An Introduction to Taking a Sexual History and Client-Centered Risk- Reduction Counseling

1. An Introduction toTaking a Sexual Historyand Client-Centered Risk- Reduction Counseling Linda Creegan, FNP California STD/HIV Prevention Training Center STD Clinical Series

2. STDs in the New Millennium:Scope of the Problem • STDs are among the most common infectious diseases in the U.S. today • Chlamydia is the most common reportable disease • About 1 in 5 adults has HSV-2; HPV is even more common in some populations • STDs increase transmission risk for HIV by 2-5 fold • Current syphilis outbreaks in many urban centers including Honolulu, SF, LA , NY, Chicago

3. A Sexual History is an essential part of many provider/patient interactions…. • Allows individualization of STD/HIV diagnosis and screening • Guides counseling through risk assessment • Allows patient to express concerns and ask questions • Enables appropriate referrals

4. …However, it is often given short shrift. • Fewer than half of physicians report taking a sexual history from their patients • 40% of MDs screened teen patients for sexual activity • 15-40% asked questions of adult patients about # and gender of partners, and condom use • Kaiser Family Foundation patient survey, 1997 • 39% were asked about sexual history • 12% were asked about STDs • 83% felt STDs should be discussed at a first-time Ob/Gyn visit Millstein et al, Jour. Adol . Med ., Oct, 1996 Haley et al, AJPH, June 1999

5. Why is this? • Structural barriers (time/reimbursement concerns) • Patient barriers (privacy/confidentiality concerns) • Provider barriers • Low priority given to STD prevention • Acute versus preventive role perception • Low priority given to sexual health issues • Devaluation of behavioral interventions • Provider discomfort discussing sexual issues • Concern for patient privacy • Unfamiliarity with content or language • Perceived complexity of the sexual history • Inadequate training

7. Primary Factors in Taking a Sexual History • Ensure privacy and confidentiality • Establish rapport • Accurately define the problem(s) • Determine the level of HIV risk • Ensure successful patient management • Diagnosis and treat symptomatic disease • Detect asymptomatic disease • Prevent serious sequelae, (i.e.infertility in women) • Promote behavior changes to prevent future infections

8. Young age (15-35) Higher prevalence in urban areas Disproportionately affect those of lower economic status Exposure to an STD History of certain STDs Sexual practices or behaviors multiple partners new partner casual partners improper or inconsistent condom use earlier age at first sexual activity Who is most at-risk for an STD?Risk Factors and Markers

9. Discharge (vaginal, urethral, rectal) Vaginal odor Dysuria (frequency, urgency) Skin lesion(genital or extragenital) Rash Itching Pain Swelling Change in bowel habits Vaginal or rectal bleeding Sexual dysfunction Who is most at-risk for an STD? Presenting Symptoms Remember: Many STDs give no symptoms.

10. Introducing the Sexual History • Acknowledge personal nature of the subject matter • Emphasize confidentiality • Stress health issues related to sexual behaviors • Be able to explain how the information will help you care for the patient “I’m going to ask some questions about you sexual history. I know this is very personal information, but it involves important health issues and everything we discuss is confidential”

11. Chief complaint General health history Allergies Recent medication Past STDs Women: brief Gyn history HIV risk factors (IVDU, partner’s status) HIV testing history Past and current sexual practices Gender of partners Number of partners Most recent sexual exposure New sex partners Patterns of condom use Partner’s condition Substance abuse Domestic violence issues Sexual History - Content

12. Summary: The Five “P’s” • Past STDs • Pregnancy history and plans • Partners • (Sexual) Practices • Prevention of STDs/HIV

13. Communication Skills to Facilitate the Sexual History • Use open-ended questions rather than leading or “yes/no” questions • Who, what, when, where? • “Tell me about…” • Cone Style of interviewing • Encourage patients to talk, when needed • Permission-giving: “Say it in your own words” • Give range of behavior and ask for patient’s experience • Active listening cues to urge patient on • Eye contact, nodding, “Yes, go ahead”

14. General Considerations for Taking a Sexual History • Make no assumptions • Ask all patient about gender and number of partners • Ask about specific sexual practices • Vaginal, anal and oral sex • Be clear • Avoid medical jargon • Restate and expand • Clarify stories when necessary

15. General Considerations for Taking a Sexual History • Be tactful and respectful • Use an unrelated translator whenever possible • Use accepting, permission-giving language and cues • Be non-judgmental • Recognize patient anxiety • Recognize our own biases • Avoid value-laden language (“You should..”, “Why didn’t you..” “I think you..”)

16. Primary PreventionIntegrating Risk-Reduction Counseling into Routine Patient Encounters • A client-centered approach is most effective • Similar messages will help patients prevent HIV, STD, and unintended pregnancy • Emphasize remaining uninfected, by changing behaviors to decrease risk for acquisition and/or transmission of STD/HIV

17. Client-Centered Counseling:Definition • Counseling conducted in an interactive manner through the use of open-ended questions and active listening, which focuses on developing prevention objectives and strategies with the client rather than simply providing information. CDC HIV Prevention Case Management Guidelines, 1997

18. Knowledge Perceived risk Perceived consequences Attitudes (beliefs) Skills Self -efficacy Actual consequences Access Intentions Perceived social norms Policy Factors that Affect Behavior Change

19. Dialog Individualized Takes feelings and beliefs into account Helps client understand themselves better Short and focused One-way Levels of detail but not tailored to an individual Sticks to the facts Helps client understand a subject better Short and focused Counseling vs. Education

20. Project Respect - A Relevant Model for STD/HIV Clinical Settings • Large, randomized, multi-center study funded by CDC, completed in 1997 • Evaluated efficacy of STD/HIV prevention counseling in changing risky sex behaviors and preventing new STDs • Almost 6000 patients attending large publicly-funded STD clinics (SF, LB, Denver, Baltimore, Newark) • Patients received client-centered counseling by trained (non-clinical) staff • Outcome measures:GC,CT,Syphilis, HIV • Findings: two short counseling sessions (20 minutes each) successfully increased condom use and prevented new STDs Kamb et al, JAMA Oct.7,1998

21. General Principles for Client- Centered Counseling • Approach each patient as an individual • Focus first on issues and realities that the patient identifies • Use open-ended questions and active listening skills to establish a dialog • Maintain a neutral, non-judgmental attitude • Offer options, not directive • Onus of action and responsibility remains with the patient

22. Three Steps in a Client-CenteredRisk Reduction Session • Focus on personal risk assessment • Identify patient’s personal perception of risk • Identify safer goal behaviors • Identify patient’s level of readiness for change • Assess barriers to behavior change efforts • Develop a personalized action plan • Negotiate small, realistic risk-reduction steps • Refer to specialized services, if needed

23. Assess Client Risk Begin dialogue with patient to determine • number, gender of partners • sexual practices (anal, oral, vaginal sex) • patterns of condom use • prior STD testing history, and diagnoses • Identify factors affecting patient risk • current/past history of unprotected sex • intentions for becoming pregnant • history of domestic violence • history of injection drug use

24. Sample Risk AssessmentQuestions • What are you doing in your life that might be putting you at risk for STD/HIV? • What are the riskiest things that you are doing? • What are the situations in which you are most likely to be putting yourself at risk for HIV or STD? • What is your experience with shooting up drugs? • When was the last time that you put yourself at risk for STD/HIV? What was happening then? • When do you have sex without a condom? • How do drugs or alcohol influence your STD or HIV risk behaviors?

25. Assess Personal Perception of Risk • Identify factors affecting patient’s personal perception of risk (knowledge, attitudes, beliefs) Note: if perception of risk is not accurate, counselor assists patient in recognizing risk • Consider patient’s level of readiness for change:* • Pre-contemplation • Contemplation • Preparation • Action • Maintenance

26. Safer Goal Behavior Questions • How would you like to change that? • What would you like to do differently? • What might be better for you to do?

27. Client Centered Counseling Risk Behavior Unprotected vaginal sex with new partner Safer Goal Behavior Consistent condom use with this partner

28. Possible Goal Behaviors for STD Risk Reduction • Reducing # of sexual partners • Increase in condom use with main/non-main partners • Partner testing • Monogamy • Abstinence • Consideration of any of the above

29. Client Centered Counseling Risk Behavior Safer Goal Behavior Factors that influence behavior Barriers Benefits

30. Identify Barriers/Sources of Support for Change • Personal perception of risk • Self efficacy related to negotiating safer sex • Power and control dynamics in relationships • Cultural issues • Access to care • Significant others

31. Client Centered Counseling Safer Sex Goal Risk Behavior Barriers Benefits Factors that influence behavior Personalized Action Plan 1. 2. 3.

32. Negotiate Realistic, Simple Risk Reduction Steps with Patient Risk reduction plan must be patient-driven, based on pt. history, readiness, & ability to adopt safer behaviors Health care providers should: • support efforts previously attempted by patient • offer options, not directives • remain non-judgmental

33. Personalized Action Plan Questions • How will you go about that? • What will you need to do first/next? • When will be a good time to try/begin this? • What is one thing you could do to begin? • Who can you talk to about this for support?

34. Refer to Specialized Services, If Needed • Alcohol or drug treatment programs • Partner/domestic violence services • Partner counseling and referral services • Couples counseling • Benefits counseling to obtain access to services

35. Taking Personal Stock • Helping clients change behavior may begin with changing some of our own • Recognize our biases and keep them in check • Talk less, listen more • Encourage step-wise, incremental, realistic changes • Avoid “should/shouldn’t”,”I think you…..” “You need to…..” • Be willing to give it a try!