At IDWeek 2023 in Boston, one session aimed to give infectious disease doctors tips for incorporating HIV treatment and care into their practices. Beyond getting up to speed on the medications and indications for HIV treatments and pre-exposure prophylaxis (PrEP), presenters said clinicians may need to first adopt a slightly different mindset when caring for patients.
Dr. Rachel Harold, who is the supervisory medical officer at the District of Columbia Department of Health, started by saying that people living with HIV and people who could benefit from HIV prevention are not two distinct populations. “They’re one group with similar medical and social service needs.” Harold said the term “status neutral” prevention and care, a “person-first, not disease-first model,” is a helpful framework for infectious disease (ID) clinicians who want to encourage and maintain engagement of their clients.
“Despite countless innovative and incredible programs to prevent HIV and to take care of those living with HIV, we’re still not reaching some people or we’re not reaching them in the way they need or we’re not providing the care they need. And PrEP services are very underutilized, only about a quarter of those who would benefit from PrEP are on PrEP.”
One of the main reasons HIV care services are underutilized, she said, is stigma, which keeps people from seeking HIV prevention services. “And many of the barriers to care that those living with HIV face are the same as people without HIV face,” she said. “It may be health insurance, mental health concerns, substance use or housing instability.”
What does status neutral prevention look like? Harold offered an example of HIV testing as “no wrong door.”
“When you enter the system, the first thing would be an HIV test,” she said. “And for people who are HIV-negative, they enter into this continuum of intensive proactive HIV prevention services. That can be safe syringe programs, that can be harm reduction, education and continuous engagement. Those who [get tested often], or [who test] positive, enter into a similarly intensive comprehensive care continuum. And anyone who may be in the prevention pathway, were they to become diagnosed with HIV, they could seamlessly go to the treatment pathway.”
An example of status neutral services is at the DC Health and Wellness Center, which is operated by the District of Columbia. The Center has an on-site lab and phlebotomy services as well as a pharmacy that provides PrEP, PEP and ART directly from the clinic. “And then the wonderful help of disease investigators who can help with partner services and making sure that if we are having a hard time finding someone who needs treatment, they can assist us,” Harold said.
Harold admitted that the center has the benefit of being a categorical STI clinic, and that many general ID practitioners might not be able to offer such a wide variety of on-site sexual health services, but they can refer clients to clinics that do, and they can adopt a status neutral approach to keep clients in the continuum of care.
Other examples of status neutral services at the DC Health and Wellness Center:
- Express clinic services that bypass the need to see a clinician; clients can check off the testing that they want to have done, in and out
- Free at-home STI testing
- A 24-7 hotline for PEP
We ask every patient, Are you aware of PrEP? If the answer is no, then we teach them about PrEP and offer it to them. If the answer is yes, we offer it to them.
In the first 18 months of the PEP program, the Center had more than 400 initiations, many who might not have accessed PEP if it had meant long lines in the ER and a big bill. “The program may be an on-ramp to PrEP,” Harold said. “We ask every patient, ‘Are you aware of PrEP?’ If the answer is no, then we teach them about PrEP and offer it to them. If the answer is yes, we offer it to them. It’s a unique opportunity to screen for STIs as well.”
Getting comfortable talking about sex
In the same session, Dr. Jill Blumenthal, associate clinical professor of medicine at University of California, San Diego, shared how general ID practitioners can incorporate inpatient HIV care in their practices. She echoed Dr. Harold, that status neutral care is best. One of the most important ways to incorporate HIV care, including prevention and treatment, is learning to take a patient’s sexual history in a non-judgmental way. To accomplish that, some doctors may have to step outside their comfort zone and ask some very personal questions.
“Staying sex-positive and open-minded is crucial,” she said. “You’re not the judge. You want patients to be able to tell you things about themselves.”
Blumenthal said the CDC’s five P’s of sexual history taking, which many doctors learn in med school—partners, practices, protection, past history of STIs and pregnancy intention—is only a start in learning about a patient’s vulnerabilities, including potential partner violence.
Her advice: No assumptions should be made when you talk with a patient. Validate all sexual practices. Don’t assume people are limited to certain kinds of effects based on their gender. And ask open-ended questions.
“For example,” she said, “What kinds of sex are you having? Which body parts of yours touch which body parts of another partner? It’s also important to ask about engaging in sex for money, housing, drugs or other services.”
Remember that PrEP is indicated for adolescents and adults ages 15 to 65 years who are especially vulnerable to HIV, Blumenthal added. A doctor can assess vulnerability by asking non-judgmental questions.
Having a sex partner who had HIV, especially if the partner did not know their viral load and/or had a recent bacterial STI, may be a sign that an HIV test is needed, Blumenthal said. “We can incorporate a lot of people [who are] just not using condoms with sex partners whose HIV status is unknown; that’s going to be a lot of people. And of course, persons who inject drugs, and have a drug injecting partner who has HIV sharing injection equipment.”
She added, “If a patient brings up PrEP, that’s easy: they think they might need it, and that opens up a conversation about the benefits (and possible risks) of PrEP medication and the affordable—sometimes free—ways to get it. It’s also a good time to address PrEP misconceptions. And when a patient asks for PrEP, this sets up a need to perform an HIV test.”
The default, Blumenthal suggested, is testing for HIV rather than not testing. “If they’re in the right age range, or they’re having sex at all, start with an HIV test, and then the conversation can continue.”
Larry Buhl is a multimedia journalist based in Los Angeles. He has covered HIV/AIDS and other infectious diseases for more than two decades. In addition to POSITIVELY AWARE, he is a regular contributor to TheBody.com, Everyday Health and capitalandmain.com. His work has appeared in USA Today, Salon, Undark, KQED, the New York Times and others.