Prep toolkit ebrief1 v05 final

Cultural Competence and Taking Patient Sexual Histories

African American individuals, men who have sex with men (MSM), people who inject drugs (PWID), and residents of the southern United States (US) account for a disproportionate percentage of new human immunodeficiency virus (HIV) infections in the country. The factors that have led to high rates of HIV in these groups are variable and complicated and can be highly specific depending on the group. This means that any HIV prevention effort that seeks to reduce the rate of new HIV infections (including efforts related to the adoption of pre-exposure prophylaxis [PrEP]) must be delivered in a culturally competent way that takes into account the unique characteristics and cultures of the individuals within these groups.

Groups Disproportionately Affected by HIV In 2014, more than 44,000 people were diagnosed with HIV infection in the US, with the following groups having the highest risk: 

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Racial minority populations: Although African Americans represent only approximately 12% of the US population, they accounted for 44% of all new HIV diagnoses, and although Hispanics/Latinos represent only approximately 17% of the population, they accounted for 23% of all new HIV diagnoses MSM: MSM accounted for 83% of all new HIV diagnoses among men and 67% of diagnoses overall; African American MSM accounted for 25% of all new diagnoses; and diagnoses among Hispanic/Latino MSM increased by 24%, whereas rates in white MSM declined by 18% PWID: Although only approximately 6% of all HIV diagnoses were attributable to injection drug use (IDU) in 2014, the 2015 HIV outbreak in Scott County, Indiana, has drawn attention to the effects that IDU and unsafe injection practices can have on HIV transmission in resource-poor communities that lack adequate harm-reduction services (eg, syringe exchange programs, access to medication-assisted treatment for those with opioid addiction) Southern residents: The South has the largest number of people living with HIV (44% of those diagnosed with HIV) and the highest rate of new infections. The Southern epidemic is both an urban and rural issue, driven by structural factors including economic inequality, poverty, and lack of access to quality healthcare

Patient Sexual Histories and Culturally Competent Language Cultural competence is defined as the ability to respond effectively to people from different cultures and backgrounds. Healthcare professional cultural competence is associated with improved quality and effictiveness of care in minority patients with HIV and starts by recognizing the importance that race, ethnicity, religion, socioeconomic status, age, and sexual orientation have on the experiences of your patients and clients.

Cultural competence also factors into one of the first steps in determining whether an individual is a candidate for PrEP: conducting a sexual history. As a medical professional and/or patient advocate, it is likely that you will be responsible for gathering a complete sexual history from a patient with a background different than yours. It is essential to use nonjudgmental, culturally competent language when surveying patients on their sexual histories to gather the most accurate information possible, assess their HIV risk, and consider whether PrEP for HIV prevention is an appropriate choice. The following are several suggestions for conducting culturally competent sexual histories:  Explain why you need to ask questions, especially as they become more personal and sensitive, for example, “I am asking you this question to better understand your sexual health goals. We consider sexual health to be an important part of one’s overall health.”  Ask transgender patients how they would like to be addressed (birth name or transgender name) and which gender they associate with. If medical-record notes require that birth names be used, explain that to the patient.  Interview the patient/client privately, without other family members present. Keep in mind that you may need to create the opportunity for the patient to be alone, rather than specifically ask family members to leave.  Reassure the patient that your interview is confidential. Many individuals may not be open with their families or communities regarding their sexual behavior and may be reticent to discuss it with you; this may be especially true in communities where religion plays an important role.  Ask questions in ways that are both sensitive and matter-of-fact. Start with questions that are the least intrusive, for example, “Tell me about your living situation” or “Who do you live with?” and work your way to ones that may be more difficult for patients to answer.  Do not assume that patients are heterosexual or monogamous, and do not ask questions that imply those behaviors. Examples of questions that do not make these assumption include “Do you have a significant other or partner?” or “Are you in an intimate relationship with someone?”  Ask open-ended questions regarding the patient’s sexual history and experiences, for example, “Tell me a little about your sex life,” followed by a prompt for additional details if they are necessary (ie, “Who does what and what goes where?”).

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Tips to Promote a Culturally Competent Atmosphere  Display posters identifying your clinic/practice as nondiscriminatory  Provide information about culturally relevant resources and services (eg, items specific to MSM, African Americans)  Use intake forms that do not assume a heterosexual family structure  Conduct cultural competence training with all staff to ensure an inviting and nonjudgmental experience for patients at every step in their care  Provide interpreters for patients whose first language is not English, and provide patient materials in different languages  Offer sliding-scale fees for patients with limited economic means, or recommend federally qualified health centers that can help patients without adequate health insurance coverage

References Centers for Disease Control and Prevention (CDC). HIV in the United States: At A Glance. www.cdc.gov/hiv/statistics/overview/ataglance.html.

Accessed November 3, 2016.

Centers for Disease Control and Prevention (CDC). HIV Surveillance Report 2015. www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hivsurveillance-report-us.pdf. Accessed November 3, 2016.

Peters PJ, Pontones P, Hoover KW, et al. HIV infection linked to injection use of oxymorphone in Indiana, 2014-2015. N Engl J Med. 2016;375(3):223-239.

Substance Abuse and Mental Health Service Administration. Tip 59: A Treatment Improvement Protocol: Improving Cultural Competence. https://www.ncbi.nlm.nih.gov/books/NBK248428/pdf/Bookshelf_NBK248428.pdf. Accessed November 3, 2016.

Saha S, Korthuis PT, Cohn JA, Sharp VL, Moore RD, Beach MC. Primary care provider cultural competence and racial disparities in HIV care and outcomes. J Gen Intern Med. 2013;28(5):622-629.

This activity was developed by Med-IQ in collaboration with HealthHIV, Pozitively Healthy, and the National Coalition for LGBT Health.

The information provided through this activity is for continuing education purposes only and is not meant to substitute for the independent medical judgment of a physician relative to diagnostic and treatment options of a specific patient’s medical condition.

Supported by an educational grant from Gilead Sciences, Inc. © 2016 Med-IQ. All rights reserved.

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