Enhancing HIV Risk Assessment in Clinical Practice: Overcoming Barriers and Engaging Patients

1. HIV Risk Assessment/Sexual History Taking Christina Price, MPH HIV Trainer Delta Region AIDS Education and Training Center

2. Disclosure Statement • The speaker does not have any financial interest or relationship with any product or service which may or may not be discussed in this presentation. • If any conflict of interest existed, it would be noted at this time.

3. Our Goals • Articulate the benefits of conducting a risk assessment as a means of HIV prevention • Recognize and overcome provider barriers to conducting an HIV risk assessment • Demonstrate heightened skill in discussing risky behavior with patients/clients

4. What Exactly is an HIV Risk Assessment? • What? A conversation • Who? Between providers/patients • When? Upon initial/routine visit or after one or more factors indicates a person may be infected with HIV • How? By asking key questions and participating in active listening • Why? To identify and initiate

5. Who Benefits From Assessing Risk? • Patient Perspective • Opportunity to ask questions • Initiates conversation - circumstances surrounding pt’s risky behaviors • Provides patients insight into personal HIV risk behaviors • Guides patients in making a prevention plan • May affect self-motivation for behavior change • Normalize the Process • All patients will know to expect these questions • No one feels singled out

6. Who Benefits From Assessing Risk? • Clinician Perspective • Assists in clinical intervention/exam • Provides direction for risk reduction or referral • Increases provider skill and comfort talking about sex and drug use behaviors • Provide early treatment

7. Provider Barriers to Conducting a Risk Assessment/Sexual History • Inexperience or discomfort asking questions • Limited time is available • Discomfort responding to issues that arise • Incorrect assumptions about sexual behavior and risk • Patient perception of stigma from a medical care provider • Fear of offending the patient

8. Overcoming Barriers • Identify specific questions to ask all patients • Develop clinic policy for risk screening and integration into overall care (When and Where) • Develop plan to respond to information that might surface

9. General Risk Assessment Guidelines • Your initial approach • Confidentiality is essential • Focus on cultural sensitivity • Be non-judgmental • Assume Nothing • Address the fact that these may be uncomfortable topics to talk about • Active Listening Skills • Ask open-ended questions

10. Key Point If YOU as the provider are doing most of the talking then it is not Patient Centered

11. JAY Sam Eva Valerie

12. Jay • 17 year old male • Presents with a request for his yearly physical • As an athlete, feels healthy • Plays football, basketball, and runs track • Lives with his mother and two younger brothers

13. Valerie • 38 year old woman, presents for a physical • Feels “pretty healthy” but has experienced recent • vaginal yeast infections • headaches • sleeping problems • Lives with 9 and 11 year old sons • Works as an interior decorator (independent) • No primary care for a few years

14. Sam • 26 year old male • Diagnosed with severe hemophilia and HIV • Presents to establish primary care • Recently started a new job teaching at the local high school

15. Eva • 24 year old woman • Presents after a positive home pregnancy test • Has been “nauseous and throwing up” for a few weeks • Married 18 months and excited about the pregnancy • Works at a local gym as an aerobics instructor

16. What do We Want to Know? • Substance Abuse (current and past) • Sexual behaviors (current and past) • Including previous STD diagnoses • Pregnancy/childbirth intentions • Other Relevant History • Blood exposure

17. Initiating the Conversation • Permission Statement • “I’m going to ask you some questions…” • “I see from your chart…” • “Since our last visit…”

18. Sexual Behaviors and Drug Use • Risky Behavior Related to Drugs and Alcohol • Frequency (Partners?) • What and Where? • Protection? • Risky Sexual Behavior • Who? • What and Where? • Protection?

19. Substance Use • Never, “You don’t use drugs, do you?” • Legal First • “What has been your experience with injecting medication or steroids?” • “Tell me about your alcohol and drug use.” • “When was the last time you used drugs?” • “What do you do to protect yourself when injecting drugs?”

20. Substance Use - Jay • Has a couple of beers at weekend parties • Tells you some of the guys on his basketball team inject steroids • No illicit drug use

21. Substance Use - Valerie • Smokes half a pack a day – trying to quit • Drinks socially • Injected heroin and “booty bumped” crack – high school and college • Has not used in over 15 years • Shared equipment

22. “I don’t know what you mean, could you explain..?”

23. Responding to Difficult Language • Why might a patient use words that make you uncomfortable? • “Testing the water” • Afraid you may make assumptions about them • Doesn’t know any other word to use

24. Words often used to Describe Behaviors • Promiscuous • Non-compliant • Hooker • Illegal • Junkie “How many sexual partners…” “What makes it difficult for you to…” “Exchanged sex for money, drugs, ect. …” “Non-prescription drugs…” “User” “Addicted to drugs”

25. Substance Use - Sam • Drinks wine occasionally • Never injected drugs – “I’ve had enough holes stuck in me”

26. Substance Use - Eva • Never injected drugs • Tried marijuana a few times in high school • Used to drink socially • Stopped drinking when she began trying to get pregnant

27. Sex – The DON’Ts • Never: • “You don’t have sex do you?” • “So, you’re monogamous with your spouse right?” • “You’re married, so your not at risk for HIV are you?” • “Why aren’t you using condoms?”

28. Key Point Strike the word “why” from your vocabulary: it puts your patients on the defensive

29. Sex • “So, tell me about your partners.” • “Tell me about your past sexual activity” • “What types of sex do you have?” • “What do you know the drug using habits of your partners?” • “What do you know about any other sexual activities of your partners?” • “When are you are more likely to use protection? Less likely?”

30. Sex - Jay • Sexually active three years • 3 partners – 2 female (vaginal) 1 male (anal) • Insertive partner (“mostly”) • Does not know the risks of partners • Uses condoms “sometimes” with female partners

31. Sex – Valerie • Divorced 6 years • 2 male partners since • Vaginal and oral sex • “I don’t remember everyone I had sex with when I was using.” • Protection: birth control pills

32. Sex - Sam • Has a girlfriend • They kiss but no sexual intercourse • “She knows I have hemophilia and I would tell her about my HIV before we decided to have sex.”

33. Sex - Eva • She and her husband were virgins when they got married • Vaginal intercourse • No reason to believe she ever had sex under the influence of alcohol or marijuana

34. Other Relevant History • Blood Exposure • History of STDs • “Have you ever been diagnosed with an STD?” • “When, which one?” • Previous HIV test • Reason? Results? • “What encouraged you to be tested in the past?” • Violence • Forced sex • Fear in a sexual situation

35. Blood Exposure Valerie- no transfusions, cleaned up blood after children Jay – no transfusions, no blood exposures Eva – no transfusions, cleans up blood at gym with gloves Sam – diagnosed with hemophilia at 6 mo of age; 15-20 transfusions since 1983, last transfusion 3 years ago

36. Other Relevant History Valerie – never had an STD, exchanged sex for drugs twice, tested (-) for HIV in 1990, stopped using in 1992 Jay – really bad case of the flu last year, “I missed three games;” never tested for HIV Eva – no other relevant history, never tested for HIV Sam – HIV diagnosis at age 3, on HAART with CD4 count of 540 and undetectable VL

37. What Next? • Does (s)he need an HIV test? • What else does (s)he need? • Why?

38. Other Considerations • Offer Opt-Out HIV screening to • All patients with high risk behaviors • All pregnant women • Offer Sexually Transmitted Infection (STI) screening to: • All primary care patients annually • More frequently for those with high risk behaviors • For the reluctant patient: • Work to establish trust and rapport • Continue to approach

39. Are Risk Assessments only for those NOT already diagnosed with HIV? • NO! • Unprotected sex can lead to secondary infections that can accelerate disease progression to AIDS • STIs can facilitate the transmission of HIV • Risk behaviors increase with the length of time since testing HIV positive

40. When Working With HIV Infected Patients • “Have you notified your partner of your HIV status?” • “Has your partner been tested?” • “Are you currently on antiretroviral medications?” • “How often do you take your medication as prescribed?” • “Do you know what re-infection is?” • “Has finding out you are HIV+ affected your “outlook or behavior?” • Does patient reach out to community programs, friends, family, ect. to find support? If not, Why?

41. Confronting Difficult Questions /Statements The 3 C’s • Confirm • Recognition of the client’s emotions regarding the question or concern • Clarify • Ask an open-ended question to encourage the client to talk more about the concern • Content or Contract • Contract for a referral or another appointment to address the concern

42. Referral • View referral agencies as team members in your patient’s care • Follow up at next visit • Clinical • Case Management • Addiction Services • Mental Health Services • http://www.deltaaetc.org