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May 2019

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Antiretroviral Agents Recommended for PEP

Updated May 2018

Dolutegravir (DTG) Safety Statement, updated March 20, 2019

On December 7, 2018, the DHHS Guidelines Panel issued an update to its prior statement in response to preliminary results from a study that reported increased risk of NTD in babies born to mothers taking DTG-based ART at the time of conception. 

Updated data are pending and expected to be released in 2019. Until that time, the panel’s conservative, interim recommendations remain that DTG-containing regimens should be avoided in the first trimester of pregnancy or in any HIV-exposed individual who may become pregnant. If there are no alternatives to DTG use for individuals of child-bearing potential, then clinicians should strongly advise effective contraception use and should obtain a pregnancy test before initiating treatment.

For pregnant women already taking DTG who present to care in the first trimester of pregnancy, patient-centered counseling should address the risks and benefits of continuing DTG or switching regimens and include the following information:

  • The importance of accurate gestational dating as neural tube development is complete by 28 days post-conception or 6 weeks after the first day of the last menstrual period.
  • NTD may have already occurred, and the added risk in the remaining weeks of the first trimester may be slight.
  • A background risk of NTD ranging from 0.05% to 0.1% exists for all pregnancy regardless of HIV status or antiretroviral treatment.
  • Changing ART regimens in pregnancy is often associated with viral rebound that may increase the risk of perinatal HIV transmission.

DTG remains a preferred agent for use in women after the first trimester of pregnancy. Individuals who continue use of DTG after delivery should be counseled regarding possible risk in future pregnancies and should be offered effective, ongoing contraception options.  

For more information, see: DHHS Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States

The medications listed below include antiretroviral agents recommended for PEP (tenofovir disoproxil fumarate, emtricitabine, and either raltegravir or dolutegravir) as well as alternative antiretroviral drugs that may be used in the setting of potential HIV resistance, toxicity risks, or constraints on the availability of particular agents. For information on all antiretroviral medications, see Antiretroviral Therapy.

More information about these antiretroviral agents, including dosage and dose adjustment, potential adverse events and drug interactions, and FDA pregnancy categories, can be found through the links included in the table All FDA-Approved HIV Medications. Before using these drugs, package inserts should also be consulted.

Recommended PEP medications:

Alternative PEP medications:

FDA Pregnancy Categories

A: Adequate and well-controlled studies of pregnant women fail to demonstrate a risk to the fetus during the first trimester of pregnancy (and there is no evidence of risk during later trimesters).

B: Animal reproduction studies fail to demonstrate a risk to the fetus and adequate and well-controlled studies of pregnant women have not been conducted.

C: Safety in human pregnancy has not been determined, animal studies are either positive for fetal risk or have not been conducted, and the drug should not be used unless the potential benefit outweighs the potential risk to the fetus.

D: Positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experiences, but the potential benefits from the use of the drug in pregnant women may be acceptable despite its potential risks.

X: Studies in animals or reports of adverse reactions have indicated that the risk associated with the use of the drug for pregnant women clearly outweighs any possible benefit.

References

AIDSinfo. Statement on Potential Safety Signal in Infants Born to Women Taking Dolutegravir from the HHS Antiretroviral Guideline Panels. 2018 May 18. https://aidsinfo.nih.gov/news/2094/statement-on-potential-safety-signal-in-infants-born-to-women-taking-dolutegravir [accessed 2018 May 23]

U.S. Food and Drug Administration (FDA). FDA Drug Safety Communication: FDA to evaluate potential risk of neural tube birth defects with HIV medicine dolutegravir (Juluca, Tivicay, Triumeq). 2018 May 18. https://www.fda.gov/Drugs/DrugSafety/ucm608112.htm [accessed 2018 May 23]

Defendant Testing Guidance

November 2016

Background

As of November 1, 2007, New York Criminal Procedure Law § 210.16 requires testing of criminal defendants, indicted for certain sex offenses, for human immunodeficiency virus (HIV), upon the request of the victim.

The NYS Department of Health (NYSDOH) is responsible for issuing guidance for the Court on the following:

  • Medical and psychological benefit to the victim
  • Appropriate HIV test to be ordered for the defendant
  • Circumstances when follow-up testing for the defendant is recommended
  • Indications for discontinuation of post-exposure prophylaxis (PEP)

The NYSDOH AIDS Institute’s Medical Care Criteria Committee and the Mental Health Guidelines Committee carefully reviewed the issues involved and developed this guidance through a consensus-based process. As requested, the committees specifically addressed HIV risk; however, the victim’s healthcare provider should also consider risk of transmission of hepatitis B, hepatitis C, and other sexually transmitted infections (STIs). The guidelines on the care of sexual assault victims, PEP for Victims of Sexual Assault, developed by the Medical Care Criteria Committee of the NYSDOH AIDS Institute, include recommendations for the post-exposure management of HIV, hepatitis B, and hepatitis C.

Definitions of Significant Risk and Sexual Assault Exposure

The defendant testing law refers to “significant exposure” as defined by 10 NYCRR § 63.10. PEP for Victims of Sexual Assault offers a definition of significant exposure during sexual assault that warrants assessment of the victim. Both definitions are listed below.

  • Significant Risk, as defined by 10 NYCRR § 63.10: Three factors are necessary to create a significant risk of contracting or transmitting HIV infection:
    • The presence of a significant-risk body substance and
    • A circumstance that constitutes significant risk for transmitting or contracting HIV infection and
    • The presence of an infectious source and a noninfected person
  • Significant risk body substances: Blood, semen, vaginal secretions, breast milk, tissue, and the following body fluids: cerebrospinal, amniotic, peritoneal, synovial, pericardial, and pleural
  • Circumstances that constitute “significant risk of transmitting or contracting HIV infection”:
    • Sexual intercourse (e.g., vaginal, anal, oral) that exposes a noninfected individual to blood, semen, or vaginal secretions of an HIV-infected individual
    • Sharing of needles and other paraphernalia used for preparing and injecting drugs between HIV-infected and noninfected individuals
    • Gestation, birthing, or breastfeeding of an infant when the mother is HIV-infected
    • Transfusion or transplantation of blood, organs, or other tissues from an HIV-infected individual to a noninfected individual, provided such blood, organs or other tissues have not tested conclusively [negatively] for antibody or antigen and have not been rendered noninfective by heat or chemical treatment
    • Other circumstances not identified in paragraphs 1 through 4, above, during which a significant risk body substance (other than breast milk) of an infected individual contacts mucous membranes (e.g., eyes, nose, mouth), nonintact skin (e.g., open wound, skin with a dermatitis condition, abraded areas), or the vascular system of a noninfected person. Such circumstances include, but are not limited to, needlestick or puncture wound injuries and direct saturation or permeation of these body surfaces by the infectious body substance.
  • Circumstances that do not involve “significant risk”:
    • Exposure to urine, feces, sputum, nasal secretions, saliva, sweat, tears, or vomitus that does not contain blood that is visible to the naked eye
    • Human bites where there is no direct blood-to-blood, or blood-to-mucous membrane contact
    • Exposure of intact skin to blood or any other body substance
    • Occupational settings where individuals use scientifically accepted preventive practices and barrier techniques in circumstances that would otherwise pose a significant risk, provided that such barriers are not breached and remain intact

The NYSDOH AIDS Institute guideline, PEP for Victims of Sexual Assault defines a significant exposure during “sexual assault” as follows: “Direct contact of vagina, penis, anus, or mouth with semen, vaginal fluids, or blood of the alleged assailant, with or without evidence of physical injury, tissue damage, or presence of blood at the site of the assault.”

Maximizing Medical and Psychological Benefit to the Victim

The guidelines for initiation of PEP for the sexual assault victim DO NOT change from that which is currently recommended in the NYSDOH AIDS Institute guidelines for PEP following sexual assault. The sexual assault victim should be evaluated in an emergency department (ED) as soon as possible for treatment and discussion of PEP. If a significant exposure, as defined above, did occur and the decision is made to initiate PEP, it should be initiated ideally within 2 hours and generally no later than 36 hours from the time of the exposure. Studies have shown that the sooner PEP is initiated, the more likely it is to be effective. A 28-day course of a 3-drug regimen, as outlined in the guideline PEP for Victims of Sexual Assault, should be used for PEP. The victim should receive HIV testing at baseline (within 72 hours of the exposure) and at 4 weeks and 12 weeks post-exposure, even if PEP is declined.

1. Court-Ordered HIV Testing of Defendants: 7 to 30 Days from the Time of the Exposure

RECOMMENDATION
The Medical Care Criteria Committee recommends that a plasma HIV RNA assay should be used in conjunction with a standard HIV-1 ELISA antibody test when the defendant is tested 7 to 30 days from the time of the victim’s exposure.
  • Rationale for the 7- to 30-day time frame: HIV can be detected as early as 7 days when using both a plasma HIV-1 RNA assay and an HIV antigen/antibody screening test. After 30 days from the time of exposure, the victim will have completed the 28-day PEP regimen; therefore, the testing recommendations change because the use of a plasma HIV-1 RNA assay in addition to the antibody test is not medically beneficial. See Court-Ordered HIV Testing of Defendants: 30 Days to 6 Months from the Time of the Exposure, below, for the psychological benefit that may be gained from defendant testing after 30 days.
  • Medical benefit for the victim when testing the defendant between 7 and 30 days: The only clear medical benefit for the victim of testing the defendant for HIV would be the discontinuation of PEP to avoid potential toxicity and side effects; for this benefit to be realized, the defendant’s test results would need to be available within the 28-day period for which the PEP regimen is prescribed.
  • The medical decision to discontinue PEP on the part of the victim should be made only in full consultation with the victim’s clinician. The victim’s clinician should consult with a clinician experienced in managing PEP before discontinuing the regimen. The NYSDOH AIDS Institute Clinical Education Initiative (CEI) Line (1-888-6372342) can be used for phone consultation. When using the CEI Line, providers from New York State should identify themselves as such.
  • Psychological benefits of defendant testing for the victim: Defendant testing for HIV may have the following psychological benefits for the victim:
    • Providing information that may help the victim understand the degree of risk for acquiring HIV
    • The comfort of knowing that exposure to HIV is unlikely in those instances when the defendant tests negative on both the HIV antigen/antibody test and plasma HIV RNA assay
    • Allowing the victim to participate more fully in the decision of whether to continue or discontinue the PEP regimen

Because the results of the defendant’s test may be the only criterion used to decide to terminate the victim’s PEP regimen, the Committee concluded that it was necessary to exclude the possibility of the defendant being in the acute stage of HIV-1 infection. The acute stage is the stage in which the virus and viral RNA are present in the blood but the person has not developed enough specific antibodies to be detected by an antibody test. An HIV antigen/antibody immunoassay may detect HIV-1 p24 antigen as early as 14 days and will also detect HIV-1 and HIV-2 antibodies produced once seroconversion has occurred. An HIV-1 RNA assay is capable of detecting HIV-1 as soon as 7 days after infection and would establish a diagnosis; therefore, it is important to use both an HIV antigen/antibody immunoassay and a plasma HIV-1 RNA assay when the completion of the victim’s PEP regimen is contingent on the defendant test results. If the HIV antigen/antibody immunoassay is positive, the laboratory should complete the recommended HIV testing algorithm, which includes supplemental testing using an HIV-1/HIV-2 differentiation test (see NYSDOH AI: HIV Testing Guideline). If the defendant is infected with HIV and is on antiretroviral treatment, the HIV-1 RNA may be suppressed below the test’s detection limit.

Negative test results from both the HIV antigen/antibody test and the HIV-1 RNA assay would indicate that the defendant is not infected with HIV and would permit discontinuation of the victim’s PEP regimen. Positive test results for either the HIV antibodies or HIV-1 RNA assay, or both, would indicate that the defendant is infected with HIV and that the victim’s PEP regimen should be completed. When making decisions regarding the management of the victim, the defendant should be considered to be HIV-infected until proven negative. Table 1 outlines the different possibilities of test results, how each result would affect the victim’s PEP regimen, and the necessary follow-up.

Table 1. Defendant Testing Recommendations: 7 to 30 Days from Time of Sexual Assault

Tests to obtain: HIV antigen/antibody test (4th generation screening test) and HIV RNA test, either qualitative or quantitative plasma HIV-1 RNA assay. If antibodies are not confirmed, but the HIV-1 RNA assay is positive, the defendant is considered infected and is likely to be in the acute stage of infection.

Defendant Test Results Victim PEP Defendant Retesting and Follow-Up
  • RNA test: Negative (-)
  • Antigen/antibody test: Negative (-)

 

PEP may be discontinued after consultation with physician
  • No follow-up testing of defendant recommended for benefit of victim
  • As a standard of care for defendant, repeat antigen/antibody testing in 3 months if at ongoing risk for infection
  • RNA test: Positive (+)
  • Antigen/antibody test: Positive (+)

 

PEP should be continued
  • An HIV-1/HIV-2 supplemental antibody test should be performed.  If test does not confirm antibodies, HIV-1 infection is still present but may be in the acute or early stage.
  • No other follow-up testing is required
  • Defendant should be referred for care
  • RNA test: Positive (+)
  • Antigen/antibody test: Negative (-)

 

PEP should be continued
  • Repeat both tests as soon as possible
  • There is a very brief window within the acute stage of infection when RNA is detectable but HIV-1 p24 antigen has not reached detectable levels
  • RNA test: Negative (-)
  • Antigen/antibody test: Positive (+)
PEP should be continued
  • To confirm antibodies, an HIV-1/HIV-2 supplemental antibody test should be performed
  • Defendant should be referred for care or continue care if already receiving it
Inconclusive or invalid results from either the antigen/antibody or RNA test PEP should be continued
  • Repeat both tests as soon as possible in consultation with in HIV specialist

2. Court-Ordered HIV Testing of Defendants: 30 Days to 6 Months from Time of Exposure

RECOMMENDATIONS
  • The Medical Care Criteria Committee recommends that an HIV antigen/antibody test is obtained when the defendant is tested 30 days to 6 months from the time of the assault (see Table 2).
  • When HIV testing is ordered within 30 to 42 days from the time of exposure, a laboratory-based HIV antigen/antibody immunoassay should be used
  • When HIV testing is ordered 42 days to 6 months from the time of exposure, either a point-of-care rapid HIV test or a laboratory-based HIV antigen/antibody immunoassay can be used.
  • Reactive results on any type of HIV screening assay should be confirmed in a laboratory using the recommended HIV testing algorithm.
  • Medical benefit for the victim when testing the defendant between 30 days and 6 months: There is no medical benefit for the victim when testing the defendant for HIV during the 30-day to 6-month period. If the victim chose to receive PEP, the 4-week PEP regimen will have been completed at this point. If the victim tests negative at 3 months, then HIV transmission by exposure from the assault can be excluded.
  • Psychological benefits for the victim when testing the defendant between 30 days and 6 months: Defendant testing for HIV may be mandated by the court for up to 6 months after the assault have the following psychological benefits for the victim:
    • Providing information that may help the victim understand the degree of risk for acquiring HIV
    • The comfort of knowing that exposure to HIV is unlikely in those instances when the defendant tests HIV negative
Table 2. Defendant Testing Recommendations: 30 Days to 6 Months from Time of Sexual Assault

Test to obtain: HIV screening test
When testing 30 days to 42 days from time of assault: Use an antigen/antibody test.*
When testing 42 days to 6 months from time of assault: Use either a rapid HIV antibody test or a laboratory-based antigen/antibody test

Defendant Test Results Defendant Retesting and Follow-Up
Negative
  • No follow-up testing of the defendant is recommended for benefit of victim
  • As a standard of care for defendant, repeat antigen/antibody test in 3 months if at ongoing risk for infection
Positive
*According to the manufacturer package inserts, the window period for some rapid tests is up to 42 days; therefore, a laboratory-based HIV antigen/antibody test should be used for defendant testing between 30 and 42 days from the time of the assault.

Responsibilities of the Public Health Officer, County, or State

  • Responsibilities to the defendant:
    • Provide pretest information
    • Obtain appropriate HIV test(s), depending on the timing of testing in relation to when the exposure occurred
    • Provide post test counseling
  • Responsibilities to the victim:
    • Notify the victim of the defendant’s test results
    • Instruct the victim to inform his/her healthcare provider of the results and discuss how to proceed with PEP
  • Responsibility to the court: Notify the court in writing that the test(s) was performed and the results were shared with victim
  • Reminder: Disclosure of confidential HIV-related information shall be made to the defendant upon his or her request. Disclosure to a person other than the defendant will be limited to the person making the application (i.e., the victim). The victim may then disclose the defendant’s HIV test results to the victim’s medical care provider, legal representative, and close family members or legal guardian. The victim may also share the HIV-related information with his or her sex or needle-sharing partners if it is believed that these individuals were exposed to HIV. Victims cannot disclose the defendant’s name during these discussions.

Disclosure shall not be permitted to any other person or the court.

GOALS Framework for Sexual History Taking in Primary Care

Download PDF | Download Pocket Guide

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 with in 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 [download chart PDF]
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.

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]