care 18 .
Older adults presented an increase in the number of HIV and syphilis cases over the last years, drawing attention to the role of sexuality in this age group 20,21 .There are essential aspects that increase vulnerability, as lower genital lubrication in women, and male erection difficulty [20][21][22] .Besides, it is a generation that was not sexually initiated with safe sex.

RISK ASSESSMENT, VULNERABILITIES, AND STI TRACING
In risk assessment for STI in sexually active individuals, we recommend investigating structured questions, identifying factors associated with sexual practices and behaviors, and alcohol and drug use.From the contents obtained, it is possible to make an adequate assessment for risk management and identify opportunities for recommending preventive actions.The professional must individually provide the attendance, and in a private environment 1,16,23 .Figure 2 presents questions for the attendance towards risk assessment.
Risk assessment can guide STI tracing.After identifying clinical cases, it is crucial to call and treat the sexual partnerships, 4/7 aiming to interrupt the chain of infection, prevent complications, and avoid reinfections 1 .In Brazil, the PDCT recommends screening asymptomatic subgroups 1 to identify and treat infected individuals earlier, looking to prevent STI dissemination and their complications 24 .
European guidelines recommend managing sexual partners of people with STI, indicating emotional support and contact identification and notification, through a strategy guided by pattern operational procedure for control, monitoring, treatment, and report of cases 25 .Susceptible person is the one who does not have a record of a complete vaccine scheme and presents non-reacting surface antigen for hepatitis B virus (or nonreacting rapid test for hepatitis B); e) Hepatitis C: preferably with a rapid test; f) If the pregnant woman has not carried out tracing in prenatal care, perform a rapid test for hepatitis B at the moment of delivery.Hepatitis B vaccine is safe during pregnancy, and susceptible women must be vaccinated.Brazil presents a trend of HIV and syphilis increase in the population between 13 and 29 years of age 20,21 .For this reason, it recommends the annual tracing of such infections in people up to 30 years old who are sexually active.Other diseases are screened depending on population groups and sexual practices that expose people to more significant risks.Figure 3 presents recommendations for tracing people in any age group.

Subgroups
It is important to trace some infections, such as chlamydia and gonococcus, aiming at preventing pelvic inflammatory disease that, BRAZILIAN PROTOCOL FOR SEXUALLY TRANSMITTED INFECTIOUS 2020 5/7 even if asymptomatic, can reduce chances of pregnancy 26 .In Brazil, screening for chlamydia infections is recommended for pregnant women younger than 30 years old due to the high prevalence of infection in this age group 27 .
Figure 3 presents recommendations for tracing STI according to population subgroups, as proposed by the PDCT for Comprehensive Care for People with STI 2020 1 .

CONDOM USE
Using female, or male condoms is a preventive strategy that should be offered to sexually active people, in order to reduce the risk of HIV and other STI transmission and prevent pregnancy 28 .Despite the low adherence and acceptance of the female condom, it is deemed necessary in situations where it is difficult for the women to negotiate the use of the male condom 29 .

Care with latex male condom
Care with female latex condom Factors contributing to rupture or leakage of male condom Store it away from heat, observing package integrity, as well as best before date.
Store it away from heat, observing package integrity, as well as best before date.Poor storage conditions.
It must be placed before penetration, during penis erection.Do not use it together with a male condom.Non-compliance with best before date.
Press the edge of the condom between your fingers while placing it, taking all air inside.
The female can be placed even before the relationship and taken out freely after intercourse, preferably before the women get up, to avoid sperm drips from inside the condom.
Package damage.
Still holding the condom edge, unroll it to the base of the penis.
The female condom is already lubricated; then, there is no need for lubricants.

Insufficient vaginal lubrication.
Use water-based lubricants (lubricating gel).The lubricating gel makes anal sex easier and reduces the chances of the lesion.
To put it correctly, the woman must find a comfortable position (standing up with one foot on a chair, sit with knees apart, squatting or lying down).
Use of oily lubricants, such as vaseline or food oil.
Anal sex without adequate lubrication.
In case of rupture, the condom must be immediately replaced.
Press and introduce the movable ring of the condom into the vagina.Using the index finger, pull it as deep as possible to reach the cervix; the fixed (external) ring must be around three centimeters out of the vagina.During penetration, guide the penis to the center of the outer ring.
Use of oily lubricants.
After ejaculation, take the penis out, still erect, holding the base of the condom, so there is no sperm leaking.
A new condom must be used for each new relation.
Air and lack of space for taking the sperm in the edge of the condom.
The condom cannot be reused, and it must be dismissed in the trash (not in the toilet seat) after use.
Improper size for the penis.
Erection loss during sexual intercourse.
Contraction of the vaginal musculature while taking the penis out.
Pulling the penis out without holding the base of the condom firmly.
Use of two condoms (due to friction between them).
Use of the same condom during long intercourse.The offer of condoms must take place without the quantity restrictions and without requiring identification documents.Figure 4 presents the guidelines for conservation and correct use of male and female condoms.They should be part of the healthcare staff's approach in all services, especially highly vulnerable individuals.

CONCLUDING REMARKS
Healthcare professionals must incorporate sexuality into services to sexually active individuals, mainly those with STI complaints.This approach must develop, without prejudice and judgment, with a focus on sexual and reproductive health.In this way, it is possible to contribute to exercise their sexuality fully, responsibly, and safely.The right preventive approach can favor the decrease of STIs and their consequences.

FIGURE 3 :
FIGURE 3: Tracing indication for sexually transmitted infections according to population subgroups.

FIGURE 4 :
FIGURE 4:Use and adequate conservation of male and female condom.