Few PCPs take complete sexual histories, perform HIV tests
A complete sexual history was taken at less than 2% of initial visits to a primary care physician in 2015 in the United States, and HIV testing occurred at less than 1% of PCP office visits annually from 2009 to 2017, data show.
In a cross-sectional cohort study, Leonidas Palaiodimos, MD, MSc, an assistant professor of hospital medicine at Montefiore Medical Center, and colleagues reviewed 1,017 first-time visits that adults made to a PCP. To meet the definition of a complete sexual history, the visit needed electronic health record documentation of discussions about sexual partners, sexual practices, pregnancy prevention, protection from sexually transmitted infections (STI) and past history of STIs — also known as the CDC’s “five P’s” approach.
Researchers reported that only 11 (1.08%) visits met those criteria. There were 345 (33.92%) visits that partially followed it, and the remaining 661 (65%) visits did not follow it at all. Also, sexual history was more likely to be taken from female patients than male patients (P < .001) and less likely to be obtained from older patients vs. younger ones (P < .001). Although a PCP’s title and the level of training were independent predictors of sexual history taking (P < .001), their sex was not (P = .753).
“Overall, the rates of sexual history taking were alarmingly low,” Palaiodimos and colleagues wrote in The Journal of Sexual Medicine, adding that previous studies have shown that educational materials, intervention workshops and educational role-playing have improved physicians’ abilities to obtain a thorough sexual history.
In a recent MMWR, Karen W. Hoover, MD, a medical epidemiologist at the CDC, and colleagues analyzed data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey to estimate trends in HIV testing of males and nonpregnant females aged 13 to 64 years at physician offices, community health centers (CHCs) and EDs from 2009 to 2017.
Hoover and colleagues reported that HIV testing was performed at 0.63% of 516 million physician office visits, 2.65% of 37 million visits to CHCs and 0.55% of 87 million ED visits during the study period. The percentage of visits with an HIV test did not increase at physician offices, according to the researchers, but rates did increase at CHCs and to some extent at EDs.
“Clinical decision supports can be developed that use information in EHRs to order an HIV test for patients who need one and standing orders can increase routine opt-out testing, thereby reducing clinical barriers to HIV testing,” the researchers wrote.
References:
- Hoover KW, et al. MMWR Morb Mortal Wkly Rep. 2020;doi:10.15585/mmwr.mm6925a2.
- Palaiodimos L, et al. J Sex Med. 2020;doi:10.1016/j.jsxm.2020.05.004.
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To increase sexual history taking and HIV testing, make these tasks part of routine health maintenance — things like mammograms, Pap smears, tetanus shots, etc. Another strategy is to periodically offer patients a checklist to fill out while waiting for their appointment that contains questions about their sexual partners and sexual history. Physicians can then look at the checklist and decide if they need to have a sexual health conversation during the patient’s visit.
These strategies can take away the stigma around being tested, but it also puts the testing in the hands of the patient and takes away the expectation that the screening has to be driven by the doctor.
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Often people who are diagnosed with HIV have had it for many years and were never tested, even though many of these same people had encounters with the health care system. This suggests that the CDC’s 2006 recommendation of offering opt-out HIV testing to essentially everyone who is sexually active has never had the uptake by primary care providers that it deserves.
I understand that many health care providers are reluctant to get into the topic of HIV, especially if this is something that they do not normally do. They may not feel comfortable asking questions about sexuality and gender identity either because they've never been trained to do it or feel that they may not have time to do it. I would say to these health care providers that offering HIV testing does not need to be difficult or time-consuming. And data show patients like to talk about their sexuality when you help them feel at ease.
Just as we might ask, “Do you smoke? Do you drink alcohol?” we can ask: “Are you sexually active? Do you have sex with men, women or both?” And depending on their answer, then you might say, Do you have sex with one or more partners? Have you ever had a screening test e for chlamydia, gonorrhea, syphilis or HIV? During a physical exam, I tell patients about the tests that we recommend, such as those to assess their blood counts, thyroid, kidney, liver, and cholesterol levels, and ask if they have any infections that might need treatment including viral hepatitis and HIV. When you explain it that way, almost all the time patients will agree to the test and you don't have to go into any great depth about HIV or HIV testing.
We have also seen study after study that indicate primary care practitioners are not properly conducting STI screening. One way to screen for this is to say to patients, “Most people who have sexually transmitted infections don't have any symptoms. The best way to screen for STIs is to screen any body part that you ever use for having sex. So, do you have oral sex? Do you have anall sex? Do you have vaginal sex?” Depending on the answers, offer the appropriate swab or urine sample to try to find an infection that might be present.
Just remember, you can't find what you don't look for or ask about. Your patients will appreciate you for caring.
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