February 7, 2011
As I was sitting homebound in Super Bowl XLV land due to the Groundhog Day blizzard, I thought about what I could do for U.S. National Black HIV/AIDS Awareness Day on Feb. 7, 2011, in addition to my role as a nurse practitioner providing direct patient care. In other words, how could I further assist in reducing the transmission of HIV among African Americans? So, I decided to do what I do best, which is run my mouth about sex.
As a provider, having the safer sex conversation with your patient (interchangeable with client) can be truly and utterly daunting if you have not had training, do not understand your own bias, or just feel plain uncomfortable. Years ago, when I was the program director for the Midwest AIDS Training and Education Center, I was asked to attend a Partnership for Health training in Oakland, Calif. What a fabulous opportunity that turned out to be: Me, a shy and retiring woman at sex training. Hah! Believe that!
The Partnership for Health program was designed at the University of Southern California (USC), Keck School of Medicine, originally as a research study funded through the National Institutes of Mental Health. It then evolved into a training program run through the Pacific AIDS Education and Training Center and the Department of Preventive Medicine at USC. This program introduced a brief safer sex intervention (3-5 minutes per visit) for HIV outpatient clinics that emphasizes the importance of the partnership between the patient and his or her health care provider. The program's slogan is "The action of one. The partnership of two. The power of many," and focuses on the provider-patient relationship to stop HIV transmission.
This program requires that the provider give safer sex messages framed as a "gain" or "loss." Framing is an intervention that links a behavior with an outcome -- good or bad. A "gain frame" message is one that emphasizes a gain or advantage. For example: If you use protection, it will help keep other people free of HIV infection.
On the other hand, a "loss frame" message is one that has a loss or negative consequence as an outcome. For example: If you engage in unprotected anal or vaginal sex, your partner could get infected. Therefore, the loss frame emphasizes the loss or consequences for high-risk behaviors.
The study results reported that there was a 38 percent reduction in unprotected vaginal/anal sex (UAV) with a loss/consequences-framed message for clients with multiple sex partners. I don't know what you are seeing in your practices, but I see a lot of patients with multiple sex partners. Quick thought: Just last week I had a four-some, all HIV-positive men who have sex with men and all with syphilis from the same confirmed case, but I digress. Anyway, the loss/consequence frame was more effective than gain/advantages-framed messages because of the emotional weight; these messages may require more cognitive processing and involvement with the issue.
Aside from all of this wonderful and truly fascinating data that Jean Richardson and colleagues have provided, there was information directed toward training providers to teach safer sex to their clients. Yeah, right? What's new? Yes, I know you've heard this before, but this was special. Special, she says? Well, what can I say when there was every sex toy there known to man and some that I think they made up?
The purpose of all that visual and tactile stimulation was to train us on safer sex by making it fun and erotic for the patient and her or his partner(s). Train the trainer! Right after my own heart. How else could you get a horse to the drink if he didn't feel like it? Oops, I digress again.
So, imagine your health care provider having a candid or frank discussion with you on your sexual practices as a way to assess whether you have high-risk behaviors for sexually transmitted infections (STIs). Are you with me so far? OK, imagine that your health care provider, filled with genuine concern, discussed and broke out examples of how you can have safer sex while making it erotic. Brilliant! Yes, some of you will be mortified and others titillated; but truly, patients want to discuss their sexual practices, but are afraid to bring them up for fear of judgment -- real or perceived.
You may be younger, older, or of a different sexual orientation than your client, making it difficult for her or him to broach the topic of high-risk sexual practices. You may have your own hang-ups about what you consider just plain "nasty" sexual practices -- but it's not about you! When I tell you that a patient can read your body language right down to the curl of your eyelash, believe it. So that disgusted look should not be in the dialogue or the patient will shut down and that would be an utter hot mess.
Before we attempt to do this work, I recommend that as providers we should check out our own biases and proceed with caution. If you can't handle talking about bottoms, tops, rimming, tea bagging and other slang terms, than I suggest another person on your team take your place. This intervention truly works with health care provider buy-in with a committed team. That's what makes it successful.
Anyway, as an example, my precious patients throughout the years have come to me not recognizing that unprotected oral sex can lead to STIs. OK, well yes it can and will if you continue to have a steady diet of raw "partner(s) du jour." So, the message is: If you don't have protected oral sex, you can get ugly oral human papillomavirus, syphilis or herpes, so that everyone will know what you've been munching on when they look at your lips (hmm, was that a loss frame message?).
In my practice, I engage in a dialogue in very down-to-earth language that includes enjoying your "diet," but protecting yourself (and others) by using latex, polyurethane, dental dams or plastic wrap over the object of desire (i.e., anus, vagina or penis). If you don't have a flavored barrier, by all means use what is on hand: whipped cream, honey, chocolate, etc., to make it more palatable so that you can and will protect yourself. It's just simply eroticizing safer sex.
To reduce the transmission of HIV further in the African-American community this awareness day, remember to engage your patients in discussion. Keep my version of Beyoncé's song "Single Ladies (Put a Ring on It)" in mind to help your patients: "If you like it better put a ring (latex or polyurethane) on it."
Tell them if they don't they will be saying, "Wa oh, oh, oh-oh, oh, oh oh-oh-oh, Wa oh, oh, oh-oh, oh, oh-oh" when you give the diagnosis of gonorrhea, chlamydia, syphilis, herpes or human papillomavirus. Handle your business!
Bethsheba Johnson, MSN, CNS, GNP-BC, AACRN, AAHIVS, is a nurse practitioner at Peabody Health Center/AIDS Arms, Inc., in Dallas, Texas. Stay tuned for more of her writings on HIV/AIDS care on TheBody.com and TheBodyPRO.com.