As the incidence of sexually transmitted disease (STD) increases, the impact on society continues to escalate. Despite the availability of antibiotics, the 20th century has witnessed a preponderance of newly identified STDs, the most recent of which is human immunodeficiency virus (HIV). The incidence of STDs in the elderly population is significant for both newly acquired diseases and residual complications from prior infections. During 1986, 900,868 cases of gonorrhea were reported in the US; of these, 4% were in persons 40 years of age or older. Of the 27.883 reported cases of primary and secondary syphilis, 11% were in persons 40 years of age or older. Of the 12,932 reported cases of AIDS , 20% were in persons aged 40 to 49 years, 8% aged 50 to 59 years, and 3% for persons 60 years of age or over.1 In the US, the oldest reported person with AIDS acquired from a blood transfusion is 82 years of age.2
The actual incidence of AIDS in the elderly population may be considerably higher than the reported figures indicate because of underreporting, missed diagnoses, and the 1985 criteria revision to include Kaposi's sarcoma as an indication of AIDS.3 In addition, these numbers do not represent the elderly asymptomatic carrier or the patients afflicted with AIDSrelated complex (ARC) or other syndromes attributed to HIV infection.4 By 1991, it is estimated that 1,100 cases of AIDS in persons over 70 years of age will be identified.
This article will discuss existing knowledge about the relevant issues regarding STDs in the aging population and recommendations for appropriate preventive health-care strategies. Effective preventive techniques are vital since there is no known cure for AIDS, and infections with other STDs may have residual complications. Health-care workers delivering care to the elderly need to be informed about the spectrum of STDs to appropriately educate the public and counsel patients, families, and personnel in extended care facilities.
Primary prevention of STDs, which focuses on avoiding infection, has assumed greater importance since the advent of sexually transmitted infections for which there is no known curative therapy. The etiology and risk factors related to STDs are the basis for developing primary prevention interventions.
The causative organism, mechanism of transmission, portals of entry, and anatomic location of the infection must all be considered in preventive strategies. The more than 30 etiologic agents that cause STDs may be transmitted by both sexual and nonsexual means. The skin and mucosal linings of the urethra, cervix, vagina, rectum, and oropharynx are portals of entry and local sites of infection. Local diseases generally remain confined to the skin or mucous membranes near the portal of entry and include chiamydial infection, chancroid, gonorrhea, genital warts, Mycoplasma infections, pelvic inflammatory disease, pubic lice, scabies, trichomoniasis, and Vreaplasma. In localized STDs any discharge, mucus secretion, or other fluid that originates from or comes in contact with the infected area should be considered infectious.
Organisms causing systemic infections (such as AIDS, cytomegalovirus infection, hepatitis B, disseminated gonorrhea, and syphilis) remain in the blood for varying lengths of time. HIV weakens or destroys the body's immune system by attacking white blood cells, and the infected person may or may not demonstrate AIDS by acquiring an infection with one of the common organisms. All body fluids and tissues of a person with a systemic STD are potentially infectious, thus, prevention strategies focus on avoidance of skin and mucosal contact with infectious lesions or body fluids. HIV is transmitted by exchange of blood, semen, and vaginal secretions in activities that involve direct blood or mucous membrane contact. Prophylactic antibiotics administered in conjunction with sexual intercourse are not recommended as protection against STDs.5
SAFE SEX PRACTICES FOR PRIMARY PREVENTION OF SEXUALLY TRANSMITTED DISEASES
Epidemiologie studies have characterized risk factors for AIDS for elderly persons. The elderly person is at higher risk for acquiring HIV infection through blood transfusion than from sexual practices or intravenous drug abuse. Blood components implicated in the transmission of HIV include pooled plasma products, clottingfactor concentrates , cry oprecipi tate , red blood cells, platelets, plasma, and whole blood. Patients who received blood components from large numbers of donors have a higher risk of being exposed to HIV; this is reflected in the incidence of AIDS in older hemophiliacs. The incidence of transfusionacquired AIDS will decrease with improved methods for blood screening, preparation of blood components, and treatment of hemophilia.6 In April 1985, a safer blood supply in the US was ensured by the implementation of a national screening program for HIV antibody in donated blood and plasma.7 However, a newly infected person could unknowingly donate blood before the antibody test becomes positive because the antibodies do not form immediately after exposure to HIV.
The effects of national screening of blood may not become apparent for several years because of the long latency period that may follow HIV infection. The incubation period in patients infected via blood transfusion appear to be age-related with a mean of 5.5 years for elderly patients age 60 years and older.8 During the incubation period, which may range from months to years, the carrier is asymptomatic but is able to transmit the virus.
More than 90% of the elderly AIDS patients are men, although homosexual exposure to the HIV has, to date, not been a significant problem for the elderly male homosexual. The aging homosexual population, which numbers nearly 1 million men age 65 years and older, is at greater risk for acquiring AIDS with the increasing numbers of elderly asymptomatic carriers. Studies of the aging male homosexuals suggest that longer monogamous relationships, fewer anonymous sexual partners, and possible lessening of sexual activity are factors that have afforded a degree of protection from exposure to my 9-10
All members of the health-care team need to understand the impact of STDs on elderly clients and become skilled in educating and counseling at risk and infected clients. Primary prevention counseling should include safe sex guidelines recommended by the CDC (Table 1). Behavioral modification for sexually active persons at risk includes monogamy, reducing the number of sexual partners, avoiding certain sexual practices such as anorectal intercourse and oral-anal and digital-anal activity, and questioning and inspecting partners for a rash, discharge, or genital lesions. Barrier methods (latex condoms, diaphragms) and spermicides should be encouraged to reduce the risk of acquiring certain infections, regardless of the need for contraception. Patient education and counseling may be particularly useful for the elderly homosexual at risk for exposure to asymptomatic carriers.
Community education is imperative for the prevention of STDs. The elderly population, although not at high risk, should be included in STD public education campaigns because STDs, particularly AIDS, have the potential to affect all of society. The social dynamics, rituals, and sexual practices of the elderly need to be assessed to delineate obstacles to change and to determine the most effective way to reach this group. The AIDS pandemic, one of the most devastating infectious diseases, poses a threat to the public health of all citizens.
In response, the CDC launched the National AIDS information campaign in 1987 to prevent the transmission of AIDS through changes in the social norms and behavior of the public. This campaign requires addressing the specific needs of target authences and learning the most appropriate strategies for communicating vital health information . l ' High public credibility enhances the role of health professionals in a public education campaign designed to aid in the understanding and prevention of the transmission of AIDS . It is important for professionals to allay unfounded fears, best accomplished by arming oneself with accurate and precise data, presenting material in a calm, professional manner, and allowing questions. Community education and individua! counseling are among the best defenses against STDs.
Secondary prevention of STDs includes prompt identification and effeclive treatment of infected and at risk persons. Although venereal infection is uncommon in the elderly, unrecognized disease may enhance morbidity in persons already compromised by other disease states. Recent physiologic research on sexual capacity suggests that aging need not lead to diminished sexual activity but a continuation of satisfying sexual experiences. Also, health-care practitioners should be aware that confusion and dementia in some elderly persons may complicate the determination of an accurate history.12 Tertiary syphilis should always be considered in the evaluation of persons with dementia.
SYPHILIS: SEROLOGIC INTERPRETATION
The elderly may be referred for possible STDs, mostly due to reactive blood tests for syphilis. A careful history is imperative to identify conditions that can produce a false positive result. Risk assessment is also facilitated by including a sexual history as an integral part of all health histories, although this is often neglected in the elderly.
Special sensitivity in communication and attentive listening are necessary for exploring personal areas that may elicit significant emotional responses, particularly when age, language, gender, or cultural differences exist between the client and practitioner. Questions about the possibility of sexually transmitted diseases, sexual preference, and activity may be perceived as embarrassing. Good communication skills are essential in eliciting personal information. A brief explanation of the purpose of a sensitive question may be helpful if a negative or emotional reaction is anticipated, such as: "I am trying to learn about you so that the best health care can be provided. The following questions are personal, but they are not intended to pry into your private life nor to imply anything about you." An initial question that allows considerable latitude in response and projects a nonjudgmental attitude is: "Tell me about your sexual partner or partners .
ASPECTS OF COUNSELING
Information acquisition in the domain of a sexual history should be based on the assumption that everyone has engaged in every type of sexual activity. The data base should include information about sexual partners, sexual preferences, practices, and problems or satisfaction with sex life. In the event of a negative emotional reaction to a sensitive question, mutual respect and trust can best be established by dealing directly with the issue, emphasizing the desire to provide quality care, and offering assurance that there is no intent of disrespect or judgment. A particularly troubling or embarrassing issue may be reserved until the end of the session, but time must be allowed to deal with the concern as it may be of considerable significance and may yield important data for the subsequent plan of health care.
In conjunction with the sexual history, assessment should include a thorough physical examination and appropriate diagnostic tests. The physical examination is directed toward the skin, oral mucosa, genitalia, ocular fundí, lymphadenopathy, abdominal pain, discharge, as well as such extragenital manifestations as asymmetrical polyarthritis, arthralgia, and tenosynovitis.13
Laboratory data should consist of both screening and confirmatory tests to rule out false positive results, but these results must be interpreted with caution (Table 2). A number of studies have indicated an increased frequency of biologically false positive seroreactions for syphilis in aged persons. l4· 15 If these persist for 6 months or longer, the presence of autoimmune disease or fundamental autoimmune characteristics of aging is indicated.16 Past records should be researched to determine previous treatment for syphilis. Syphilis is never infectious after it has been present for 5 years or longer. The continued reactive test result does not indicate current infection unless the titers are significantly elevated. It is possible to distinguish true latency from active disease by examining the cerebrospinal fluid, electrocardiogram, and screening the aorta.
There is no specific diagnostic test for AIDS. A positive enzyme linked immunosorbent assay (ELISA) may indicate that the person has been exposed to and has developed antibodies to the HIV, usually 2 weeks to 3 months after infection. Because the ELISA test may give a false positive reading, a Western blot test is used to confirm a positive ELISA result . l7 According to the CDC, a diagnosis of ADDS consists of an opportunistic infection and one of the specific cancers associated with AIDS, such as Kaposi's sarcoma, in the presence of an otherwise unexplained immunodeficiency. The symptoms associated with AIDS depend on the type of opportunistic infection or cancer that is present but may include dementia, diarrhea, rapid weight loss, oral thrush, recurrent fever, night sweats, and swollen lymph glands.
A diagnosis of AIDS in the generally low-risk elderly population may be unexpected; however, contamination of blood has made this diagnosis a possibility. Neurological dysfunction, including subacute encephalitis, vacuolar myelopathy, psychiatric disorders, and peripheral neuropathies, has been identified in more than two thirds of the patients with AIDS.18·19 Subacute encephalitis results in progressive cognitive, motor, and behavioral abnormalities.20 Ageism and the expectation of some decline in mental and physical ability may obscure the relationship of clinical manifestations to the neurologic consequences of the neurotropic HIV and result in misdiagnosis. Healthcare practitioners must be aware of the varied manifestations of an impaired immune system to appropriately screen all elderly patients.
Guidelines for appropriate drug treatment for specific STDs have been developed by the CDC.21 Treatment based on clinical or epidemiologie findings remains appropriate, but follow-up tests for positive diagnoses are recommended. A test of cure 3 to 4 days after the medication treatment is completed should be an integral part of all treatment protocols. Appropriate treatment should be initiated when clinical evidence supports the laboratory findings of acute stage syphilis.22 Clinical evaluation and serologie testing are required at 3-, 6-, and 12-month follow-up visits to assess the adequacy of therapy for syphilis. Successful treatment of primary and secondary syphilis is characterized by a serological response of an approximate fourfold and eightfold drop in Venerai Disease Research Laboratories liters at 3 and 6 months, respectively.23 Secondary syphilis in the elderly should be treated, but medical opinion indicates that reversal of seropositivity need not be achieved.24 Although AIDS is not currently curable, drug therapies directed against HIV, secondary infection or cancers, and to the restoration of the immune system have helped to prolong life.
A myriad of difficult ethical issues that coalesce in the care of elderly clients and their families must be considered in relation to patient confidentiality, notification of sexual partners, and treatment regimens. Quality preand post-test counseling is the only sensible prescription for individual and public health (Table 3). Principles of counseling pertain to all STDs; however, the social stigmatization and catastrophic illness and death related to AIDS require a uniquely empathetic approach.
Screening for HIV requires knowledge about various homosexual practices and the ability to discuss these with clients. A direct nonjudgmental approach promotes trust and is conducive for obtaining a complete, relevant sexual history. Pre-test counseling should identify appropriate candidates for screening. Clients not at high risk should be counseled to alleviate unfounded fears and to provide information about the disease, particularly preventi ve measures.
The following guidelines may be useful for appropriate STD pre- and post-test counseling. A multidisciplinary team comprised of a nurse, social worker, physician, and psychiatrist should ideally be available for initial counseling and subsequent follow-up sessions. The availability of psychiatric consultation in the pretest counseling session is particularly desirable with patients who manifest severe psychological disturbances related to a possible positive test result. The goals of pretest counseling include provision of education about the STD and the particular diagnostic test, discussion of risk reduction measures, description of the consequences of disease, implications of the sharing of testing information with others, discussion of options, and assessment of the clients' coping strategies and support networks.
Nurses must be careful to allow sufficient time for clients to ask questions to ensure informed consent. Due to the anxiety generated by the fear of AIDS, it may be necessary to reiterate information during the discussion. Confidentiality concerning STD test results is essential to protect the privacy of the person and should be extended to the entire testing procedure. However, in all states, confirmed cases of AIDS, gonorrhea, and syphilis constitute a reportable condition.25
Clients should be instructed to behave as if positive until they are informed of negative results. Written educational materials should be provided to supplement the discussion. Coping strategies can be evaluated by exploring the client's usual way of dealing with stress and inquiring about the manner in which they would react to a positive test result. This approach enables the client to consider options before the test results are available and to mentally deal with the worst possible scenario. Assessment of the client's support network and identifying a significant supportive person is a preparatory step in dealing with the reaction to a potential positive test result. Under all circumstances, the client should be encouraged to return to the health-care facility to discuss test results or the implications of refusing testing.
The post-test counseling session for clients with negative test results provides an opportunity for discussion of STD risk reduction measures, mode of transmission, and the general concept of health. This session also provides the opportunity to answer questions and to provide information about support groups, telephone hotlines, and risk factor reduction. If the client has a history of high risk exposure to AIDS or syphilis, retesting should be encouraged. Latex condoms should be distributed with guidelines for their use and educational handouts are particularly useful in reinforcing recommendations for prevention. The elderly client often requires more time to comprehend new information; therefore, written materials and a follow-up session are appropriate.
Positive screening tests for syphilis and HIV need confirmatory testing before clients are told they have the infection. The client should be assured that the presence of HIV antibodies does not mean they have AIDS , but that they can infect a sexual or needle- sharing partner. During the first 7 years following seroconversion, more than two thirds of seropositive persons have not developed AIDS. Therefore, instruction regarding health maintenance and the need to minimize exposure to viral infections are critical. Counseling the client with a positive test result (particularly with HIV infection) should ideally be conducted by the members of the health-care team, with one member acting as the informer and another retaining the support person role. The session should be conducted at a leisurely pace, based on the person's cognitive ability and emotional state.
HIV seropositive elderly clients who have been infected through contaminated blood product transfusion have special needs. The counselor must be prepared to assist clients in coping with the element of total surprise and devastating shock. Anger is often the initial reaction followed by anxiety and depression. The nurse needs to validate these feelings as a normal reaction to notification of seropositivity. Overwhelming emotional reactions leave clients unable to internalize information, therefore several counseling sessions are required.
NURSING INTERVENTIONS FOR PREVENTION OF SEXUALLY TRANSMITTED DISEASES
Tertiary prevention consists of alleviating client disability resulting from disease and restoring optimal functioning. This important component of STD care focuses on maximal use of the person's residual abilities to prevent continued deterioration and may require a skilled multidisciplinary approach. This level of prevention is often given minimal attention by busy professionals as they screen and treat cases and bring clients' sexual contacts in for treatment. The complex combination of physiologic sequelae, psychiatric distress, and social stigmatization associated with STD requires sufficient funding to provide services over a prolonged period. Practitioners need to be aware of referral sources and provide appropriate anticipatory guidance.
The emotional sequelae to STD may encompass loss of trust in a sexual partner; diagnosis of STD may be the first indication that a sexual partner is not monogamous.26,27 Despite changes in sexual mores, diagnosis of STD may cause an individual to question personal worth. An individual who is HIV seropositive must also deal with the real threat of developing a lifethreatening disease. Frequently, the person is unable to talk with others in the usual support network because of the fear of rejection. The overall goal of supportive intervention is to assist patients and their families in coping with this illness and in restoring the ability to manage their lives. This involves adapting to the limitations of the illness and finding new meaning in life.27
Although mature clients are usually highly motivated to care for both themselves and their sexual contacts when a STD is diagnosed, those who are married may present a unique problem: they may want to have their spouses treated but not tell them it is because of exposure to STD. It is important for the diagnosed client to inform the spouse and arrange for medical screening or treatment. Another difficult situation involves questions about which partner introduced the STD into the relationship. The professional does not discuss one spouse with another, and stating that the confidentiality of all clients is protected can diffuse the issue. A referral for marriage counseling is generally appropriate for these couples. Practitioners need to become sensitive to emotional reactions of clients so that appropriate counseling can be offered. This is important so that clients can develop or continue a healthy social life and the potential for sexual activity and well-being.
IMPLICATIONS FOR HEALTH-CARE PROVIDERS
Despite antibiotics, STD continues to escalate in both scope and complexity. Nurses are encouraged to implement primary prevention education for individuals, at risk groups, and the community. The complexity and change in both causative organisms and treatment protocols necessitates continuous updating of knowledge so that appropriate secondary prevention measures can be instituted. Nurses are encouraged to include tertiary prevention as an integral part of care for clients with STDs. Anticipatory guidance and appropriate referrals for counseling and medical care are often necessary. Effective nurses are open and nonjudgmental during patient interactions. They are able to comfortably discuss sexual practices and mores that are not consonant with their personal beliefs and practices.
In 1987, the CDC updated its recommendations for prevention of HIV transmission in health-care settings.28,29,30 The precautions, modeled along guidelines to prevent hepatitis B virus transmission, are recommended for routine usage and not just for patients diagnosed with AIDS. Following these guidelines should be imperative for all health-care workers.
Good handwashing practices, proper handling of blood and body secretions, sufficient patient care supplies, and the availability of mouth to mouth devices for emergency resuscitation are important infection control precautions.31'33 As of April 1988, 12 US health-care workers had been identified as being infected with HIV as a direct result of occupational exposure.34 Scrupulous attention to established infection-control and needlestick recommendations can virtually eliminate the risk of occupationai transmission of the HIV to health-care workers.34·35 Staff education and policy design are vital for the provision of compassionate, skilled care for the elderly in health-care facilities (Table 4).
All STDs, but particularly AIDS, take an emotional toll on the patient, family, and health-care staff. The diagnosis of AIDS often evokes a powerful response in health-care workers based on fear of contagion and homophobia that may lead to suboptimal care, diagnostic imprecision, and significant distress. Discriminatory policies may exclude these elderly patients from longterm care facilities and home care agencies. A compassionate caregiver is vital if the patient and family are to restructure their world.
- 1. Summary of notifiable diseases. United States (1986). MMWK. 1985; 35(55): 10.
- 2. PetermanJA.JaffeHWfcorinoPM.Getchell JP, Warfield DT, Haverkos HW, et al. Transfusion-associated acquired immunodeficiency syndrome in the United States. JAMA. 1985;254<20):2913-29I7.
- 3. Centers for !Disease Control. Revised case definition of acquired immunodeficiency syndrome for national reporting - United States. MMWR. 1985; 34:373-375.
- 4. Moss RJ, Miles SH. AIDS and the geriatrician. J Am Geriatr Soc. 1987; 35(5):460464.
- 5. Stone KM, Grimes DA, Magder LS. Primary prevention of sexually transmitted diseases. JAMA. 1986;225(13):1763-1766.
- 6. Peterman TA, Dortman DP, Curran JW. Epidemiology of the acquired immunodeficiency syndrome. Epidemial Rev. 1985; 7:1-21.
- 7. Centers for Disease Control. Provisional public health service intra-agency recommendations for screening donated blood and plasma for antibody to the virus causing acquired immunodeficiency syndrome. MMWR. 1985; 34:1-5.
- 8. Medley GF, Anderson RM, Cox DR, Billard L. Incubation period of AIDS in patients infected via blood transfusion. Nature. 1987; 328:719-721.
- 9. Gray H, Dressel P. Alternative interpretation of aging among gay males. Gerontologist. 1985; 25<l):83-87.
- 10. Councí] on Scientific Affairs. Health care needs of a homosexual population. JAMA. 1982; 248(6):736-739.
- 11. Dan BB. The national AIDS information campaign. JAMA. 1987; 258(14):1942.
- 12. Luke EA. Syphilis in the elderly. 7AAfA. 1985;254(13):1722-1723.
- 13. Geelhoed-Duyvestijn PHLM, \&n der Meer JWM,Lichtendahl-BernardsAT,MuIder CJ, Meyers KAE, Poolman JT. Disseminated gonococcal infection in elderly patients. Archlmern M ed. 1986; 146(9):17391740.
- 14. Carr RD, Decker SW, Carpenter CM. The biological false-positive phenomenon in elderly men. Arch Dermatol. 1966; 93:393395.
- 15. JohanssonEA, LassusA, ApajalahtiA, Aho K. Serological tests for syphilis in the elderly. Ann Clin Res. 1970; 2:47-50.
- 16. Tuffanelli DL. Aging and false positive reactions for syphilis. British Journal of Venereal Diseases. 1966; 42:40-41.
- 17. Landesman SH, Ginzburg HM, Weiss SH. The AIDS epidemic. N Engl J Mea. 1985; 312(8):521-524.
- 18. Gabuzda DH, Hirsch MS. Neurologic manifestations of infection with human immunodeficiency virus. Ann Intern Med. 1987; 107(3):383-39I.
- 19. Ho DD, Pomerantz RJ, Kaplan JC. Pathogenesis of infection with human immunodeficiency virus. N Engl J Med. 1987; 317(5):278-286.
- 20. Grant 1, Atkinson JH, Hesselink JR, Kennedy CJ, Richman DD, Spector SA, et al. Evidence of early central nervous system involvement in the acquired immunodeficiency syndrome (AIDS) and other human immunodeficiency virus (HIV) infections. Ann Intern Med. 1987; l07(6):828-836.
- 21. i985 STD Treatment Guidelines. US Departaient of Health and Human Services, Public Health Service Center for Disease Control, Center for Prevention Services, Division of Sexually Transmitted Diseases, 1985.
- 22. Woolley PD, Anderson AJ. Prevalence of undiagnosed syphilis in the elderly. Lancet. 1986; 2(85 14): 1034.
- 23. Guiñan ME. Treatment of primary and secondary syphilis: Defining failure at threeand six-month follow-up. /AAfA. 1987; 257(3):359-360.
- 24. Krishnan MV, Lomax W. Venereal infection in the elderly. Geronwl-Clin Basel). 1970; 12(2):76-79.
- 25. Koop CE. Surgeon General's report on acquired immunodeficiency syndrome. JAMA. 1986; 256f20):27S4-2789.
- 26. Bierman SM. The "terrible" question. 7AMA. I985;253(5):641.
- 27. Harries AD. Syphilis in the elderly. Lancet. 1986;2(8521-8222):1469.
- 28. Centers for Disease Control. Recommendations for preventing transmission of infection with human T-lymphotropic virus type III - Lymphadenopathy-associated virus in the workplace. AfAfWA. 1985; 34(45):681695.
- 29. Centers for Disease Control. Recommendations for prevention of HIV transmission in health-care settings. Leads from the Morbidity Mortality Weekly Report. JAMA. 1987; 258(10):1293-1305.
- 30. Centers for Disease Control. Recommendations for prevention of HlV transmission in health-care settings. Leads from the Af orbidity Mortality Weekly Report. JAMA. 1987; 25S(11):1441-1452.
31. Centers for Disease Control. Update: Human immunodeficiency virus infections in health-care workers exposed to blood of infected patients. Leads from the Morbidity Mortality Weekly Repon. JAMA. 1987; 257(22):3032-3039.
- 32. Brown BL, Brown JW. The third international conference on AIDS: Risk of AIDS in health-care workers. Nursing Management. 1988; I9(3):33-35.
- 33. Schobel DA. Management's responsibility to deal effectively with the risk of HIV exposure for health-care workers. Nursing Management. 1988; 19(3):38-42.
- 34. Decker MD, Schaffner W. Risk of AIDS to health care workers. JAMA. 1986; 256<23):3264-3265.
- 35. Health policy and biomedicai research news of the week. Twenty-one health-care workers worldwide infected with HIV due to work exposure; PHS to issue guidelines. TheBlueSheet. 1988; 31(15):?.
SAFE SEX PRACTICES FOR PRIMARY PREVENTION OF SEXUALLY TRANSMITTED DISEASES
SYPHILIS: SEROLOGIC INTERPRETATION
ASPECTS OF COUNSELING
NURSING INTERVENTIONS FOR PREVENTION OF SEXUALLY TRANSMITTED DISEASES