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HIV testing remains key to ending the epidemic. Those who test negative can be offered PrEP (pre-exposure prophylaxis—medication to prevent HIV). Those who test positive can be linked to the medical care and effective treatment that can keep them healthy for a normal lifespan, and once their viral load is suppressed they can’t pass HIV on to a sex partner (called U=U, for “undetectable equals untransmissible). 

But a year after our article looking at testing during a time of pandemic (“Testing the Testers,” January+February 2021), the U.S. still experiences a lag in people getting tested to see if they have any STIs (sexually transmitted infections). 

One thing that remains the same: the need to have someone to talk to, and someone who will listen to and answer questions about what remains a sensitive topic: sex.

Joshua Gutierrez is the Prevention and Health Education Manager at TPAN, the non-profit HIV services organization that publishes Positively Aware. He’s had more than 10 years of experience discussing sexual health and wellness with people seeking an HIV test. He started at TPAN during the COVID-19 shutdown of 2020–2021.

Enid Vázquez: What do people most misunderstand? 

Josh Gutierrez: People have misconceptions about what STIs are and how you get them. So basically, education is missing, that is what I am finding. There are a lot of misconceptions and a lot of rumors, things that they’ve heard from friends or on Google. 

Then when they’re symptomatic, they may not know what it is. We know that STI symptoms come and go, but they believe that, “Oh, I’m no longer having symptoms so I’m okay.” And obviously most STIs, in particular syphilis and HIV, can lead to serious health consequences if left untreated. 

I had someone come in recently who asked me, “Can I still get HIV? I had bottom surgery [vaginoplasty].” Nobody had that conversation with her. That, yes, you can still get an STI or HIV. We discussed modes of transmission and prevention and I was able to make a Fast Track PrEP referral. She came in later to see me and tell me she was on PrEP and to pick up condoms and lube. She was very happy to have been given information about PrEP and wanted to tell me personally. That was one of my prouder moments.

I always ask clients, “Tell me what you know about how someone acquires HIV?” One young person told me they heard that if you take a slice of orange and rub it on a woman’s labia and the orange turns green, that she has HIV.

EV: What year was that?

JG: This year [2021]. This was a relatively young person, 19. And I think when people are in high school, they just come up with random things that they read on Reddit or on the internet. They believe what their friends tell them. And that’s what he really thought, and I explained that’s not true. It was great that he trusted me, because then we can have an open and honest conversation. We give folks accurate, science-based information. I always tell them, make sure you tell your friends that no, you cannot acquire HIV that way.

One young person asked me, what’s the best way to have anal sex? His partner was rather large and so we had a discussion about it.

We take the time to explain what the rectum is, how it works, and that anal sex can be pleasurable. We also teach how to care for your rectum and anus before and after sex, and talk about using toys, condoms, and lubes. As well as having conversations with your partner and stressing the importance of getting tested for STIs and HIV.

I had a very open conversation with a married mom. She’s been married for 10 years and she gets tested two to three times a year. I had noticed her high anxiety and stress levels when I initially greeted her. So I’m asking her all the open-ended questions. How many sexual partners have you had? She had one sexual partner, in a monogamous relationship for the last 10 years. She explained to me that when she was younger that she had “a past.” I assured her that most people have “a past,” and she laughed, which made me feel better as a counselor because I felt she was getting comfortable with me and the session. So I started to ask about her baseline knowledge about HIV and about HIV and STI transmission. She was saying that she heard that HIV can incubate, so you should test at least once a year. Nobody had taken the time to explain the window period to her or what the tests look for and how to interpret them. Once I explained that her results and her information indicated that she did not have HIV, she released all this stress and fear that she had been dealing with for 10 years, and she started crying. She asked me, Why didn’t anybody ever tell me that? I told her, “That was a failure in the testing process. I’m glad you came in today, and I’m glad that we had this discussion.”

Once people feel safe to open up, you can begin to shape the conversation. I do ask people, “How many partners have you had in the last 30 days? In the last six months?” And one person said that they had 30 partners in the last 30 days. And then the client asked me, “Is that a lot?” And I said, “Is it a lot to you?” It’s a question of how do you feel about your sexuality—what concerns do you have about it? We’re not here to judge you.

Something that we regularly explore with clients is their relationship with sex and their own sexuality. What does someone’s sex, sexuality, and identity mean to them? Are you enjoying the sex you are having with your partner or partners? What do you use to prevent STIs and protect yourself? Does sex validate you in some way? Sex can be pleasurable or fun, or it can be a burden and stressful. Having good information can be vital in a person’s overall health.

What information does this person need? What can the person leave with today to better help them protect themselves and their partners? It is very important to us that our clients are treated with respect and compassion, regardless of their baseline knowledge. For some folks, coming to get tested and be vulnerable is a giant step for them and we should acknowledge that and speak to that courage with our clients.

We offer more than just testing. We offer sexual wellness counseling. That young man was able to join our Lifeline program, which helps folks recognize their personal vulnerability for HIV/AIDS, come up with attainable risk-reduction goals, develop increased health awareness overall, improve their physical and emotional health, and create a healthier lifestyle for them. What is great about this program is that they can receive six free mental health sessions from one of our amazing therapists. 

I have found that those who are in routine care don’t get sexual health information from their providers. Their providers also may not test them for STIs. So I don’t think they’re having

that conversation with their medical provider or care team regardless of age, gender, or sexual identity. That’s probably the most astonishing thing that I find. That sexual wellness, sexual health, and STIs and HIV are not discussed during an office visit. We try to teach folks to initiate the conversation with their primary care providers and to advocate for themselves. 

We try to create a conversation with clients that is age appropriate, but I also don’t make assumptions. When I introduce myself, I always let them know that the questions I’m going to ask are questions I ask of everyone. If you wish not to answer, just say pass, and I will keep going, although if I need to circle back to the question, I will. I want them to know that we are here for them. That the sharing of information is confidential, if you feel comfortable. Often, folks don’t want to talk about their sex life with their providers. Other people don’t talk about their sex life with their sex partners. They don’t know how to broach the topic or how to talk about it. They might not have the terminology they need for a discussion. But again, it’s just information. We provide “coaching” with clients, providing a safe space for folks to practice what they want to say to their partners or medical providers. Hopefully, this tool, this skill, will allow them to feel comfortable having open and honest dialogue when it concerns their sexual health. 

From the moment they walk through our doors, how we greet them, even asking about their preferred pronouns, is a great way to help folks relax. 

Some folks are dealing with shame or stigma. I always tell people that this is a safe space. You can ask me anything or you can ask me nothing. It’s up to you. In my experience, I feel that folks really like to talk about themselves. And some really like to talk about sex.

There’s no negative language in the signage that we have. Nothing scary. We even have a nice little stress toy that people can squeeze when we’re testing them.

Make it a positive experience, even fun! Because if you have a positive experience, you’re more likely to come back. We are sex positive here. If you have a negative experience somewhere, you’re more likely to never to go back. And that could be a reason why folks are not getting tested, and in some cases not getting treated.

I’ve had clients come in who didn’t want to tell me anything. I don’t force them to either. I hope that we are able to provide a warm, safe, and welcoming experience so that maybe the next time they come in, they’ll be a little bit more open.

EV: What are the STIs being seen the most now? Do we still have a syphilis epidemic in the country? Or is it only among MSM (men who have sex with men)?

JG: Language is also very important. We do not have a syphilis epidemic. It is endemic in a lot of urban areas. It’s just part of communities, particularly large urban communities, and in certain rural areas. But yes, part of the CDC data of 2018, I believe, did indicate a rise in syphilis, gonorrhea, and chlamydia, and particularly concerning was congenital syphilis [which is passed in utero to the child, before and during birth]. I believe that went up by 143% from the previous year.

STIs do not discriminate; bacteria and viruses are opportunistic. So it is very important that folks get tested, treated when needed, and also that partners are notified. The messaging sometimes goes back to the stigma and shame of acquiring an STI or HIV. I think sometimes the messaging could have a more positive spin on it.

With COVID-19, STIs and HIV testing services have been curtailed as people who were working as partner disease intervention specialists were pulled to work on COVID-19 contact tracing. Testing has been limited at some sites. It’s sort of like a perfect storm. Behaviors may not have changed during COVID-19, but access to testing, PrEP, and HIV care did. 

Making testing routine, as part of your overall health, could lower the rates of infections. I think we need to start early in schools and colleges and just make it part of your overall health checkup.  

EV: And being non-judgmental goes hand in hand with being comfortable.

JG: Absolutely.

As part of the sexual wellness counseling session, we ask, “Are you having any signs or symptoms of an STI? Has a partner notified you that they tested positive for an STI? Do you believe you have may have been exposed to HIV in the last 72 hours?” I don’t ask if they have ever had an STI because that could make people very uncomfortable. How you approach your clients and the questions asked lead to an understanding of respect and trust.

The 10 to 20 minutes waiting for an HIV test result can be a long time. So it is a perfect opportunity to have a relaxed conversation with someone. I like to ask questions like, “So, tell me what you know about PrEP?” “Tell me what you know about STIs?” But surprisingly, what they do tell me is that they don’t test for STIs because they don’t know where to go. Or they had a terrible experience at another facility. In a perfect world I would love to have express clinics around the city, like pop up clinics, where it would be very seamless. If we see in the data that there is a high prevalence of STIs or HIV in certain neighborhoods, then the pop-up clinic could move to that community. There they could offer comprehensive testing and treatment, PrEP, and HIV care for folks in real time at the point of care. 

We need more testing clinics, better treatment options, and comprehensive sexual health services, such as PrEP, PEP, and free birth control. I could go on, but my point is that If services were offered, people would take advantage of them. 

EV: This is exactly what I was going to ask you, where do you send them?

JG: In a perfect world I would love to have express clinics around the city, like pop up clinics, where it would be very seamless. If we see in the data that there is a high prevalence of STIs or HIV in certain neighborhoods, then the pop-up clinic could move to that community. There they could offer comprehensive testing and treatment, PrEP, and HIV care for folks in real time at the point of care.

We need more testing clinics, better treatment options, and comprehensive sexual health services, such as PrEP, PEP, and free birth control. I could go on, but my point is that If services were offered, people would take advantage of them.

Also see "A sense of trust--and a matter of access" and "Oh my gosh, I can't believe you talk like that!"