Selected Resources

Selected Resources

For Care Providers

May 2019

EDUCATION

GUIDELINES

LAW

SERVICES

TOOLS

Q/A: HIV and STIs

January 2008

It is common knowledge that the same sexual behaviors that place someone at risk for an STD (unprotected anal, vaginal and oral sex) also pose risk for HIV. Increasing evidence demonstrates that there is an even stronger link between STDs and HIV. Recent studies in Africa have shown that routine screening and early treatment of STDs in a community can significantly lower the number of new cases of HIV infection. This question and answer sheet is designed to provide you with information about: 1) how an untreated STD can increase a person’s chance of getting or transmitting HIV when engaging in unprotected sexual activity; 2) the importance of routine screening and early treatment of STDs as an approach to preventing new HIV infections; 3) key messages to share with your clients and community about the link between HIV and STDs.

How does the presence of an untreated STD increase a person’s risk of acquiring HIV?

Ulcerative STDs (herpes, syphilis, chancroid) can cause sores or breaks in the skin on and around the genitals. These sores or breaks in the skin provide a site of entry for HIV if the individual is exposed to blood, semen or vaginal secretions containing HIV. Both ulcerative and non-ulcerative STDs (chlamydia, gonorrhea, trichomoniasis) cause the body to bring CD4 cells to the site of infection to fight the STD. CD4 cells are the prime target cells for HIV. The increased number of CD4 cells means that it is easier for HIV from the infected person’s blood, semen or vaginal secretions to find and infect target cells in the uninfected person. Studies show that the presence of an untreated STD increases the risk of getting HIV by 3-5 times.

How does the presence of an untreated STD in an HIV-infected person increase the person’s risk of transmitting HIV to others?

New research has shown that when a person is infected with both HIV and an STD the amount of HIV in the person’s semen or vaginal secretions is significantly increased and the chances of transmitting the virus is 3-5 times higher, compared to a person not infected with an STD. This means that these individuals are more able to infect partners if they have unprotected sexual intercourse. Early treatment of STDs can help reduce the higher level of HIV in the semen and vaginal secretions. Individuals unknowingly infected with both HIV and an STD will be unaware that they can infect others and may be unaware of the importance of HIV/STD risk reduction, testing and treatment.

Why is routine screening, early identification and treatment of STDs important for people living with HIV infection?

New York State Department of Health Clinical Guidelines recommend routine evaluation of risk for STDs at the initial medical visit for all persons newly diagnosed with HIV infection. Thereafter, annual evaluation for STDs is recommended. Evaluation and screening for STDs in people with HIV infection is important for several reasons: 1) STDs can cause increased damage to the body when a person’s immune system is compromised; 2) STDs frequently do not have symptoms and are only detected through medical tests; 3) if left untreated many STDs can cause irreversible problems such as cervical cancer, birth defects or infertility. The progressive nature of untreated STDs underscores the importance of ongoing counseling regarding risk reduction and partner notification services for people living with HIV. These services can prevent the spread of HIV to others and help to protect the person with HIV from exposure to STDs and other strains of HIV.

What are the key messages about HIV and STDs that Providers should share with their clients and communities?

All clinical and non-clinical HIV/STD service providers should educate their patients, clients and communities about:

  • how routine screening and early treatment of STDs can help prevent new HIV infections;
  • the importance of recommending H IV testing for all individuals diagnosed with an STD;
  • the importance of routine screening for STDs because STDs frequently do not have symptoms and are only detectable through screening;
  • the general symptoms of STDs- sores, lesions, irritation, discharge;
  • the importance of prompt screening and treatment whenever symptoms are present.

Historically, knowledge about STDs has been very low, even in communities where there is high prevalence of STDs. In some cases, STDs may be viewed as unavoidable or may even be viewed as an “initiation” into adulthood. There may be lack of concern about STDs because they may be viewed as easily curable. Education about how STDs can increase a person’s chance of acquiring HIV is critical and may help change the view that STDs are a harmless “fact of life.”

Community HIV/AIDS educators, outreach workers and other health educators should become familiar with basic information about STDs. Educators and outreach workers can play an important role by:

  • helping to establish routine screening and early treatment of STDs as a community norm;
  • working with clinical providers to ensure availability of in-depth HIV education and risk reduction/harm reduction counseling for individuals at highest risk for HIV/STD;
  • providing in-depth education and risk reduction/harm reduction counseling for individuals engaging in HIV/STD risk behavior, especially substance users and their partners;
  • educating their communities about local resources for STD screening and treatment and making referrals as needed.

Each county health department in New York State offers STD screening and treatment. STD  service providers should:

  • work with community educators and health care providers to ensure that STD screening and treatment services are available and accessible;
  • routinely recommend and provide voluntary HIV testing to all individuals at risk for or diagnosed with an STD;
  • be able to provide or refer clients for HIV testing and a comprehensive array of HIV-related prevention and care services.

Further reading

  • Grosskurth H, Mosha F, Todd J, et al. Impact of improved treatment of sexually transmitted diseases on HIV infection in rural Tanzania. Lancet 1995;346(8974):530-36. [PubMed]
  • Hitchcock PJ. Screening and treatment of sexually transmitted diseases: an important strategy for reducing the risk of HIV transmission. AIDS Patient Care STDS 1996;10(1):10-15. [PubMed]
  • Sullivan AK, Atkins MC, Boag F. Factors facilitating the sexual transmission of HIV-1. AIDS Patient Care STDS 1997;11(3):167-77. [PubMed]

GOALS Framework for Sexual History Taking in Primary Care

Download PDF

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 Prevention, 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]