1. Cure your infection: Take all your medication as instructed even if symptoms disappear or you feel better. The symptoms may come back if you do not take all of the medication.

2. Do not spread STDs: Do not have sex again until you take all your medication as directed and you have no more symptoms. If you do not wait, you may give an STD to your sexual partner. Also, do not have sex again until your partner is treated. If you do not wait until your partner is treated, you may get the infection again from your partner. If you must have sex, use condoms with all partners.

3. Help your sexual partners get treatment: Tell them to come for treatment or else bring them in.

4. Come back to make sure you are cured: If you still have symptoms, you can get more medicine to cure your infection.

5. Stay cured with condoms: Always use condoms with any occasional sexual partners and, if possible, with your steady partner. If using condoms is not possible, using spermicides provides some protection.

6. Keep safe by staying with just one sexual partner: If you have sex with several people, there is more risk that one may have an STD and infect you. If possible, encourage your partner to stay just with you.

7. Protect yourself against AIDS: Sexually transmitted diseases increase your risk of getting AIDS.

8. Protect your baby: Go (or send your wife) to an antenatal clinic within the first three months of pregnancy for a physical exam and syphilis test.

Although these messages are obviously critical, STD providers often neglect counseling (150, 166, 194, 261). For example, in a US study involving 60 STD patients, one-quarter received no information about preventing STDs (261).

Counseling can be challenging. Patients may resist counseling messages, and providers may lack training. For some patients avoiding STDs is not enough motivation to use condoms or to avoid sex until cured; providers often see the same people returning for treatment (72). Others may not understand how STDs spread or why their sexual partners need treatment; they need to understand the reasons for the counseling messages. Patients, especially adolescents, may underestimate their risk of getting an STD. Some patients may understand the risks but not change behavior until they sense that others in their community have changed (6). Men may prevent women from changing their behavior.

To counsel well, providers need to be empathetic, nonjudgmental, honest, and respectful of patients (see Population Reports, Counseling Guide, J-36, December 1987). Providers also need to take time to counsel. Communicating all counseling messages thoroughly may take 20 minutes. Few providers can spend that much time with each patient. Thus in some programs specially trained counselors talk to patients after they have seen a doctor, nurse, or nurse-midwife.

Providers can use a number of techniques to help patients complete treatment and remember and follow the counseling messages. For example, they can:

• Help patients decide how they best can remember to take the medication, such as taking it at the same time every day;
• Write down the instructions and messages or give the patient a brochure;
• Discuss past attempts at prevention, try to find out why they failed, and help resolve these problems;
• Ask patients if they need help to follow the counseling messages;
• Help women and men practice for a discussion of STDs and safe sex with their sexual partners;
• Repeat the counseling messages;
• Ask the patient to repeat the instructions (7, 33, 95).

• Have a condom before you need it. (Providers should always give patients a supply of condoms, tell them where to get condoms, and advise them to store condoms in a cool, dark place, if possible.)
• Use a condom with every act of sexual intercourse unless you are sure that neither you nor your partner has an STD.
• Roll the condom on after the penis becomes erect. (Providers should show patients how to put a condom on—by demonstrating on a model of a penis, a banana, or a broom handle, for example—and then let the patient demonstrate.)
• Do not use oil or oil-based lubricants such as petroleum jelly, which damage latex condoms. In contrast, water-based lubricants—for example, glycerin and K-Y Jelly—are safe, as is spermicidal foam.
• After ejaculation hold the rim of the condom while you withdraw.
• Throw the used condom away or bury it where children cannot find it. Do not reuse condoms.

Encouraging patients to get their sexual partners to treatment also is an essential part of counseling (see Chapter 6.3, Partner Notification).