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SEXUALLY TRANSMITTED INFECTIONS

Sexually transmitted infections (STIs) and blood borne pathogens (BBPs) are more common in street-involved youth than in the general population. Many of these youth engage in risky behaviours such as unprotected sex, sex with many partners, and the use of alcohol and drugs (Alberta Health Services, 2011).

Furthermore, for many of these youth, meeting the basic needs of life is more important than preventing possible health problems. As a result, street-involved youth do not always take the actions needed to prevent STIs and BBPs (Lokanc-Diluzio, 2014).

JEN’S STORY…

 

Last week my boyfriend was driving me to work when all of a sudden I had bad stomach pains. It was terrible — it honestly felt as though my guts were being squeezed. He took me to the Emergency and I was told that I had PID, caused by chlamydia. I never thought this could’ve been caused by a sexually transmitted infection. I had no symptoms up until then and we’ve been together for almost six months. Besides, I had a Pap test done about a month ago and everything came back normal. My boyfriend says he doesn’t want to go to the doctor ‘cause he says the test really hurts for guys.

In a 2010 study of Edmonton street-involved youth ages 15-24, 12.7% tested positive for chlamydia, and 2.0% tested positive for gonorrhea (Alberta Health Services, 2011).

Whereas in 2010, about 1.6% of all Albertan youth ages 15-24 years tested positive for chlamydia and 0.1% tested positive for gonorrhea (Lokanc-Diluzio, 2014).

This is important because if not treated, chlamydia and gonorrhea, can cause pelvic inflammatory disease (PID) in females, which can lead to chronic pain, ectopic pregnancy, or infertility. In males, untreated infections can lead to testicular infections, infertility and/or chronic pelvic pain. Also having an STI increases a person’s risk for getting or spreading HIV (PHAC, 2015).


 

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Sexual contact means any intimate skin-to-skin contact in the genital area. This includes touching, oral, vaginal or anal sexual activity with partners of any sex. Youth may need information that both giving and receiving oral sex carries risk for STIs.


 

TIP:

 


Service providers should encourage youth to get tested for STIs:

 

  • At least once a year. Every 3 to 6 months if they have a new sexual partner, or if partners have other sexual partners.
  • If a person is having symptoms or problems.
  • If there was sex without a condom, or the condom broke.
  • If there was sex with someone known to have an STI (Government of Alberta & Alberta Health Services, 2013).

WHAT ARE STIs AND BBPs?

Sexually Transmitted Infections (STIs) are types of infections that are spread through sexual contact. STIs are sometimes called sexually transmitted diseases or STDs. There are many types of STIs. Some are easily cured with prescribed medication; others have no cure (PHAC, 2015).

 

Blood borne pathogens (BBPs) are infections that are spread by the blood and other high risk body fluids such as semen, vaginal or rectal fluid.

TYPES OF STIS

Sexually transmitted infections are classified as:

  • Bacterial (e.g., chlamydia, gonorrhea, syphilis).

  • Viral (e.g., HPV, genital herpes).

  • Parasite (e.g., public lice, scabies).

 

If detected early, bacterial and parasite STIs are generally easy to treat. Viral STIs can be treated, but are more difficult to cure. Some viral STIs are not curable at this time.


 

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The most common symptom of STIs is having NO symptom. If a person experiences any problems (e.g., unusual bleeding or discharge, pain, lumps, bumps, sores or rashes) they should see a healthcare provider ASAP.

Bacterial STIs

The most common reportable STI is Chlamydia, followed by Gonorrhea.

 

The table below provides an overview of transmission, symptoms, testing, treatment, and consequences of chlamydia and gonorrhea.

Syphilis is a bacterial STI that progresses in three stages and is infectious during the first year.

 

Click on the name below to open the table which provides an overview of transmission, symptoms, testing, treatment, and consequences of syphilis.

Transmission

  • Spread through unprotected vaginal and anal sex and less often through unprotected oral sex.
  • Penetration or ejaculation are not required for transmission.
  • Can also spread from a mother to newborn during childbirth (PHAC, 2015).

Symptoms

  • The most common symptom is no symptom.
  • Symptoms in females may include unusual discharge or bleeding from the vagina, burning while urinating (peeing), or pain in the lower abdomen or pain during sex.
  • Symptoms in males may include burning while urinating (peeing), itchy urethra (the tube that carries urine or semen), swelling or pain in the testicles, or unusual discharge (clear, green, watery, or milky) from the penis.
  • Pain, itching and/or discharge from the rectum may be a sign of infection (PHAC, 2015).

Testing

  • Can be detected with urine testing or swabbing of a specific site (e.g. cervix, urethra, throat, eye, or rectum) (PHAC, 2015).
  • Although urine testing is widely available, the test of choice may be based on the situation or healthcare provider. For example, urine testing may be available if the person has held their urine for at least one hour.

Treatment

  • Easy to treat with antibiotics, if detected early (PHAC, 2015).

Consequences

  • In females, untreated infections can lead to pelvic inflammatory disease (PID), which is an inflammation of the internal female reproductive organs. PID may lead to chronic pelvic pain, ectopic pregnancy, or infertility.
  • In males, untreated infections can lead to testicular infections, rashes, sores, joint pain and in rare cases infertility.
  • Having an STI increases a person’s risk for spreading or getting HIV infection (PHAC, 2015).

 

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If a person has a positive chlamydia or gonorrhea test, all partners within the past 60 days need to be tested for infection. People should abstain from all sexual contact for 7 days after everyone (the person and all partners) have finished treatment.

Transmission

  • Spread through unprotected oral, vaginal and anal sex or direct contact with a syphilis rash or sore.
  • Can be passed from mother to newborn during pregnancy and childbirth, resulting in congenital syphilis or even death (PHAC, 2015).

Symptoms

  • There are three stages of syphilis. The symptoms are different at each stage.
    • Stage 1 (30-90 days after contact): symptoms include small, painless sores 3 days to 3 months after exposure at the site of entry (in or around the vagina, on the penis, or in the rectum or mouth). The sores go away within 3-8 weeks; however, the bacteria stay in the body. Stage 1 is very contagious, and the symptoms often go unnoticed.
    • Stage 2 (2-24 weeks after contact): symptoms include flu like symptoms (e.g., fever, fatigue, joint or muscle pain); painless rash on the feet, hands or entire body; swollen lymph nodes; or hair loss. The symptoms may go away; however, the bacteria stay in the body. Stage 2 is very contagious.
    • Stage 3 (2-40 years after contact): the infection may cause deafness, blindness, paralysis, mental health issues, brain and heart problems, or even death (PHAC, 2015).

Testing

  • Can be detected through blood tests or swabs (e.g., rash or sores) (PHAC, 2015).

Treatment

  • It is treated with antibiotics. If detected early, long term effects can be reduced (PHAC, 2015).

Consequences

  • If left untreated the infection may cause deafness, blindness, paralysis, mental health issues, brain and heart problems, or even death.
  • Babies born with syphilis may have birth defects or die.
  • Having syphilis increases a person’s risk for spreading or getting HIV infection (PHAC, 2015).

 

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Over the past decade, there have been several syphilis outbreaks across Canada including Calgary, Edmonton, Montreal, Ottawa, Toronto, Winnipeg, Vancouver, Yukon and North West Territories (PHAC, 2011). In Alberta, all pregnant women are screened for syphilis during their first trimester or during their first prenatal visit and screened again when the baby is born (Alberta Health Services & ProvLab Alberta, 2012).

Viral STIs

 

Common viral STIs include human papillomavirus (HPV) and genital herpes.

HPV is easy to spread and difficult to detect and prevent. HPV is probably the most common STI in Canada. It is estimated that roughly 70% of adults will have at least one type of HPV infection during their lifetime (PHAC, 2015). There are over 130 strains of HPV with about 40 types affecting the genital tract.

 

The table below provides an overview of transmission, symptoms, testing, treatment, and consequences of HPV.

Genital herpes is a virus that is easy to spread and difficult to detect and prevent. Herpes type 1 is often associated with sores on the lips or mouth (cold sores), and herpes type 2 is usually associated with sores on or around the genitals (genital herpes). However, it is possible to get both types of herpes in any area (e.g., type 1 in the genitals).

 

Click on the name below to see the table which provides an overview of transmission, symptoms, testing, treatment, and consequences of genital herpes.

Transmission

  • HPV is spread through vaginal, oral and anal sex in addition to skin-to-skin sexual contact (PHAC, 2015).

Symptoms

  • Many people infected have no symptoms.
  • Certain strains of HPV cause genital warts whereas others cause abnormal cell growth on the cervix, which may lead to cancer if untreated.
  • HPV is also linked to oral, penile and anal cancers.
  • Genital warts look like cauliflower-like bumps in the genital area (PHAC, 2015).

Testing

  • Many people infected have no symptoms.
  • Certain strains of HPV cause genital warts whereas others cause abnormal cell growth on the cervix, which may lead to cancer if untreated.
  • HPV is also linked to oral, penile and anal cancers.
  • Genital warts look like cauliflower-like bumps in the genital area (PHAC, 2015).

Treatment

  • Most HPV infections generally clear up within two years, without treatment.
  • Genital warts can be treated through burning, freezing or laser treatments.
  • Abnormal cervical cell changes are watched closely by a healthcare provider. If treatment is required, the client will be referred to a specialist.

Consequences

  • If left untreated and over the long term, abnormal cell changes on the cervix may lead to cervical cancer.
  • There is an association between genital HPV and various types of cancer (e.g., vagina, throat, anus, and penis) (PHAC, 2015).

 

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  • A Pap test is a screen for changes to the cells of the cervix. This is also called cervical cancer screening test (CCST). All people with a cervix need the screen regardless of sexual orientation or gender identity and expression. If a person reports spotting or bleeding between periods or spotting/ bleeding after sex, it is important that they see a healthcare provider (Alberta Health Services, 2012).
  • There are three types of vaccines available to prevent different strains of HPV: Gardasil, Cervarix, and Gardasil 9. In Alberta, girls and boys are given Gardasil vaccinations in grade 5 as a part of the routine childhood vaccination program (Lokanc-Diluzio & Troute-Wood, in press). For information on HPV vaccine, see Health.Alberta.ca – HPV

Transmission

  • Herpes is spread by having direct contact with the sores or blisters of an infected person (e.g., having close sexual contact or vaginal, anal or oral sex with someone who has herpes blisters or sores).
  • The virus can also be spread when sores cannot be seen. This may happen right before an outbreak or if there are sores in a place not visible (e.g., inside the anus or vagina).
  • Can be passed from mother to newborn during pregnancy and childbirth (PHAC, 2015).

Symptoms

  • Symptoms may start 2-21 days after contact with an infected person; however, they may take weeks or months to appear and include:
    • One or more groups of painful, watery blisters, on or around the genitals, or where there was skin-to-skin contact (e.g., anus, hips, nipples, lips) with an infected person.
    • Itching, tingling, redness and swelling.
    • Burning while peeing.
    • Flu-like symptoms such as chills, fever, or muscle aches.
    • Tender and swollen glands in the groin.
  • Repeat outbreaks tend to be shorter and less severe than the first outbreak (PHAC, 2015).

Testing

  • Genital herpes is diagnosed by looking at the sore or testing the fluid from the sore (PHAC, 2015).

Treatment

  • There is no cure for herpes; however, outbreaks can be managed through medications (PHAC, 2015).

Consequences

  • Condoms and medication can reduce but not eliminate the risk of transmission. It is possible to infect partners when there are no symptoms. It is important that partners have open and honest communication about herpes, wear condoms to reduce the risk and not have sex when having any symptoms (PHAC, 2015).

TIP:

For an accurate diagnosis, all sores should be examined and tested when they first appear and before they have healed.

Parasites

 

Parasites are also known as ectoparasites and include pubic lice (crabs) and scabies.

Pubic lice bite their host to feed on blood and lay eggs in the genital and surrounding hair. The eggs hatch within 5-10 days.

Scabies are parasitic mites, which burrow under the skin. Scabies prefer warm places (e.g. folds of skin on elbows, wrists, buttocks, knees, armpits, breasts, and penis).

The table below provides an overview of transmission, symptoms, testing, and treatment of pubic lice and scabies.

Transmission

  • Parasites can spread through sexual or non-sexual contact (e.g., contact with infected objects). Public lice can live for one to two days, and scabies can live for three days on bedding, towels, and clothes of infected people.

Symptoms

  • Pubic lice symptoms include:
    • Skin redness, irritation and itching.
    • Small blue spots on the skin where lice have bitten.
    • Fine black feces in the infected person’s underwear.
    • Lice and their eggs found in genital and nearby hair, and less often in facial, chest and armpit hair.
  • Scabies symptoms occur within three to four weeks of infestation and include:
    • Red bumps or reddish rash.
    • Intense itching, especially at night (PHAC, 2015).

Testing

  • Detection is through examination of the infected areas.

Treatment

  • Easy to treat with over-the-counter creams or lotions that can be purchased from the drug store. All clothing, bedding and towels used in the three days before treatment must be washed in hot water. If items can’t be washed, they should be put into the freezer for 7 days (PHAC, 2015).

TYPES OF BLOOD BORNE PATHOGENS (BBPs)

Human immunodeficiency virus (HIV) is a virus that attacks the immune system and makes it hard for the body to fight diseases and infection. There is no cure for HIV. However, with early diagnosis and treatment people can live long, healthy lives. HIV can lead to a condition called AIDS. This happens when the immune system gets too weak to fight infections and gets HIV-related infections (PHAC, 2015).

 

The table below provides an overview of transmission, symptoms, testing, treatment, and consequences of HIV.

Hepatitis B is another BBP. It is a liver infection caused by the hepatitis B virus and is more infectious than HIV.

 

Click on the name below to see the table which provides an overview of transmission, symptoms, testing, treatment, and consequences of Hepatitis B.

Transmission

  • Can be spread through contact with infected body fluids (blood, vaginal secretions, semen, rectal fluid or breast milk). This can happen when people:
    • Have unprotected sex (oral, anal, vaginal).
    • Share needles or other drug equipment.
    • Share sex toys, razors or toothbrushes.
    • Have HIV and are pregnant, give birth or breastfeed.
    • Use dirty equipment for tattoos, piercing or acupuncture.
    • Have contact with an infected object (e.g., needle) by accident (PHAC, 2015).

Symptoms

  • It is common to have no symptoms for years.
  • Some people experience flu-like symptoms 2-6 weeks after exposure.
  • For most people, symptoms don’t happen until years after exposure and may include: frequent fever, sweats, joint or muscle pain, skin rashes, swollen glands, sore throat, lack of energy or fatigue, weight loss, nausea, vomiting or diarrhea (PHAV, 2015).

Testing

  • Detection is through blood testing (PHAC, 2015).

Treatment

  • HIV can be treated (not cured) with drugs, which can delay HIV from progressing to AIDS (PHAC, 2015).

Consequences

  • HIV eventually leads to AIDS. AIDS may cause life-threatening infections, dementia, cancer, and eventually death (PHAC, 2015).

 

Good

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A person can have HIV and not know it. A blood test is the only way to know if you have HIV. It is estimated that about 25% of people who have HIV, do not know it (PHAC, 2013).

Transmission

  • Can be spread through contact with infected blood and body fluids such as vaginal secretions, semen, breast milk or saliva. This can happen when people:
    • Have unprotected sex (oral, anal, vaginal).
    • Share needles or other drug equipment.
    • Share sex toys, razors or toothbrushes.
    • During childbirth.
    • Use dirty equipment for tattoos, piercing or acupuncture.
    • Have contact with an infected object (e.g., needle) by accident (PHAC, 2015).

Symptoms

  • It is common to have no symptoms.
  • Symptoms may not start for two to six months and may include jaundice (the yellowing of the eyes and skin), nausea, fatigue, decreased appetite, and joint and/or or stomach pain (PHAC, 2015).

Testing

  • Detection is through blood testing.

Treatment

  • Approximately 90% of infected adults will clear the virus on their own. If the virus does not clear, infected persons become chronic carriers. There are medications available to treat chronic hepatitis B and prevent damage of the liver (PHAC, 2015).

Consequences

  • Chronic carriers of hepatitis B are at risk for liver damage or cancer and require monitoring (PHAC, 2015).

 

Good

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An Edmonton study of street-involved youth showed that protection against hepatitis B has increased over time. In 2010, nearly 66% of youth tested positive for hepatitis b antibodies compared to 15% in 1999. This protection was primarily due to immunization (Alberta Health Services, 2011).

 

TIP:

 

All household contacts and sexual partners of people who have hepatitis B should be immunized to prevent infection. For more information about hepatitis B immunization, click here.


 

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A Canadian study of youth 15-24 years old revealed that 66% of Canadian youth ages 15-19 had sexual intercourse at least once (Rotermann, 2012). Whereas an Edmonton study of street involved youth found that 98.5% had sex at least one time (Alberta Health Services, 2011).


 

TIP:

 


Service providers can educate youth about preventing STIs and BBPs. Some key messages for prevention include:

  • Abstinence is the best way to prevent STIs and BBPs.
  • Partners can engage in lower risk forms of sexual activity or sexual simulation such as mutual masturbation or sensual massage.
  • If sexually active, the best way to prevent STIs and BBPs is to use condoms and/or dental dams for oral, vaginal, and anal sex.
  • Limit the number of sexual partners.
  • Partners should have open and honest communication with each other.
  • If either partner has symptoms, they should not have any sexual contact.
  • Don’t share sex toys, clean between use, and cover with a new condom before each use.
  • Get tested for STIs at least once a year and when symptoms are present.
  • Consider getting tested every 3 to 6 months if there is a new sexual partner, or if partners have other sexual partners (Government of Alberta & Alberta Health Services, 2013).

 

PREVENTION

Ideally, youth should be encouraged to consider or re-consider abstinence. Abstinence means avoiding vaginal, anal, oral intercourse and behaviours that expose a person to semen, vaginal or rectal secretions, and blood. Abstinence may not be an option for all youth given their life circumstances. For those who do not abstain, condoms and dental dams should be considered.

Dental Dams

 

Dental dams are square pieces of latex, similar to the material condoms are made from.  They are used to cover the vulva or anus during oral sex to lower the risk of STIs.

 

For tips on how to use dental dams, see SexGerms.com

 

For a dental dam demonstration, click here.

HighRisk_STI_03

Condoms

 

Condoms reduce the risk of STIs and BBPs.  It is recommended that people use a condom (male or female) every time they have vaginal, anal, or oral sex, and genital to genital contact. Even though using condoms are important for reducing the risks of STIs and BBPs, not all youth use them because:

  • They are embarrassed to get condoms.
  • They are on a hormonal method of birth control.
  • They may not have a condom at the time of sexual activity.
  • Their partner may not want to use condoms.
  • The use of substances such as alcohol or drugs may impact their ability to get or use them.
  • They may think they are in a monogamous relationship.
  • They may be in an abusive relationship.
  • They may not know how to negotiate the use of condoms.
  • Condoms may be too expensive.


 

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Condom use tends to decrease with age.

A 2009/2010 Canadian study showed 80% of youth ages 15-17 used condoms during their last intercourse compared to 63% of youth ages 20-24 (Rotermann, 2012):

15-17 year olds who used condoms0%
18-19 year olds who used condoms0%
20-24 year olds who used condoms0%

Even when condoms are used, there is risk for condom failure. Common causes of condom failure are that they are not used consistently (e.g. with every act of intercourse) or correctly. Misusing condoms are a common reason for condom breakage or slippage.

 

Tips for condom use:

 

  • Male and female condoms should not be used together as this may cause them to break or slip.
  • Using two male condoms together (“double bagging”) may cause condoms to break.
  • Air should be squeezed out of the tip of the male condom before putting it on.
  • Oil based lubricants should not be used with male (latex) condoms (water based lubricants are fine).
  • Male condoms made from latex or polyurethane are recommended. Condoms made from natural skin (lambskin) do not protect from STIs and BBPs.

 

For instructions on how to use a male condom, see SexGerms.com – Minimize your Risk

For a male condom demonstration,  click here.

For instructions on how to use a female condom, see SexGerms.com – Minimize your Risk

For a female condom demonstration,  click here.

How to Talk to a Partner about Condoms

For some people, discussing STIs with a partner comes easy. Others struggle with having this conversation, especially those reluctant to use a condom. Some people are embarrassed to start a sexual conversation. Others are intimidated by their partner, feel they need to comply in order to “keep” a partner (or the peace), or simply believe the excuse a partner gives for not wanting to use condoms.

Service providers can support youth to negotiate condom use. Service providers can recommend the following strategies for youth:

  • Set personal values and boundaries regarding condom use.
  • Have a discussion about condom use before intimate activity begins…ideally long before it begins as one of the steps in getting to know each other and setting personal boundaries and limits.
  • Be willing to start the conversation.
  • Carry condoms to avoid the excuse “I don’t have a condom so we can’t use one.”
  • Make sexual decisions when sober so that it is easier to consider and communicate values and limits.
  • Be willing to walk away from the activity if a condom will not be used (as long as this does not put a youth in harm).

  • Have comebacks or suggestions ready for the most common reasons why partners resist using condoms. Take a look at our conversation box below for example,

“I don’t have a condom.”

“Don’t worry, I do.”

“It takes away from the spontaneity.”

“We can use the condom as part of foreplay.”

“Condoms get in between us.”

“If we don’t use a condom,
there will be a great deal of space between us.”

“My penis is too big for condoms.”

“This condom fits over my fist and down my arm…!”

For more information on how to talk to sexual partners about sex, see:

SexGerms.com – Talking to your partners

SexualityAndU.ca – Talking to your partner about sex

Condom Problem-Solving

For some youth, using latex condoms may negatively impact their sexual experience. Here are some suggestions.

For those allergic or sensitive to latex:

  • Use a non-latex condom that is still tested to lower the risk of STI or HIV infection (lambskin or animal membrane condoms do not provide protection against STI or HIV transmission or lower protection against pregnancy).
  • Use a female condom.

For those who feel the condom is too small:

  • Try different brands of condoms (this can be used if the whole condom or just the ring feels too tight). Note: a loose fitting condom can result in a less secure fit and provide the potential for pregnancy and/or STI transmission.
  • Use a non-latex condom (these retain body heat better than latex and may feel less restrictive).
  • Use a female condom.

For those who find that condoms decrease sensitivity:

  • Recognize this may prolong sexual activity in a positive way.
  • Use a small drop of water or silicone based lubricant in the tip of the condom before applying it.
  • Try an ultra-thin style of condom.

Other Ways to Prevent STIs and BBPs

There are other ways to prevent STIs and BBPs besides abstinence, using condoms and dental dams.

 

  • HPV Gardasil vaccinations are routinely given to grade 5 boys and girls in Alberta. Gardasil protects against four common strains of HPV.
  • Hepatitis B vaccinations are routinely given to grade 5 boys and girls in Alberta. The vaccine may be given during the first year of life, if parents were born in an endemic area or if they are carriers of the disease (Lokanc-Diluzio & Troute-Wood, 2016).
  • HIV and hepatitis B can also be prevented by not sharing drug equipment (e.g., needles, pipes, etc.) or toothbrushes, razors or sex toys.

WHERE TO GET HELP

For STI testing, treatment, education and support in Calgary, youth can go to an Alberta Health Services Sexual and Reproductive Health Clinic. For information on community resources, click here.

Youth can also get help at:

 

REFERENCES

Alberta Health Services. (2011). E-SYS. Enhanced street youth surveillance Edmonton site results (1999-2010). Edmonton AB: Communicable Disease Control, Alberta Health Services.

 

Alberta Health Services, & ProvLab Alberta. (2012). Laboratory bulletin: Discontinuation of second trimester syphilis screening on pregnant women. Retrieved from http://www.provlab.ab.ca/partner_updates.htm

 

Government of Alberta, & Alberta Health Services. (2013). Getting tested & treated. Retrieved from http://sexgerms.com/getting-tested

 

Lokanc-Diluzio, W., & Troute-Wood, T. (2016). Sexually transmitted infections and blood borne pathogens. In L. L. Stamler, L. Yiu, & A. Dosani (Eds.) Community health nursing: A Canadian perspective (4th ed.). Toronto: Pearson Education.

 

Lokanc-Diluzio, W. (2014). A mixed methods study of service provider capacity development to protect and promote the sexual and reproductive health of street-involved youth:

An evaluation of two training approaches. (Doctoral dissertation). Available from http://hdl.handle.net/11023/1507

 

Public Health Agency of Canada (PHAC). (2013). Human Immunodeficiency Virus: HIV screening and testing guide. Ottawa, ON: Author. Retrieved from http://www.phac-aspc.gc.ca/aids-sida/guide/hivstg-vihgdd-eng.php

 

Public Health Agency of Canada (PHAC). (2011). Report on sexually transmitted infections in Canada: 2009. Ottawa, ON: Author. Retrieved from http://www.catie.ca/sites/default/files/2009%20Report%20on%20STI%20in%20Canada_EN.pdf

 

Public Health Agency of Canada (PHAC). (2015). Canadian guidelines on sexually transmitted infections. Retrieved from http://www.phac-aspc.gc.ca/std-mts/sti-its/cgsti-ldcits/index-eng.php

 

Rotermann, M. (2012). Sexual behaviour and condom use of 15- to 24-year-olds in 2003 and 2009/2010. Health Reports, 23(1).