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Selected Resources

For Care Providers: Online Resources

July 2021

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Health Equity Competencies for Health Care Providers

August 2021

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GOALS Framework for Sexual History Taking in Primary Care

Developed by Sarit A. Golub, PhD, MPH, Hunter College and Graduate Center, City University of New York, in collaboration with the NYC Department of Health and Mental Hygiene, Bureau of HIV, July 2019

Background: Sexual history taking can be an onerous and awkward task that does not always provide accurate or useful information for patient care. Standard risk assessment questions (e.g., How many partners have you had sex within the last 6 months?; How many times did you have receptive anal sex with a man when he did not use a condom?) may be alienating to patients, discourage honest disclosure, and communicate that the number of partners or acts is the only component of sexual risk and health.

In contrast, the GOALS framework is designed to streamline sexual history conversations and elicit information most useful for identifying an appropriate clinical course of action.

The GOALS framework was developed in response to 4 key findings from the sexual health research literature:

  1. Universal HIV/STI screening and biomedical prevention education is more beneficial and cost-effective than risk-based screening [Wimberly, et al. 2006; Hoots, et al. 2016; Owusu-Edusei, et al. 2016; Hull, et al. 2017; Lancki, et al. 2018].
  2. Emphasizing benefits—rather than risks—is more successful in motivating patients toward prevention and care behavior [Weinstein and Klein 1995; Schuz, et al. 2013; Sheeran, et al. 2014].
  3. Positive interactions with healthcare providers promote engagement in prevention and care [Bakken, et al. 2000; Alexander, et al. 2012; Flickinger, et al. 2013].
  4. Patients want their healthcare providers to talk with them about sexual health [Marwick 1999; Ryan, et al. 2018].

Rather than seeing sexual history taking as a means to an end, the GOALS framework considers the sexual history taking process as an intervention that will:

  • Increase rates of routine HIV/STI screening;
  • Increase rates of universal biomedical prevention and contraceptive education;
  • Increase patients’ motivation for and commitment to sexual health behavior; and
  • Enhance the patient-care provider relationship, making it a lever for sexual health specifically and overall health and wellness in general.

The GOALS framework includes 5 steps:

  1. Give a preamble that emphasizes sexual health. The healthcare provider briefly introduces the sexual history in a way that de-emphasizes a focus on risk, normalizes sexuality as part of routine healthcare, and opens the door for the patient’s questions.
  2. Offer opt-out HIV/STI testing and information. The healthcare provider tells the patient that they test everyone for HIV and STIs, normalizing both testing and HIV and STI concerns.
  3. Ask an open-ended question. The healthcare provider starts the sexual history taking with an open-ended question that allows them to identify the aspects of sexual health that are most important to the patient, while allowing them to hear (and then mirror) the language that the patient uses to describe their body, partner(s), and sexual behaviors.
  4. Listen for relevant information and fill in the blanks. The healthcare provider asks more pointed questions to elicit information that might be needed for clinical decision-making (e.g., 3-site versus genital-only testing), but these questions are restricted to specific, necessary information. For instance, if a patient has already disclosed that he is a gay man with more than 1 partner, there is no need to ask about the total number of partners or their HIV status in order to recommend STI/HIV testing and PrEP education.
  5. Suggest a course of action. Consistent with opt-out testing, the healthcare provider offers all patients HIV testing, 3-site STI testing, PrEP education, and contraceptive counseling, unless any of this testing is specifically contraindicated by the sexual history. Rather than focusing on any risk behaviors the patient may be engaging in, this step focuses specifically on the benefits of engaging in prevention behaviors, such as exerting greater control over one’s sex life and sexual health and decreasing anxiety about potential transmission.

Resources for implementation:

  • Script, rationale, and goals: Box 1, below, provides a suggested script for each step in the GOALS framework, along with the specific rationale for that step and the goal it is designed to accomplish.
  • The 5Ps model for sexual history-taking (CDC): Note that the GOALS framework is not designed to completely replace the 5Ps model (partners, practices, protection from STI, past history of STI, prevention of pregnancy); instead, it provides a framework for identifying information related to the 5Ps that improves patient-care provider communication, reduces the likelihood of bias or missed opportunities, and enhances patients’ motivation for prevention and sexual health behavior.
Box 1: GOALS Framework for the Sexual History
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Component Suggested Script Rationale and Goal Accomplished
Give a preamble that emphasizes sexual health. I’d like to talk with you for a couple of minutes about your sexuality and sexual health. I talk to all of my patients about sexual health, because it’s such an important part of overall health. Some of my patients have questions or concerns about their sexual health, so I want to make sure I understand what your questions or concerns might be and provide whatever information or other help you might need.
  • Focuses on sexual health, not risk.
  • Normalizes sexuality as part of health and healthcare.
  • Opens the door for the patient’s questions.
  • Clearly states a desire to understand and help.
Offer opt-out HIV/STI testing and information. First, I like to test all my patients for HIV and other sexually transmitted infections. Do you have any concerns about that?
  • Doesn’t commit to specific tests, but does normalize testing.
  • Sets up the idea that you will recommend some testing regardless of what the patient tells you.
  • Opens the door for the patient to talk about HIV or STIs as a concern.
Ask an open-ended question.

Pick one (or use an open-ended question that you prefer):

  • Tell me about your sex life.
  • What would you say are your biggest sexual health questions or concerns?
  • How is your current sex life similar or different from what you think of as your ideal sex life?
  • Puts the focus on the patient.
  • Lets you hear what the patient thinks is most important first.
  • Lets you hear the language the patient uses to talk about their body, partners, and sex.
Listen for relevant information and probe to fill in the blanks.
  • Besides [partner(s) already disclosed], tell me about any other sexual partners.
  • How do you protect yourself against HIV and STIs?
  • How do you prevent pregnancy (unless you are trying to have a child)?
  • What would help you take (even) better care of your sexual health?
  • Makes no assumption about monogamy or about gender of partners.
  • Avoids setting up a script for over-reporting condom use.
  • Can be asked of patients regardless of gender.
  • Increases motivation by asking the patient to identify strategies/ interventions.
Suggest a course of action.
  • So, as I said before, I’d like to test you for [describe tests indicated by sexual history conversation].
  • I’d also like to give you information about PrEP/contraception/other referrals. I think it might be able to help you [focus on benefit].
  • Allows you to tailor STI testing to the patient so they don’t feel targeted.
  • Shows that you keep your word.
  • Allows you to couch education or referral in terms of relevant benefits, tailored to the specific patient.
References

Alexander JA, Hearld LR, Mittler JN, et al. Patient-physician role relationships and patient activation among individuals with chronic illness. Health Serv Res 2012;47(3 Pt 1):1201-1223. [PMID: 22098418]

Bakken S, Holzemer WL, Brown MA, et al. Relationships between perception of engagement with health care provider and demographic characteristics, health status, and adherence to therapeutic regimen in persons with HIV/AIDS. AIDS Patient Care STDS 2000;14(4):189-197. [PMID: 10806637]

Flickinger TE, Saha S, Moore RD, et al. Higher quality communication and relationships are associated with improved patient engagement in HIV care. J Acquir Immune Defic Syndr 2013;63(3):362-366. [PMID: 23591637]

Hoots BE, Finlayson T, Nerlander L, et al. Willingness to take, use of, and indications for pre-exposure prophylaxis among men who have sex with men-20 US cities, 2014. Clin Infect Dis 2016;63(5):672-677. [PMID: 27282710]

Hull S, Kelley S, Clarke JL. Sexually transmitted infections: Compelling case for an improved screening strategy. Popul Health Manag 2017;20(S1):S1-S11. [PMID: 28920768]

Lancki N, Almirol E, Alon L, et al. Preexposure prophylaxis guidelines have low sensitivity for identifying seroconverters in a sample of young Black MSM in Chicago. AIDS 2018;32(3):383-392. [PMID: 29194116]

Marwick C. Survey says patients expect little physician help on sex. JAMA 1999;281(23):2173-2174. [PMID: 10376552]

Owusu-Edusei K, Jr., Hoover KW, Gift TL. Cost-effectiveness of opt-out chlamydia testing for high-risk young women in the U.S. Am J Prev Med 2016;51(2):216-224. [PMID: 26952078]

Ryan KL, Arbuckle-Bernstein V, Smith G, et al. Let’s talk about sex: A survey of patients’ preferences when addressing sexual health concerns in a family medicine residency program office. 2018;2. https://journals.stfm.org/primer/2018/ryan-2018-0004

Schuz N, Schuz B, Eid M. When risk communication backfires: randomized controlled trial on self-affirmation and reactance to personalized risk feedback in high-risk individuals. Health Psychol 2013;32(5):561-570. [PMID: 23646839]

Sheeran P, Harris PR, Epton T. Does heightening risk appraisals change people’s intentions and behavior? A meta-analysis of experimental studies. Psychol Bull 2014;140(2):511-543. [PMID: 23731175]

Weinstein ND, Klein WM. Resistance of personal risk perceptions to debiasing interventions. Health Psychol 1995;14(2):132-140. [PMID: 7789348]

Wimberly YH, Hogben M, Moore-Ruffin J, et al. Sexual history-taking among primary care physicians. J Natl Med Assoc 2006;98(12):1924-1929. [PMID: 17225835]

Consumer Q/A: Treatment of Hep C with DAAs

August 2021

This Q/A fact sheet covers the topics in the New York State Department of Health AIDS Institute guideline about treating Hep C to help people talk with their healthcare providers about Hep C.

About the Guideline

What is the purpose of the guideline? The guideline is a set of recommendations for healthcare providers. It explains how to treat Hep C using direct-acting antiviral drugs. “Direct-acting antiviral” is abbreviated as “DAA.” On average, DAAs cure Hep C in 90% or more of the people who take them.

Who wrote the guideline? The guideline was written by a group of doctors in New York who specialize in treating Hep C and liver disease. It was also reviewed by people living with Hep C. The recommendations are based on research studies and the doctors’ experience treating patients.

About Hep C

What is Hep C? Hep C is a virus that infects the liver. Most people do not have symptoms for many years.

Over time, Hep C can cause the liver to thicken and scar. This scarring is called “fibrosis.” As the scarring becomes worse, the liver does not function correctly. The late stage of scarring is called “cirrhosis.” Cirrhosis can lead to life-threatening liver failure or liver cancer. 

Treatment with direct-acting antivirals (called “DAAs”) can cure Hep C, and cure can prevent or slow down liver damage.

How is Hep C spread? Hep C is spread when the blood of a person who has the virus enters the body of a person who does not have the virus. Hep C is not spread through casual contact, such as sneezing, hugging, or sharing eating or drinking utensils.

Who should get tested for Hep C? Hep C testing is recommended for all adults who are 18 years of age and older and for all adults who are pregnant (during every pregnancy). People who engage in activities that may expose them to Hep C may need to be tested more than once. Those activities include condomless sex, sex with partners who have Hep C, or unsafe use of needles or other drug equipment.

Diagnosing Hep C

How is Hep C diagnosed? Hepatitis C diagnosis requires two tests: an antibody test and an RNA test. Both tests require a blood sample.

1. Antibody test: Hepatitis C antibodies form in your blood when you have been exposed to the virus. If the antibody test is negative, then you don’t have Hep C infection. If you have engaged in risky behavior in the past 6 months, you should be tested again.

A positive Hep C antibody test by itself does not mean that you have Hep C. It means you have been exposed and might have chronic Hep C. You need an RNA test to confirm the diagnosis. 

If you have been treated for Hep C and cured in the past, your antibody test will be positive. 

2. RNA test: An RNA test measures the amount of Hep C virus in your blood. If the RNA test finds Hep C virus in your blood, then you have active Hep C infection. If Hep C virus is not detected, then you do not have an active Hep C infection. 

If you do have Hep C, you should talk with your healthcare provider about treatment.

Treating Hep C

What does your healthcare provider need to know before giving you treatment? A healthcare provider needs to know about your health history and current health. She or he will ask you questions, examine you, and perform tests to help decide which medications are best for you.

What are DAAs? DAAs are pills that combine more than one medication that works directly against the hepatitis C virus to treat it. Treatment usually lasts for 12 weeks (3 months) to 24 weeks (6 months). Different combinations of DAAs work best for different people. Some people take DAAs with another drug called ribavirin.

How will your healthcare provider pick the DAA combination for you? You and your healthcare provider will work together to decide the best treatment for you. The specifics of your situation will guide the choice, such as:

  • Your Hep C genotype. Different strains of the virus are called “genotypes.” Genotype 1 is the most common in the United States.
  • Whether you were treated for Hep C before.
  • Whether you have liver damage. A simple blood test can determine if you have liver damage. A liver biopsy is no longer required.
  • Other medications you are taking.
  • The number of pills you are comfortable taking.
  • Whether you are pregnant or trying to get pregnant.
  • Whether your partner is trying to get pregnant.
  • Your health insurance: Almost all types of health insurance cover the DAAs, but not all companies cover all of the DAAs. Your healthcare provider will find out what your company covers. If you don’t have health insurance, your healthcare provider can help you find payment assistance programs.

Do DAAs have side effects? Most people don’t get side effects when they take DAAs. Some people have experienced tiredness, diarrhea, headache, trouble sleeping, and stomach upset. If you take DAAs and feel any side effects, tell your healthcare provider.

How will you know if you are cured? Your healthcare provider will perform an HCV RNA follow-up test 12 weeks (3 months) after you finish treatment. If the test does not detect Hep C virus in your blood, you are cured of Hep C infection. If there is still Hep C virus in your blood, you are not cured.

If you are not cured, then a different combination of DAAs might work for you.

Preventing Hep C After Treatment

Can you get Hep C again after you are cured? Yes. Being treated for and cured of Hep C infection does not protect you from getting it again. To protect yourself from being infected with Hep C again, do not share needles, syringes or drug use equipment, personal items like toothbrushes or razors and use condoms.