Review Material Risk Reduction MD Brochure

ABOUT:

Safer

Sexual
Behaviors
How medical providers can help patients living
with HIV reduce risky sexual behavior

9_PIC_W3_Risk_MD_ Brochure_v245 12-4-13

Small Talks

Small Talks

ABOUT

Safer Sexual Be

IT CAN BE DIFFICULT TO DISCUSS
SEXUAL BEHAVIOR
(But it’s important to do so.)
Encouraging safer sexual behavior of patients living with HIV is
paramount to protecting their health. Safer sex helps prevent
acquisition of sexually transmitted diseases (STDs) or hepatis C
virus (HCV), which can complicate both patient health and HIV
treatment outcomes. It is also crucial to help reduce new infections
by preventing transmission to partners.
Medical providers can play a pivotal role in helping patients
reduce their risk by taking the opportunity to discuss their sexual
behaviors. Yet, it’s a difficult discussion to have—for many reasons.

Why medical providers don’t talk to
patients about sex
Sometimes physicians and other providers ascribe the difficulty of
talking about sex to the patient, but very often it is the provider
who is uncomfortable with this subject. Discussing sexual risk
behavior with every patient, however, becomes easier over time.

Medical providers most frequently cite time constraints
as the biggest barrier to discussing risky sexual
behaviors. Other barriers include:
• Discomfort discussing sexuality
• Belief that patients are uncomfortable discussing
sexuality
• Concerns about cultural differences
• Belief that their older patients (age 60+) are
“probably not having sex.”

2

ehaviors
Why do patients take sexual risks?
An important starting point in helping patients to reduce risky
sexual behaviors is understanding why they may take sexual
risks, including unprotected sex, sex with multiple partners, or
sex with anonymous partners.
Persons living with HIV may take sexual risks because they:
• Lack critical information about the virus and its transmission
• Are uncertain about factors that may affect the risk of
transmission
• Lack skills to practice safer sex behaviors
• Lack skills to disclose their HIV status
• Are not motivated to modify the risky behavior
• Are excessively optimistic about the effectiveness of antiretroviral
therapy (ART) in preventing the sexual transmission of HIV
• Use alcohol and/or drugs excessively or have mental health issues
such as depression or anxiety, which can interfere with judgment
and lead to risky sexual behaviors.

Medical providers help patients reduce their risky
sexual behaviors by:
• Having brief talks with patients to identify risky
sexual behaviors
• Providing factual information about HIV and
transmission
• Referring patients to resources to help them
address mental health, drug, or alcohol abuse
issues.

The goal is to have brief discussions about
risky sexual behaviors at every visit with
every patient.

3

BRIEF DISCUSSIONS WORK TO HELP
REDUCE RISKY SEXUAL BEHAVIOR
Screening for risky sexual behavior has historically relied on
regular screening for STDs and prompt, effective treatment.
But the increased incidence of STDs and HCV indicates that
risky sexual behavior is continuing and is on the rise.
Recent research suggests that brief discussions between
medical providers and patients during routine clinical care
are very effective in helping patients to modify risky sexual
behavior.1,2

Clinical evidence: brief provider/patient
discussions effect positive changes in
sexual behavior
Study and
Author
• Cliniciandelivered
intervention
during routine
clinical care
reduces
unprotected
sexual behavior
among HIVinfected patients.
Fisher et al,
2011.3

4

Methods
• Prospective clinical trial
• Impact of brief provider/patient
discussion during routine clinical
care at each visit vs. a standardof-care control arm
• Providers assessed patients’
sexual behaviors; provider and
patient negotiated behavior
change (or maintenance goal);
patients were given a “prevention
prescription” that summarized the
agreed-upon goal to be reached
by the next visit

Results
Unprotected sex
among HIV-infected
persons during 18
months of followup was significantly
reduced (P<0.05)

Study and
Author

Methods

Implementation
and evaluation
of a clinic-based
behavioral
intervention:
positive steps for
patients with HIV.
Gardner et al,
2008.4

• A demonstration project

HIV intervention
for providers study:
a randomized
controlled trial of a
clinician-delivered
HIV risk-reduction
intervention for
HIV-positive people.
Rose et al, 2010.5

• Randomized controlled trial

Routine brief
risk-reduction
counseling with
biannual STD
testing reduces STD
incidence among
HIV-infected men
who have sex with
men in care. Patel et
al, 2012.6

• Prospective observational cohort
study

• Medical providers at 7 US HIV
clinics screened for behavioral
risks, gave targeted counseling,
and delivered prevention
messages to HIV-infected patients
(n=767)
• Patients completed a baseline
questionnaire and two follow-up
questionnaires (6-month intervals)
after the intervention was initiated

• Providers at 4 clinics in California
were assigned to either the
intervention (assessing for and
holding brief discussions about
risky sexual behavior) or control
condition (usual care)

Results
Unprotected anal or
vaginal intercourse
significantly
declined by 42%
(P<0.001) from
baseline to 3
months
At 6 months and 12
months, unprotected sex
significantly declined
by 26% and 23%,
respectively, and in direct
relation to the frequency
of safer sex discussions

Significant decrease
in number of sexual
partners (OR=0.49,
95% CI=0.26 to
0.92) in the group
who received the
risk-reduction
intervention

• 386 patients of the randomized
providers were enrolled

• Conducted in 4 US cities to
determine whether routine
biannual STD testing coupled with
brief risk-reduction counseling
reduces STD incidence and highrisk sexual behaviors

STD incidence
(including syphilis,
chlamydia, and
gonorrhea) in HIVinfected patients
declined from 8.8%
to 4.2% (P<0.04).

5

HOW MEDICAL PROVIDERS CAN
RECOGNIZE TEACHABLE MOMENTS
...and Enable Positive Behavior
Change
• Because patients rarely initiate discussions about
sexual risk behaviors with their medical providers,7
providers should make time during appointments to
do so.
• To initiate such a discussion, medical providers should
be alert for teachable moments­—opportunities to
stimulate patient action, particularly with regard to
health behavior change.8
• When a teachable moment is discovered, the message
should be brief, accurate, and nonjudgmental. Shorter
messages are better than longer ones.
• Teachable moments can occur throughout a patient’s
care. For example, medical providers can screen for
risky sexual behaviors at every office visit.
• All patients are candidates for discussions about
sexual behavior. Even those in stable relationships may
have life changes and additional exposures.

6

Talking to patients: briefly, openly,
nonjudgmentally
By regularly integrating routine conversations about sexual
behaviors into patient care, discussions can become more
comfortable.

Open-ended questions allow patients to speak freely:
• “How often do you use condoms?”
instead of

• “Do you use condoms?”

When medical providers show an openness or willingness to
talk to patients about their risky sexual behaviors, patients
may be more willing to confide in them.9-11 Providers should
let patients know that they appreciate their sharing concerns
about sexual issues.
Ongoing discussions with patients about risky sexual behaviors
offer opportunities to continue educating patients throughout
their care.7 Prevention messages can help patients reduce the
risk of HIV transmission to others and help them understand
how risk reduction will benefit their health as well.

Emphasize that you have these discussions with all
patients, because it helps to keep them healthy.

7

Screening for Risky Sexual Behavior
Medical providers can first determine if the patient:
• Is sexually active outside the context of a committed
relationship
• Discloses his/her HIV status to partners
• Is aware of the HIV status of his/her partners
• Has already taken steps to prevent HIV transmission
(eg, uses condoms)
• Continues to engage in risky sexual behaviors.

Then, during the screening process, providers can ask
questions such as:
• What types of sex do you participate in?
• Tell me about the last time you had sex.
• Can you tell me about the people you’ve been
having sex with?
• How do you feel about letting the people you’re
having sex with know that you’re living with HIV?
• What have you been doing about using condoms?
• Tell me about your alcohol use and whether you
take any drugs not prescribed by another doctor.

Throughout the screening process:
• Ask straightforward and open-ended questions.
• To normalize the conversation, emphasize to the
patient that all patients are asked these questions
to provide the best care possible.12
• Ensure patient confidentiality and ask permission to
note sexual orientation and gender identity in the
medical chart.

8

Screening for STDs
The presence of an STD indicates that risky sexual behavior
has occurred. Most STDs are asymptomatic, so regular STD
screening is recommended.
The following questions can help to identify STD risk, STD
symptoms, and previous STD history:
• How many male and female partners have you had
within the past month/6 months/year?
• What were the sites of sexual contact, such as receptive
anal sex or insertive oral sex, and was a condom used?
For example, ask “Have you had any anal intercourse?”
If yes, “Was it receptive or insertive and was a condom
used?”
• Have you had any discharge, sores, pelvic or anal
pain, or rash or have you noticed any of these in your
partner?
• How long have you or your partner had these
symptoms?
• Have you ever had an STD or been tested for STDs, and,
if you have been tested, what were the results?
Data from CDC’s STD Surveillance Network (SSuN) indicate that
the burden of STDs is greater among HIV-infected men who
have sex with men (MSM) than among HIV-uninfected MSM.13
Proportion of MSM Attending STD Clinics with Syphilis,
Gonorrhea, or Chlamydia, by HIV Status*
20%

20.6

HIVHIV+

16%
12.5

12%

10.1

10.8

8%
4%
0%

12.9

9.0
5.5

6.6

7.2

7.4

12.9

2.6

1º and 2º
syphilis

GC,
urethral†

GC,
pharyngeal

GC,
rectal

Chlamydia,
urethral†

Chlamydia,
rectal

MSM = men who have sex with men. GC = gonorrhea.
*
2011 data; excludes all persons for whom there was no laboratory documentation or self-report of HIV status.
†
Includes results from both urethral and urine specimens.
STD Surveillance Network, 2011. Available at: http://www.cdc.gov/std/stats11/msm.htm.

9

Topics range in scope and may change
over time
Patients’ lifestyle, health status, and personal needs change
over time. Therefore, conversations about risky sexual
behaviors can continue and evolve for as long as the patient
remains in care.

Medical providers can discuss the following topics
with patients:
• Importance of using condoms correctly and
consistently
• HIV status of partners and related risks
including STD and HIV transmission.
• Number of different partners and sex
encounters—sexual concurrency (multiple
relationships at the same time rather than
serial monogamy) is an important factor in the
spread of STDs
• Relative risk of HIV transmission associated
with different types of sexual activities (for
instance, performing oral sex has less risk for
HIV transmission than receiving anal sex)
• Need to be screened regularly for STDs and
obtain prompt, effective treatment of STDs to
reduce the risk of sexual transmission
• Any misconceptions the patient may have
about HIV transmission.

10

Suggested conversation starters for “small
talks” about risky sexual behavior
The importance of knowing the HIV status of/and disclosing
HIV status to sexual partners
“Some of my patients have told me how hard it is to decide
who to tell about their HIV status, and what the best way is
to tell someone. I was wondering if you are concerned about
this?”
“Some of my patients find it difficult to talk to a potential
sexual partner about HIV. How do you start that conversation?”

Relative risk of HIV transmission associated with type of sexual
activity
“You’ve said that you ‘pull out’ before ejaculating, is that
correct? In fact, HIV is highly present in the pre-ejaculate, too.
Were you aware of that, and if not, what do you think about
that?

Using condoms correctly and consistently
“Would you want to try to role-play with me? If I was playing
your part, and my partner had no condom, I might simply say
‘let’s use a condom’ instead of ‘go put on a condom.’ What do
you think your partner would say?”

Consequences of serosorting when choosing sexual partners
“From our conversation, it sounds as if using condoms with
HIV-negative partners is important to you, but using them with
HIV-positive partners is less important. Let’s talk about this a
little more.”
“Even when both you and your partner have HIV, you still need
to protect yourself from getting other STDs. Syphilis, chlamydia,
and gonorrhea can be painful, difficult to treat and make your
ART less effective. Can we discuss this for a minute?”

11

Using condoms even while on ART therapy
“You have been doing very well with your ART, and your virus
remains undetectable in your blood test, so congratulations. Tell
me, are you continuing to use condoms?”
“How do you feel about using condoms during sexual activity?
Did you know HIV can still be transmitted to a partner even
though viral load is undetectable in the blood? That is because
HIV virus found in the semen or vaginal fluids can be higher
even when HIV viral load in the blood is undetectable.”
“It is very important to use condoms to protect yourself from
getting hepatitis C and sexually transmitted diseases such as
syphilis or gonorrhea. These diseases can increase risk of HIV
transmission to an HIV-negative partner, increase HIV viral loads
in your blood, and decrease your CD4 count. Let’s talk about
this a little more. What questions do you have?”

Why routine screening for STDs is important throughout care
“There have been recent reports that STDs like syphilis and
gonorrhea are on the rise in men who have sex with men. This
is why we screen patients for STDs regularly. How do you feel
about that?”

How change in marital/relationship status can change sexual
behavior
“I’d like to ask you some questions about your sex life, if
you’re okay with that. I think that helping you stay healthy
includes looking at all aspects of your life and how they affect
your health. Can we spend a little time talking about your
relationship status?”

12

Structuring brief conversations for
optimal success
Be prepared for relapses
Behavior change is a process, and it is to be expected that
patients will relapse from time to time. By recognizing that
lapses are common and encouraging patients to use their
lapses as learning experiences, you can facilitate long-term
behavior change.14
“I know that safer behavior is challenging to do on a consistent
basis. You slipped in this situation, but we can learn from it.
What can you do differently next time the situation arises?”

A relapse is an opportunity to explore patients’ triggers for
risky behavior and to determine how to anticipate and manage
those triggers.

Be realistic, respecting patients as experts in
their own health and well-being
Negotiate a goal that is realistic and attainable in the context of
the patient’s situation. This increases the probability of behavior
change because it enhances the perception of personal
choice.15 Remember that each patient is unique in what
motivates them to change:
“We have talked today about using condoms with HIV-positive
and negative partners. What steps could you take to make this
possible?”

Document the goal for patients
Once the medical provider and patient collaboratively develop
a strategy that protects the patient’s health and helps prevent
HIV transmission to partners, a written action plan can be
“prescribed” to the patient, along with a clear plan for
follow-up. You can use the Action Plan available in this kit,
which the patient can take home and refer to as needed.
“Let me write this down for you, and we can talk during our
next appointment to see how it’s all going, okay?”

13

Be proactive—and protective
CDC guidance stresses the importance of targeting PrEP
(pre-exposure prophylaxis) to persons at very high risk for
HIV acquisition, such as HIV-negative men who have had sex
with HIV-infected men and other partners of HIV-infected
patients in serodiscordant relationships.16
PrEP medications are an important part of a comprehensive
set of prevention services. Making HIV-positive patients
aware of PrEP gives patients another way to protect their
partners from HIV transmission.

Continue encouraging patients
Just like everyone else, patients need encouragement,
support, and acknowledgment of all their positive efforts.14

Conclusions
• HIV-infected persons who engage in risky sexual
behaviors are at an increased risk of transmitting HIV
to others and of transmitting and acquiring STDs,
putting them at further risk for suboptimal outcomes.
• Brief discussions with patients offer opportunities to
continue educating patients throughout their care and
have been proven to be highly effective in reducing
risky sexual behavior.
• Effective discussions begin by identifying a modifiable
behavior that the patient is willing to change and end
with a tangible, realistic goal that is developed and
“prescribed.”

14

References
1. Richardson JL, Milam J, McCutchan A, et al. Effect of brief safer-sex counseling by medical providers to HIV-1 seropositive patients: a multi-clinic assessment.
AIDS. 2004;18:1179-1186. 2. Mascolini M. HIV prevention with positives: bad
marks for provider-based prevention and (simple, brief, cheap) ways to improve
them. Res Initiative. 2011;16:1-66. 3. Fisher JD, Fisher WA, Cornman DH, et al.
Clinician-delivered intervention during routine clinical care reduces unprotected
sexual behavior among HIV-infected patients. J Acquir Immune Defic Synd.
2006;41:44-52. 4. Gardner LI, Marks G, O’Daniels CM, et al. Implementation and
evaluation of a clinic-based behavioral intervention: positive steps for patients
with HIV. AIDS Patient Care STDS. 2008;22:627-635. 5. Rose CD, CourtenayQuirk C, Knight K, et al. HIV intervention for providers study: a randomized controlled trial of a clinician-delivered HIV risk-reduction intervention for HIV-positive
people. J Acquir Immune Defic Syndr. 2010;55:572-581. 6. Patel P, Bush T, Mayer
K, et al. Routine brief risk-reduction counseling with biannual STD testing reduces
STD incidence among HIV-infected men who have sex with men in care. Sex
Transm Dis. 2012;39:470-474. 7. Beach MC, Keruly J, Moore RD. Is the quality
of the patient-provider relationship associated with better adherence and health
outcomes for patients with HIV? J Gen Intern Med. 2006;21:661-665. 8. Cohen
DJ, Clark EC, Lawson PJ, et al. Identifying teachable moments for health behavior
counseling in primary care. Pat Educ Counseling. 2011;85:e8-e15. 9. Schilder
AJ, Kennedy C, Goldstone IL, et al. “Being dealt with as a whole person.” Care
seeking and adherence: the benefits of culturally competent care. Soc Sci Med.
2001;52:1643-1659. 10. Murri R, Antinori A, Ammassari A, et al. Physician estimates of adherence and the patient-physician relationship as a setting to improve
adherence to antiretroviral therapy. J Acquir Immune Defic Synd. 2002;31(Suppl
3):S159-162. 11. Roberts KJ. Physician-patient relationships, patient satisfaction,
and antiretroviral medication adherence among HIV-infected adults attending a
public health clinic. AIDS Patient Care STDS. 2002;16:43-50. 12. CDC. Sexually
Transmitted Guidelines, 2010. MMWR. 2010;59 (No. RR-12):1-116. 13. CDC.
Prevention and HIV Care. Prevention IS Care slide kit. 2013. 14. Cruess S, Cornman D, Amico KR, et al. Options Risk Reduction Strategies Manual. A Healthcare
Provider’s Guide to Reducing HIV Transmission Risk Among PLWHA. Storrs, Conn:
University of Connecticut. 2007:1-152. 15. Cornman D, Christie S, Amico, KR,
Cruess, S, et al. Options Interventions Protocol Manual, A step-by-Step Guide
for Prevention Counseling with PLWH. Storrs, Conn: University of Connecticut.
2007:1-2189. 16. CDC Fact Sheet, June 2013. PrEP: A new tool for HIV prevention. Available at: http://www.cdc.gov/hiv/pdf/prevention_research_prep_factsheet.pdf; accessed September 16, 2013.

15

Inside

How, Why, and When to Discuss Risky Sexual
Behavior with Persons Living with HIV
With a growing number of people living longer with HIV, it is important
to help patients adopt and maintain healthy behaviors to prevent coinfection with other pathogens and the transmission of HIV to others.
Medical providers are in a unique position to screen for and encourage
modification of risky sexual behavior through brief discussions during
routine office visits.
This brochure provides:
• Evidence that brief conversations between providers and patients is
highly effective in reducing risky sexual behaviors
• Proven strategies to engage individual patients in conversations
about healthier behaviors
• Conversation starters to assist medical providers in identifying
modifiable behaviors that reduce risky sexual behaviors over the
long term.
Prevention Is Care:
14_PIC_W3_Patient_Record_Form

PATIENT RECORD FORM

This form can be used as the basis for discussions with patients
about barriers to achieving optimal health, and then can serve as
a checkpoint for future visits. Information elicited may inform an
Action Plan that can help patients achieve their goals.

Patient Name/ID:
Appointment Date:
Medical Provider:

What topics were discussed with your patient during today’s visit?

❑ Adherence to medication
❑ Reducing risky sexual behaviors
❑ Remaining in medical care

❑ None of these topics (patient refused)
❑ None of these topics (other issues took precedence)

Did you set a goal with patient at previous visit?

❑ Yes

❑ No

❑ No (Today is patient’s first visit)

Was a goal set with the patient at a previous visit?

❑ Medication adherence
❑ Reducing risky sexual behaviors
❑ Other:

❑ Today is patient’s first visit
❑ Attending all medical visits

What is the patient’s progress on previous goal:

❑ No goal set at previous visit
❑ No progress on previous goal

❑ Partially achieved previous goal
❑ Fully achieved previous goal

What barriers (if any) did your patient identify during this visit?
ART Adherence

❑ Experiences side effects from ART
❑ Forgets to take medications
❑ Experiencing treatment fatigue

❑ Forgets to pick up prescriptions
❑ Cannot pay for medication
❑ Other:

Reducing
Risky Sexual
Behaviors

❑ Lacks information about safe sex
❑ Does not have access to condoms
❑ Does not like to use condoms

❑ Uncomfortable discussing safe sex with partners
❑ Experiencing prevention fatigue
❑ Other:

Remaining in
Medical Care

❑ Feels too sick to attend appointments
❑ Does not believe medical care is necessary
❑ Lacks access to transportation
❑ Other:
❑ Is concerned about seeing family/friends at clinic

Other Barriers

❑ Mental health issues
❑ Homelessness
❑ Substance abuse:

❑ Lack of social support
❑ Financial concerns
❑ Other:

What does the patient state is his or her primary barrier to achieving optimal health?
Did you and the patient discuss a plan to overcome this barrier?

❑ Yes

❑ No

What is the plan (or goal) that the patient agrees to work on before the next visit:
Referrals:

❑ Case management
❑ Partner services
❑ Mental health services
❑ Substance use services

❑ Prevention counseling
❑ Reproductive health planning
❑ Domestic violence prevention services
❑ Food services

❑ Housing services
❑ Financial services
❑ Support groups
❑ Other:
Source: Adapted from Options Patient Record Form

Protect Your Health: ACTION PLAN

Additional materials available
in this kit
• Patient Record Form—serves as a guide to (and
documentation of) conversations about sexual
behavior and helps providers and patients identify
reasonable, modifiable strategies for positive
change.

So why not use each visit to discuss something important to you?
Maybe something in your life has changed, and you have new challenges. Or maybe you have
questions about your medicine plan.

10_PIC_W3_Action_Plan

Make an Action Plan at every visit
Every medical visit gives you a chance to let your healthcare provider help you be as healthy
as possible.

Your healthcare provider will work with you to find possible solutions to the matter and set a
goal to overcome any challenges. With your provider’s support, you can create an Action Plan to
help you work toward your goal. Then, at your next visit, you can discuss how well the Action
Plan worked, or discuss and resolve any road blocks to success.
No subject is out of bounds:
You may have questions or concerns about many subjects related to your HIV. Whether it’s
about sex, condoms, partners, STDs, drugs, alcohol, side effects…your healthcare provider
can try to help you find an answer that works for you.

LET’S TALK ABOUT SEX

Being safe
means protection

FROM HIV AND MUCH MORE

ASK YOUR HIV PROVIDER

Care IS Prevention

Protect yourself.
Protect others.

• Action Plan—can be used collaboratively to
develop a strategy that protects the patient’s
health and helps prevent HIV transmission to
partners.
• Being Safe Means Protection (wall poster)—helps
foster open communication.
• Being Safe Means Protection (brochure)—
reinforces health messages after patients leave
their appointments.
The CME/CNE interactive online course Positively
Speaking: Talking about Sex Reduces Risky Behavior is
now available online at: [to come]

LET’S TALK

about:

If You’re Living
with HIV and
Not Being Safe
YOU COULD BE LIVING WITH
A LOT MORE

Protect yourself. Protect others.

http://www/cdc/gov/actagainstaids/pic/

Care IS Prevention