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Case 2: Discussion

Benefits of Screening for High-risk Behavior

Screening for high-risk behavior related to sexual and injection drug activity can have important benefits for both public health and for the individual HIV-infected patient.Identifying and altering high-risk behavior for HIV transmission may reduce the spread of HIV and sexually transmitted diseases (STDs).Still, many providers and patients may not be motivated to devote time and resources during brief clinic visits for benefits that go beyond those directed to the individual patient. Thus, medical practitioners need to realize that screening for high-risk behavior related to potential transmission of HIV provides valuable information that may lead to tangible medical benefits for the HIV-infected patient, and therefore, such screening is an important component of routine healthcare for all HIV-infected individuals.These benefits can be defined as follows:

  • An open discussion of sexual behaviors provides vital information about a patient's risk for acquiring and transmitting STDs. The information obtained can guide the frequency of STD screening, as well as the anatomic locations to be tested.
  • Any HIV-infected woman of child-bearing age who is practicing high-risk sexual behavior without effective birth control increases her risk of becoming pregnant and potentially transmitting HIV to her child. Knowledge of this information has important implications for pregnancy testing and for the choice of antiretroviral medications. In particular, efavirenz (Sustiva) should be avoided in this setting.
  • Unsafe sexual or injection behaviors place the patient at risk for superinfection with a new and possibly resistant strain of HIV.
  • Knowledge of continued unsafe injection practices can prove valuable, particularly since unsafe injection practices can cause infectious complications, including skin and soft tissue infections, endovascular infections, and osteomyelitis.
  • Screening for risk behavior, regardless of type, may improve relationships between medical providers and their patients. Many patients are eager to discuss risk behavior with their providers, but are intimidated or uncomfortable broaching this topic on their own. In addition, some patients may feel more confident in their provider's quality of care if the provider has asked about risk behaviors[1].
  • The disclosure of high-risk behavior can lead to targeted intervention, including appropriate counseling, and, if necessary, referral. Subsequent reduction in risk behaviors will likely translate into a lower risk of HIV transmission to others.
  • Finally, if an HIV-infected patient is already practicing safer sex or using safer injection practices, screening affords an excellent opportunity to positively reinforce those behaviors.

Incorporation of Risk Screening into Clinical Practice

Several options are available to incorporate screening for high-risk behaviors related to sexual and injection drug activity into the typical office visit. Self-administered questionnaires (Figure 1) or technology-assisted questionnaires, such as computer, video, and audio, can be performed while patients are waiting in the office and may actually yield more complete reports of risk behaviors than personal interviews. Risk screening can also be performed by trained clinic personnel. Even without these resources, clinicians can typically screen their own patients for high-risk behavior very efficiently, especially since most patients do not consistently engage in high-risk sexual behavior or injection practices. Healthcare providers should endeavor to ask all patients about all aspects of risk behaviors related to sexual and injection drug activity at the initial patient visit.More tailored risk assessments can be performed at regular intervals[1].

Approach to Screening for Risk Behavior

Opening a discussion of sexual risk behavior with questions that are typically perceived to be less threatening and normalize the discussion of high-risk behavior can make patients more comfortable. For example, introducing the subject with a phrase such as "I discuss sexual activity with all my patients because I think it is an important part of their medical care," avoids the suggestion that the patient was targeted for discussion. Open-ended questions are invaluable in producing detailed patient responses. Follow-up questions may be more direct and target specific behaviors. In general, clinicians should appear to be non-judgmental, comfortable, knowledgeable about discussing sex and drug use, and avoid using medical jargon, such as "insertive intercourse," "fellatio," and "genital ulcer disease." Most importantly, clinicians should avoid making assumptions (for example, beliefs that married patients are monogamous; older individuals do not inject drugs; patients who identify as straight never have sex with members of the same sex). Rehearsing questions about risk behavior and even role-playing a patient interview can help clinicians better elicit sexual and drug risk behavior. Whenever possible, screening questions should be individualized to each patient. Similarly, if risk behavior is identified, an in-depth assessment and targeted intervention is appropriate.

The Components of High-Risk Sexual Behavior Screening

An evaluation of a patient's sexual risk (Figure 2) should include (1) whether the patient is engaging in sexual activity, (2) detailed partner information (gender, HIV status, number, and long-term versus casual and/or anonymous), (3) the type of sexual activity (anatomic sites, insertive versus receptive, condom use, and contraception use), (4) circumstances surrounding sexual activity (stable relationships, venues such as bathhouses or sex parties, use of the internet to find partners, commercial sex work, and associated substance use, especially methamphetamine), and (5) a STD history. For a detailed discussion of screening and diagnosing STDs, see the case Sexually Transmitted Diseases Screening in HIV-Infected Individuals in this same Prevention for Positives module.

The Components of High-Risk Drug Use Behavior Screening

With a patient who uses injection drugs, clinicians should investigate the patient's injection practices (Figure 3), including (1) injection frequency, (2) sharing of drug paraphernalia (receptive and distributive sharing of needles, syringes, or other equipment), (3) the serostatus of any injection partners, (4) sterility of drug equipment (access to clean needles, re-use of needles and syringes, the use of bleach, clean ancillary equipment), and (5) situations in which the drug is used. In addition, the clinician should address the injection-drug user's sexual risk factors, as outlined above, the interest in quitting drugs, any history of prior drug treatments, and interest in referral for treatment of drug addiction.

Case Summary

Screening for risk behavior was performed during the initial visit and yielded important clinical information. This patient recently moved as a result of a job promotion, separating him from his long-term HIV-infected partner in the process. He has had a difficult time meeting new friends and sexual partners since his move, although he has had casual encounters with a few men he met through the internet. He has engaged in unprotected insertive oral sex and unprotected insertive and receptive anal intercourse in the prior 3 months. In the past, he was careful about using condoms when engaging in insertive anal intercourse with HIV-negative partners, but he is having a hard time broaching the topics of HIV status and condom use with his new casual partners, stating that he is lonely and fears that bringing up these issues might spoil the mood. He has no current symptoms of an STD, but says he was notified by the health department five years ago that he was exposed to syphilis. He was treated for this syphilis exposure, and his RPR has remained negative. He denies injection-drug use and methamphetamine use, but does occasionally use poppers to enhance his sexual experiences.

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    Figure 1. Patient Questionnaire for Screening for HIV-related Risk Behavior

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    Figure 1
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    Figure 2. Screening Questions for Sexual Behavior Risk Factors

    Adapted From: Centers for Disease Control and Prevention (CDC); Health Resources and Services Administration; National Institutes of Health; HIV Medicine Association of the Infectious Diseases Society of America. Incorporating HIV prevention into the medical care of persons living with HIV: recommendations of CDC, the Health Resources and Services Administration, the National Institutes of Health and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR. 2003;52 (RR-12):1-24.


    Figure 2
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    Figure 3. Screening Questions for Injection Drug-Related Risk Factors

    Adapted from Screening Questions for Sexual Behavior Risk Factors: Centers for Disease Control and Prevention (CDC); Health Resources and Services Administration; National Institutes of Health; HIV Medicine Association of the Infectious Diseases Society of America. Incorporating HIV prevention into the medical care of persons living with HIV: recommendations of CDC, the Health Resources and Services Administration, the National Institutes of Health and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR. 2003;52 (RR-12):1-24.


    Figure 3