Primary care physicians recognize the importance of taking a sexual history in the prevention and management of HIV/AIDS and other sexually transmitted infections (STIs). At the same time, many of us haven't incorporated it into our everyday work. We know what to ask, but we may be uncomfortable asking intimate questions about a patient's sex life.
Donna Sweet, M.D.
Many of our patients are sexually active, and as primary care physicians, we already ask them about aspects of their lives that aren't as universal as sex. For example, we ask almost every age-appropriate patient about smoking, but only about 15 percent of the adult population smokes(www.cdc.gov). We need to think about sex in the same way because HIV infection and STIs are seen across all health care settings.
By taking a sexual history, primary care physicians play a key role in the prevention of HIV infection(www.medscape.org). Despite a 19 percent decline in new infections(www.cdc.gov) between 2005 and 2014, progress remains uneven across communities and populations(kff.org).
In 2015, the number of three nationally reported STIs (chlamydia, gonorrhea and syphilis) that are known to increase a person's risk for acquiring and transmitting HIV infection increased for the second year in a row. Rates of syphilis, in particular, increased substantially, at a rate of 19 percent compared with 2014.
Our goals in taking a sexual history include identifying patients at high risk for HIV and STI acquisition, as well as identifying patients who will benefit from pre-exposure prophylaxis (PrEP). Studies have shown that PrEP taken daily as prescribed leads to a 90 percent reduction in the incidence of new HIV infections among individuals at high risk.
Finding Your Comfort Zone
Current guidelines from the CDC recommend that we take the sexual history of everyone who could be sexually active. But taking sexual histories in a busy practice can feel overwhelming -- where do you start? The simplest, most efficient way is to include the sexual history as a part of each new patient's social history. When you ask basic questions about smoking, alcohol and drug use, also ask two basic questions about sex.
First ask, "Are you sexually active?" Then clarify by asking, "With men, women or both?"
Wait and give the patient time to answer. You can ask follow-up questions concerning frequency of sexual encounters and with whom they occur based on what the patient tells you.
For example, a new patient recently told me he was sexually active with both men and women. Not every patient we see will need PrEP, but one in four men who have sex with men will(www.cdc.gov). To gauge this patient's level of risk for acquiring HIV, I asked, "What is your majority preference? Think about your next 10 sexual partners. Would most of them be men or would most of them be women?"
He answered, "Men."
I asked, "Do you think of yourself as gay, straight or bisexual?"
It's important to have a sense of how patients see themselves and what milieu they are living in. For example, a young black man who thinks of himself as gay has a one in two lifetime risk of becoming infected with HIV.
This particular patient told me he identified as gay, although he had never talked about his sexuality with family members. This opened a way for me to ask more specific questions:
- Do you worry about HIV?
- Have you ever considered PrEP?
- Have you ever felt you might have been exposed to HIV from a sexual partner and asked a doctor to prescribe PrEP?
How do you decide which patients will benefit from PrEP?
The young man I spoke with was concerned about acquiring HIV, and he had heard about PrEP. Based on our discussion, it was clear that he would benefit from initiating PrEP. Not all decisions are as simple. For this reason, the CDC provides clear-cut guidance to support decision-making(www.cdc.gov).
Talking With Existing Patients
Your experience talking with new patients about their sexual activities will help you begin to introduce the topic with patients you've known for a long time. Your approach will be different with each one, depending on what's going on in their lives.
For example, any patient who is experiencing a life transition (e.g., divorce, dating, initiating a new request for birth control, first year in college, moving or traveling) is more likely to also experience a change in sexual activity.
Imagine a young woman comes in for her well-woman exam and tells you she is going away to college. You have an easy segue to ask, "Are you sexually active? Are you in a relationship?" Patients who travel for business or leisure may increase or change their sexual activities when they change their environment.
Another tactic when talking with existing patients is to mention current health recommendations. For example, explain that we now conduct screening for many health issues; we do colorectal cancer screening, mammograms, cervical tests, HIV and STI tests. Remind patients that sexual activity is a normal and natural part of life, and that we want to make sure they are taking care of themselves.
And remember that older women, who are just as vulnerable as any of our other patients, are seldom asked about their sexual activities.
When Patients Don't Want to Talk About Sex
For patients who don't want to talk about sex, you can simply ask them to think about their sexual activities. Then ask again if they are sexually active the next time they visit, and the time after that. This is especially useful for patients you see frequently for chronic conditions such as diabetes or hypertension.
Patients may not always tell you the truth the first time you ask. But they will think about why you were asking, and they may be more open the next time.
Patient Literature to Encourage Conversations
Once you have made a conscious decision to take sexual histories, make that visible in your office. The CDC has excellent patient-based literature(www.cdc.gov) that you can display in reception areas and waiting rooms, similar to depression screening tools that patients can pick up and evaluate themselves. Such HIV-related information indicates that you are interested in talking about sexual activities and that you care about patients' overall health.
Taking a sexual history is not as intimidating as it may seem. Most patients welcome the chance to talk with their doctors about their sexual lives without embarrassment. Many patients also appreciate when we recognize that they are sexual beings and that we are taking care of all aspects of their health.
To learn more about taking sexual histories and how to incorporate routine HIV screening into your clinical practice, try the CDC's Serostatus Matters course(courses.elseviercme.com), which is designated for a maximum of one AMA Physician's Recognition Award Category 1 credit. Don't delay; this course is accredited only through March 21. Physicians should claim only the credit commensurate with the extent of their participation in the course.
Donna Sweet, M.D., is a professor of internal medicine at the University of Kansas School of Medicine.