The National LGBTQIA+ Health Education Center has been a pioneer in advancing the wellbeing of the LGBTQIA+ community so they receive access to the highest quality of health care, education, research and advocacy. They date back to 2005 when they first published The Fenway Guide to LGBT Health, the first medical textbook about LGBTQIA+ primary care. Now, they have a catalog of on-demand webinars for newbies and experienced clinicians. I recently completed one of their continuing education webinars for HIV and STI prevention among LGBTQ People and found it to be very informative, so I wrote a blog about it to reinforce what I learned and to share it with you.
8 minute read
LGBTQIA+ Continuing Education
I am in the middle of completing continuing education requirements for my licensure. One of those requirements is LGBTQIA+ education. I have an upcoming show on STIs on the Melanin Initiative Podcast, so this was a great opportunity to combine both topics. I’m so glad I did because it’s an aspect of care I want to be able to educate and offer my patients, with greater confidence and understanding. One thing that’s important to highlight when discussing this topic, is comfort. The more comfortable and confident we are as clinicians in having these conversations, the easier it is for our patients to do the same. Our patients want to talk to us about risk, satisfaction, performance, and safety. This couldn’t be more important for our most vulnerable populations who may not be represented elsewhere.
The Webinar
The National LGBTQIA+ Health Education Center is part of the Division of Education and Training at The Fenway Institute, Fenway Health in Boston, Massachusetts and one of the largest providers of LGBTQIA+ health care and HIV primary care in the United States. In the webinar titled, HIV and STI prevention among LGBTQ People, guest speaker Dr. Kevin Ard, MD, MPH, discusses (for about 1 hour) increasing rates of sexually-transmitted infections (STIs) in the United States, and how these infections disproportionately affect LGBTQIA+ people. In addition, transgender women, and gay and bisexual men continue to face high burdens of HIV infection. The webinar highlights evidence-based approaches to HIV and STI prevention, ranging from well-established interventions such as pre-exposure prophylaxis and vaccinations to novel strategies, including antibiotic post-exposure prophylaxis for STIs.
The website states the American Academy of Family Physicians offers 1 CME and that it is equivalent to 1 CE per the ANCC. Be sure to check the requirements and criteria for your certifying body.
Dr. Ard (he/him) is the Medical Director of The National LGBTQIA+ Health Education Center at The Fenway Institute, the Director of the Sexual Health Clinic Massachusetts General Hospital, a faculty member in the Division of Infectious Diseases, and Assistant Professor of Medicine at Harvard Medical School.
The Recommendations
The recommendations to improve sexual health outcomes for our LGBTQIA+ patients include avoiding inflicting trauma. It’s been well documented that LGBTQIA+ patients have avoided seeking medical care due to harassment, being misgendered, and being denied care by healthcare professionals.
The best way to improve care is to create an inclusive practice, learn about trauma-informed care, and hold each other accountable in implementing best practices to avoid it. This can be in the form of continuing education requirements for new and permanent staff on an annual or bi-annual basis. Everyone needs a safe place to seek care and be themselves without having to defend, explain, or deny their identity.
Dr. Ard brought up excellent points about the gap in care when it comes to collecting a sexual history and making it a standard part of care. This should include also asking about the patient’s perception of pleasure (ask about satisfaction, sexual function, and expectations), experience with pain, and opening the conversation to inquire about concerns for infection, reproductive options, and sexual health as a strategy to improve screening for risk factors. While it may not be possible to assess, diagnosis, develop a plan, offer comprehensive education, and evaluate adequate understanding during a single appointment, consider multiple ways your patients can access education about where and how to seek care for testing and treatment, even if that includes the use of other staff, remote or virtual assistance, on-demand videos, artificial intelligence, and decision support tools that automate patient education. Education should include a PEP and nPEP plan for those at high risk, updating vaccinations, and perhaps utilizing doxycycline for men who sleep with men (MSM) at high risk for developing syphilis.
Health Outcomes for LGBTQIA+ Patients
Most LBGTQ people are not at increased risk for STIs
Risk for STIs is based on anatomy and sexual activity (screen asymptomatic patients)
Gaps in data collection about sexual health, gender identity, gender-affirming treatments, and LGBTQIA+ representation in research limits our complete understanding of everyone’s risk factors, the STI incidence and prevalence rates
Approach to care
Trauma-informed care, avoid retraumatizing the patient
Greet patient while they are is still dressed
Encourage the presence of a chaperone
Only examine what is clinically relevant to the visit and explain what you’re going to do before you do it.
Strategies to Improve HIV and STIs
Condoms: consistent use is rare; less effective in MSM
Zoliflodacin oral therapy for urogenital and anal gonorrhea
Improving Care: Express testing and home testing
To remove barriers to patients being tested and treated in a timely matter before infection or reinfection takes place, identify steps in your workflow that would permit point-of-care express testing while decreasing reliance on the healthcare provider. The data supports patients are just as efficient when performing their own vaginal swab as compared to the clinician. This change has the potential to increase the number of patients who agree to be tested and ideally prevent the transmission of infection. It also doesn’t appear necessary to collect an endocervical swab, as the data shows you can yield the same outcome with a vaginal swab.
The Centers for Disease Control and Prevention: Chlamydia and Gonorrhea testing. Nucleic Acid Amplification Test (NAAT) is more sensitive and the preferred option for testing for N. gonorrhoeae and C. trachomatis for cisgender men and women. Only send about 10 cc of urine or less to avoid dilution. While some experts prefer the urine NAAT, others have ordered the vaginal/urethral NAAT for patients who’ve had a vaginoplasty and phalloplasty. See the rest of the CDC's screening guidelines for STIs which was posted in 2021.
The ultimate goal is to develop a clinical protocol specific to your setting that aims to increase same-day initiation. This can be done by improving point-of-care testing and lab processing times, offering mobile services, collaborating with community partners, thinking outside the box when identifying places where education, screening, and treatment can take place like community recreation centers and nightclubs. Streamline the workflow so patients aren’t required to see you for each visit. On-demand PrEP is one recommended strategy as an alternative to daily dosing. It’s been more efficacious for MSM at high risk for HIV. The 2-1-1 regimen requires patients to take 2 pills 2-24 hours before intercourse and 1 pill daily for two days afterwards. This regimen is not recommended for women or patients being treated for active hepatitis B as it interferes with the medication regimen which ultimately can decrease its effectiveness.
PrEP Drug Assistance Programs
Arizona. The Affordable Care Act makes it possible so patients can receive PrEP for free through all health insurance plans. This coverage includes clinic visits and lab tests needed to maintain the prescription. Interestingly, each state still provides state-based information about how they offer assistance.
District of Columbia. The DC Health Department offers Pre-exposure Prophylaxis (PrEP) Drug Assistance Program (DAP), for insured and uninsured HIV negative residents in the DC Metro region who are at high risk for HIV and are taking Truvada as PrEP.
PrEP: An STI Control Intervention
The data supports that PrEP is an evidence-based solution to improving STI prevalence and incidence rates even without consistent condom usage. This is likely due to the frequent testing of MSM at high risk who typically get tested every three to six months.
Non-Occupational Post-Exposure Prophylaxis (nPEP)
All patients who are not on PrEP should know when and how to access nPEP (nonoccupational post-exposure prophylaxis). Candidates for nPEP must meet one of two criteria:
1. Have condomless sex with an HIV positive person, they are not taking PrEP and are not being treated for HIV
2. Have condomless anal sex with an MSM of unknown HIV status, they are not taking PrEP, and are not being treated for HIV
The regimen includes starting nPEP within 72 hours of exposure and 4 weeks of antiretrovirals with tenofoviremtricitabine being the most common, along with either raltegravir or dolutegravir. This 3-drug strategy is presumed to be more effective than just using one antiretroviral based on a previous case study that showed just one antiretroviral had an 81% success rate at reducing the risk of HIV.
It’s important to screen and identify patients at who meet these criteria so they are educated about their risk and know to seek treatment immediately given the time sensitive nature of this regimen. Developing a PEP Plan for your patient includes identifying where they can access the medication which can include emergency departments.
Vaccinations to Improve STIs and Cancer
The following vaccinations are recommended for MSM and patients who share risk factors with MSM due to the prevalence of these diseases in MSM. The risk factors are having sex with multiple partners and engaging in anal-oral sex. The latest guidelines for cancer prevention, recommend administering the HPV vaccination to patients up to age 45 years of age to decrease risk for endometrial cancer.
• Hepatitis A
• Hepatitis B
• Human papillomavirus (HPV) (Meningococcus)
Doxycyline PEP (Doxy PEP) to Prevent Syphilis and Chlamydia in MSM
Dr. Ard referenced an on-demand PEP study including more than 200 MSM who were randomized to receive doxycycline within 24 hours of sex. There were no serious adverse events between the experimental and control group. The most common side effect was gastrointestinal upset which was what was already known about doxycycline in general. As a result of this study, he recommends considering this approach to treating MSM at high risk for syphilis, despite it not being FDA approved for this specific clinical situation. He supported his recommendation with multiple examples of how we currently use doxycycline in clinical practice, including using it to treat recurrent UTIs associated with sex in women, malaria in travelers, and long-term acne management.
An Oral Option for Urogenital Gonorrhea
He also referenced a study evaluating single-dose zoliflodacin (zo-li-fla-dacin), an oral medication to treat urogenital gonorrhea. Typically, gonorrhea is treated using intramuscular ceftriaxone. The study revealed a 96% success rate at treating urogenital and anal gonorrhea. Therefore, zoliflodacin is as effective as ceftriaxone and has the potential of decreasing antibiotic resistance against ceftriaxone and azithromycin. However, it was not effective against pharyngeal gonorrhea.
My Recommendation
The cutaneous manifestation of STIs is what often alerts our patients to seek medical attention. It’s imperative we understand their unique needs, especially when it is well known that our basic training does not adequately cover topics addressing our most vulnerable and under-represented populations.
I highly recommend this webinar (keep in mind it originally aired November 2018) and all the free content available on the National LGBT Health Education Center’s website. If you’re new to learning the basic health concerns, using inclusive language, and identifying strategies to improve care, then I recommend starting with their Foundations of LGBTQIA+ Health Part I and Foundations in LGBTQIA+ Health Part II. Join the community here at Mahogany Dermatology, share with your colleagues, and tell the National LBGT Health Education Center I sent you!
Kimberly Madison is a new dermatology nurse practitioner with a passion for writing, entrepreneurship, financial literacy, and mentorship. I created this blog to share my journey as I become a dermatology nurse practitioner and entrepreneur. Most importantly, I’m looking forward to helping nurse practitioners and aspiring students to better understand the business of dermatology and their role in improving access to care, providing culturally competent care, and advancing education.
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