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

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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


What are the recommendations
What are the Recommendations? Persons Living with HIV

  • 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


What are the recommendations1
What are the Recommendations? Persons Living with HIV

  • 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


Learning objectives module 1
Learning Objectives: Module 1 Persons Living with HIV

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


Why is it important now
Why is it Important NOW? Persons Living with HIV

  • 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)


Primary and secondary syphilis cases by gender california 1996 2003
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


Hiv status among men who have sex with men primary secondary syphilis cases california 2001 2003
HIV Status Among Men Who Have Sex With Men California, 1996-2003Primary & Secondary Syphilis Cases - California, 2001–2003

8/2004 Provisional Data - CA DHS STD Control Branch


Why is this occurring
Why is this Occurring? California, 1996-2003

  • 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


Do providers ask about risk
Do Providers Ask About Risk? California, 1996-2003

% of Providers Who Assessed STD Risk

Elford, Bull, Gardner, Calabrese, Duffus


Discomfort as a Barrier California, 1996-2003

“Ironically, it may require greater intimacy to discuss sex than toengage in it.”

The Hidden Epidemic

Institute of Medicine, 1997


Reported Cases with no Identified Risks California, 1996-2003

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


A missed opportunity
A Missed Opportunity… California, 1996-2003

  • 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


A missed opportunity1
A Missed Opportunity California, 1996-2003…

  • Returns 3 weeks later with rash on trunk and headache

  • Plan: topical steroids, with dermatologyfollow-up

Truncal rash


A missed opportunity2
A Missed Opportunity California, 1996-2003…

  • 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?


Learning objectives module 11
Learning Objectives: Module 1 California, 1996-2003

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


Provider barriers to risk assessment
Provider Barriers to Risk Assessment California, 1996-2003

What are some…?


Provider barriers to risk assessment1
Provider Barriers to Risk Assessment California, 1996-2003

  • 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


Overcoming barriers to risk assessment
Overcoming Barriers to Risk Assessment California, 1996-2003

  • 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


Assessing risk benefits
Assessing Risk: Benefits California, 1996-2003

  • 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


Framework for risk assessment
Framework for Risk Assessment California, 1996-2003

  • 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


Risk assessment techniques
Risk Assessment Techniques California, 1996-2003

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


Risk assessment techniques1
Risk Assessment Techniques California, 1996-2003

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...”


Risk Assessment Techniques California, 1996-2003

  • 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…”


What should we ask general questions
What Should We Ask? California, 1996-2003GENERAL 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


What Should We Ask? California, 1996-2003SEX 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


What Should We Ask? California, 1996-2003SEXUAL 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


A “Real Play” California, 1996-2003GATHERING 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


A “Real Play” California, 1996-2003INSTRUCTIONS

  • 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


Interact ! California, 1996-2003


Learning objectives module 12
Learning Objectives: Module 1 California, 1996-2003

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


Providers questions about screening
Providers’ Questions About Screening California, 1996-2003

  • 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?


Diagnostic testing vs screening
Diagnostic Testing vs. Screening California, 1996-2003

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


Percent of persons with std who are asymptomatic
Percent of Persons with STD Who Are Asymptomatic California, 1996-2003

Urethra Rectum Pharynx Cervix Rectum Urethra Any

Cervix

Chlamydia

Genital herpes

Gonorrhea


Std screening the first visit
STD Screening: the First Visit California, 1996-2003

  • 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


STD Screening: the First Visit California, 1996-2003

  • 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


STD Screening: Subsequent Visits California, 1996-2003

  • 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


Points to remember
Points to Remember California, 1996-2003

  • 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


Tests recommended for std screening
Tests Recommended for STD Screening California, 1996-2003

 See Overview of STD Syndromesfor Questions


Tests recommended for chlamydia gonorrhea screening
Tests Recommended for Chlamydia & Gonorrhea Screening California, 1996-2003

 See Overview of STD Syndromesfor Questions


Management of the symptomatic patient
Management of the Symptomatic Patient California, 1996-2003

  • 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


Treatment of std in hiv infected persons
Treatment of STD in HIV-infected persons California, 1996-2003

  • CDC STD Treatment Guidelines highlight specific regimens for HIV-infected persons when appropriate:320e

    www.cdc.gov/std/treatment

 See CDC STD Treatment Guidelines


In conclusion
In conclusion… California, 1996-2003

What is one thing you will change in your practice…?


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