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Safer Sexual Behaviors

A growing number of people are living longer with HIV, with fewer AIDS-related complications and deaths. Preventing transmission of HIV-to others remains a critical element of care to protect both the health of those living with HIV and that of their partners.

The Centers for Disease Control and Prevention (CDC) recommends1 that clinicians who treat patients living with HIV infection integrate routine discussions about safer sexual practices into every office visit.

Recent research suggests that health care provider-initiated small talks about sexual behavior at every visit, with every patient, can help HIV-infected patients adopt positive behavior changes, including:

  • Decline in sex without a condom.2
  • Fewer sexual partners.3
  • Decline in sexually transmitted disease (STD) acquisition, including syphilis, chlamydia, and gonorrhea.4

Data from CDC’s STD Surveillance Network (SSuN)5 indicate that the burden of STDs is greater among HIV-infected men who have sex with men (MSM) than among uninfected MSM. In fact, MSM comprised 72% of all primary and secondary syphilis cases in the United States. Regular screening for STDs provides a benchmark for sexual behavioral assessment for both men and women living with HIV. However, a recently published MMWR report from CDC6 showed that fewer than 20% of all HIV-infected patients were tested annually for STDs and less than half of them received counseling about available HIV and STD prevention strategies.

What Prevents Some Patients From Practicing Safer Sexual Behaviors?

Some patients living with HIV do not realize that their behaviors are not “safe.” Others may not understand the virus or how it is transmitted. They may be uncomfortable disclosing their HIV status to sexual or drug-injecting partners. Or they may use alcohol or drugs or have undiagnosed depression, any of which can cause disinhibition and lapses in judgment.

Why Are Some Health Care Professionals Uncomfortable Talking About Sex?

Sometimes health care providers ascribe the difficulty of talking about sex to the patient, but it may be the clinician who is uncomfortable with this subject. Health care professionals cite several barriers to discussing sex, including:

  • Overall discomfort discussing sex and sexuality.
  • Belief that discussing sex will take a lot of time.
  • Belief that patients are uncomfortable discussing sex.
  • Concerns about cultural differences or saying the “wrong thing.”
  • Belief that older (age 60+) patients are “probably not having sex.”

How Do Small Talks About Safer Sexual Behaviors Benefit Health Care Providers?

When health care providers are open to talking to patients about their sexual behaviors, patients may be more willing to confide with their health care providers, fostering trust and empathy and building a therapeutic relationship.

Small talks offer clinicians unique opportunities to educate patients and normalize discussions about safer sexual behaviors by:

  • Using teachable moments to impart factual information about all of the risk-reduction strategies available today.
  • Helping patients understand how to reduce their risk of HIV transmission.
  • Helping patients better understand the benefits of safer sex to their own health.
  • Helping patients feel more comfortable discussing sexual behavior.

Which Safer Sexual Behaviors & Risk-Reduction Strategies Should Health Care Providers Discuss with Patients?

Patients’ health status, relationship status, and personal needs change over time. Therefore, conversations about sexual behaviors should continue and evolve for as long as the patient remains in care.

Topics include:

  • Adhering to ART and ongoing medical care, even if viral load is undetectable.
  • Communicating HIV status with others.
  • Correctly and consistently using condoms (to prevent STDs) and appropriate non-oil-based lubricants, even when negotiation of use occurs in the heat of the moment.
  • Assessing relative risk of HIV transmission associated with various sexual activities (e.g., oral sex is less risky than receptive anal sex).
  • Discussing how alcohol and/or drug use can impair judgment.
  • Using PrEP for some HIV-negative partners, including women planning to become pregnant.
  • Using PEP for emergencies for HIV-negative or unknown status partners (e.g., if a condom breaks or is not used and the patient is not virally suppressed).

What Are Some Suggested Conversation Starters About Safer Sexual Behaviors?

Following are a few conversation starters to assist health care providers with initiating small talks with patients.

Disclosing HIV Status to Others

  • “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. Are you comfortable disclosing your HIV status to your sexual partners?”

Relative Risk of HIV Transmission Associated with Type of Sexual Activity

  • “You’ve said that you don’t always use condoms during anal sex. Did you know anal sex is the highest-risk sexual activity for HIV transmission? Overall, oral sex is much less risky. What do you think about that?”

Advice to Serodiscordant Couples

  • You said your spouse (or partner) is HIV-negative. Has (she/he) talked with (her/his) doctor about additional ways to protect herself/himself, including PrEP as an extra protective step?”
  • “I know you always use condoms, and that’s terrific. But what do you do if your condom breaks while you’re having sex with an HIV-negative partner?”

Once clinicians have started a “small talk,” they can use the teachable moment to help the patient understand how to protect their overall health and prevent transmission to partners.

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