As the HIV epidemic in the United States completes its fourth decade, the cumulative impact is staggering: more than 700,000 lives lost and incalculable economic, emotional, and social effects nationwide. Although still geographically concentrated in urban areas, HIV diagnoses have increased in rural and suburban areas and in southern and Midwestern states. HIV also continues to disproportionately affect racial and sexual minorities.1 Family physicians have played a key role in expanding HIV testing and treatment, as well as providing sexual health services in areas where specialty sexual health services are not readily available.
Family physicians can make additional efforts to advance HIV prevention through enhanced screening and early diagnosis, engaging and sustaining patients in treatment to viral suppression, and counseling patients on methods to reduce their risk of HIV. Traditional strategies of condom use and reducing numbers of sex partners still significantly reduce the risk of HIV exposure. Condom use can reduce risk by more than 80%2; however, use has decreased over the past decade for adolescents, men who have sex with men, and high-risk heterosexual individuals.3–5
Preexposure prophylaxis (PrEP) is an effective but widely underused HIV prevention approach.6 Emtricitabine with either tenofovir disoproxil fumarate (Truvada) or tenofovir alafenamide (Descovy; recently approved by the U.S. Food and Drug Administration for selected populations) is taken once daily and can reduce the risk of HIV by more than 90%.7,8 In June 2019, the U.S. Preventive Services Task Force made a grade A recommendation for the use of PrEP by individuals at increased risk of HIV, reflecting current Centers for Disease Control and Prevention guidelines.9 Expanding access to PrEP is a key part of the federal government's response to the HIV epidemic; people without prescription drug coverage can obtain medications at no cost by enrolling at GetYourPrep.com. The article by Savoy and colleagues in this issue of American Family Physician describes specific patients for which PrEP can be considered per the guidelines10; however, to fully assess a patient's HIV risk and the potential benefit of PrEP, physicians must know how and with whom their patients are having sex.
Taking a thorough and complete sexual history can assist with screening and treatment of sexually transmitted infections, which are currently at record high levels11 and can facilitate HIV acquisition.12 Sexually transmitted infections can occur at any site of sexual intercourse. Most rectal and pharyngeal infections with gonorrhea and chlamydia are asymptomatic, and screening only for urogenital infections can miss more than 70% of infections at other sites.13,14 Knowing how patients have sex is critical for appropriate screening, diagnosis, and treatment.
The article by Savoy and colleagues provides useful guidance for family physicians about how to create a safe, welcoming, and nonjudgmental space in which patients can communicate their sexual history.10 Sex and sexual pleasure are different for everyone and are a natural and healthy part of life. Physicians may be unfamiliar with sexual practices and preferences or have unintended implicit biases that limit the effectiveness of their efforts to provide patients with sexual health screening, counseling, and treatment. Savoy and colleagues outline constructive strategies to identify and address biases and to provide crucial tools to ensure that physicians can obtain useful sexual histories and have positive and understanding discussions about sex.10
The federal government recently set an ambitious goal to end the HIV epidemic in the United States within the next decade.15 Family physicians must continue to play a key role in HIV screening, counseling, treatment, and prevention, including by prescribing PrEP. If physicians do not talk about sex, we will not only miss opportunities to better serve our patients, but also fail to reach an achievable goal of ending an epidemic.