An Introduction to Taking a Sexual History and Client-Centered Risk- Reduction Counseling Linda Creegan, FNP California STD/HIV Prevention Training Center STD Clinical Series

STDs in the New Millennium: Scope of the Problem STDs are among the most common infectious diseases in the U.S. today u Chlamydia is the most common reportable disease u About 1 in 5 adults has HSV-2; HPV is even more common in some populations STDs increase transmission risk for HIV by 2- 5 fold Current syphilis outbreaks in many urban centers including SF, LA, NY, Chicago

A Sexual History is an essential part of many provider/patient interactions…. u Allows individualization of STD/HIV diagnosis and screening u Guides counseling through risk assessment u Allows patient to express concerns and ask questions u Enables appropriate referrals

… However, it is often given short shrift. Fewer than half of physicians report taking a sexual history from their patients u 40% of MDs screened teen patients for sexual activity u 15-40% asked questions of adult patients about # and gender of partners, and condom use Kaiser Family Foundation patient survey, 1997 u 39% were asked about sexual history u 12% were asked about STDs u 83% felt STDs should be discussed at a first-time Ob/Gyn visit Millstein etal, Jour.Adol.Med., Oct, 1996 Haley et al, AJPH, June 1999

Why is this? Structural barriers ( time/reimbursement concerns) Patient barriers ( privacy/confidentiality concerns) Provider barriers u Low priority given to STD prevention l Acute versus preventive role perception l Low priority given to sexual health issues l Devaluation of behavioral interventions u Provider discomfort discussing sexual issues l Concern for patient privacy u Unfamiliarity with content or language l Perceived complexity of the sexual history l Inadequate training

Primary Factors in Taking a Sexual History Ensure privacy and confidentiality Establish rapport Accurately define the problem(s) Determine the level of HIV risk Ensure successful patient management u Diagnosis and treat symptomatic disease u Detect asymptomatic disease u Prevent serious sequelae, (i.e.infertility in women) u Promote behavior changes to prevent future infections

Who is most at-risk for an STD? Risk Factors and Markers Young age (15-35) Higher prevalence in urban areas Disproportionately affect those of lower economic status Exposure to an STD History of certain STDs Sexual practices or behaviors u multiple partners u new partner u casual partners u improper or inconsistent condom use u earlier age at first sexual activity

Who is most at-risk for an STD? Presenting Symptoms Discharge (vaginal, urethral, rectal) Vaginal odor Dysuria (frequency, urgency) Skin lesion(genital or extragenital) Rash Itching Pain Swelling Change in bowel habits Vaginal or rectal bleeding Sexual dysfunction

Introducing the Sexual History Acknowledge personal nature of the subject matter Emphasize confidentiality Stress health issues related to sexual behaviors Be able to explain how the information will help you care for the patient “ I’m going to ask some questions about you sexual history. I know this is very personal information, but it involves important health issues and everything we discuss is confidential”

Sexual History - Content Chief complaint General health history Allergies Recent medication Past STDs Women: brief Gyn history HIV risk factors (IVDU, partner’s status) HIV testing history Past and current sexual practices u Gender of partners u Number of partners u Most recent sexual exposure New sex partners Patterns of condom use Partner’s condition Substance abuse Domestic violence issues

Summary: The Five “P’s” Past STDs Pregnancy history and plans Partners (Sexual) Practices Prevention of STDs/HIV

Communication Skills to Facilitate the Sexual History Use open-ended questions rather than leading or “yes/no” questions u Who, what, when, where? u “Tell me about…” u Cone Style of interviewing Encourage patients to talk, when needed u Permission-giving: “Say it in your own words” u Give range of behavior and ask for patient’s experience Active listening cues to urge patient on u Eye contact, nodding, “Yes, go ahead”

General Considerations for Taking a Sexual History Make no assumptions u Ask all patient about gender and number of partners u Ask about specific sexual practices l Vaginal, anal and oral sex Be clear u Avoid medical jargon u Restate and expand u Clarify stories when necessary

General Considerations for Taking a Sexual History Be tactful and respectful u Use an unrelated translator whenever possible u Use accepting, permission-giving language and cues Be non-judgmental u Recognize patient anxiety u Recognize our own biases u Avoid value-laden language (“You should..”, “Why didn’t you..” “I think you..”)

Incorporating Risk Reduction Counseling in Clinical Encounters Primary Prevention: Using a client-centered approach, medical providers can effectively motivate patients to reduce behavioral risks and avoid future infections with STD/HIV u Emphasize remaining uninfected, by changing behaviors that increase risk for acquisition and/or transmission of STD/HIV u Behavioral strategies utilize similar messages for prevention of HIV, STD, and unintended pregnancy

Case Presentation 16 year-old girl presents for a sports physical She is accompanied by her mother She reports excellent health and has no specific complaints Past medical history is unremarkable

Case Discussion Counseling Teens What further information is needed to assess her STD risk? What is the best way to obtain this information? How can teens be effectively counseled about reducing their risk for STDs and HIV?

Client-Centered Counseling: Definition Counseling conducted in an interactive manner through the use of open-ended questions and active listening, which focuses on developing prevention objectives and strategies with the client rather than simply providing information. CDC HIV Prevention Case Management Guidelines, 1997

Theories Contributing to Client Centered Counseling Health Belief Model Theory of Reasoned Action Stages of Change theory Social Learning Theory Change implementation theories

Factors that Affect Behavior Change Knowledge Perceived risk Perceived consequences Attitudes (beliefs) Skills Self -efficacy Actual consequences Access Intentions Perceived social norms Policy

Counseling vs. Education Dialog Individualized Takes feelings and beliefs into account Helps client understand themselves better Short and focused One-way Levels of detail but not tailored to an individual Sticks to the facts Helps client understand a subject better Short and focused

Project Respect - A Relevant Model for STD/HIV Clinical Settings Large, randomized, multi-center study funded by CDC, completed in 1997 l Evaluated efficacy of STD/HIV prevention counseling in changing risky sex behaviors and preventing new STDs l Almost 6000 patients attending large publicly-funded STD clinics (SF, LB, Denver, Baltimore, Newark) l Patients received client-centered counseling by trained (non-clinical) staff l Outcome measures:GC,CT,Syphilis, HIV Findings: two short counseling sessions successfully increased condom use and prevented new STDs

Effects of Risk Reduction Counseling: Results from Project Respect, Kamb et al, JAMA 1998

General Principles for Client Centered Counseling Approach each patient as an individual Focus first on issues and realities that the patient identifies Use open-ended questions and active listening skills to establish a dialog Maintain a neutral, non-judgmental attitude Offer options, not directive Onus of action and responsibility remains with the patient

Three Steps in a Client- Centered Risk Reduction Session Focus on personal risk assessment u Identify patient’s personal perception of risk Identify safer goal behaviors u Identify patient’s level of readiness for change u Assess barriers to behavior change efforts Develop a personalized action plan u Negotiate small, realistic risk-reduction steps u Refer to specialized services, if needed

Assess Client Risk With teens, begin by asking whether they have started sexual activity Talk with patient to determine: u number, gender of partners u sexual practices (anal, oral, vaginal sex) u patterns of condom use u prior STD testing history, and diagnoses Identify factors affecting patient risk u current/past history of unprotected sex u intentions for becoming pregnant u history of domestic violence or IVDU

Case Presentation, continued….. She became sexually active about 1 year ago She has had 2 male sexual partners; current partner for the past month LMP, about 2 weeks ago; has never been pregnant They sometimes use condoms for vaginal sex; she’s not using any other contraception but doesn’t want to get pregnant She has tried oral sex; denies anal sex No history of STDs

Assess Personal Perception of Risk Identify factors affecting patient’s personal perception of risk l knowledge l attitudes l beliefs in relation to current/past behaviors u Note: if perception of risk is not accurate, efforts should be made to assist patient in recognizing risk

Sample Risk Assessment Questions  What are you doing in your life that might be putting you at risk for STD/HIV?  What are the riskiest things that you are doing?  What are the situations in which you are most likely to be putting yourself at risk for HIV or STD?  What is your experience with shooting up drugs?  When was the last time that you put yourself at risk for STD/HIV? What was happening then?  When do you have sex without a condom?  How do drugs or alcohol influence your STD or HIV risk behaviors?

Safer Goal Behavior Questions How would you like to change that? What would you like to do differently? What might be better for you to do?

Client Centered Counseling Risk Behavior Unprotected vaginal sex with new partner Safer Goal Behavior Consistent condom use with this partner

Possible Goal Behaviors for STD Risk Reduction Reducing # of sexual partners Increase in condom use with main/non- main partners Partner testing Monogamy Abstinence Consideration of any of the above

Case Presentation, continued... She may say… u “He should get tested, too.” u “Use condoms very time.” u “Well, I didn’t really want to start doing it with him…..” u “I gotta have a serious talk with him and tell him I mean it, he’s gotta use them.”

Client Centered Counseling Factors that influence behavior Barriers Benefits Risk Behavior Safer Goal Behavior

Client Centered Counseling Risk Behavior Safer Sex Goal Factors that influence behavior Personalized Action Plan BarriersBenefits

Sample Questions for Making a Risk-Reduction Plan How would you go about that? How will you start? What might make that easier or harder? What steps do you need to take?

Assess Patient Level of Readiness for Change Level of Readiness for Change: * u Pre-contemplation u Contemplation u Preparation u Action u Maintenance * Also referred to as Stages of Change (Prochaska)

Case Presentation, continued…. She may say: u “I don’t think he’s going to give me any disease.” u “I want to use them more, but it’s embarrassing to talk about.” u “I put some condoms in my purse in the waiting room, so now I have them for next time.” u We already talked last week-end, and we agreed to use them every time from now on.”

Identify Patient Barriers to Change Personal perception of risk Self efficacy related to negotiating safer sex Power and control dynamics in relationships Cultural issues Access to care

Negotiate Realistic, Simple Risk Reduction Steps with Patient Risk reduction plan must be patient-driven, based on pt. history, readiness, & ability to adopt safer behaviors Health care providers should: u support efforts previously attempted by patient u offer options, not directives u remain non-judgmental

Case Presentation, continued….. She may say: u “I want to show him this paper about chlamydia, and talk about condoms.” u “I guess I’ll take some condoms to give him.” u “The next time I’ll see him is in school tomorrow, but we can’t talk then. Maybe we can talk on Thursday…” u “I don’t want to do this in person; on the phone would be better.”

Refer to Specialized Services, If Needed Alcohol or drug treatment programs Partner/domestic violence services Partner counseling and referral services Couples counseling Benefits counseling to obtain access to services

Taking Personal Stock Helping clients change behavior may begin with changing some of our own u Recognize our biases and keep them in check u Be willing to give it a try u Talk less, listen more u Encourage step-wise, incremental, realistic changes u Avoid “should/shouldn’t”,”I think you…..” “You need to…..”