One reason it’s important to have this discussion is to decide what precautions are appropriate for preventing sexually transmitted diseases, such as HIV. Your risk for being infected with HIV depends on a variety of factors, including what kinds of sex you’re having, how often, and who your partner is/partners are. If you fall in a high-risk group based on your sexual practices or use of intravenous (IV, or injected) drugs, your doctor should be comfortable explaining the methods available to protect yourself from becoming infected with the virus. But in case your doctor doesn’t initiate this discussion, it’s a good idea to prepare a list of your own questions to make sure you get the HIV protection you need. Here is some guidance, including tips from doctors, about how to talk about your HIV risk and prevention options at your next appointment.
Who Should Be Screened for HIV?
Part of the reason the topic may be difficult is because of the stigma surrounding HIV, including the idea that it only affects certain “types” of people. But according to current best practices, doctors should screen everyone to figure out their risk of acquiring HIV. “In general, we think of everyone that’s in front of us as needing testing at least once in their lifetime,” says Monica Gandhi, MD, a professor of medicine and associate division chief of the division of HIV, infectious diseases, and global medicine at the University of California San Francisco. “And then, if someone is more high risk, we think about both more frequent HIV testing,” she says, and pre-exposure prophylaxis (PrEP) — taking a daily pill to prevent HIV. The people at highest risk for HIV in the United States are those who have anal sex as the receptive partner (bottom) without a condom and outside of a monogamous partnership, says Dr. Gandhi. It’s standard protocol, though, to treat the insertive partner (top) as if they’re high risk also, especially since many people engage in both roles in this type of sexual activity. Vaginal sex is the next most common means of HIV transmission in the United States. This particularly applies to women who change partners, Gandhi says, noting that if you’re sexually active, “anyone who isn’t in a stable partnership can be at risk for exposure.” While most HIV transmission in the United States happens through sex, people who use injected drugs make up the third main high-risk category, says Gandhi. If you fall into any of these categories — having higher-risk anal or vaginal sex or using injected drugs — it’s important to explore which HIV prevention methods fit with your risk level and goals. Condoms are a very effective way to prevent HIV transmission if you use them faithfully, Gandhi notes. But if you’re not consistent, or if you use injected drugs, it could make sense to consider going on PrEP.
Tips for Having an Honest Conversation With Your Doctor
Ideally, Gandhi says, your doctor should ask questions about your sexual and drug-use history as part of a routine physical exam, and a conversation about HIV prevention can flow from there. “It shouldn’t really be up to the patient [to bring up the topic],” she says. “It’s up to us as a medical community to do a better job with that.” Doctors should ask questions about sexual history “in a nonjudgmental way that makes the patient feel comfortable being honest,” says Michael Wohlfeiler, MD, chief medical officer of the AIDS Healthcare Foundation and an HIV specialist in South Beach, Florida. But this doesn’t always happen, which can make patients hesitate to bring up certain topics or answer questions fully and honestly. “There can be discomfort on the patient side and the physician side,” he notes. Honesty is key to a productive conversation, Dr. Wohlfeiler says, and this can be difficult when your doctor is visibly uncomfortable discussing certain sexual practices, such as anal sex, oral-anal contact (rimming), oral sex, or gay sex in general. Some doctors don’t ask about the gender of sexual partners, he notes, which can leave patients feeling like their doctor is making assumptions or isn’t interested in getting an accurate picture of their sex life. Gandhi agrees that doctors should be asking questions about sex in a straightforward way. “I think doctors have to be comfortable with different sexual practices and not assume everyone is having sex a certain way,” she says. “We as physicians have to be completely open to just thinking about the patient’s health and how we protect them, and not bring any sort of judgment into our conversations with them.” If your doctor doesn’t ask questions that lead to dialogue about your HIV risk, “I think you should just say, ‘I’m sexually active, and I’d like to talk about my risk of acquiring STDs, including HIV,’” says Wohlfeiler. “Another way would be to simply say, ‘I’d like to talk about whether PrEP would be appropriate for me.’” Taking PrEP medication carries certain risks, Gandhi notes, such as potentially harmful effects on the kidneys and bones in some people. If you’re on PrEP, you’ll need to get regular lab work, including HIV testing. Your doctor will need to see you every three months to do this lab work and counsel you on continued safe sex practices as well as learn about any new partners. “It’s not like you just get a prescription, and that’s the end of it,” Wohlfeiler notes, so it’s important to discuss the risks and benefits of PrEP. Another consideration to discuss with your doctor is the risk of getting STDs other than HIV, which may be greater if you go on PrEP and don’t use condoms consistently. When PrEP was introduced, “We knew we would see an increase in things like syphilis, gonorrhea, and chlamydia, and that’s exactly what’s happened,” says Wohlfeiler. “Condoms help prevent those other STDs.” Ultimately, if your doctor can’t or won’t discuss these topics with you — or you don’t feel comfortable with the tone or direction of the conversation — “I think it’s absolutely appropriate to switch [doctors],” says Gandhi. If you’re interested in PrEP in particular and don’t want to find a new primary doctor, another option could be to look for a specialized sexual wellness clinic in your area, says Wohlfeiler. Some HIV-based clinics area also available to see non-HIV patients who would like to start PrEP.
Preparing for Your Appointment
If you want to discuss HIV prevention with your doctor, one strategy for making sure the topic gets brought up — by you or by your doctor — is to write a list of questions or topics and bring it to your appointment. Questions you may want to ask include:
How often should I get tested for HIV?How can I effectively use condoms to prevent HIV and other STDs?Am I a candidate for PrEP?What other steps can I take to reduce my risk of acquiring HIV?
But no matter how prepared you are ahead of time, “somebody has got to be brave enough to bring it up, either the doctor or the patient,” emphasizes Wohlfeiler. “What it comes down to is, you’ve got to find someone you’re comfortable having that discussion with.”
