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Provider Perspective #2: Tips for Integrating Safer Sex Counseling into Routine Care

Dr. Kathleen E. Squires uses a challenging case study to illustrate the critical role HIV counseling can play in routine care of HIV patients and their health.

Jim, a 25-year-old man living with HIV, presented to our emergency department complaining of painful urination and milky penile discharge. Staff on duty tested him for genital, anal, and oral sexually transmitted diseases (STDs); viral load; and CD4 cell count and presumptively treated for gonorrhea.

Two weeks later, Jim returned to the clinic for a follow-up visit, which is when I saw him for the first time. In reviewing his medical record, I saw that Jim had a long history of STDs, beginning at age 20.  He then screened positive for HIV at age 23 and was started on antiretroviral therapy (ART).

Jim, however, only stayed on ART for about a year before quitting when he had a lapse in insurance. At his latest follow-up visit, Jim’s viral load was >100,000 and his CD4 count was 250, making him highly infectious and putting any potential seronegative sex partners at risk for acquiring HIV.

After engaging Jim in a conversation about his health, I learned that although diagnosed two years prior, he was still “getting used to being HIV-positive.” He had not disclosed his HIV status to his partners, nor was he aware that his behaviors could make his HIV worse or compromise his partners’ health. Jim also shared that he routinely uses cannabis and binge drinks on the weekends.

In light of his history with STDs and his unsafe behaviors, I realized it was crucial that I get Jim to understand how to protect his health and the status of his seronegative sex partners.

Identifying Teachable Moments

Jim’s case presents a number of teachable moments.  We have learned that routinely integrating safer sexual behavioral counseling—even brief conversations—into every visit with patients living with HIV can help them reduce unsafe sexual behaviors1, 2. Brief counseling, along with biannual STD testing, also has been shown to reduce STD acquisition among HIV-positive men who have sex with men (MSM).3

I explained to Jim that acquiring another STD, in addition to being HIV-infected, can cause activation of HIV-infected CD4 cells resulting in a rise in his viral load, as well as a decline in his CD4 count.4 Further, contracting an STD makes it easier for Jim to transmit HIV to his sex partners.

Jim and I then discussed the importance of disclosing his HIV status to his sex partners and encouraging them to get tested for HIV. I explained that if his partners’ test results are positive, they can be linked to care, and if they’re negative, they can be offered pre-exposure prophylaxis (PrEP), post-exposure prophylaxis (PEP), and other strategies to prevent HIV acquisition.

Importantly, I emphasized to Jim that his sex partners have a right to be informed that they may have been exposed to and are at risk for HIV. I shared that there is a free service called Partner Services, which he could use to confidentially notify his partners of their potential HIV exposure. Partner Services is a function of local and state health department staff who help identify and locate sex partners or drug-injecting partners to inform them that they may have been exposed to HIV and provide them with testing, counseling, and referrals for other services.

Jim is just one case. Health care providers should recognize the overall importance and benefits of routine STD screening, as well as integrating brief sexual behavioral counseling into standard care. These initiatives can help people living with HIV take action and make positive changes, including the practice of safer sex behaviors.

Tips for Integrating Safer Sex Counseling Into Small Talks

Making these important conversations happen requires listening to what your patient is sharing and being ready to jump in with positive and supportive statements. Many patients wait for their health care provider to initiate these discussions. At the same time, it can be challenging to recognize the various dynamics of each patient’s sexual relationships. It helps if you can become familiar with the language that your patients use to describe their relationships and to express confidence in having these discussions.

Here are some other important tips that health care providers may use to leverage opportunities for safer sex counseling:

  • Integrate brief safer sex behavioral counseling into every visit with a patient who is living with HIV.
  • Engage patients positively and become familiar with the language that your patients use to describe their relationships.
  • In talking with your HIV-infected patients, consider that there may be a dynamic of who controls sex in their relationships. Try to help them solve how they can get their partner(s) to practice safer sex. Suggest bringing in their seronegative partners to chat with you about ways to protect their health.
  • At every visit, emphasize the importance of staying in care and adhering to ART to protect their health as well as their partners’ health.
  • Reiterate and encourage the correct and consistent use of condoms and lubricants.
  • Ask about the HIV status of the patient’s sex partners, recommend periodic HIV testing to partners of negative or unknown status, and discuss PrEP and PEP.
  • Recommend Partner Services for patients who feel unable to disclose their HIV status directly to sex partners. Partner Services confidentially helps notify sex and drug-use partners that they may have been exposed to HIV.

Published: September 25, 2017

Related Resources

About the Author

Dr. Kathleen E. Squires

Kathleen E. Squires, MD, W. Paul and Ida H. Havens Professor in Infectious Diseases and Director of the Division of Infectious Diseases at Thomas Jefferson University, Philadelphia, PA. Prior to joining Thomas Jefferson University, Dr. Squires was an Associate Professor at the Keck School of Medicine of the University of Southern California. She was also the Associate Chief for HIV affairs, Division of Infectious Diseases at the Keck School of Medicine and the Medical Director of the HIV Clinic of the LAC/USC Medical Center.

References

1Fisher 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 Syndr. 2006;41:44-52.

2Rose CD, Courtenay-Quirk 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(5):572-581.

3Patel 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(6):470-474.

4Jarzebowski W, Caumes E, Dupin N, et al. Effect of early syphilis infection on plasma viral load and CD4 cell count in human immunodeficiency virus-infected men: results from the FHDH-ANRS CO4 Cohort. Arch InternMed. 2012;172(16):1237-1243.

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