Conversations about sexual health are critical to ensuring that all persons eligible for PrEP (pre-exposure prophylaxis for HIV) receive it. The AFP review article on "Sexual Health History: Techniques and Tips," epublished ahead of print this past week, provides pragmatic guidance to obtain the often sensitive history elements required to meet these aims.
The authors encourage physicians to take a proactive approach to obtaining a sexual history. They review steps to creating an environment conducive to sexual history conversations, introduce the "5 Ps" model (partners, practices, past STI history, pregnancy plans, pleasure) for obtaining a detailed sexual history, and remind readers of trauma-informed care resources to minimize retraumatizing victims of prior abuse.
In addition to these universally useful tips, the February 1 AFP review article on "Screening and Counseling Young Adults" emphasizes the importance of providing adolescents with the opportunity to be evaluated confidentially by a physician, as teens are then more likely to disclose sensitive information. The SSHADESS tool advocates for a strengths-based interviewing approach instead of focusing solely on risks. "Clinicians should thank patients for disclosing personal information, share their concerns respectfully and empathetically..., and reflect patients' previously disclosed examples of resilience."
Both adolescents and adults can lower their risk of HIV infection with PrEP. As this editorial, also just epublished ahead of print, succinctly states:
Taking a thorough and complete sexual history can assist with screening and treatment of sexually transmitted infections, which are currently at record high levels and can facilitate HIV acquisition.Roughly 1 million persons in the United States are candidates for PrEP, but only about 77,000 received prescriptions in 2016 (latest year for which data is available). Black and Hispanic men who have sex with men were less likely to receive PrEP prescriptions than white men in one study; this same study showed that rates for PrEP initiation are similar across all backgrounds if patients were offered PrEP by their physician. Obtaining an adequate sexual health history on all of our patients, regardless of their race or ethnic background, may help to correct this disparity.
You can find more information about identifying persons who may benefit from PrEP in the CDC's 2017 Clinical Practice Guideline, which is summarized on the CDC PrEP website. Relevant AFP resources include this overview of the United States Preventive Services Task Force (USPSTF) "A" recommendation to prescribe PrEP, this POEM on "Preexposure Prophylaxis with Tenofovir/Emtricitabine Prevents HIV Infection in Men Who Have Unprotected Anal Intercourse," and the AFP By Topic on HIV/AIDS.