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CME

Sexual History: Skills for HIV Assessment and Prevention

  • Authors: Donna E. Sweet, MD, MACP
  • CME Released: 9/27/2016; Reviewed and Renewed: 9/28/2017
  • THIS ACTIVITY HAS EXPIRED
  • Valid for credit through: 9/28/2018
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Target Audience and Goal Statement

This activity is intended for primary care physicians, ID/HIV specialists, and public health & preventive medicine specialists.

The goal of this activity is to: increase the knowledge of primary care physicians on taking a sexual history and how it can prevent HIV infection.

Upon completion of this activity, participants will have increased knowledge regarding:

    1. Effective sexual history taking
    2. Risk factors for acquiring HIV infection
    3. HIV testing in the primary care setting

 


Disclosures

As an organization accredited by the ACCME, Medscape, LLC, requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner, that could create a conflict of interest.

Medscape, LLC, encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.


Faculty

  • Donna E. Sweet, MD, MACP

    Professor; Director Ryan White Programs, The University of Kansas School of Medicine, Wichita, Kansas

    Disclosures

    Disclosure: Donna Sweet, MD, MACP, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: Pfizer Inc.
    Served as a speaker or a member of a speakers bureau for: AbbVie Inc.; Bristol-Myers Squibb Company; Gilead Sciences, Inc.; Janssen Pharmaceuticals;
    Received grants for clinical research from: Merck & Co., Inc.

    Dr Sweet does not intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics approved by the FDA for use in the United States.

    Dr Sweet does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.

Editor(s)

  • Charles Howe, PharmD

    Scientific Director, Medscape, LLC

    Disclosures

    Disclosure: Charles Howe, PharmD, has disclosed the following relevant financial relationships:
    Owns stock from GlaxoSmithKline

  • Susan L. Smith, MN, PhD

    Lead Scientific Director, Medscape, LLC

    Disclosures

    Disclosure: Susan L. Smith, MN, PhD, has disclosed no relevant financial relationships.

CME Reviewer

  • Robert Morris, PharmD

    Associate CME Clinical Director, Medscape, LLC

    Disclosures

    Disclosure: Robert Morris, PharmD, has disclosed no relevant financial relationships.


Accreditation Statements


Medscape, LLC is accredited by the American Nurses Credentialing Center (ANCC), the Accreditation Council for Pharmacy Education (ACPE), and the Accreditation Council for Continuing Medical Education (ACCME), to provide continuing education for the healthcare team.

    For Physicians

  • Medscape, LLC designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    Medscape, LLC staff have disclosed that they have no relevant financial relationships.

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For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]


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CME

Sexual History: Skills for HIV Assessment and Prevention

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  • Sexual History: Skills for HIV Assessment and Prevention

    Donna E. Sweet, MD, MACP: Hello. I am Dr Donna Sweet, director of the HIV Clinic at the University of Kansas School of Medicine in Wichita, Kansas. Welcome to this program, titled "Sexual History: Skills for HIV Assessment and Prevention," developed with support by the Centers for Disease Control and Prevention in Atlanta, Georgia.

  • Slide 1.

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  • Agenda

    I am going to discuss the importance of taking an effective sexual history, the role of the sexual history in identifying patients at high risk for human immunodeficiency virus (HIV) infection and other sexually transmitted infections (STIs), and most important, the rationale for routine HIV testing in primary care settings.

  • Slide 2.

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  • HIV in the United States

    There is some good news about the HIV epidemic in the United States. The annual number of new HIV infections has not increased in the past few years and efforts at reducing the rates of HIV transmission have been effective. However, we have hit a plateau and there is still work to do.[1]

  • Slide 3.

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  • HIV in the United States (cont)

    There is some bad news as well. In 2014, it is estimated that more than 44,000 persons were diagnosed with HIV infection, and almost 21,000 of those were diagnosed with Stage 3 HIV infection or AIDS, those we would hope to identify and diagnose sooner.[1] Overall, an estimated 1.2 million persons are living with HIV infection in the United States today, and 1 in 8 are unaware they are infected.[2] Some are patients in your practice. It is simply a matter of recognizing patients who are at an increased risk for HIV acquisition.

  • Slide 4.

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  • Estimated New HIV Diagnoses in the United States for the Most-Affected Subpopulations, 2014

    Some subpopulations are affected more than others; specifically, black men and black women have a much higher lifetime risk of acquiring HIV infection than do their white and Hispanic counterparts.[1] If you care for patients in these groups you should be screening them for HIV. Patients at risk for HIV infection are in plain sight in our practices, yet we do not recognize them.

  • Slide 5.

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  • Take a Sexual History: Uncover the Risks

    Taking a sexual history can help you identify persons at risk for STIs, including HIV infection, and to determine the appropriate anatomical sites to perform certain tests for STIs.[3] Where you swab for chlamydia and gonorrhea depends on the type of sexual activity the person engages in.

    Persons who may benefit from risk-reduction counseling can be identified by asking questions about their behaviors, especially if they are not taking precautions to protect themselves.[3] You can identify potential candidates for a new biologic means of prevention called antiviral pre-exposure prophylaxis (PrEP), which if indicated, is paid for by most insurance companies and is a very effective way of helping prevent high-risk persons from acquiring HIV infection, and decreasing the annual incidence of HIV infection.[13]

    Before you take a sexual history, it is important to examine your personal biases about persons who engage in risky behaviors and those living with HIV. Thinking about how you feel may allow you to have a more open relationship with your patients.[3]

  • Slide 6.

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  • When and How To Take a Sexual History

    When do you take a sexual history? It is important to start with the initial patient visit. It is easier to ask these questions if your patients are used to you asking them. During all routine preventive health visits, tell your patients that it is now the standard of care to screen for HIV and to talk about risky sexual behaviors. Anytime there are signs or symptoms of an STI, ask about the how, what, when, and where. How did they get it? How many different partners have they been exposed to recently? Once you identify someone who is engaging in risky behavior, counsel them to change that behavior, and periodically ask them if they have changed it.[3]

    Asking about private behaviors is not always easy for health care providers, especially busy primary care physicians. By asking a few open-ended questions, you can identify sexual behaviors that are associated with risks for acquiring HIV infection and other STIs.

  • Slide 7.

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  • Questions to Ask

    What do you ask? I tend to start with, "Do you have sex with men, women, or both?" It is important to pause and let them answer. If you give them enough time, you may find out things that they have wanted to talk to you about, but have never felt safe bringing up. Ask them if they have ever had an STI, or if they have ever been treated for chlamydia, gonorrhea, syphilis, herpes, or venereal warts. Some persons do not understand that these infections are STIs.[2]

    Ask, "How many different men and/or women have you had sex with in the past 6 months?" Determining how many partners is too many is sometimes difficult, because we all have our own ideas about promiscuity, but it is important to find out if they are having sex with a lot of different partners. It is especially important to find out if they are engaging in “hook-ups” because they probably do not know much about those partners, which puts them at high risk for acquiring STIs, including HIV.[2]

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  • Ask both men and women how they have sex. Ask if they have receptive anal sex. It is not an uncommon heterosexual behavior. Ask men who have sex with men (MSM) if they are the receptive anal partner, the insertive anal partner, or both.[3]

    Asking about condom use is important. Ask them: How many times have you had vaginal and/or anal sex when neither of you wore a condom? How often do you use condoms? In what situations do you use condoms? Are there partners you feel safe having condomless sex with? Have you ever had sex with someone who is HIV infected or that you thought might be infected? Do you use amphetamines or methamphetamines during sexual activity? Do you use large amounts of alcohol or other drugs during sexual activity? Disinhibition leads to increased acquisition of HIV and other STIs.[3]

  • Slide 9.

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  • HIV + STI = Increased Transmission of HIV

    There is a strong link between HIV and other STIs, so it is important that you know about and treat patients for both. Testing for and treatment of STIs can be an effective tool in preventing the spread of HIV, because we know an HIV-infected person who is also infected with another STI is more likely to transmit HIV through sexual contact with an HIV-negative person. Persons who are infected with STIs are 2 to 5 times as likely as uninfected persons to acquire HIV infection if they are exposed to HIV infection when they have an STI outbreak.[4,5,6]

    All patients who are tested or treated for any STI should also be tested for HIV, and evaluated for PrEP. If you are not familiar with PrEP, the Centers for Disease Control and Prevention has excellent guidelines on their website.[14]

  • Slide 10.

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  • A 60-Year-Old Man With Periorbital Vesicular Rash

    Now, let us apply this to practice. Let me tell you about a patient I recently saw in my clinic. He was a 60-year-old man; men and women have sex well into their 70s and 80s. He had a periorbital vesicular rash. He presented with classic herpes zoster ophthalmicus that was quite painful. In taking his sexual history, I learned that he is bisexual, has frequent sex with relatively unknown persons, and has condomless sex with MSM.

    He was found to be HIV infected, which was not surprising, because zoster is one of the diseases that occurs early in immunocompromised persons. He was not surprised at the positive HIV test, even though he said he had never really had an HIV test before. He felt okay and was really not particularly worried.

    A few years ago, we believed that the majority of new HIV infections were transmitted from persons who did not know they were infected and were spreading it unknowingly. Now, a lot of persons fall out of care who are not getting antiretroviral therapy (ART), and we think the majority of new infections come from persons who do know their status, but have opted not to remain in care.[7] This is another reason that we need to find those persons, retest them, and relink them into care.

    This patient was tested for HIV and found to be positive. I treated his zoster with valacyclovir, and I got him into HIV care. He should live a long and relatively normal life as long as he is able to get and take his daily ART.

  • Slide 11.

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  • What Did I Learn From This Patient’s Sexual History

    What did I learn from his sexual history? It gave me a more complete picture of his risk factors for acquiring both HIV and other STIs. It triggered me to screen him for HIV and other STIs. It provided an opportunity to do risk reduction counseling and to link him to HIV care and other services so that he can have a normal life.[3]

  • Slide 12.

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  • HIV Screening is the Standard of Care

    Let us talk about why screening for HIV infection is so important. It is the standard of care. The CDC has said, since 2006, that in all health care settings, screening for HIV should be performed routinely for all patients aged 13 to 64 years. Health care providers should subsequently test all persons likely to be at high risk for HIV at least annually, based on their sexual history. Testing should be done more frequently for patients at substantial risk for acquiring an HIV infection. MSM and heterosexual men and women who have frequent and different sexual partners are at higher risk and need to be screened much more frequently.[8,14]

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  • US Preventive Services Task Force Recommendations

    The 2013 United States Preventive Services Task Force (USPSTF) recommendations are that adolescents and adults aged 15 to 65 years, younger adolescents, and older adults at increased risk for infection should be screened for HIV infection at least once in their lifetimes. Those are Grade A recommendations, which means that the test is covered as a preventive service under the Affordable Care Act, so it will be paid for.[9]

  • Slide 14.

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  • HIV Screening is Cost Effective

    HIV screening is cost-effective.[12,13] It is relatively inexpensive and highly effective. The diagnosis of HIV infection, when followed by prompt linkage to medical care, can lead to initiation of ART and substantial survival benefits for patients.[10,11,12] HIV testing of MSM as frequently as quarterly is cost-effective compared with annual HIV testing. Saving 1 person from becoming infected is cost-effective.[12,13]

  • Slide 15.

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  • Persons at Substantial Risk for Acquiring HIV

    Who is at risk for HIV infection and how do we identify them? Again, asking about sexual history is the best way to identify patients at risk for HIV infection. Ask, are you having sex with someone who is known to be HIV infected? Ask this question to MSM as well as heterosexual persons. How many different sexual partners do you have on a regular basis? It is always difficult to know how many partners constitutes high risk because just 1 person with HIV is all it takes to become infected.

    Persons who have sexual activity with multiple partners, especially in social venues such as sex parties, where sexual partners are relatively anonymous, puts all involved at much higher risk. Persons who engage in this behavior should be screened more frequently than just once time in their lifetime. Ask patients about condom use. Are they used to having sex without condoms even with partners they do not know well? Anyone who is trading sex for money, food, or drugs is at high risk of acquiring HIV infection. Be sure to readdress all of those questions when you are trying to determine who needs to be tested more frequently.[14]

  • Slide 16.

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  • HIV Testing is Simple To Do

    How do you test? This has changed a great deal. For the first 30 years of the HIV epidemic, we used the same method of testing, an enzyme-linked immunosorbent assay (ELISA). If 2 ELISA tests were positive for a given person, we sent the specimen for the western blot test. It was a difficult test to interpret, so we often had indeterminate results.

    We have changed the way we test for HIV. The new algorithm is relatively simple. The first step is to order a fourth-generation HIV test. This test detects the p24 antigen, which is an HIV-specific antigen, and antibodies to both type 1 and type 2 HIV. This test has very high sensitivity and high specificity. If it is positive, then the second step is to confirm infection with a supplementary test.[15] I use the Multispot HIV-1/HIV-2 Rapid Test (Bio-Rad Laboratories, Redmond, WA), an ELISA assay. Generally, patients will be found to be HIV-1 antibody positive. HIV-1 is the most common type in the United States, but some will be HIV-2 antibody positive. If the ELISA test is positive, you should then do an HIV RNA test because you need to know the patient's viral load before ART is begun. If the ELISA test is negative, then the patient probably has an acute infection and has not had time to make antibody. You should then confirm that with an HIV RNA assay.[15]

    There is the potential for a 4th generation test to be false-positive, especially when persons in low-risk populations are screened. If the HIV-1/2 ELISA and the HIV RNA test are both negative, it means that an unusual false-positive result has occurred, and you would be able to tell the patient that he or she does not have HIV infection.

  • Slide 17.

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  • You’ve Done the HIV Test, What’s Next?

    Once you have done the HIV test, confirmed the positive test result, interpreted the false positive result (if applicable) appropriately, you can deliver the test result to the patient. If it is negative, you do risk-reduction counseling for HIV prevention. If it is positive, you should also do risk-reduction counseling and link the patient to care. It is critical to get individuals into care, because if they are not treated they have the potential to spread HIV to others, and because HIV will negatively impact their health.[8,15]

  • Slide 18.

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  • Beyond Initial Routine Testing: The Need to Re-engage and Retest

    We know that high-risk persons who have tested HIV negative may continue high-risk behaviors and can become infected at any time, so they should be screened more often. Persons who have tested positive and are not in care for a variety of reasons should be retested. Retesting can provide opportunities to get them back to into care. For example, there are routine screening programs in a number of emergency departments in this country. Health care providers may be disappointed when patients, who, when they are told they are HIV positive, say that they knew but did not want to tell you. You should never feel bad about that. Instead, think of it as another opportunity to get that person into care. I have found in my practice that women tend to fall out of care. It is important to test all women, even if you assume they are not engaging in high-risk behavior.[14]

  • Slide 19.

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  • A 46-Year-Old Heterosexual Woman With Vaginal Discharge and Burning During Urination

    Let me tell you about another patient I recently saw in my clinic, a 46-year-old heterosexual woman. She presented with vaginal discharge and dysuria, or burning during urination. Her sexual history revealed that she has had a large number of sexual partners since her divorce a few years ago. She has sex with a number of men, sometimes with a different man each month. She inconsistently uses condoms because they decrease her pleasure.

    I suspected a chlamydia infection based on her symptoms, so I did a nucleic acid test on a swab from her vagina. That is where her symptoms were. If she had rectal itching, then I would have thought about doing the swab at that site. [16] She was treated with oral azithromycin; a single dose is all it takes.

  • Slide 20.

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  • What Did I Learn from This Patient’s Sexual History?

    Her HIV test was negative, but it triggered me to screen for HIV infection and other STIs. It provided me with an opportunity to provide risk-reduction counseling and possibly to discuss PrEP. If she was going to continue to have sex with multiple partners without condoms, she would continue to put herself at risk for HIV infection. She is someone for whom PrEP might prevent HIV infection in the long-term. It also gave me an opportunity to link her to medical care and services. The science is clear: HIV prevention can and does save lives. If we can prevent HIV infection in this woman, she will likely live a long time without having to take ART.

  • Slide 21.

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  • Why is Linkage to HIV Care Important?

    Even in HIV-negative patients, it is important that you do not stop at testing; linkage to care is critical.

    Linkage to care provides an opportunity for treatment, viral suppression, risk-reduction counseling, HIV primary care, and access to critical resources. HIV-positive patients in care and not receiving treatment were found to be 50% less likely to transmit HIV because of behavioral changes.[7] When these patients are prescribed ART, most will have undetectable virus, and HIV transmission can be reduced by 93%.[17]

  • Slide 22.

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  • Treatment As Prevention: Treatment is Effective and Can Prevent HIV Transmission

    Treatment is prevention. Treatment is effective and it can prevent HIV transmission as well as decrease illness and morbidity. There are 31 FDA-approved antiretroviral agents for the treatment of HIV infection, and it is important to know that 6 single-tablet, once-daily regimens are available.[18]

    Some of you may not have kept up with the science and medicine of ART and remember the days when treatment was handfuls of pills that had a lot of toxicities. We do not have to do that to patients anymore. Generally, we can prescribe newly diagnosed patients 1 pill a day, and as long as they take it regularly, viral suppression will occur within the first 3 months.

    When taken as prescribed, treatment suppresses HIV replication, prevents HIV Stage 3 or AIDS-related complications, and provides a life expectancy similar to that of the general population.[18,19] That means if you are a 40-year-old man with diabetes, hypertension, and HIV, you can live just as long as a 40-year-old man with diabetes and hypertension who does not have HIV, as long as you take your medications. That is largely unknown. I often talk about it to my patients when I am screening them to help them understand why it is so important if they have been exposed and become infected that they know now, so that they can be treated.

    It is also important how you link patients to care. Just giving them a referral to go see a doctor who treats HIV infection is probably not enough. If you have made the effort to test that person, help them understand how important it is that they stay in care.

    Sometimes it is difficult to keep women in care. They are caregivers themselves. They tend to put their needs aside when they are taking care of their husbands, children, or parents. In our office, we make special efforts to get women to their appointments and keep them in treatment. Women at risk for HIV infection are a special population that needs extra help.[20]

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  • Summary

    In summary, much progress has been made in our efforts to reduce the incidence and prevalence of HIV infection, but we still have work to do. It begins with a sexual history to identify persons at risk for HIV and other STIs. It is critical that you learn how to ask those questions: Are you sexually active? Do you have sex with men, women, or both? And tell your patients you are asking only because you are interested in keeping all aspects of their lives as healthy as possible.

    Routine HIV screening is the standard of care. Please make sure that you open the door to prevention, whether the patient is HIV negative or HIV positive, by testing, and if they are infected, linking them to care. Treatment is effective in suppression of the virus, and suppression of the virus prevents transmission of HIV. HIV-infected persons can live as long as the general population, and without a great deal of morbidity, but it takes doing that test.

    Get out there, do the test, and get your patients linked to care. Most importantly, think about your practice and learn how to ask tough questions. You ask about smoking, alcohol, and seatbelts. You do cholesterol screening and you do colonoscopies in everyone over age 50. Those are the guidelines. Those are standards of care. HIV screening is also the standard of care. There are ways of learning about it. The best thing to do is learn how to talk about sex with your patients. They will appreciate it. Many of them have sexual issues, but they do not want to embarrass you by bringing them up. You are the provider. You are the one who should be bringing it up.

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    I would like to thank you for participating in this activity. Please continue on to answer the questions that follow and complete the evaluation.

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  • This transcript has been edited for style and clarity.

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