Taking a Sexual History and Behavioral Risk Assessment

Clinical Education Initiative [email protected]

TAKING A SEXUAL HISTORY AND BEHAVIORAL RISK ASSESSMENT Maureen P Scahill, NP, MS Nurse Practitioner and Senior Public Health Advisor CEI STD ECHO Project Coordinator University of Rochester - Center for Community Practice

4/18/2018

Taking a Sexual History and Behavioral Risk Assessment [video transcript]

[00:00:23] So I'm going to go ahead and get started. We do have a number of people on the line. Thank you all for joining us. So good afternoon everybody, welcome to This Month in HIV. Our April presentation is Taking a Sexual Sistory at Behavioral Risk Assessment and that will be presented by Maureen Scahill. She is a nurse practitioner and public health specialist with the University of Rochester. My name is Jessica Steinke, I'm a program coordinator for HIV AIDS education and training department with the Mt. Sinai Institute for Advanced Medicine. Before I officially introduce our speaker, I would like to thank our funder the New York State Department of Health AIDS Institute Clinical Education Initiative, the Mt. Sinai Institute for Advanced Medicine serves as a cosponsor of This Month in HIV. A couple housekeeping notes for the duration of today's presentation all lines will be muted to ensure that there will be no distractions during the presentation. If you have a question at any time you can type it into the chat box and direct it to all panelists or you can use the Q&A feature, and at the end of the presentation I will read your questions out to Maureen. After today's presentation later this afternoon you will also receive an email with instructions on how to evaluate today's presentation and claim your CME or CNE any credit. Please do remember that This Month in HIV is supported via our CEI grants and your participation in the evaluation process does help us keep this program free of charge for all attendees.

[00:01:46] So at this point I would like to introduce our speaker, Maureen Scahill. Maureen received her Master's Degree in Primary Care from the University of Rochester in 1992. She has practiced as a Nurse Practitioner for over 26 years, 22 of which have been in STD and HIV prevention and care in public health. She also has over 36 years of training and clinical precepting in research experience as well as experience and curriculum development and technical assistance to a variety of clinical and other health care and human services providers. Currently she's a Nurse Practitioner in the HIV STD prevention program at Monroe County Department of Public Health and a trainer and TA provider at the Center for Community practice within the University of Rochester Infectious Diseases Division. Additionally she is the coordinator of the CEI STD Center of Excellence ECHO project. So thank you so much Maureen for being here. And I'll turn it over to you.

[00:02:42] Well thank you very much Jessica. As you know today's topic is Taking a Sexual History and Behavior Risk Assessment and the subtitle could be 'give me the words to say.' So I'll proceed and I am with the University of Rochester the Center for Community Practice and we are under the CEI, like Mount Sinai, we are a center of expertise for STDs.

[00:03:10] I have no relevant disclosures. Objectives for today are list complications of undiagnosed and untreated STDs, there will be a little bit on that. Recognize that taking a Sexual History and Behavioral

Risk Assessment, here abbreviated as indicated, is now a standard of medical care and primary care settings to promote sexual health. And to list three main components of taking a sexual history and behavioral risk assessment. And then finally list three open ended questions used to ask about sexual, substance use, and health promotion behaviors.

[00:03:50] This is a little bit about the Center for Community Practice. As noted we are funded by the New York State Department of Health AIDS Institute Clinical Education Initiative as the center of STD Center of Excellence. We are also regional training center for the AI and we also provide Capacity Building Assistance or CBA through the CDC. And address and contact information are there.

[00:04:19] So let's get into it. Why take a sexual history? Well sexual health promotion which includes the following. And just let me say about sexual health and sexual health promotion, those are good words to use with your patients to be able to sort of introduce the idea that you're going to talk about sex, drugs, and rock and roll. So sexual health promotion is a nice way to frame it. And it includes these topics. Healthy sexuality, which some of which may be beyond your scope of practice but certainly something you can attend to in terms of referrals. You want to be able to identify actual or potential risk for STD, HIV, viral hepatitis, injury, and violence to conduct screening and testing. So that it also addresses reducing sequelae and complication of STDs, for example avoiding congenital infections. And as you may know in New York State we now have a new increase in congenital syphilis infections. And this is a newer piece of our incidence and prevalence. And you can look more into that by checking the CEI web site. Impaired fertility is another outcome of STDs, particularly chlamydia but also gonorrhea, and then HIV transmission via a sexual root. And so there are also for example STD related neoplasms. So we want to, also thinking about health promotion, identify what STDs, HIV, and viral hepatitis screening and testing is needed depending on the patient situation and circumstances which is slightly addressed in the second point. You certainly might be in the situation where you're addressing reproductive health needs or concerns, and if you are not in the position of providing reproductive health specifically around such things as birth control or prenatal care, you certainly can understand what needs or concerns your patients may have and make appropriate referrals. And then the use of information gained in this sexual health assessment can be used to develop patient centered risk reduction counseling or education. And certainly as already noted, determine needs for referral.

[00:07:03] So what is sexual health? There are two long quotes here. I'll let you read those. But one is from the World Health Organization and I want to point out that the CDC sort of added a few more points to that including access to services, including diagnosis and management of STDs, accurate risk reduction information,, contraception and safe abortion. And the citations are noted.

[00:07:33] The CDC initiated a sexual health strategy already now seven years ago and it was after a national consultation and they concluded and included "the framework also brings groups together

around common concerns including academic curricula, social networks, and professional education and accreditation. It is empowering and a holistic approach to sexual health promotes both a right to health and also personal responsibility." Which I think are important concepts as we think about working with individual patients.

[00:08:12] So are we there yet? These are also a couple of quotations here from Warner et al saying "a crucial deficit in sexual health care is a proactive and preventive approach in primary care setting and in a perfect world health care providers would be both trained and proficient in all areas of care. In reality sexual health is often the exception." Now if you note this citation at the bottom of the page it's from 1999 and another one is indicated from 2002. And current references that I will cite a few, often echoed the same sentiments and concerns.

[00:09:00] So over the past 20 or so years there have been a growing number of these kinds of publications related to sexual health. Conducting a sexual history and behavioral risk assessment. Many of these look at practices of providers who are out there in the world of primary care and other settings, including HIV care settings. And they also identify some strong elements that would be needed to improve providers ability to conduct these assessments. There is a reference list for this presentation to provide case studies and guidance documents, so each slide has got a citation but the full list is in the last several slides of this set. The next few slides will highlight some of the studies I've mentioned.

[00:09:57] So undereducation of many medical providers causes deficits and knowledge and importantly in skills to address sexual health. In a study in 14 by Lanier and others, it was noted that less than 40 percent of providers conduct sexual histories with patients and many do not receive formal sexual history training in med school, and this was specifically about physicians. Coleman and others in 13 stated that medical students and practicing physicians report being underprepared to adequately address their patients sexual needs.

[00:10:38] Looking at some other professions within the healthcare field, we have another study in 2014 that while identifying the importance of sexual health it yet remains a topic that is uncomfortable to discuss for both patients and healthcare professionals. And one important thing to note is and some of the citations include this information, is that there are also studies that show that patients do want to discuss sexual health and may feel a little weird or uncomfortable the first time it's brought out particularly if it's an existing patient, but the point is that they are not likely to bring it up themselves but are glad to have providers address their topic with them. So again another reference here from 2011 surveyed nurse practitioners and found that only 2 percent always conduct a history with their patients aged 50 and older, which certainly includes me, and 23 percent seldom or never did such an assessment for that age group citing that time constraints and limited skills in communication were barriers. So it's important that we identified the issue of time constraints and so some of this webinar is to try and give

you some sort of quick and easy ways to approach this that you can gather as part of your reason for visit and hit HPI and your review of systems. And hopefully will also address some of the skills and communication. Regarding physicians nurses and other clinical providers Ford and others recommended that "the approach to matters of sexuality and sexual behavior will need to be reframed in subtle but critical ways and that educational efforts for health care providers will need to shift to support a more comprehensive approach to understanding and promoting sexual health throughout the lifespan." OK. These all sound great but the point is we also need the skills and the self efficacy to pull that off.

[00:12:48] So a couple more studies to highlight is that this other found that less discussions occurred when there were gender and race discordance, that is between the provider and the patient. And so that the difficulties that providers may have in conducting such an assessment might be worsened or aggravated by a discordance of gender and race between the provider and the patient. One important thing they pointed out is something I just mentioned about improving, in this case it was physicians, but the self advocacy that is the confidence in the ability to do the task. And so that's part of our hope with this webinar is that we can help you get some skills that you can practice perhaps with each other in your care setting or just dive right in and start using them with your patients. And it might give you some other ways to address a topic you've already felt comfortable addressing. With regard to health care providers specifically asking about sexual orientation, sexual identity, and same sex attraction or practices, studies show that this is truly wanting and here are several citations some already mentioned and again in the reference list at the end of the slide set.

[00:14:09] So again this is all magnified when patients are also persons of color, regardless of the color or match of the provider. Because we do know particularly for African-Americans there are high levels of medical mistrust related to many historical and cultural experiences, including vicarious experience through community history and community perspective. Lack of disclosure and affecting medical screening and testing, diagnosis and treatment, occurs then when we cannot get all of this information. And in particular this paper looked at black MSM, but this has been shown with all races, ethnicity. So in 2008 Bernstein and others did this study that among black MSM the average number who disclosed their status of being a man who has sex with other men was about 33 percent, while among the white MSM the number disclosing was 81 percent. So we know that in some interventions for black MSM, whether they identify as gay or not, there is some work being done to try and improve their skill and self efficacy in disclosing their MSM status to a health care provider. And in these days when we're looking at HIV incidence and prevalence, we know that among black MSM and not far behind Latino MSM, there are high rates that are disparate compared to white and other races of men who have sex with men. High rates of new HIV cases, and so this is important information, thinking about addressing some of the biomedical interventions including PrEP or post exposure prophylaxis and STD screening.

[00:16:12] So let me proceed. So I just wanted to give you this list and the website is there and there are in the New York State Department of Health's website sexual health information and training available.

Not the least of which would be the clinical education initiative or CEI who is sponsoring this talk. And the list is here for you to review.

[00:16:39] Sexual health is addressed in a number of programs and plans including these listed here, including more attention to this being paid in the area of substance use treatment. It's not as prevalent as it is in HIV and STD or even primary care, but it is increasing. And so the websites for various groups to refer to are here and will give you some more information and some tools. And in our current situation with the opiate epidemic, these are important considerations for looking at sexual health that may or may not be associated with substance use.

[00:17:24] Lots of guidelines and standards and many of them identified here. So let's look at, this is from unpublished data but from the Gonorrhea Community Action Project which asked primary care providers to answer a survey asking if they conduct sexual histories with their patients. Now this is, as you can see by the legend there, it is 15 to 17 year olds or 18 to 25 year olds. So in the males we see that in those aged 15 to 17, these primary care providers indicated that less than 40 percent of them conducted sexual health histories. And it's a little higher for the males 18 to 25, but still under 50 percent. For the females both rates are higher and this is often connected with reproductive health concerns. But in both cases it's still much too low.

[00:18:23] So how did a lot of us learn to conduct a sexual history? Well I'm dating myself and maybe some of you but just the facts ma'am, just the facts. That's not the best way to get the information. Traditionally it involves closed ended questions, just get the facts as already noted and possibly provide some prevention information often in the form of a few prevention messages like use condoms or get some birth control. Sexual behaviors, that is the sex of their partners, the types of sex they have with those partners, of the patient might be identified but not usually identifying risk behaviors of both the patient and the partner. Often it's only about the patient in front of you. And often without getting anything specific about sexual or gender identity. Furthermore if any risk reduction were promoted, it was generally only in the universal messages regardless of the patients situation and circumstances. And then often condoms would be given or offered without fully knowing the patient's attitude or history of condom use, without addressing condom skills or partner situations related to that. We'll get into that a little bit.

[00:19:42] So a common approach to sexual history, if done at all, was don't ask but tell. Like I just said not individualised and it leads to less sexual health. So this is a little bit more about the adverse outcomes of STDs including HIV transmission I already mentioned, adverse pregnancy outcomes which also could lead to impaired fertility. So those are linked in some ways. And then STD related cancers. And in the US according to CDC statistics, over two million new STD cases occur each year in the U.S. and

that 50 percent of those occur in ages 15 to 24. And so thinking about that survey of primary care providers that's an interesting backdrop.

[00:20:39] So why is it a sexual history and behavior risk assessments aren't routinely done? Much of it has already been identified, but most providers will feel uncomfortable initially, just like everything else we had to learn to do in clinical care is the more you do it usually the easier it gets. And many many inexperienced providers or even those with experience who felt pretty comfortable conducting these kinds of assessments, would say to us in training 'just give me the words to say.' OK so there is a hand out which we did not send ahead of time that can be sent after, it has information about common principles, common assumptions to avoid, and another handout about interactive using open ended and close ended question combination. Actually something with some words that you could say.

[00:21:40] So how do you open the doors to this? Thinking about STD, HIV, and viral hepatitis prevention. So there's sex, drugs, and not rock and roll but healthcare. So this is a mnemonic that our director at the STD clinic and Center for Community Practice Patricia Coury-Doniger, this was her mnemonic big on initials, and it was one that I could remember. So it's RNACTS, and there's my Rochester accent with the flat A. The R stands for current relationship and the gender or gender identity of partners and the sex of partners, that is are they males, females, or is there a gender identity that matches their genetic birth assigned sex. N is the nature and number of partners and the types of sex. A is the, this is a little bit of a stretch here, but the attitudes and history of condom use, testing for HIV, STD and Hep C, and substance use. So we'll come back to how we use that as we proceed.

[00:23:00] Start with open ended questions in all situations followed by close ended. And you don't want to forget the partner situation. So let me just go through this and then I have an audio clip for you. So what is your current partner situation? What kind of sex do you have? If a regular partner, and clarify the sex of their partner, how long have you been seeing that person? What's that relationship like for you? When is the last time you had sex with that person? And how about with someone other than that person? And that gets at that when was the last time you had sex with your regular or main partner and when was last time you had sex with somebody else without trying to get into sounding judgmental. And then you want to clarify the sex of any and all partners. And what about for your partner? So how many different partners would you say you've had in the last three months, so that's the closed ended question. And you could add 6 and or 12 months, I know some standard sexual health history forms that may be in your electronic medical record or surveys that you give patients to complete by paper and pencil before you see them will include 6 or 12 months. And beyond 12 months or beyond the last time the person was tested is not really relevant in this case, although it's often asked as how many lifetime partners you've had. More in the context of HIV risk. But the three months is a good time period considering behavioral science, it's considered a good window of time to understand common habits for a person from a behavioral perspective. That is if you asked about smoking you might ask, have you smoked in the last three months and if this person says no, but I quit. So you delve into that more. So for

sexual behavior, three months is considered a good window to sort of understand the habits of that person. But asking about 6 or 12 months in addition to the three months can give us a bigger snapshot of where that person has been in recent history.

[00:25:16] AUDIO CLIP: 'The baby's father I see him. Okay. But I wouldn't like say he is my boyfriend or anything, we don't go out on dates. Okay and how long have they been in a relationship with him? 4 years. Okay yeah. So what's that relationship like for you then, you're saying that you're not really dating him. Well when I'm low on something for the baby or if I need someone to watch the baby for a couple hours, I usually go over there. That maybe happens once or twice a week. So sometimes he helps out with things that you need for your son? Right. And does he babysit sometimes you said? Yeah. Okay, good. And then so does it happen that like if you're over there or something that you might have sexual contact with him then? Yeah. Okay. And when's the last time you said that was the case? Last week. Okay, about a week ago. How about with persons other than him? I don't have like a boyfriend, but I do like to go out on the weekends. If I go to party or something I might hook up with someone. Okay, and so would those be people that you know or just meet for that evening? Yes. Okay. When's the last time that happened would you say? Oh maybe four weeks ago. Okay, so how many different partners would you say have had in the last three months?'

[00:26:49] The last word kind of dropped out low, but she said she's had three partners in the last three months. So again getting to a sexual history, you want to know about the types of sex the person is having to guide not only your risk assessment and identification of potential risk reduction counseling or education, you also need to know as one provider once said in a training 'where do I put the swab' if you're going to do STD testing. So something like this can be said to a patient, 'you know you can get infections in your penis or vagina, your rectum and or mouth' depending on who's sitting in front of you and what body parts he or she has. 'And then these infections can occur depending on the kind of sex you have, which helps us know what kind of testing to do. And so can you tell me about the kinds of sex you have.' So you're going to ask, depending on who's in front of you, 'is it penile oral, penile vaginal, penile rectum?' 'Is there a oral vulvar or vaginal contact? Is there oral anal contact?' And I see there is a typo here the one that says in the second column penile oral should be penile vaginal. So sorry about that. Anyway you get the point. So you want to clarify. However, once you know that 'are you the one that is the insertee or the inserter?' That is, 'do you receive or conduct it' and that's important because if you perform oral sex then you'd want to consider testing that person's throat for gonorrhea. But if the person is a receiver of oral sex and does not perform, then testing the throat may not be necessary.

[00:28:46] Okay let me move on. So again starting with those open ended and following with closed. This is one that was a very big revelation to me, to ask how about condoms. Because if you ask directly 'do you use condoms' you're likely to get a response from a patient saying yes or sometimes, something that would make you feel good about the patient and also might shut you up. So that what you can try instead and this was an awkward question for me initially, but 'what's been your experience using

condoms?' And then you get the response and you say 'what about with your main, if there is one, or regular partner? And what about with others?' So then what you want to know a little more about is what are the differences between the time someone might use them or doesn't use them or the reason that I don't use them at all. So you could say 'tell me about a situation in which you might use a condom as opposed to when you don't. And do you think it would be a good idea to use condoms in your current situation with your main partner? And what does your partner think? What about other partners you might see?' So let's hear what Jackie has to say when she is asked this question.

[00:34:37] AUDIO CLIP: 'I use condoms. Okay and how long we've been using them would you say? Well ever since I got herpes. Oh. I use them whenever I go out to parties. Okay. I don't use them with my baby's father. Oh okay. And what will be your thinking about that? Well he would not want to use a condom. Okay. So he doesn't like using the condoms, as far as your relationship with him? He would be angry if I used the condom. Okay. I can't use them with him. Okay. Then what would he be angry about specifically Jackie, do you think? Well he thinks that I only have sex with him. Okay so he's not aware of the other partners? Right. Okay. And in terms of using condoms with the other partner how does that usually work, like do you bring that up or do they with the other partners that you have sometimes? I carry in my purse I always have one on me, I just pull one out. Good. So that seems to work ok for you? Yeah. Okay great.'

[00:31:18] Okay so you can hear that a lot of information was gathered from Jackie about condoms and we now know that she does use them routinely with outside partners, but not with her baby's father who is her main partner because he would not agree with that. And that's important when you ask about relationships, the importance of a relationship can dictate how things like barrier use or choices about what kind of sex is had occur based on the strength or weakness of our relationship or the ongoing nature of one. So again here we are talking about substance use. So what's been your experience with drinking alcohol? How much do you drink? How often? So what's been your experience is that open ended, followed up by those two closed ended. What's been your experience with other drugs? Tell me about what you've used? Tell me how you've used and whether or not it involves needles or smoking or whatever snorting and so on? What about your partners? Again sexual risk has to do in general with at least one other person, because sexual contact is with at least one other person. Another question is are there times when you've had sex when you weren't planning to because you were drunk or high? And then the follow up is, does that influence condom use for example? And have you ever had sex in order to get high get money or other things? And so we know that in the context of substance use, people will often slip their usual sort of rules for themselves about how they have sex, who they have sex with, and whether or not protection is used in the form of barriers and choices they make. And not only is it the nature of the partner but it's also the substance use. And that also is a case for our partners, because if they're using and they're injecting drugs then that poses a whole new risk perhaps for your patients that you're seeing. So we have another little bit of Jackie's history here.

[00:33:36] AUDIO CLIP: 'What's your experience been? I've had some experience using stuff. Okay. You know I go out to parties and I might have a beer or whatever might be being passed around. Okay. So beer sometimes or other alcohol, and what about other drugs? Sometimes I smoke. Marijuana, cocaine? Depends what's around. Okay. Whatever? Yeah. Okay. Would you say that you're using on a regular basis or like you said sort of when you go out? When I go out to parties, but it's not a problem or anything if that's what you're trying to get at. Okay. So you feel like you're doing this sort of recreationally? Yeah. Okay. What about the baby's father? What about him? Does he have a history of using any drugs? Oh sure. Okay yeah. Do you know what kind? I know he likes to smoke dope. Okay. How about cocaine? I wouldn't doubt it. And how about shooting up, do you think that he uses needles at all? I don't think so.'

[00:34:46] We just heard that section where Pat was asking her about her, Pat is the person that was conducting the interview, my director Pat Coury-Doniger. She asked Jackie about her experience with using substances. So we heard from Jackie, 'I've got experience' and she tells her that she is using different drugs including alcohol, but that she's not using needles and that her partner is likewise at least using drugs and she does not believe that he uses needles. Now you don't hear the section where Pat asked her has she missed condom use if she were high or drunk and so on. And in this case I can tell you that the patient said no, she felt really clear that she didn't ever get compromised by her substance use such that she would not use a condom which she feels very strongly about using. Okay.

[00:35:41] All right. So then we want to ask about health care promotion or health care seeking. So what's been your experience with STDs, HIV, viral hepatitis testing? Have you ever been told you've had one of these infections? And what care or medications did you get? Now I work in an STD clinic and all of times you get patients say 'oh yeah I had all those infections.' Then you'll say which ones and they are always really sure. Then we ask them about what medicine or treatment they got and they might say they got a big shot in the butt and that might indicate syphilis treatment or 'I got a shot in the arm and some pills' and that could indicate you know perhaps gonorrhea treatment. So sometimes you can get a hint about that from whatever they can tell you about the treatment. You want to specifically ask what's your HIV status. And do you know the status of your main partner, if there is one, and maybe the people that you see otherwise? When was your last HIV test, did you get the results? And what about your partner's last HIV test? And do you know his or her results? And have you had STD related vaccines which would include HPV, Hepatitis B, Hepatitis A under many circumstances for sexual risk reduction, and meningococcal? And you are likely aware that we've had some, not for a while now, but for some outbreaks of invasive meningococcal infections related to sexual contact only seen in men we have sex with other men as far as the surveillance is aware. And this is occurring around the country in different places. And when it occurs in a region, the state or local health department will alert you as to the importance of considering offering meningococcal vaccine to people who don't fall into the normal criteria that we use for that vaccine. And you can certainly learn more information from this from the New York State Department of Health website and the CDC website. So let's hear this conversation with Jackie.

[00:37:59] AUDIO CLIP: 'OK. Did you get tested when you were pregnant, do you remember that? Yep. Okay, and did you find that your results? Oh yeah. I was negative. Okay, good. Have you had a test since that time? No I don't think so. Okay. That's good. Has he ever been tested for HIV? I have no idea. Never brought it up to him. No way. Because? He'd want to know why I wanted him to get tested. So you think he'd be sort of suspicious to you? Yeah, and want to know what I'm doing. And I need things from him, I need supplies for the baby, I can't get him mad at me. Okay. What do you think about the idea of using condoms with him for yourself? I would really like to. I mean he's the one who gave me herpes four years ago. You probably think I'm stupid that I'm not using them. No, I don't think you're stupid. You know I just can't bring it up.'

[00:39:07] So this is a common situation in relationships that the patient you're seeing may see the need to use condoms or other barrier protection or some other issues around substance use or sexual practices, but cannot necessarily address those with a regular partner. And again assessing partnership, partner relationship and the importance of it is very helpful in understanding the circumstances of this person sitting in front of you. And we heard from Jackie that she was tested and it was a little blurred I heard, but she was tested when she was pregnant. She had that baby four years ago and she doesn't believe she's been tested since. She has already told us that she has herpes and not on this audio part of the tape, you didn't hear that she had denied other infections except for chlamydia once in the past. But when Pat asked her about HIV test in terms of her partner, what did she say? 'I can't do that. I can't go there because it's going to be a problem.'.

[00:40:20] So let's proceed here. And what you want to do then is, this kind of a diagram of Jackie. Right. So Jackie's had two outside partners males in the last three months and she's also had her male partner and he has had at least two others as far as she knows, which you didn't exactly hear on the audio clip that we played. Jackie's situation is that she uses some substances including alcohol, but no injection use. She does not use condom with her main as he does not know of her other partners and she needs that relationship with him. She does have other partners occasionally. The last was about a month ago. And she uses condoms with others and has negotiation skills, we heard her say 'I always carry one with me. I just bring it out.' And so she's kind of in charge. And his, the main partner situation, is also substance use probably not injection it's an ongoing relationship with her, but he has other partners and she's doubtful that he uses condoms with them. And she is not aware of his HIV status and has never been able to bring that up. So when you get this history in one single sentence you can summarize it to make sure you're both on the same page.

[00:41:46] So let me play that last audio clip so you can hear.

[00:41:50] AUDIO CLIP: 'You're saying that you have a regular relationship with the baby's father for about four years. You're saying that you know you have a regular relationship with the baby's father for about four years and occasionally you have outside contacts if you go out and meet people at a party and you're using condoms with them, but with the baby's father you think it'd be a good idea but you're not going to risk him getting angry.'

[00:42:17] So you see that Pat was able to summarize the information that we've gotten from Jackie. And again, it was basically one sentence and pretty straight forward. And Jackie acknowledged that you are right and this is important because it makes sure we know what we were hearing and that the patient gets an acknowledgement that we were listening and that we took it in and that we want to assure that we understand his or her situation. So it has a lot of benefits to doing this one sentence summary.

[00:42:51] So back that mnemonic of RNACTS. So for Jackie we learned about current relationship, gender of her partners, the nature and number of partners, types of sex, attitudes and history towards condom use, testing, and substance use. So let me give you an idea of how that could play out in the documentation. If you were to use that same sort of mnemonic, the current relationship she has a regular who has others and outside partners, all are male. And the number of partners that she has and the types of sex, which you didn't hear all of this on the audio clips that we played, but she's had three in the past three months, she's had receptive vaginal and oral, she performs oral sex on the man or fellatio. Her attitudes toward the history of condoms, she doesn't use them with her regular, she sees a need to which is important but she cannot. She uses consistently with outside partners and she initiates the use. Testing for STDs and HIV last about four years ago, has genital herpes, is HIV negative from that test sometime back. Unsure about regular and outside partners in terms of status of HIV or STD testing otherwise. And substance use we already discussed. So this could be a way to sort of document Jackie's history at least in your own mind and you might be able to set up a history taking form for yourself that could get this information quickly by checkboxes and so on. I know that changing EMRs is not always easy, but we could discuss that with you at another time.

[00:44:43] Okay so want you to have the opportunity, we have about 14 minutes left to use the worksheet, the RNACTS worksheet hand out, and listen to another audio clip and see if you can identify this case the components of that for the audio clip you hear.

[00:45:06] So let me go back to this.

[00:45:21] AUDIO CLIP: 'Hello Val, I'm Bobby. I am one of the counselors at the teen clinic. How are you doing today? Fine. I see by your chart you are coming in for your depo shot, how is that going for you? It's going okay, I am not pregnant. That's always good.

[00:45:34] We try to take so time before the nurse comes in to administer that shot and talk a little bit about HIV. And just so that I don't give you the same information you've heard before, why don't you tell me a little bit about what you know. You can get in through having sex with people that they got HIV and are not clean and stuff. You can get it through sharing needles with people that have HIV. And pregnant moms can pass it to their babies. Well, it seems like you've got a lot of information. All three of those things are correct. Do you ever think about HIV, are you worried about it? No, not really. I don't see myself in one of those situations. Well why don't you tell me a little bit about your situation. I'm in a relationship with Roger, it's been going okay we have our problems. We always work them out. Well how long have you and Roger been together? For about two years. And how has that been going? It has been going okay, like I said we have our problems but we work them out. Now right now Roger is your only sexual partner? Yes. How about Roger? Roger still sees his baby's mother. How do you feel about that? I don't like her, but it is something that me an Roger have been dealing with. He was with her before he was with me and they a baby together. Well have you and Roger or in any of your relationships, have you had any experience in condom use? No. Why do you think that is? I don't need to use them, not with Roger because we get tested. He makes sure I get tested, he's tested and he makes sure his baby's mom gets tested also. Okay so let me make sure that I got your information correctly, let me know if anything is out of place. You're in a relationship right now with your boyfriend Roger. Roger is involved in another sexual relationship that you're aware of. You and he don't see or you don't see any condoms right now. Right.'

[00:48:05] Okay so let me go back to that. How did you and if you got a chance to kind of take some notes you can learn from this that Valerie who was coming for a reproductive health visit not an STD or HIV visit, but Valerie indicated that she has one partner and he is a regular partner and is a man. And that he has at least one other partner that she knows of who is a woman, his baby's mother. And when, you didn't hear this part in the clip, but asking about the types of sex was a piece of this. But when the counselor Bobby, who is really a counselor, she asked about attitudes and history of condom use. Valerie said 'well we don't use them because we don't need to.' And she explained why she believes they don't need to, because Roger make sure they all get tested. Valerie, Roger, and his baby's mother. We didn't hear the rest of the piece because I wanted to just focus on the relationship and condom situation, but I can tell you that Valerie denied any substance use other than an occasional alcohol and she had been HIV tested most recently three months ago, because remember Roger insist that they do this. And she had been STD tested six months ago at that reproductive health setting. I want you to think about all of the clips that you heard. And I sometimes had to fill in the blanks a little bit, but none of them of Jackie's were more than a minute. And the one you just heard between Valerie and Bobby started at the beginning of Bobby walking in the room and sitting down, but it was four minutes. And this section in which she asked her about relationship status was down to a minute and a half. So if you

had five minutes for a visit, that could be a pretty good chunk but it can be rolled into again to your review of systems and your HPI.

[00:50:33] So a couple other things to a point to make is another barrier for doing this kind of history is that it has not always been something you could bill for which we know is a reality in our practices. Under the Affordable Care Act which is still the law of the land, HIV and STD screening are now billable as part of the preventive portions of the ACA. They put this section in to include a wide range of preventive care such as tobacco cessation, mammograms, pap smears, all those kinds of routine things but they also included HIV and STD testing so you don't have to have a compelling reason other than gathering history and identifying that this would be a good preventive method. No one model is required for this to document it, but it needs to be a one on one brief clinic based intervention, it does not have to be a provider it can be a counselor if you have them or case managers if they are working with patients and so on, you need to have evidence of a sexual history and behavioral risk assessment. And it should be interactive with individualized elements, meaning what you learn from the patient you feed back to them some questions or some suggestions or some considerations based on their circumstance. So for Jackie, it might be looking at ways she could reduce harm if she cannot bring up condoms with her male partner. Perhaps she could choose some less risky forms of sex, as in oral sex instead of penile vaginal. And with Valerie it would be trying to get her to wake up and see that it might be reasonable for her to consider some kind of protection, because she's not really in a mutually monogamous relationship. It will provide you then the opportunity to provide education and skills training which may be something to which you refer a patient. And in HIV care, there are often interventions that are done in your setting or in community based organizations with which you partner that provides some various, more intensive interventions for persons living with HIV to reduce their chances of transmitting or acquiring other infections. So the guidance and support for behavior change must be based on the attitudes and circumstances. So it isn't just about what you know, it's about what your perception is of risk, what your perception is of need to reduce a possible risk, and what are the circumstances in which you might have to make these considerations.

[00:53:43] That is the end of the formal talk. As you know the CEItraining.org website provides lots of opportunities for a live online and Face-To-Face training for HIV, Hepatitis C that is through Mt. Sinai, STD through us, and LGBT health and drug user health through any one of us. And our own website for the Center for Community Practice is also identified here and there is an additional training resource the national network of prevention training centers which provide STD clinical training as does the CEI through our program. And that map here shows you that there are like four quadrants of the U.S., and it's only the contiguous 48 states but it includes the others including also territories like Puerto Rico and Virgin Islands. So if you go to that website you can get online training, you can get onsite training. And all of this comes with continuing education units.

[00:54:50] Don't forget the CEI line to call and ask about HIV, hepatitis C, STDs, PEP or PrEP. And in all cases you speak with a clinician who is an expert and you can do the request through the website or by the phone call and you'll be directed accordingly. And again a reminder that CEI is a way to get some free training that will provide you with lots of good information, some skills, and some continuing education units. What questions do you have? I didn't see a chat box, so Jessica do we have any questions?

[00:55:37] Thank you so much Maureen, that was really fantastic. Very comprehensive, really enjoyed it. So just a reminder to everybody on the line you can chat in your questions for Maureen now. You can type them into the chat box there and I can read them out, or you can send them in the Q&A. So I'll give people a few minutes to do that. Maureen, I'll just start with a question. So what would you say is the biggest barrier that's preventing primary care providers from asking some of these questions?

[00:56:05] I think it is probably a perception that they don't have time and some will, as some of the literature review indicated, some don't think it's their place but a lot just don't feel secure to be able to do it. Worry about how the patient will interpret it, and you know they have concerns like that. They're really important concerns. Time is really a huge issue, which is why we wanted to put the audio clips into this presentation because we wanted to indicate that it really doesn't take that long. Even though in any clinical encounter you do usually you have a time constraint. And you know if you have standing room only in the waiting room, you're concerned about that. One thing in HIV centers and other specialty care settings like you know for hepatitis, there can be counselors that can help with some of this. But when you're in primary care, it's usually up to the clinical provider. And also could be done by others who have encounters with a patient like the nurses in the office or perhaps case managers, depending on the situation and so on. But I think time, and a sense of skill, and comfort are the main reasons.

[00:57:29] Great thank you. So we do have one question here. One person on the line is asking if you could please explain the current recommendations for oral pharyngeal swabbing for STDs and is it only for GC?

[00:57:42] Great question. It is only for gonorrhea according to the CDC. Now if you look at some guidelines for MSM health, they'll say chlamydia as well but it is not recommended by the CDC because although chlamydia can colonize the pharynx it does not. It is not known to be transmissible. So gonorrhea from the pharynx not the mouth but the pharynx, is recommended for anyone who performs oral sex. But especially always for men who have sex with men, even if they say they use condoms or don't perform oral sex because it is important that in population studies show that there could be inoculation even if it isn't the full on oral sex that some people might conceive. So I hope that answers your question, and the CDC guidelines have that pretty clearly down to something it's like just a table.

[00:58:44] Great. Thank you so much. So we're just about out of time here. Of course if people have additional questions that come up, they can always send them to me and I can link you with more directly. Oh one more question was just asked, do you only perform those tests on people who themselves perform oral sex or do you also perform it if they receive oral sex?

[00:59:06] It might be depending on the patient that's in front of you, but typically in our clinic which populations studies say that STD clinic patients just on population, have a higher risk than some other settings. Always not clear, but that we may do oral sex if the person says he or she receives it. But typically unless it's a man who has sex with other men, we only do the pharyngeal test for gonorrhea for those who perform oral sex whether it's on a penis, external female genitalia, or anal oral contact. And of course it's important to look in the mouth and you know raise the tongue and all of that, to look for evidence of syphilis which could be acquired through oral sex. And you know the signs and symptoms of possible HIV infection. But really we mostly only do it, unless it's a man who has sex with other men, for people who say they perform oral sex on any genitalia including the anal and perianal areas.

[01:00:22] Great. Thanks so much. So we are out of time. Thank you again Maureen for leading this presentation, it was fantastic. Thank you to our funder the New York State Department of Health AIDS Institute Clinical Education Initiative. As a reminder to everyone, you will receive an email later this afternoon with instructions on how to evaluate this presentation and claim your CME or CNE credits. And that e-mail will also contain resources that support the content of this webinar. So next month, This Month in HIV webinar will be on May 16th with Jeff Cuong presenting on post exposure prophylaxis. Thank you again everyone for joining us and we hope you'll join us next month. Thank you very much.

[01:01:00] Thanks everyone.

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