Incorporating HIV Prevention into the Medical Care of Persons Living with HIV

1. Incorporating HIV Prevention into the Medical Care of Persons Living with HIV Ask∙Screen∙Intervene Module 1: Risk Assessment & STD Screening Developed by: The National Network of STD/HIV Prevention Training Centers, in conjunction with the AIDS Education Training Centers

2. What are the Recommendations? • Developed by CDC, HRSA, NIH, HIVMA with evidence-based approach • Apply to medical care of all HIV-infected adolescents and adults • Intended for all who provide medical care and deliver prevention messages to HIV-positive persons MMWR, July 18, 2003

3. What are the Recommendations? • Medical providers can substantially affect HIV transmission when they • screen for risk behaviors • identify and treat other STDs • communicate prevention messages • discuss sexual and drug-use behavior • positively reinforce changes to safer behavior • refer patients for services (substance abuse treatment) • facilitate partner notification, counseling, and testing MMWR, July 18, 2003

4. Learning Objectives: Module 1 Upon completion of training, providers who care for HIV-infected persons will be able to: • Describe rationale for implementing consensus recommendations • List elements of effective risk assessment for behaviors that can transmit HIV/STD • Outline correct approach to periodic STD screening

5. Why is it Important NOW? • Emerging trends in HIV-infected persons: • Increases in unsafe sex • Increases in syphilis, gonorrhea incidence • Increases in rates of primary HIV resistance • Concern about increasingly resistant HIV • STD increase amount of HIV shed at genital mucosa (cervix, urethra, rectum) • Directly increases infectiousness of HIV+, risk of transmitting HIV to vulnerable partners • Wilson AJPH 2004 (women), Tun CID 2004 (IDU)

6. Primary and Secondary Syphilis Cases, by Gender - California, 1996-2003 ALL MALE KNOWN MEN WHO HAVE SEX WITH MEN FEMALE 8/2004 Provisional Data, CA DHS STD Control Branch

7. HIV Status Among Men Who Have Sex With Men Primary & Secondary Syphilis Cases - California, 2001–2003 8/2004 Provisional Data - CA DHS STD Control Branch

8. Why is this Occurring? • Improved HIV therapy, well-being, and survival • “Prevention fatigue” • Increased use of prescribed and non-prescribed drugs • erectile dysfunction drugs, methamphetamine, poppers • Resurgence of old & discovery of new ways to meet partners, who may be anonymous • Baths, parks • Internet Ciesielski 2003, Katz 2002

9. Do Providers Ask About Risk? % of Providers Who Assessed STD Risk Elford, Bull, Gardner, Calabrese, Duffus

10. Discomfort as a Barrier “Ironically, it may require greater intimacy to discuss sex than toengage in it.” The Hidden Epidemic Institute of Medicine, 1997

11. Reported Cases with no Identified Risks 50 National HIV/AIDS Reporting System1985 to 2003 40 30 Percent 20 10 AIDS cases HIV cases 0 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 Year of Diagnosis CDC

12. A Missed Opportunity… • Tony is a 40 year-old HIV-positive married man with a CD4 count of 350, a viral load below detection limit, on HAART • He presents for a routine visit, feeling well • His wife, who is also HIV+, recently had a yeast infection; around the same time, he noticed irritation on his penis, which resolved with miconazole cream • Physical exam, including external genitalia: normal • Plan: Continue current regimen, and follow-up in 3 months

13. A Missed Opportunity… • Returns 3 weeks later with rash on trunk and headache • Plan: topical steroids, with dermatologyfollow-up Truncal rash

14. A Missed Opportunity… • Dermatology orders RPR: positive at titer of 1:128 • Returns, and reports receptive/insertive anal and oral sex w/ 5 male partners in prior 3 months • Uses Internet to meet partners, mostly anonymous • ‘Almost always’ uses condoms with them, while reports no condom use with wife What went wrong?

15. Learning Objectives: Module 1 Upon completion of training, providers who care for HIV-infected persons will be able to: • Describe rationale for implementing consensus recommendations • List elements of effective risk assessment for behaviors that can transmit HIV/STD • Outline correct approach to periodic STD screening

16. Provider Barriers to Risk Assessment What are some…?

17. Provider Barriers to Risk Assessment • Inexperience or discomfort asking questions • Discomfort responding to issues that arise • Incorrect assumptions about sexual behavior and risk • Patient perception of stigma from a medical care provider

18. Overcoming Barriers to Risk Assessment • Identify specific questions to be asked • Determine how to integrate into overall care • Develop clinic policy for when and where risk assessment will be conducted • Train providers to perform risk assessment • Develop plan to respond to information that might surface

19. Assessing Risk: Benefits • Clinician Perspective • Aids in clinical intervention/exam • Provides focus for risk reduction or referral • Patient Perspective • Opportunity to ask questions • May affect self-motivation for behavior change • Patients want to have these discussions yet often will not initiate on their own

20. Framework for Risk Assessment • Reinforce confidentiality • Establish rapport • Make no assumptions… Ask all patients about: • Sexual and STD history • Gender and number of partners: who • Specific sexual practices: how • Partner meeting venues: where • Substance use

21. Risk Assessment Techniques Be tactful and respectful • Eye contact, affirmative gestures Be clear • Avoid medical jargon, for example“have you had genital ulcer disease?” • Restate and expand patient statements • Clarify stories when necessary

22. Risk Assessment Techniques Be non-judgmental • Recognize patient anxiety • Recognize our own biases • Anger/response to behavior • Belief in possibility for behavior change • Avoid value-laden language • “You should..” • “Why didn’t you..” • “I think you...”

23. Risk Assessment Techniques • Broaching the topic • Use a phrase or question that works for you • Begin with open-ended questions • “Tell me about your sex life” • Follow by closed-ended questions, as indicated • “When was the last time you had sex with a man?” • “When was the last time you had sex with a woman?” • Encourage patients to talk, when needed • Permission-giving: “Say it in your own words” • Give range of behavior and ask for patient’s experience • “Some of my patients…”

24. What Should We Ask?GENERAL QUESTIONS • Determine whether the patient has been having sex… OPEN-ENDED: “To provide the best care, I ask all my patients about their sexual activity – so, tell me about that”OPEN-ENDED: “When you say you’ve had sex, what exactly do you mean?” CLOSED-ENDED: “Have you been having sex since our last visit?” • Statements about sex practices may need clarification…OPEN-ENDED: “I don’t know what you mean, could you explain..?”  See Pocket Risk Assessment Guide for Questions

25. What Should We Ask?SEX PARTNERS • Determine number and sex of partners, current and past…OPEN-ENDED:“So, tell me about your partners”OPEN-ENDED: “Tell me about the number of partners in the last month; the last six months” CLOSED-ENDED: “Do you have sex with men, women or both?” • Ask about HIV status of sex partners…OPEN-ENDED:“Talk to me about the HIV status of your partners”CLOSED-ENDED: “Do you know the HIV status of your partners?”CLOSED-ENDED: “Are all your partners positive; or negative?”  See Pocket Risk Assessment Guide for Questions

26. What Should We Ask?SEXUAL ACTIVITY • Ask about various types of sexual activity…OPEN-ENDED:“Tell me about the types of sex you have”CLOSED-ENDED: “Do you have oral sex? vaginal sex? anal sex?” • Determine where patient meets sex partners(e.g., venues)…OPEN-ENDED:“Where do you meet your partners?”CLOSED-ENDED:“Do you use the Internet to meet partners?”CLOSED-ENDED:“…sex with someone you didn’t know?” Don’t forget: the Internet, bars, bathhouses, circuit parties, public venues, travel and sex abroad  See Pocket Risk Assessment Guide for Questions

27. A “Real Play” GATHERING THE INFORMATION • Purpose This exercise will emphasize the importance of a quality patient/client-health provider interaction for gathering sensitive information about high-risk behaviors • Objectives • Practice the essential elements of an effective behavioral risk assessment • Use open-ended questions to initiate a conversation with a patient/client • Use closed-ended questions to gather more specific information

28. A “Real Play” INSTRUCTIONS • Divide into groups of two • Decide who will be the patient/client and who will be the health provider • Read your character’s description • Interact (Behavioral Risk Assessment) • Remember to use open-ended questions • Time allocated: 3 minutes

29. Interact !

30. Learning Objectives: Module 1 Upon completion of training, providers who care for HIV-infected persons will be able to: • Describe rationale for implementing consensus recommendations • List elements of effective risk assessment for behaviors that can transmit HIV/STD • Outline correct approach to periodic STD screening

31. Providers’ Questions About Screening • How often should I do it? • What tests should I use? • What anatomic sites should I collect specimens from? • Do I need to treat if the patient is asymptomatic? • Do I need to treat patient’s sex partners if screening reveals an STD? • How much time does screening take? • Who pays?

32. Diagnostic Testing vs. Screening Screening • Goal: test apparently healthy people to find those at increased risk of disease • Patient is asymptomatic! Diagnostic Testing • Goal: assess signs, symptoms, patient complaint

33. Percent of Persons with STD Who Are Asymptomatic Urethra Rectum Pharynx Cervix Rectum Urethra Any Cervix Chlamydia Genital herpes Gonorrhea

34. STD Screening: the First Visit • All patients • Syphilis: serology (usually a non-treponemal test, i.e., RPR or VDRL) • Hepatitis A/B status (by serology or history) • Women • Chlamydia: routinely test all sexually active women <25 years; test older women if at risk • new partner, no condom use • Trichomoniasis: vaginal fluid • Gonorrhea: if at risk • new partner, no condom use

35. STD Screening: the First Visit • First visit: • Patients who report receptive anal sex • Rectal gonorrhea • Rectal chlamydia • Patients who report receptive oral sex • Pharyngeal gonorrhea * Check with local laboratory/program regarding availability of approved tests for pharynx/rectum

36. STD Screening: Subsequent Visits • Periodic retesting for all sexually active patients • Annually for all, and more frequent (every 3-6 months) depending on risk, including: • Multiple or anonymous sex partners • Elevated STD transmission risk, i.e., unprotected vaginal or anal intercourse with partner(s) of unknown HIV status • Sex or needle-sharing partners with above risks • “Life changes” associated with increased risk

37. Points to Remember • Screen more frequently rather than less if any suspicion for exposure • Screen at all anatomic sites exposed (rectum, urethra, pharynx, cervix) • Condoms are not always used consistently or correctly • Report of condom use does not always predict absence of STD

38. Tests Recommended for STD Screening  See Overview of STD Syndromesfor Questions

39. Tests Recommended for Chlamydia & Gonorrhea Screening  See Overview of STD Syndromesfor Questions

40. Management of the Symptomatic Patient • Recognize common syndromes and know the directed work-up • Key descriptions provided in ancillary course materials • Use available tools (wall charts, pocket cards, reference manuals/atlases) • Online resources: The Practitioner’s Handbook for the Management of Sexually Transmitted Disease www.STDhandbook.org  See Overview of STD Syndromes & STD Treatment Guide

41. Treatment of STD in HIV-infected persons • CDC STD Treatment Guidelines highlight specific regimens for HIV-infected persons when appropriate:320e www.cdc.gov/std/treatment  See CDC STD Treatment Guidelines

42. In conclusion… What is one thing you will change in your practice…?