Part 3: Responding to Patients:Providing Risk Reduction Counseling: Part 3: Responding to Patients: Providing Risk Reduction Counseling The Kenneth B. Schwartz Foundation


Disclosure: Pandora’s Box?: Disclosure: Pandora’s Box?


Disclosure: Pandora’s Box?: Disclosure: Pandora’s Box? “I worry about Pandora’s box – issues that may get opened up that are beyond the doctor’s limit. It would make me really uncomfortable if the doctor had no idea what to say to me, especially if I had just divulged something that was difficult for me to talk about”


How Should We Respond?: How Should We Respond?


First Step: Affirmation: First Step: Affirmation


First Step: Affirmation: First Step: Affirmation “The best reaction I ever got when I told a doctor about my sexual orientation was: thank you for telling me. This comment really helped establish a sense of trust and made me feel comfortable opening up even more.”


Next Steps…Depend on Disclosure / Context: Next Steps… Depend on Disclosure / Context


If Patient Self-Identifies as Belonging to a Sexual Minority Group…: If Patient Self-Identifies as Belonging to a Sexual Minority Group… Explore level of self-acceptance, experiences/consequences coming out Goal: to encourage formation of a positive identity, a critical foundation for establishing a healthy lifestyle and healthy relationships Identify key supports and encourage connection to the LGBT community


Sexual Minority Status:Sample Questions: Sexual Minority Status: Sample Questions “Are you out to your family?” “People at work?” “What have coming out experiences been like?” “Who are the key support people in your life?” “Is there anyone you would like to include in your care?” “Do you feel connected to the LGBT community?”’


Slide10: Poor Self-Esteem Mental Health Issues


Slide11: Sexual Minority Resources Gay and Lesbian Medical Association GLMA: www.glma.org Gay and Lesbian National Hotline 1-888-THE-GLNH glnh@GLBTNationalHelpCenter.org GLBT Helpline: 1-888-340-4528 ISNA: www.isna.org WPATH: www.wpath.org


If a Patient Discloses Abuse…: Listen Believe the patient Reassure them it was not their fault Let them know they are not alone, and arrange appropriate support / services If a Patient Discloses Abuse…


Sexual Abuse: Useful Resources: Sexual Abuse: Useful Resources Sexual Abuse Response Teams Rape Crisis Centers National Sexual Assault Hotline 1-800-656-HOPE National Sexual Violence Resource Center www.nsvrc.org National Organization on Male Sexual Victimization www.malesurvivor.org


If the History Suggests a Patient is at Risk for Unintended Pregnancy / STDs: If the History Suggests a Patient is at Risk for Unintended Pregnancy / STDs Assess the patient’s perception of risk Provide information about actual risk Review strategies that decrease risk Help the patient make behavioral changes


“Safe” Sex?: “Safe” Sex?


Slide16: Some People Thrive on Risk


Why Do People Take Sexual Risks?: Why Do People Take Sexual Risks? Excitement / thrill Lack of knowledge Misconceptions Denial / invincibility Anger / defiance Depression / apathy Low self esteem Poor negotiation skills Poor impulse control Fear of rejection / abuse Negative attitudes about safer sex


Some People are Risk Averse: Some People are Risk Averse


People Have Different Risk Limits: People Have Different Risk Limits


People Have Different Risk Limits: People Have Different Risk Limits “Some people avoid sex completely because they are so worried about HIV and other STDs… other people don’t worry at all, and take a lot of risks.”


What Can We Hope to Do?: What Can We Hope to Do? Help patients find a balance– define the risks they are willing to take and they ones they do not want to take… Succeed in avoiding activities that fall outside their risk limits… Use protection to reduce risk during the activities they choose to engage in


Help Patients Shift Risk Limits: Help Patients Shift Risk Limits


Counseling ApproachEffecting Behavioral Change: Counseling Approach Effecting Behavioral Change Assess risk perception Address misconceptions Provide accurate information Assess readiness for change Identify and address obstacles Provide support and follow up


Assess Risk Perception: Assess Risk Perception “Do you think you are at risk for becoming pregnant/getting a STD?” “How much at risk (low, medium, high) do you think you are?” “What makes you think you are/are not at risk?”


Address MisconceptionsAbout Pregnancy: Address Misconceptions About Pregnancy It happens! Percentage of reproductive-age women who will become pregnant within one year: 85%, if using no contraceptive 27% if using withdrawal 25% if using the rhythm method Managing Contraception 2003-4


Contraceptive Efficacy: Contraceptive Efficacy


Contraception Adherence Factors: Contraception Adherence Factors Convenience Partner support Effects on lifestyle Frequency of intercourse Protection against STDs Desire for children in the future Personal, religious, cultural convictions Cost http://www.who.int/topics/contraception/en/


Emergency Contraception: Emergency Contraception


Address MisconceptionsAbout STDs: Address Misconceptions About STDs STDs are common You can get infected… If you are on the pill If you are the insertive partner If your partner has no symptoms While doing things other than intercourse If your partner is taking protease inhibitors


Provide Accurate Information: Provide Accurate Information


STD Prevention Strategies: STD Prevention Strategies Abstinence Monogamy Partner screening Limit number of partner(s) Practice low-risk sexual activities Consistent/correct use of barrier methods Avoidance of excess alcohol/drug use Immunization and chemoprophylaxis


Abstinence Alone is Not Enough: Abstinence Alone is Not Enough Makes the heart grow fonder BUT… Abstinence


Practice Monogamy or Limit Number of Sexual Partners: Practice Monogamy or Limit Number of Sexual Partners


Avoid Sexual Contact Until Partner(s) Have Been Screened: Avoid Sexual Contact Until Partner(s) Have Been Screened


Practice Low-Risk Sexual Activities: Practice Low-Risk Sexual Activities


Relative Risks of Various Activities: Relative Risks of Various Activities NO RISK: Self-masturbation Internet or phone sex Dry kissing (no sores) Vibrators/sex toys (not shared)


Relative Risks of Various Activities: Relative Risks of Various Activities LOW RISK: Wet (French) kissing Body-body rubbing (no fluids involved) Sharing sex toys using a barrier Vibrators/sex toys (not shared)


Relative Risks of Various Activities: Relative Risks of Various Activities MEDIUM RISK: Hand/genital contact with cuts/sores Oral-genital contact without a barrier Genital-genital/anal contact with a barrier


Relative Risks of Various Activities: Relative Risks of Various Activities HIGH RISK: Sharing sex toys without a barrier Cunnilingus without a barrier during menses Vaginal secretions/ejaculate in vagina or anus Rimming without a barrier Fisting without a barrier


Slide40: http://www.advocatesforyouth.org/youth/advocacy/yan/condom/upload/be_evolved.jpg Advocates for Youth Public Service Announcement


Use Barrier Methods Consistently and Correctly: Use Barrier Methods Consistently and Correctly Male condom Female condom Other safer sex supplies


Male Condoms: Male Condoms


The Female Condom: The Female Condom


Additional Safer Sex Supplies: Additional Safer Sex Supplies


Barriers Reduce Risk (1)Latex Male Condoms and HIV: Barriers Reduce Risk (1) Latex Male Condoms and HIV Study of HIV transmission in serodiscordant heterosexual couples followed for 20 months: No seroconversion if condoms used correctly and consistently for vaginal and anal intercourse 10% seroconverted if condoms used inconsistently 15% seroconverted when condoms were not used


Effectiveness of Barriers (2)Latex Male Condoms and HSV2: Effectiveness of Barriers (2) Latex Male Condoms and HSV2 Study of HSV2 transmission in 528 serodiscordant, monogamous, heterosexual couples followed for 18 months 267 susceptible women; 261 susceptible men Condom use during >25% of sex acts protective for women (HR 0.085, 95% CI 0.01-0.67) but not for men Most common sites of viral shedding: Men: penile skin (covered by condom) Women: vulva/perianal skin (condom affords less protection)


Effectiveness of Barriers (3)Latex Male Condoms and HPV: Effectiveness of Barriers (3) Latex Male Condoms and HPV Data are inconsistent Best study to date (web-based diary): 82 newly sexually active heterosexual women Followed up every 4 months X 1 year with Pap smears and cervical/vaginal HPV DNA testing Incidence of HPV infection was lower w/ 100% vs. <5% condom use group (37.8 vs. 89.3 cases per 100 patient-years at risk) Winer et al, N Engl J Med 2006;354:2645-54.


Effectiveness of Barriers (4)Female vs. Male Condoms: Effectiveness of Barriers (4) Female vs. Male Condoms Data are limited Medical record study: 1442 women at an STD clinic Randomized to female vs. male condoms Subsequent STD incidence determined from medical records review Trend toward  STD recurrence in female condom group (OR 0.75, 95% CI 0.56-1.01)


Barriers are not Perfect: Barriers are not Perfect People don’t always use them They may not use them correctly Even when used correctly and consistently, they are not foolproof


Why Don’t People Use Barriers?: Why Don’t People Use Barriers? Embarrassment re: buying/discarding Discomfort/shyness touching genitals Concern re: interference with spontaneity Concern re: reduction/elimination of sensation Concern re: ineffectiveness due to breakage, slippage, imperfect protection (HPV, HSV) Perception that condoms are associated with casual sex, infidelity, and disease Inability to negotiate with partner(s) They cost too much


Teach and Allow Practice: Teach and Allow Practice


Assess Knowledge/Comfort Level: Assess Knowledge/Comfort Level “Have you ever tried using barrier methods like condoms?” If yes: “Have you had any problems using condoms?” “What kinds of problems?” If no: “Would have any trouble getting a condom if you needed one?” “Would you know how to put it on?” Do you feel comfortable discussing safer sex with your partner(s)?


Help Patients Develop Strategies for Negotiating with Partners: Help Patients Develop Strategies for Negotiating with Partners


Negotiation Strategies: Negotiation Strategies I’m clean, believe me! Don’t you trust me? Are you telling me you have some kind of disease or something? It’s no fun for me when I wear one of those! It doesn’t feel as good and I don’t feel as close to you with a barrier between us.


Negotiation Strategies: Negotiation Strategies But we’re already using birth control. Why do we need condoms too? It’s too much of a hassle to put one on. It always breaks the mood. We’ve been going steady for 6 months. We don’t need these. It makes me uptight to use condoms. I lose my erection.


Male Condom Tips: Male Condom Tips Have a readily available supply Latex or polyurethane only Handle gently; store properly Put the condom on after the penis is erect and before contact with mouth/anus/vagina Leave space at the condom tip


Male Condom Tips: Male Condom Tips Ensure adequate lubrication Use only water-based lubricants Withdraw promptly after intercourse Hold condom to base of penis while withdrawing Never re-use condoms


Female Condom: Tips: Female Condom: Tips Lubricate the closed end (end with the small ring) Squeeze the sides of the ring together and insert into the vagina/anus like a tampon or diaphragm Insert until it goes no further (covers the cervix) Allow the large ring to hang outside the vagina To remove, squeeze the outer ring, twist, and pull


Only Water-Based Lubricants Should be Used with Latex Barriers: Only Water-Based Lubricants Should be Used with Latex Barriers


Nonoxynol-9 Should Not be Used: Nonoxynol-9 Should Not be Used A spermicide / microbicide initially touted to reduce risk of HIV transmission Unfortunately, a review of randomized trials demonstrated no significant difference in relative risks of HIV, GC, chlamydia, or trichomoniasis in N-9 vs. placebo groups Genital lesions more common in N-9 groups  potential for harm Wilkinson, Lancet Infectious Dis, 2002


‘Slips’ are Inevitable: ‘Slips’ are Inevitable


Even When Used Consistently and Correctly, Condoms Are Not Foolproof: Even When Used Consistently and Correctly, Condoms Are Not Foolproof Most effective in preventing transmission via fluids from mucosal surfaces: Chlamydia, GC, Trichomonas, HIV Less effective in preventing transmission from skin-to-skin contact: HSV, HPV, Syphilis, Chancroid


Therefore, Sexually Active Patients Should be Screened Regularly: Therefore, Sexually Active Patients Should be Screened Regularly Refer to USPSTF guidelines


High-Risk Patients Should be Immunized: High-Risk Patients Should be Immunized Hepatitis A and B: All high-risk adults HPV: Females aged 9-26 yrs Studies in males pending


What about When a Patient Already Has an Incurable STD?: What about When a Patient Already Has an Incurable STD? Viral STDs (HPV, HSV, HBV, HIV) Encourage them to tell their partner(s) Consider chemoprophylaxis (HSV)


Prevention of HSV 2 Transmission with Valacyclovir: Prevention of HSV 2 Transmission with Valacyclovir 1494 HSV-2 discordant couples; infected person given valacyclovir 500 mg po qd or placebo for 8 mos Monthly follow-up with HSV-2 serology, clinical assessment, and safer sex counseling Symptomatic genital herpes acquisition rates Valacyclovir 4/743 (0.5%) Placebo 17/741 (2.3%) P = 0.006 (95% CI 0.1-0.7) Total genital herpes acquisition rates Valacyclovir 14/743 (1.9%) Placebo 28/741 (3.8%) P = 0.04 (95% CI 0.3=0.9)


The key is to provide consistent, positive messages about safer alternatives: The key is to provide consistent, positive messages about safer alternatives


Slide70: http://www.wanderings.net/notebook/Main/CondomAdDurex Durex Condom Ad


Slide71: http://img.timeinc.net/time/europe/magazine/2005/0926/uganda.jpg Life Guard Condoms ad in Uganda


Slide72: http://www.7thchapter.com/portfolio/print/condom.jpg Contex Condoms Ad for “Happy Hour Condoms with flavour”


Slide73: http://boingboing.net/images/skullsex.jpg Tulipan Condoms Public Service Announcement in Argentina Be Careful


Slide74: LOVE LIFE STOP AIDS Public Service Announcement http://littleoslo.com/img/pickture/200702501.jpg


Slide75: http://www.sfaf.org/aboutsfaf/gallery/img/full/bathrm6.jpg SFAF Aids Foundation Public Service Announcement


Slide76: http://www.inpuntadipenna.com/wp-uploads/ 2007/06/safe-sex-aids-hiv-condom.jpg Ireland Safe Sex Public Service Announcement


Slide77: Safe Sex Public Service Announcement


Slide78: Safe Sex Public Service Announcement


Slide79: Chlamydia Public Service Announcement


Slide80: Chlamydia Public Service Announcement


Slide81: Safe Sex Public Service Announcement


Slide82: http://www.pantagraph.com/content/articles/2007/07/28/wtf/doc46aba83c7989f986402267.jpg “Vrij Veilig” is Dutch for "Safe Sex In Amsterdam, Netherlands a campaign for safe sex included a hot air balloon in the shape of a condom