for Health Care Providers
Taking Patients' Sexual and Substance Use Histories
Taking a patient's sexual and substance-use histories allows you to further assess their risk for HIV and their general health status. There are many assessment tools and approaches used in these types of history taking. No one tool or approach is exactly right for all situations and as such, the examples referenced in this section are based on literature reviews, their use of non-confrontational language, and the need for brevity. It is important to take a patient's history in a room or setting where privacy and confidentiality can be ensured.
Taking a Sexual History
Taking a patient's sexual history is like any other type of history; you ask basic questions and build on those questions if necessary. The following sexual history questions can help you branch into a more detailed discussion with your patient:
|Sexual history questions|
Note. From HIV & Primary Care: Putting Prevention into Practice (p. 12), by the AIDS Institute, New York State Department of Health, 1998. Reprinted with permission.
|"When was the last time you had sex and was that person your regular partner?"|
|"When was the last time you had sex with someone other than this last individual?"|
|"Have you had other partners in the past year?"|
|"Do you have any questions about the safety of any sexual practice?"|
|"When you have sex, do you use a condom?" [When appropriate, explore other types of barrier protection such as dental dams.]|
|"Have you had sex with anyone you know or suspect has HIV infection?"|
|"Have you ever had a sexually transmitted disease?"|
|"Do you have sex with men or women [or both]?"|
Often, patients will answer "no" to some of these questions because they may feel uncomfortable or embarrassed. A "no", however, does not eliminate the need for you to review safer sex practices with the patient.(1) Some patients want to know the degree of HIV transmission risk associated with specific sexual activities. It may be helpful to use Table 1 to initiate discussions on this topic once your patient has begun to provide you with some information on his or her sexual history or has indicated that they have not routinely practiced safer sex. Table 1 will help patients begin to assess their own relative risk for HIV.
|Listed in order of NO RISK to HIGHEST RISK|
*Risk associated with gender of partners not differentiated due to lack of research.
**Data suggests that HIV transmission through insertive anal intercourse is more efficient than oral intercourse but less efficient than receptive anal intercourse. The relative risk of transmission through insertive anal intercourse compared to vaginal intercourse is unclear.
Note. From HIV & Primary Care: Putting Prevention into Practice (p. 55), by the AIDS Institute, New York State Department of Health, 1998. Reprinted with permission.
|Abstinence; Monogamous relationship (both partners uninfected); Self masturbation; Dry (social kissing)|
|Mutual Masturbation; Deep kissing|
|Vaginal intercourse; female to male|
|Vaginal intercourse; male to female|
|Insertive anal intercourse**|
|Receptive anal intercourse|
Taking a Substance-Use History in a Primary Care Setting
Epidemiology strongly supports the nexus between substance abuse and the risk for infectious diseases. These risk behaviors include injection drug use, unsafe sexual practices while high or intoxicated, and/or trading sex for drugs or drug money.
Substance use and abuse, especially injection drug use, which may involved the sharing of hypodermic syringes, cottons (material used to filter the drug mixture), or other drug 'works', has always been one of the leading risk factors for HIV in the United States.(2) CDC reports that injection drug use has accounted for 25% of all cases of AIDS in the United States. This statistic does not include cases of infection experienced by men who have sex with men and inject drugs, and individuals who have heterosexual sex with an injection drug user.
As the nation's largest single provider of substance abuse treatment, VA sees a large number of veterans who are at risk for HIV because of their current substance abuse or history of injection drug use. Because many of these veterans may not currently be in substance abuse treatment or may not have been identified as drug or alcohol abusers, it is important to integrate routine substance-use histories as part of primary care screening.
The most recent estimates indicate that there were approximately 317,000 veterans with a diagnosis of substance abuse and 540,000 veterans with a psychiatric diagnosis (excluding a substance abuse diagnosis) receiving care in the VA in 1999. The VA has 31 opiate agonist or opiate substitution treatment clinics and provided treatment to 30,000 opiate dependent veterans in 1999.
According to the hepatitis C virus antibody screening flow chart accompanying VA IL 10-2001-009, any individual who presents with an history of injection illicit drug use -- past or present -- any number of injections -- skin or intravenous site, should be counseled and tested for the hepatitis C virus antibody.
Health care providers screening for drug and alcohol problems perform a critical function and have the potential to identify many patients who need further assessment or treatment in order to reduce their risk for HIV.
Unfortunately, most medical schools do not include training on how to screen for these problems and many providers may feel uncomfortable or ill equipped to assess for information on as sensitive a topic as substance use. Consequently, many medical care providers have not been very good at identifying active drug and alcohol users.
In approaching substance-use screening in primary care settings, patients must feel comfortable in discussing their use. It may be helpful for providers to:
- "normalize" screenings by prefacing them with a comment that they, the provider, have begun to routinely ask about alcohol and drug use with all their patients to better evaluate their complete health needs,
- conduct screening in a private setting and ask questions and use probes that are non-judgmental,
- use substance abuse screening questions that focus on gaining an accurate assessment of the quantity and frequency of use,
- start substance abuse screening by asking about alcohol and more commonly used substances and then proceed to questions about injection drug use,
- ask about early drug use in a patient's youth or early adult years and then proceed up to questions about current use,
- ask about illegal drug use during service (especially when coping with combat stressors) when working with combat veterans, and
- perceive substance addiction as any other chronic disease.
There are several self-administered questionnaires that can help the patient and health care provider identify patterns of drug and/or alcohol use that require further assessment or treatment. These include the Michigan Alcohol Screening Test (MAST),(3) the Drug Abuse Screening Test (DAST),(4, 5) and the Alcohol Use Disorders Identification Test (AUDIT).(6) A dual strategy approach such as the use of self-administered questionnaire and a provider-screening interview increases the chance for patient disclosures. It is important to keep in mind that many people are willing to talk about their use but are never asked.
Two initial screening questions that researchers found to be effective in initially screening for alcohol and other drug-use problems in a large primary care setting are:
- Have you ever felt that you wanted or needed to cut down on your drinking or drug use in the last year?
- In the last year, have you drunk or used more drugs that you meant to?(7)
It is imperative to note that injection drug use currently accounts for most hepatitis C virus transmission in the United States.(8) The National Institute on Drug Abuse reports that hepatitis C infection occurs rapidly among new injection drug users as 50-80% become infected with the virus within 6-12 months of injection initiation.(9) Any patient that reports that they have used injection drug use equipment should be considered at risk the hepatitis C virus.
Substance Abuse Treatment as HIV Prevention
Substance abuse treatment has been a cornerstone of national HIV prevention efforts.(10) Substance abuse treatment programs play two critical, yet distinct roles in HIV prevention. First, treatment programs serve to reduce the frequency of high-risk behaviors such as the injection of drugs, aiding in the direct prevention of HIV transmission. But also by gaining access to treatment, injection drug users also gain important access to a broader range of public health interventions such as risk reduction counseling and HIV testing and screening.(10)
Substance abuse treatment programs were the site of the earliest HIV prevention efforts with high-risk populations such as injection drug users and there is a large body of literature that has established an association between participation in treatment and lowering one?s risk for HIV.(10) While substance abuse treatment is a highly effective HIV intervention, limited access to treatment can be a potential barrier for many injection drug users and other high-risk substance-abusing populations. In addition, relapse is a common occurrence so many substance abusers may move in and out of treatment over time. As such, their risk for HIV will likely vary over time, but there still appears to be an overall decline in the frequency of drug use and related risk behaviors even for those who relapse after treatment.(10)
Should you need to provide prevention counseling to patients who continue to inject, CDC recommends that people who inject drugs should be regularly counseled to:
- stop using and injecting drugs or
- to enter and complete substance abuse treatment.
For injection drug users who cannot or will not stop injecting drugs, the following steps may be taken to reduce personal and public health risks:
- never reuse or "share" syringes, water, or drug preparation equipment,
- only use syringes obtained from a reliable source (such as pharmacies or needle exchange programs),
- use a new, sterile syringe to prepare and inject drugs,
- if possible, use sterile water to prepare drugs; otherwise, use clean water from a reliable source (such as fresh tap water),
- use a new or disinfected container ("cooker") and a new filter ("cotton") to prepare drugs,
- clean the injection site prior to injection with a new alcohol swab, and
- safely dispose of syringes after one use.(11)
- AIDS Institute, New York State Department of Health (1998). HIV & Primary Care: Putting Prevention into Practice [Manual].
- Centers for Disease Control and Prevention. (2001). HIV and AIDSUnited States, 1981-2000. Morbidity and Mortality Weekly Report, 50 (21), 430-433.
- Selzer, M. (1971). The Michigan Alcoholism Screening Test: The quest for a new diagnostic instrument. American Journal of Psychiatry, 127, 1653-1658.
- Skinner, H. A. (1982). The Drug Abuse Screening Test. Addictive Behavior, 7, 363-371.
- Gavin, D. R., & Ross, H. E. (1989). Diagnostic validity of the DAST in the assessment of DSM-III drug disorders. British Journal of Addiction, 84, 301-307.
- Saunders, J. B., Aasland, O. G., de la Fuente, J. R., & Grant, M. (1993). Development of the Alcohol Use Disorder Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption - II. Addiction, 88, 791-804).
- Brown, R. L., Leonard, T., Saunders, L. A., & Papasouliotis, O. (2001). A two-item conjoint screen for alcohol and other drug problems. Journal of the American Board of Family Practice, 14, 95-106.
- Centers for Disease Control and Prevention. (1998, October). Recommendations for prevention and control of Hepatitis C virus infection and HCV-related chronic disease [Electronic version]. Morbidity and Mortality Weekly Report, 47 (RR-19), 1-39.
- National Institute on Drug Abuse. (2000, May). Community drug alert bulletin: Hepatitis C [Bulletin]. Bethesda, MD: Author.
- Metzger, D. S., Navaline, H., & Woody, G. E. (2000). The role of drug abuse treatment in the prevention of HIV infection. In J. L. Peterson and R. J. DiClemente (Eds.), Handbook of HIV Prevention (pp. 147-156). New York: Kluwer Academic/Plenum Press.
- Centers for Disease Control and Prevention. (1998, November). How can people who use injection drugs reduce their risk for HIV injection? Retrieved June 21, 2001 from http://www.cdc.gov/hiv/pubs/faq/faq26.htm