Client education

David Lee: Melbourne Sexual Health Centre 
Cherie Bennett: NSW STI Programs Unit

Nurses play a pivotal role in managing human immunodeficiency virus (HIV), in particular by providing clients with evidence-based education, so that they can make choices, evaluate decisions and choose the best options to maintain and improve their health. The scope of this work may vary both in the role of the nurse according to his or her clinical practice and the needs of the client. How to prevent future infections (including sexually transmitted infections [STIs] and blood-borne viruses [BBVs]), empowering patients to take an active role in their health care and preventing onward transmission of HIV, are some examples. People will differ in their health needs and being aware of their level of health literacy is critical in order to tailor the information and ensure their understanding, giving them the ability to make informed health decisions.

Educational strategies

Educational strategies in HIV and sexual health take into account individual values, knowledge and situations, and ensuring the ethical principle of primum non nocere (first, do no harm) is adhered to.  Nursing input into the sexual health of individual clients, couples, partners and cultural groups, needs to take into consideration diverse issues: sexuality, gender identity and gender equality, sex, fertility and reproductive health rights, relationships and STIs including HIV.[1] Should a nurse not feel comfortable discussing these issues, it is important that he or she refer the client to a specialist HIV or sexual health service.

In order to gain trust, the nurse needs to present a non-judgmental outlook and to reassure the client of confidentiality when discussing sexual health and sexual practices. The nurse may provide basic information such as that available on quality internet sites; or the nurse may choose to use his or her full professional potential, experience and skills as a patient advocate[2] to gain an understanding of the individual’s values. It is important to dispel misperceptions or internalised (or societal) phobia surrounding sexual health and STIs.[3] [4]

Strategies and tools that can be used to engage and assess clients’ needs and values include: HEADSS assessment (Home and Environment, Education and Employment, Activities, Drugs, Sexuality, Suicide, Depression) [5] or the PLISSIT model (Permission, Limited Information, Specific Suggestions, Intensive Therapy)[6] or a specific sexual health history and risk assessment: See for example, https://www.health.qld.gov.au/publications/clinical-practice/guidelines-procedures/cm-guidelines01.pdf

Client education for HIV prevention

Sex and sexuality involve complex human dynamics. The aim of patient education is to develop positive and protective factors to assist the client in achieving optimal sexual health.[7]

Sex is foremost about pleasure; whether it is masturbating alone, or with a companion; or physical, psychosocial or emotional intimacy in partnerships and relationships. Example discussion points for nurses when addressing HIV/STI prevention with clients include:

  • The earlier an individual is diagnosed with an STI, the earlier it can be treated and transmission prevented. Recognising symptoms of STIs (dysuria, urethral discharge; genital pain) early may prompt an individual to access clinical services[8]
  • Factors that contribute to STI transmission are dependent on the type of sexual activity people engage in.[9] The use of condoms is protective against most STIs, especially HIV. However, other STIs such as human papilloma virus (HPV) and herpes simplex virus (HSV) only require close genital skin-to-skin contact for transmission to occur[10]
  • While condoms are considered the gold standard for prevention, there are alternative methods, referred to as biomedical prevention methods. These methods can involve the client taking antiretroviral drugs prophylactically following a high-risk exposure (postexposure prophylaxis [PEP]) or before and ongoing, in the case of repeated high-risk exposures (pre-exposure prophylaxis [PrEP])[11] See HIV pre-exposure prophylaxis for more information.
  • Concurrency in partnerships (having more than one partner at any one time) may occur throughout life. Factors that may contribute to concurrency may vary. However, ensuring that clients know the HIV status of their partner/s and the importance of open communication around what HIV/STI prevention strategies will be used with each type of partner is critical, i.e. regular partner/s versus casual partner/s.[12]

Client education at the point of diagnosis

To establish the education needs of a client at the point of diagnosis, acknowledge that each person is different in how they respond to their diagnosis and what questions they may have.  People’s level of health literacy is variable and responses to open ended questions may help target information to levels that will be understood and assist in prioritising the individual’s concerns. It is important to remember at the point of diagnosis, people are usually overwhelmed. The nurse can provide written material, direct clients to suitable internet sites (if appropriate), acknowledge that the diagnosis may be overwhelming and allow clients to ask and repeat any questions they may have.  (See Section 1 New diagnosis of HIV for further information.)

After clarifying the clients' main concerns, other critical points to discuss include that:

  • HIV is a treatable and manageable chronic disease
  • Treatment is safe, highly effective and most beneficial if started as soon as possible after diagnosis
  • There are many supports available (including psychosocial, community and peer supports) - see http://www.afao.org.au/ to locate services in the relevant state or territory
  • Contact tracing and partner notification are important, and the nurse can explain ways this can be done (see also Section 3 Partner notification and contact tracing)
  • There are ways in which to prevent onward transmission
  • How to disclose their status in the future (Note: the legal framework around HIV disclosure varies in each state and territory – see: http://www.ashm.org.au/Pages/Guidelines/Australian-HIV-Laws-Policies-Guide.aspx)

Ongoing client education

Following diagnosis, the role of ongoing education and maintaining a rapport with your client can be critical in their remaining linked into clinical care.  Just as during other times throughout the continuum of care, people’s ongoing education needs will vary. Ensuring a holistic approach is taken is key in ensuring that all aspects of client care are considered and addressed. The following is not an exhaustive list but provides guidance on topic areas that should be addressed with people with HIV:

  • Assessing their understanding of adherence once they commence treatment. (See also Section 11 Adherence support)
  • Ways of preventing other STIs and BBVs in terms of preventing onward transmission
  • The importance and role of maintaining a healthy lifestyle (diet, exercise, limiting the use of alcohol and other drugs)
  • What being HIV positive will mean in terms of how often they will need to attend medical appointments (such as monitoring, annual check-ups, vaccinations, STI checks, prescriptions.)
  • Fertility choices and options
  • Referrals are available for support services and counselling (may include those relating to drug use, potential self-harm, family violence)
  • Encourage questions or concerns when you meet at follow-up appointments.

Other useful resources

http://stipu.nsw.gov.au/wp-content/uploads/FINAL_PREPARING-FOR-TREATMENT_V11-1.pdf/

http://stipu.nsw.gov.au/wp-content/uploads/FINAL_SUPPORTING-ADHERANCE_V9.pdf/

Motivational Interviewing in STI prevention: http://www.racgp.org.au/afp/2012/september/motivational-interviewing-techniques/

Mindfulness: http://www.mindfulness.net.au/micbt-foundation-course.html

Sexuality and coming out

http://www.sexualityandu.ca/sexual-health/sexual-orientation-and-coming-out

http://multicultural.usf.edu/pdf/safezone/support_identity.pdf

Building up relationships

http://www.loveisrespect.org/healthy-relationships/

Normal genital anatomical variances; penile sizes; vulval appearances; body image http://www.stiatlas.org/SearchAtlas.aspx

www://labialibrary.org.au/

1.
World Health Organization. Developing Sexual Health Programs [Internet]. Geneva: [updated 2010; cited 2-15 Aug 25]. Available from: http://apps.who.int/iris/bitstream/10665/70501/1/WHO_RHR_HRP_10.22_eng.pdf 
2.
Ezekiel JE, Ezekiel LL. Four models of the physician-patient relationship JAMA 1992; 16:2221-2226. 
3.
World Health Organization. Developing Sexual Health Programs [Internet]. Geneva: [updated 2010; cited 2-15 Aug 25]. Available from: http://apps.who.int/iris/bitstream/10665/70501/1/WHO_RHR_HRP_10.22_eng.pdf 
4.
Ezekiel JE, Ezekiel LL. Four models of the physician-patient relationship JAMA 1992; 16:2221-2226. 
5.
Cohen E, Mackenzie RG, Yates GL. HEADSS, a psychosocial risk assessment instrument: implications for designing effective intervention programs for runaway youth. J Adolesc Health 1991 Nov;12(7):539-44. 
6.
Taylor B, Davis S. Using the extended PLISSIT model to address sexual healthcare needs. Nurs Stand 2006;21(11): 35–40 
7.
World Health Organization. Developing Sexual Health Programs [Internet]. Geneva: [updated 2010; cited 2-15 Aug 25]. Available from: http://apps.who.int/iris/bitstream/10665/70501/1/WHO_RHR_HRP_10.22_eng.pdf 
8.
Garnett GP. Transmission dynamics of sexually transmitted infections. In: Holmes KK, Sparling PF, Mardh M-A et al. editors Sexually Transmitted Diseases, 4th ed. New York: McGraw-Hill; 2008:27-39. 
9.
Garnett GP. Transmission dynamics of sexually transmitted infections. In: Holmes KK, Sparling PF, Mardh M-A et al. editors Sexually Transmitted Diseases, 4th ed. New York: McGraw-Hill; 2008:27-39. 
10.
Garnett GP. Transmission dynamics of sexually transmitted infections. In: Holmes KK, Sparling PF, Mardh M-A et al. editors Sexually Transmitted Diseases, 4th ed. New York: McGraw-Hill; 2008:27-39. 
11.
Zablotska I, McAllister J, McNulty A. Biomedical prevention of HIV. In:  HIV, Viral Hepatitis & STIs A Guide for Primary Care Providers. Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine, Chapter 14, Biomedical prevention of HIV; 2014:167-169. 
12.
Garnett GP. Transmission dynamics of sexually transmitted infections. In: Holmes KK, Sparling PF, Mardh M-A et al. editors Sexually Transmitted Diseases, 4th ed. New York: McGraw-Hill; 2008:27-39.