Folks have been asking for a Tweetorial on talking to patients about PrEP and sex more generally. I’m by no means an expert but here are a few tips that have helped me! And please respond with any tips of your own; we're all learning! #tweetorial #gaymedtwitter #familymedtwitter

1/ I try to talk to patients about sex and sexuality at their annual physicals and when they present for concerns related to sex (STD testing, starting PrEP, pregnancy options, etc).

2/ I always ask patients permission to talk about sex and I explain why I’m asking.

3/ “When patients come in for STD testing, I like to ask some questions about sex. These questions help me to recommend the best tests for you to stay healthy. Would it be ok to ask you some of these questions now?”

4/ If the patient agrees, I approach with open-ended general questions. I always use gender-neutral and sex-positive language. “Could you tell me a bit about the kinds of sex you’re enjoying right now? Could you tell me a bit about your sexual partners?"

5/ I ask follow-up questions to help clarify a patient’s type of risk and to determine which tests or interventions I might offer them.

6/ “Would it be ok if I ask the gender of your sexual partners? Would it be ok if you describe for me a bit more about the kind of sex you’re talking about now?”

7/ I try hard to avoid questions that don’t help me to answer a medical question or decide on a particular test or intervention. A few common pitfalls include asking things like number of lifetime partners or estimating number of current partners.

8/ Another common pitfall is asking the question “do you have sex with men, women, or both?” This question doesn’t really provide helpful information and has a number of hidden implications to which patients may respond negatively.

9/ I try to create a non-judgmental segue into discussion of STD prevention if patients are interested in that discussion. “Some patients who come in for STD testing are also interested in talking about STD prevention. Is that something you’d like to discuss today?”

10/ If patients agree, I talk about PrEP as an effective and relatively simple way to prevent HIV.

11/ I tell a bit about the medicines currently approved (Truvada for all patients and Descovy for MSM and trans women) as well as those in the pipeline (long-acting injectable cabotegravir, dapivirine ring, and islatravir implant).

12/ I also emphasize that there are many ways to prevent HIV in addition to PrEP. Those include condoms, dental dams, as well as TASP (treatment as prevention) or U=U (undetectable = untransmissible) if patients have a partner who is living with HIV.

13/ For people who inject drugs, I discuss the other evidence-based methods of HIV prevention including medications for OUD (methadone, bupe, and XR-NTX), needle exchanges, and bleach kits.

14/ I explain that PrEP can help many patients to add another layer of protection against HIV.

15/ “Lots of patients worry about HIV infection. It’s difficult for many patients to use a condom every time they have sex. It’s also difficult for many patients to know the status of their partners. PrEP can add another layer or protection in those situations.”

16/ I avoid implying that patients are at “high risk” for HIV infection. This can be stigmatizing and problematic. As a gay man, I am particularly attuned to the stigma that my identity carries with regard to HIV infection and I don’t want to pass that along to my patients.

17/ I also avoid saying somebody “should” take PrEP. There is tons of excellent evidence that patients do a great job assessing their own levels of risk and often make the right decision about whether to start or continue PrEP. Trust your patients.

18/ Close your encounter by affirming your patient’s decisions, whatever they are. Make sure they know you are a resource if they want to discuss this more in the future.

19/ Finally, just remember that talking about sex with patients will be just as awkward as you make it. Practice some phrases in the mirror at home before you try them with patients so that they roll off your tongue. #formerlyawkwarddoctor