Introduction
Maintaining and promoting good sexual health is not only important for preventing sexually acquired infections and unintended pregnancies, but also for the prevention of transmission and acquisition of resistant strains of HIV, hepatitis C, preventable infertility and anogenital cancers [1]. Sexual health, although having been in the spotlight for a long time [2], has primarily focused on sexual infection and disease prevention [3]; however, this focus is now shifting to become more inclusive of other aspects of human sexuality. It now encompasses the broad spectrum from sex education in schools [4] to sexual function, in part because of the HIV epidemic and its associated research. Poor sexual health disproportionately affects men who have sex with men (MSM) and women [1], and in the UK the focus is now on developing a sexually healthy society, with a large number of government initiatives and standards set by health organisations [5-8].
Maintaining and promoting good sexual health is not only important for preventing sexually acquired infections and unintended pregnancies, but also for the prevention of transmission and acquisition of resistant strains of HIV, hepatitis C, preventable infertility and anogenital cancers [1]. Sexual health, although having been in the spotlight for a long time [2], has primarily focused on sexual infection and disease prevention [3]; however, this focus is now shifting to become more inclusive of other aspects of human sexuality. It now encompasses the broad spectrum from sex education in schools [4] to sexual function, in part because of the HIV epidemic and its associated research. Poor sexual health disproportionately affects men who have sex with men (MSM) and women [1], and in the UK the focus is now on developing a sexually healthy society, with a large number of government initiatives and standards set by health organisations [5-8].
What is sexual health?
Sexual health is not a timeless concept [9] and the definition is broad; however, there are a number of definitions and three overarching themes [10]:
* The capacity to enjoy and control sexual and reproductive behaviour in accordance with a social and personal ethic;
* Freedom from fear, shame, guilt, false beliefs and other psychological factors inhibiting sexual response and impairing sexual relationship;
* Freedom from organic disorders, disease and deficiencies that interfere with sexual and reproductive functions.
Assessing sexual health
A sexual history should be taken on a 6-monthly basis and patients should be offered annual sexual health screens [11]. Patients engaging in high-risk behaviours and those with symptoms should be offered a check-up more regularly. Risk-taking behaviours and barebacking are common: one in three MSM engage in unprotected anal sex [12]. While being essential to identify and discuss, it is important to approach sexual risk-taking and drug use with sensitivity, as a judgemental approach will alienate and become a barrier for people attending services for diagnosis and treatment [9,12,13]. Routine sexually histories should identify potential sites of infection and include questions about sexual practices that may increase the likelihood of transmission of infections: multiple sexual partners, drug use for sex, unprotected intercourse, the use of sex toys that are shared and shared lubricant when sex involves multiple partners. A travel history is also useful.
Screening
Asymptomatic patients should have routine checks for gonorrhoea, chlamydia, syphilis, and hepatitis B and C. Always ensure that patients are up to date with their hepatitis A and B vaccinations and, if vaccinated, annual checks of their anti-HBs to ensure adequate protection. Routine examination should include the skin, oral cavity, anus, vagina or penis and testicles. Patients with symptoms should be screened dependent on symptoms as per national guidelines [14]. However, in routine presentations a high index of suspicion for the unusual should always be exercised in patients engaging in high-risk behaviours given the increases in previously uncommon conditions such as LGV and irregular presentations of conditions such as syphilis. Atypical anogenital lesions should be referred for assessment to exclude pre-cancerous changes (intraepithelial neoplasia) or other chronic dermatological complaints.
Women and HIV
It is recommended that women with HIV should have an initial colposcopy at diagnosis followed up with annual cervical cytology [11]. Contraception is as important as it is for negative women; however, consideration is required for interactions with antiretroviral therapy. For example, as liver enzyme-inducing medication such as atazanavir increases the metabolism of progesterone-only emergency contraception, a woman would require double the dose of the contraception [15]. Pre-conceptual care and pregnancy services are also necessary as specialist advice or support may be required for interventions such as sperm washing, changes in treatment and support post delivery.
Sexual function
Sexual function issues are common in patients with HIV [16]. This is hardly surprising given the psychological and physical impact that HIV can have--the diagnosis itself, the fear of transmission, altered body image, stigma, fear of rejection, discordant relationships, loss of a partner, the impact of the disease on the body, the various medications and co-infections, to name but a few. Untreated sexual dysfunction may cause other issues, including unprotected anal sex because of erectile dysfunction as it is difficult to use condoms, or complete avoidance of sex and forming attachments, so impacting on quality of life. Assessments of patients should include questions about sexual function, with referral to specialist services as appropriate. Do make sure, however, you understand what is available before assessing sexual function as it is a little unfair to raise a patient's expectations and not be able to follow through with appropriate interventions.
Raising status issues
Discussing HIV status with prospective partners is fraught with potential problems and issues of rejection, stigma and potentially violence [9]. As well as 'killing the mood', stigma may lead to low self-esteem, which in itself can lead to increased sexual risk-taking [9]. However, talking about HIV status in a discordant relationship can lead to both partners working hard to maintain the negative partner's negativity [17]. Where both partners are HIV-positive, it is also important for sexual partners to broach status issues of resistant HIV and hepatitis C, especially if they are planning to engage in unprotected sex.
Legal issues
Since the successful prosecution of a man in Scotland in 2001 [18], there have been relatively few prosecutions for reckless transmission of HIV. However, it is important to discuss with patients the potential legal issues if they are engaging in risky sexual behaviours. There is a wide assumption of safety from prosecution if you inform your negative or untested partner of your HIV status prior to unprotected sex [19]. The law can also apply to other infections [20], although there have been no successful prosecutions as yet [19]. This has potential implications for HIV-positive patients who are co-infected with hepatitis C or infections like herpes, or have resistant strains of HIV.
Health promotion and protection
When working with patients it is important to discuss post-exposure prophylaxis for sexual exposure (PEPSE), ensuring that they are aware of when it should be used and how it can be accessed especially out of hours. Also (where indicated) discussions should occur relating to risk-taking behaviours, drug use (including alcohol and smoking), resistant HIV and hepatitis C.
Implementing sexual health initiatives
When implementing initiatives it is important to make them as seamless as possible for the patient and, where possible, involve patients in the planning stages. It is also best to avoid, where possible, extra clinic visits, referrals to various other professionals/services and multiple long waits. It may be easier and more convenient for the patient to have any further tests incorporated into their routine blood screens/appointments. Using proformas can standardise care and make auditing easier for clinicians. The use of questionnaires that patients fill in can also speed up the process (especially for asymptomatic patients). This can be supported with prompts on computer systems or in the patients' notes. If local sexual health contraceptive services are not co-located/ integrated, developing links is very helpful.
Further reading
Sexual function
Bancroft J. Human Sexuality and its Problems. 2nd edn. Churchill Livingstone, Edinburgh, 1989.
Barebacking
Halkitis P, Wilton L, Drescher J. Barebacking: Psychosocial and Public Health Approaches. Haworth Medical Press, New York, 2005.
Sexually transmitted infections
Pattman R, Snow M, Handy P, Sankar K, Elawad B. Oxford Handbook of Genitourinary Medicine, HIV and AIDS. Oxford University Press, Oxford, 2005.
Clinical skills
Grundy-Bowers M snd Davies J. Advanced Clinical Skills for GU Nurses. Wiley, London, 2007.
Contraception
Guillebaud J. Contraception: Your Questions Answered. Churchill Livingstone, London, 2008
References
[1] Kinghorn G. A sexual health and HIV strategy for England. BMJ, 2001, 323, 243-245.
[2] Grundy-Bowers M. Defining advanced practice. In Advanced Clinical Skills for GU Nursing (Grundy-Bowers M and Davies J, eds), Wiley, London, 2007.
[3] Rosenthal D and Dowsett G. The changing perceptions of sex and sexuality. Lancet, 2000, 356, 58.
[4] Coyle K, Baen-Engquist K, Kirby D et al. Short-term impact of safer choices: a multicomponent, school-based HIV, other STD, and pregnancy prevention program. J Sch Health, 1999, 69, 181-189.
[5] Department of Health. The National Strategy for Sexual Health and HIV. Department of Health, London, 2001.
[6] Department of Health, Choosing Health: Making Healthy Choices Easier. Department of Health, London, 2004.
[7] Medical Foundation for and Sexual Health. Recommended Standards for NHS HIV Services. MedFASH, London, 2003.
[8.] Medical Foundation for AIDS and Sexual Health. Recommended Standards for Sexual Health Services. MedFASH, London, 2005.
[9.] Vanable P, Carey M, Blair D, Littlewood R. Impact of HIV-related stigma on health behaviours and psychology adjustment among HIV-positive men and women. AIDS Behav, 2006, 10, 473-482.
[10.] Mace D, Bannerman R, Burton J. The teaching of human sexuality in schools for health professionals. WHO Public Health Papers, No 57, 1974. WHO, Geneva. Cited in Edwards W, Coleman J. Defining sexual health: a descriptive overview. Arch Sex Behav, 2004, 33, 189-196.
[11.] British HIV Association. Standards for HIV Clinical Care. BHIVA, London, 2007.
[12.] Richard M. Sexual health: one in three HIV-positive gay men have unprotected sex. Practitioner, 2007, May 28, 33.
[13.] Valdiserri R. HIV/AIDS stigma: an impediment to public health. Am J Public Health, 2002, 92, 341-343.
[13.] BASHH National Guidelines. www.bashh.org/guidelines (last accessed 25/09/2008).
[15.] Faculty of Family Planning and Reproductive Health Care Clinical Effectiveness Unit. Faculty statement from the CEU on Levonelle 1500 and the use of liver enzyme inducing drugs. 2006. www.ffprhc.org.uk/admin/uploads/563_Levonelle1500KeyStatement.pdf (last accessed 25/09/2008).
[16.] Lamba H, Goldmeier D, Mackie N, Scullard G. Antiretroviral therapy is associated with sexual dysfunction and increase serum oestradiol in men. Int J STD AIDS, 2004, 15, 234-237.
[17.] Hong D, Goldstein R, Rotheram-Borus R et al. Perceived partner serostatus, attribution of responsibility for prevention of HIV transmission, and sexual risk behaviour with 'main' partner among adults living with HIV. AIDS Educ Prev, 2006, 18, 150-162.
[17.] AIDSmap website. www.aidsmap.com/en/news/D5C5C7B8-0D45-44BA-9284-BAD743EFE3D0.asp (last accessed 25/09/2008).
[19.] The Eddystone Trust website. www.eddystone.org.uk/hiv07/hiv_pages/prosecutions.php (last accessed 25/09/2008).
[20.] Crown Proscution Service website. www.cps.gov.uk/legal/section5/chapter_g.html (last accessed 25/09/2008).
Sexual health is not a timeless concept [9] and the definition is broad; however, there are a number of definitions and three overarching themes [10]:
* The capacity to enjoy and control sexual and reproductive behaviour in accordance with a social and personal ethic;
* Freedom from fear, shame, guilt, false beliefs and other psychological factors inhibiting sexual response and impairing sexual relationship;
* Freedom from organic disorders, disease and deficiencies that interfere with sexual and reproductive functions.
Assessing sexual health
A sexual history should be taken on a 6-monthly basis and patients should be offered annual sexual health screens [11]. Patients engaging in high-risk behaviours and those with symptoms should be offered a check-up more regularly. Risk-taking behaviours and barebacking are common: one in three MSM engage in unprotected anal sex [12]. While being essential to identify and discuss, it is important to approach sexual risk-taking and drug use with sensitivity, as a judgemental approach will alienate and become a barrier for people attending services for diagnosis and treatment [9,12,13]. Routine sexually histories should identify potential sites of infection and include questions about sexual practices that may increase the likelihood of transmission of infections: multiple sexual partners, drug use for sex, unprotected intercourse, the use of sex toys that are shared and shared lubricant when sex involves multiple partners. A travel history is also useful.
Screening
Asymptomatic patients should have routine checks for gonorrhoea, chlamydia, syphilis, and hepatitis B and C. Always ensure that patients are up to date with their hepatitis A and B vaccinations and, if vaccinated, annual checks of their anti-HBs to ensure adequate protection. Routine examination should include the skin, oral cavity, anus, vagina or penis and testicles. Patients with symptoms should be screened dependent on symptoms as per national guidelines [14]. However, in routine presentations a high index of suspicion for the unusual should always be exercised in patients engaging in high-risk behaviours given the increases in previously uncommon conditions such as LGV and irregular presentations of conditions such as syphilis. Atypical anogenital lesions should be referred for assessment to exclude pre-cancerous changes (intraepithelial neoplasia) or other chronic dermatological complaints.
Women and HIV
It is recommended that women with HIV should have an initial colposcopy at diagnosis followed up with annual cervical cytology [11]. Contraception is as important as it is for negative women; however, consideration is required for interactions with antiretroviral therapy. For example, as liver enzyme-inducing medication such as atazanavir increases the metabolism of progesterone-only emergency contraception, a woman would require double the dose of the contraception [15]. Pre-conceptual care and pregnancy services are also necessary as specialist advice or support may be required for interventions such as sperm washing, changes in treatment and support post delivery.
Sexual function
Sexual function issues are common in patients with HIV [16]. This is hardly surprising given the psychological and physical impact that HIV can have--the diagnosis itself, the fear of transmission, altered body image, stigma, fear of rejection, discordant relationships, loss of a partner, the impact of the disease on the body, the various medications and co-infections, to name but a few. Untreated sexual dysfunction may cause other issues, including unprotected anal sex because of erectile dysfunction as it is difficult to use condoms, or complete avoidance of sex and forming attachments, so impacting on quality of life. Assessments of patients should include questions about sexual function, with referral to specialist services as appropriate. Do make sure, however, you understand what is available before assessing sexual function as it is a little unfair to raise a patient's expectations and not be able to follow through with appropriate interventions.
Raising status issues
Discussing HIV status with prospective partners is fraught with potential problems and issues of rejection, stigma and potentially violence [9]. As well as 'killing the mood', stigma may lead to low self-esteem, which in itself can lead to increased sexual risk-taking [9]. However, talking about HIV status in a discordant relationship can lead to both partners working hard to maintain the negative partner's negativity [17]. Where both partners are HIV-positive, it is also important for sexual partners to broach status issues of resistant HIV and hepatitis C, especially if they are planning to engage in unprotected sex.
Legal issues
Since the successful prosecution of a man in Scotland in 2001 [18], there have been relatively few prosecutions for reckless transmission of HIV. However, it is important to discuss with patients the potential legal issues if they are engaging in risky sexual behaviours. There is a wide assumption of safety from prosecution if you inform your negative or untested partner of your HIV status prior to unprotected sex [19]. The law can also apply to other infections [20], although there have been no successful prosecutions as yet [19]. This has potential implications for HIV-positive patients who are co-infected with hepatitis C or infections like herpes, or have resistant strains of HIV.
Health promotion and protection
When working with patients it is important to discuss post-exposure prophylaxis for sexual exposure (PEPSE), ensuring that they are aware of when it should be used and how it can be accessed especially out of hours. Also (where indicated) discussions should occur relating to risk-taking behaviours, drug use (including alcohol and smoking), resistant HIV and hepatitis C.
Implementing sexual health initiatives
When implementing initiatives it is important to make them as seamless as possible for the patient and, where possible, involve patients in the planning stages. It is also best to avoid, where possible, extra clinic visits, referrals to various other professionals/services and multiple long waits. It may be easier and more convenient for the patient to have any further tests incorporated into their routine blood screens/appointments. Using proformas can standardise care and make auditing easier for clinicians. The use of questionnaires that patients fill in can also speed up the process (especially for asymptomatic patients). This can be supported with prompts on computer systems or in the patients' notes. If local sexual health contraceptive services are not co-located/ integrated, developing links is very helpful.
Further reading
Sexual function
Bancroft J. Human Sexuality and its Problems. 2nd edn. Churchill Livingstone, Edinburgh, 1989.
Barebacking
Halkitis P, Wilton L, Drescher J. Barebacking: Psychosocial and Public Health Approaches. Haworth Medical Press, New York, 2005.
Sexually transmitted infections
Pattman R, Snow M, Handy P, Sankar K, Elawad B. Oxford Handbook of Genitourinary Medicine, HIV and AIDS. Oxford University Press, Oxford, 2005.
Clinical skills
Grundy-Bowers M snd Davies J. Advanced Clinical Skills for GU Nurses. Wiley, London, 2007.
Contraception
Guillebaud J. Contraception: Your Questions Answered. Churchill Livingstone, London, 2008
References
[1] Kinghorn G. A sexual health and HIV strategy for England. BMJ, 2001, 323, 243-245.
[2] Grundy-Bowers M. Defining advanced practice. In Advanced Clinical Skills for GU Nursing (Grundy-Bowers M and Davies J, eds), Wiley, London, 2007.
[3] Rosenthal D and Dowsett G. The changing perceptions of sex and sexuality. Lancet, 2000, 356, 58.
[4] Coyle K, Baen-Engquist K, Kirby D et al. Short-term impact of safer choices: a multicomponent, school-based HIV, other STD, and pregnancy prevention program. J Sch Health, 1999, 69, 181-189.
[5] Department of Health. The National Strategy for Sexual Health and HIV. Department of Health, London, 2001.
[6] Department of Health, Choosing Health: Making Healthy Choices Easier. Department of Health, London, 2004.
[7] Medical Foundation for and Sexual Health. Recommended Standards for NHS HIV Services. MedFASH, London, 2003.
[8.] Medical Foundation for AIDS and Sexual Health. Recommended Standards for Sexual Health Services. MedFASH, London, 2005.
[9.] Vanable P, Carey M, Blair D, Littlewood R. Impact of HIV-related stigma on health behaviours and psychology adjustment among HIV-positive men and women. AIDS Behav, 2006, 10, 473-482.
[10.] Mace D, Bannerman R, Burton J. The teaching of human sexuality in schools for health professionals. WHO Public Health Papers, No 57, 1974. WHO, Geneva. Cited in Edwards W, Coleman J. Defining sexual health: a descriptive overview. Arch Sex Behav, 2004, 33, 189-196.
[11.] British HIV Association. Standards for HIV Clinical Care. BHIVA, London, 2007.
[12.] Richard M. Sexual health: one in three HIV-positive gay men have unprotected sex. Practitioner, 2007, May 28, 33.
[13.] Valdiserri R. HIV/AIDS stigma: an impediment to public health. Am J Public Health, 2002, 92, 341-343.
[13.] BASHH National Guidelines. www.bashh.org/guidelines (last accessed 25/09/2008).
[15.] Faculty of Family Planning and Reproductive Health Care Clinical Effectiveness Unit. Faculty statement from the CEU on Levonelle 1500 and the use of liver enzyme inducing drugs. 2006. www.ffprhc.org.uk/admin/uploads/563_Levonelle1500KeyStatement.pdf (last accessed 25/09/2008).
[16.] Lamba H, Goldmeier D, Mackie N, Scullard G. Antiretroviral therapy is associated with sexual dysfunction and increase serum oestradiol in men. Int J STD AIDS, 2004, 15, 234-237.
[17.] Hong D, Goldstein R, Rotheram-Borus R et al. Perceived partner serostatus, attribution of responsibility for prevention of HIV transmission, and sexual risk behaviour with 'main' partner among adults living with HIV. AIDS Educ Prev, 2006, 18, 150-162.
[17.] AIDSmap website. www.aidsmap.com/en/news/D5C5C7B8-0D45-44BA-9284-BAD743EFE3D0.asp (last accessed 25/09/2008).
[19.] The Eddystone Trust website. www.eddystone.org.uk/hiv07/hiv_pages/prosecutions.php (last accessed 25/09/2008).
[20.] Crown Proscution Service website. www.cps.gov.uk/legal/section5/chapter_g.html (last accessed 25/09/2008).
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