In February 2019, the federal government announced a plan to reduce the number of new HIV infections in the United States by 75% within 5 years and by 90% within 10 years.1 In the United States, the burden of new HIV infections remains highest among men who have sex with men (MSM).2 The Centers for Disease Control and Prevention (CDC) estimates that of the 38,739 new cases of HIV reported in 2017, 70% were among MSM.2
Factors such as stigma, homophobia, poverty, violence, and racism have been identified as major contributors to the health disparities associated with the increased HIV prevalence among MSM. 3 By providing MSM with culturally affirmative care and offering HIV prevention services, such as pre-exposure prophylaxis (PrEP) and non-occupational post-exposure prophylaxis (nPEP), nurse practitioners and physician assistants can help address the HIV epidemic among this population.
Assessing Risk: Asking the Right Questions
Providing comprehensive HIV prevention services begins with obtaining a thorough sexual history. 4 Data have shown that many providers are not discussing sexual health with MSM patients, leading to missed opportunities for preventing HIV infection.4,5 Before taking a sexual history, clinicians should tell patients that the information being gathered is intended to ensure they are receiving appropriate care. Clinicians should reassure the patient of the confidential nature of the responses. A statement such as, “in order for me to provide you with appropriate care, I am going to ask you questions that I ask all of my patients. All of your answers will be kept confidential,” can help to inform the patient of the objective of the questioning and encourage cooperation.
A pamphlet describing how to take a sexual history that includes asking the 5 “Ps”: partners, practices, past history of sexually transmitted infections (STIs), prevention of STIs, and plans for pregnancy is available on the CDC website.6 According to guidelines developed by the National Coalition of STD Directors and the National Network of STD Clinical Prevention Training Centers, the sexual history should be expanded to include a 6th “P” for pleasure, as comprehensive assessment of sexual history should include a discussion on sexual satisfaction and pleasure.4
There are various ways to ask patients about their sexual partners. Some clinicians begin with a general screening question such as, “Do you have sex with men, women, or both?” Although this direct approach can be successful, another option is to use an open-ended request, such as, “Tell me about the gender of your partners.” This approach provides patients with an opportunity to define the gender of their partners. Not all MSM have sex exclusively with other men. Some MSM have sex with cisgender women, transgender men, and/or transgender women.7
Additionally, it is helpful to assess if they have a primary partner or if they have more than 1 partner. Some MSM may have a primary relationship that is sexually monogamous. Other individuals may have partners outside of their primary relationship. Understanding the gender of a patient’s partners and the number of partners can help determine the type of education, counseling, testing, and preventive health interventions that should be provided.
Once information about a patient’s partners has been obtained, clinicians should enquire about sexual practices. Does the patient engage in oral sex, anal sex, oral-anal sex (“rimming”)? Does the patient practice insertive sex (“top”), receptive sex (“bottom”), or both (“vers” or “versatile”)?8 Data have shown that physiologic changes in the rectal mucosa occur in MSM who engage in receptive anal sex, which places them at increased risk for HIV infection.9
Clinicians should enquire about other practices such as use of toys, fisting, and use of recreational drugs or substances while having sex. For the latter question, the clinician should ask about what type of drugs are used: for example, crystal methamphetamine (also known as “chemsex” or “party and play”), amyl nitrate (“poppers”), or alcohol.4 Answers to these questions can help provide a better assessment of risk for STIs, HIV prevention, need for extragenital screening, and/or other preventive health counseling or risk reduction interventions.