East Bay HIV/STI Case Management Manual

Authors: Jessica Torres, Manuela Guevara, and Mauricio Perez

The World Health Organization (WHO) defines sexual health as “a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination, and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected, and fulfilled.” 

According to the WHO, achieving sexual health and well-being depends on:

• access to comprehensive and high-quality information about sex and sexuality;
• awareness of potential risks and vulnerabilities associated with condomless sexual activity;
• availability of sexual health care services; and
• residing in an environment that supports and promotes sexual health.

Sexual health is part of the intake process for medical case management services. This means case managers need to equip themselves with the knowledge to engage clients in a conversation about their past, current, and/or future sexual behaviors, within a framework of respect and inclusivity. Moreover, patient-centered case management requires an understanding of sexual health that includes sexual orientation, gender identity, sexual relationships, and pleasure. It also requires an open and engaged attitude towards cultural humility and cultural competence. 

Case management and wrap-around services in the field of HIV and sexually transmitted infections (STIs) engage with a broad range of people from diverse cultural, socio-economic, and educational backgrounds. In order to successfully and fairly assess each client, case managers need to overcome the limitations and biases internalized from their own culture.

This section will review the importance of taking a sex-positive approach, sexual orientation and gender identity, as well as sexual health basics such as STIs, hepatitis C, and partner services such as PrEP/PEP and disclosure.

Reference:

1. World Health Organization. Sexual Health [Internet]. World Health Organization. 2024 [cited 2024 Jul 31]. Available from: https://www.who.int/health-topics/sexual-health#tab=tab_1

Sex-positive approach

Sex positivity generally refers to having a positive attitude about sex, respecting others’ sexual preferences and consensual sexual practices, treating sex as a healthy part of life rather than a taboo topic or something to be ashamed of, and accepting that sex and sexuality are not meant only for reproductive purposes. Sex positivity is not sex promotion; this means that sex positivity does not dictate that everyone must enjoy or be interested in sex, nor does it place moral judgments on whether people are or aren’t sexually active.

It is important for case managers to apply sex-positive principles to their work. Sex-positive approaches to use when working with clients include:

• accepting the consensual behavior of others, rather than judging
• advocating for sexual health and safer sex practices
• not assuming people only have one type of sex
• knowing that people have or do not have sex independently of their age, gender, sexual orientation, body ability, race, religion, and sexual expression

On the other hand, there are sex-negative attitudes and behaviors. Obvious or subtle signs of sex negativity may include:

• assuming anything that is not cisgender heteronormative is a sign of a mental health condition
• believing that anal sex is only for people who identify as gay
• referring to heterosexuality and being cisgender as “normal” or “natural”
• victim-blaming for sexual assault
• describing sex and sexuality to be “dirty,” “sinful,” or other negative adjectives

After receiving the news of an HIV diagnosis, many clients stop all sexual practices due to feelings of shame, fear of rejection, and concern about HIV transmission. For these clients, a sex-positive approach could include validating their feelings and acknowledging that it’s common to experience grief (as well as denial, anger, depression, and/or acceptance), while reminding them that they will be able to have a fulfilling sexual life if they choose. 

Other clients continue their sexual behaviors and may opt to engage in new behaviors. For these clients, it is important to identify ways they can enjoy sex without increasing their exposure to other STIs and/or transmitting HIV to partners. 

Talking with clients about sexual behaviors within a sex-positive and trauma-informed framework is key to providing comprehensive clinical and public health services without adding to the stigmatization and victimization of both individuals and communities.

Reference:

1. Fava NM, Fortenberry JD. Trauma-informed sex positive approaches to sexual pleasure. Int J Sex Health [Internet]. 2021 [cited 2024 Aug 5];33(4):537–49. Available from: http://dx.doi.org/10.1080/19317611.2021.1961965

“SOGI” stands for sexual orientation and gender identity. This refers to characteristics that are common to all individuals, not only those who identify as lesbian, gay, bisexual, transgender, and/or queer (LGBTQ+). 

Sexual orientation and gender identity are not one and the same. Sexual orientation refers to attraction to other people and can include physical, romantic, or emotional attraction. 

Sexual orientations can include, but are not limited to: 

• Asexual (“ace”): completely or partially free of attraction to or interest in sexual activity with others
• Queer: an umbrella term expressing a spectrum of sexual identities; formerly a slur, now reclaimed by many in the LGBTQ+ community
• Gay: attracted to people of your own gender
• Bisexual: attracted to people of your own and other genders
• Pansexual: attracted to people of any gender
• Lesbian: a woman attracted to other women
• Heterosexual (straight): attracted to people of the “opposite” gender
• Questioning: exploring your own sexual orientation

It is important to remember that a person’s sexual orientation may or may not correlate with their sexual experience; i.e, a client who has only had sexual experience with women may identify as pansexual. 

Gender identity refers to someone’s inherent understanding of their own gender and is invisible to others, meaning that we cannot just observe a person and know their gender identity. Gender expression, on the other hand, is visible: It is how a person expresses themself through clothing, body characteristics, behavior, etc. 

Gender identity exists on a spectrum and can include, but is not limited to: 

• Non-binary: having an identity that is neither completely female nor completely male
• Transgender: having an identity that does not align with the sex assigned at birth
• Cisgender: having an identity that does align with the sex assigned at birth
• Gender-fluid: having an identity that is fluid or not fixed
• Gender-expansive: an umbrella term often used for youth exploring the possibilities of their gender identity
• Intersex: an umbrella term for having variations in reproductive or sexual anatomy that do not fit binary ideas of male or female bodies

Again, the language used to describe these orientations and identities does not encompass all orientations/identities and is ever-evolving. We encourage case managers to continue to research on their own to learn more about SOGI. 

References: 

1. World Health Organization. Sexual Health [Internet]. World Health Organization. 2024 [cited 2024 Jul 31]. Available from: https://www.who.int/health-topics/sexual-health#tab=tab_1
2. Gay and Lesbian Alliance Against Defamation (GLAAD). Glossary of Terms LGBTQ. Gay and Lesbian Alliance Against Defamation (GLAAD). [cited 8/9/2024]. Available from https://glaad.org/reference/terms
3. Human Rights Campaign. Resources: Glossary of Terms. Human Rights Campaign. 5/31/2023. [cited 8/9/2024]. Available fromhttps://www.hrc.org/resources/glossary-of-terms
4. Cleveland Clinic. Understanding Gender Identity. Cleveland Clinic. 5/30/2022. [cited 8/9/2024]. Available from https://health.clevelandclinic.org/what-is-gender-identity

STI basics

Sexually transmitted infections are very common among people who are sexually active, and anyone who has sex can be exposed to STIs. STIs originate from bacteria, viruses, and parasites. These are spread from person to person through condomless or barrier-free sexual activity (vaginal, anal, and oral sex) and sometimes through skin-to-skin contact. The good news is that most STIs can be cured and/or treated, and testing for them is simple, painless, and accessible. Bacterial infections are treatable but repeatable, so encourage clients to test, treat, and repeat. 

For case managers, the most relevant STIs include:

• Human Immunodeficiency Virus (HIV) is caused by a virus that attacks the body’s immune/defense system. Without treatment, it can lead to AIDS (acquired immunodeficiency syndrome) Most people have flu-like symptoms that can appear within four weeks after infection, but some people have no symptoms; the only way to know if a person has HIV is to get tested. HIV can be transmitted through sex via semen, pre-seminal fluid, rectal or vaginal fluid, and blood. The virus can also be transmitted through blood when sharing needles, syringes, and other drug injection equipment. HIV can be transmitted from parent to child through blood and/or breast milk during pregnancy, childbirth, and/or breastfeeding, especially if a parent is not on antiretroviral therapy. HIV is not transmitted by sharing utensils, hugging, kissing, holding hands, coughing, sneezing, tears, or toilets, or through food and water. Nowadays, HIV is highly preventable by using condoms the right way every time a person has sex, by not sharing needles or drug injection equipment, and by using PrEP and/or PEP medications (see below). Also, antiretroviral therapy can suppress the virus so well that it is undetectable in a blood sample. People whose HIV stays undetectable over time on antiretroviral therapy cannot transmit HIV through sex, and are much less likely to transmit HIV from parent to child. This HIV prevention strategy is known as undetectable equals untransmittable, or U=U. 
  
  For people who are HIV negative, testing is recommended at least once in a lifetime, but more often if the person is sexually active with multiple partners (every 3 to 6 months), and/or if they use injectable drugs. 
  
  At the moment, there is no cure for HIV, and people who get HIV have it for life; nevertheless, with proper medical care, adherence to antiretroviral therapy, and viral suppression, people can live long, healthy lives, and protect their partners. 
  
  
• Chlamydia and gonorrhea are both caused by bacteria. Chlamydia and gonorrhea can be cured with antibiotics; however, they are also repeatable, meaning that people can get chlamydia and gonorrhea again—there is no lifelong immunity. Most people do not have symptoms, and the only way to know about a present infection is to test. These infections are localized to the point of entry in the body, so localized three-site testing is advised. (Key point: If you use your penis, mouth, and/or vagina for sex, test it!) Untreated chlamydia and gonorrhea can lead to pelvic inflammatory disease and make it difficult to get pregnant, and may increase a person’s chances of getting or transmitting HIV.
  
  Additionally, gonorrhea can rarely spread to other sites of the body causing a more disseminated disease.
  
  
• Syphilis, also caused by bacteria, is curable with antibiotics, and repeatable. Syphilis can be transmitted through sex and from parent to child during pregnancy and childbirth. 
  
  Syphilis has four stages with different symptoms. They range from sores called chancres on the penis, vagina, anus, rectum, lips, or mouth, to skin rashes/eruptions in one or more areas of the body. These symptoms last several weeks. 
  
  Syphilis is a complex, multi-stage, systemic infection (meaning it affects the whole body). Untreated syphilis can increase a person’s chances of getting or transmitting HIV. Over time, untreated syphilis can cause multi-organ damage and even death. 
  
  
• Hepatitis B is a vaccine-preventable infection of the liver caused by the hepatitis B virus (HBV). HBV can be transmitted in the same ways as HIV, and people with HIV are frequently also affected by acute (short-term) or chronic (long-term) viral hepatitis. 
  
  Acute HBV is a short-term illness that typically takes place within the first six months after initial exposure, with symptoms ranging from none/mild to severe illness that may require hospitalization.
  
  Chronic HBV may occur if acute HBV is left untreated, and can result in liver damage, cirrhosis (permanent liver scarring), liver cancer, and even death; liver disease is a major cause of non-AIDS-related deaths among people with HIV. Everyone living with HIV should be tested for HBV when they are initially diagnosed, and people who have continuous exposure opportunities should be tested annually.  
  
  
• Genital Herpes is caused by the herpes simplex virus type 1 and type 2 (HSV-1 and HSV-2). Herpes can be transmitted through kissing; vaginal, anal, and/or oral sex; and skin-to-skin contact, especially when sores or blisters are present. It can also be transmitted when there are no visible sores.
  
  The first herpes outbreak tends to be more painful and uncomfortable; repeated outbreaks are usually shorter and less severe. Herpes infection is not curable, but its symptoms and infectiousness are treatable. Herpes infection may cause sores or breaks in the skin or lining of the mouth, vagina, and rectum, providing an entryway for HIV; having both HIV and genital herpes increases the chances of transmitting HIV to partners during oral, vaginal, and/or anal sex. 

Changing sexual behavior to reduce exposures to STIs can be a challenge. Obstacles include low public awareness, stigma around STIs, limited resources to cover out-of-pocket expenses, inadequate training for healthcare workers, and lack of inclusive and affirming health services. Case managers can provide information, education, and counseling to support clients’ own STI prevention efforts and help them identify STI symptoms and seek treatment (and encourage their partners to do so). 

References

1. CDC. About [Internet]. HIV. 2024 [cited 2024 Aug 5]. Available from: https://www.cdc.gov/hiv/about/index.html
2. Sexually transmitted infections [Internet]. Hiv.gov. [cited 2024 Aug 5]. Available from: https://www.hiv.gov/hiv-basics/staying-in-hiv-care/other-related-health-issues/sexually-transmitted-diseases
3. CDC. About [Internet]. Syphilis. 2024 [cited 2024 Aug 5]. Available from: https://www.cdc.gov/syphilis/about/index.html
4. Hepatitis B & C [Internet]. Hiv.gov. [cited 2024 Aug 5]. Available from: https://www.hiv.gov/hiv-basics/staying-in-hiv-care/other-related-health-issues/hepatitis-b-and-c
5. Hepatitis B Basics [Internet]. CDC.GOV [cited 2024 Aug 23]. Available from: https://www.cdc.gov/hepatitis-b/about/index.html
6. CDC. About [Internet]. Genital Herpes. 2024 [cited 2024 Aug 5]. Available from: https://www.cdc.gov/herpes/about/index.html?CDC_AAref_Val=https://www.cdc.gov/std/herpes/default.htm
7. Sexually transmitted infections (STIs) [Internet]. Who.int. [cited 2024 Aug 5]. Available from: https://www.who.int/news-room/fact-sheets/detail/sexually-transmitted-infections-(stis)

• Hepatitis C is another viral infection of the liver. Hepatitis C virus (HCV) can lead to acute illness or cause chronic, potentially life-threatening disease. The virus is primarily spread through blood, such as by sharing needles or syringes, or through unsafe medical procedures, such as blood transfusions with unscreened blood products. It can also be transmitted through sexual practices that lead to exposure to blood, and from parent to child during pregnancy and childbirth. 
  
  HCV is not spread by sharing utensils, hugging, kissing, holding hands, coughing, or sneezing, or through food and water. Most people do not experience symptoms, but if they do, they may include fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, dark urine, and yellowing of the skin or eyes (jaundice). Testing for HCV is the only way to know. (Test, treat, repeat!) Everyone living with HIV should be tested for HCV when initially diagnosed, and people who have continuous exposure opportunities should be tested annually. 
  
  There is no vaccine for HCV, but it can be treated and cured with antiviral medications; however, HCV reinfection is possible after successful treatment. Early detection and treatment are crucial to preventing serious liver damage and improving long-term health outcomes. 
  
  Acute HCV infections are often asymptomatic and rarely lead to life-threatening conditions; approximately 30% of people clear the virus spontaneously within six months without treatment. About 70% develop chronic hepatitis C, and among those with chronic infection, 15% to 30% develop cirrhosis within 20 years.
  
  What is the connection between HIV and HCV? HIV and HCV can be transmitted through blood, so sharing needles or other drug equipment increases exposure opportunities for both viruses. It is recommended that every person living with HIV gets tested for HCV and vice versa.
  
  HCV can be prevented by not sharing needles, syringes, or other injection drug equipment. Other ways to reduce exposure opportunities for HCV include:
  • not sharing toothbrushes, razors, or other personal items that may come in contact with another person’s blood;
  • when getting a tattoo, ensuring the instruments used are sterile; and
  • using condoms the right way every time.

References:

1. Hepatitis C [Internet]. Who.int. [cited 2024 Aug 8]. Available from: https://www.who.int/news-room/fact-sheets/detail/hepatitis-c
2. HIV and Hepatitis C [Internet]. Nih.gov. [cited 2024 Aug 8]. Available from: https://hivinfo.nih.gov/understanding-hiv/fact-sheets/hiv-and-hepatitis-c
3. Hepatitis B & C [Internet]. Hiv.gov. [cited 2024 Aug 5]. Available from: https://www.hiv.gov/hiv-basics/staying-in-hiv-care/other-related-health-issues/hepatitis-b-and-c

Partner services (PrEP and PEP, disclosure)

Disclosure, the process of telling others your HIV status, is a very personal issue for clients. As a case manager, your duty is to inform clients of the different options that are available to them via partner services. 

Most clients choose to self-disclose. This is option number one, and clients may need assistance with how to begin the conversation, choosing the words to use in the discussion, and next steps for their partner(s) after disclosure (e.g., getting tested, getting on PEP/PrEP). 

Dual disclosure is option number two. This is a less frequently chosen option, in which a client discloses to their partner(s) accompanied by staff like a trained case manager or public health advisor. The staff person is there to offer social support to the client and share information on next steps for the partner(s). 

The third option for disclosure is called anonymous third-party disclosure. This is when the client gives the medical case manager and/or public health advisor as much information about their partner(s) as possible, including but not limited to name, address, telephone number, a general physical description, the app where they met, and the make/model of their car. This information will help to locate the partner(s) for disclosure. Disclosure is done anonymously, meaning the partner is never told any information about the reporting client. In fact, the public health advisor who performs the actual disclosure is never the person who took the information from the reporting client. 

In all of these scenarios, partners are offered information on next steps, including but not limited to testing options, access to PEP/PrEP as appropriate, and access to doxycycline post-exposure prophylaxis (Doxy-PEP). 

PEP

PEP stands for post exposure prophylaxis. PEP is a 28-day course of antiretroviral medicines used after potential exposure to HIV. PEP must be started within 72 hours of exposure—the sooner, the better. Case managers should be aware that potential recent exposure to HIV is an urgent situation and PEP may be indicated. PEP is free to the public and can be accessed through any medical provider, most county clinics, and emergency rooms. 

PrEP

PrEP stands for pre-exposure prophylaxis. PrEP uses antiretroviral medicines to prevent HIV infection before exposure to the virus. It is available in two forms: as oral pills and injections. When used as prescribed, PrEP can reduce the risk of contracting HIV via sexual contact by about 99% and reduces the risk of getting HIV by at least 74% among persons who inject drugs. 

Truvada and Descovy are the two current pill forms of PrEP. Descovy (emtricitabine/tenofovir alafenamide) works differently on rectal tissue than it does on vaginal tissue, and it is currently approved for use only by cisgender men and transgender women who have sex with men. Truvada (emtricitabine/tenofovir disoproxil fumarate) is for people of all sexes and genders at risk for HIV through sex or injection drug use. These medications are generally taken once a day, and ongoing PrEP care includes regularly scheduled visits with a clinician/provider for updated labs and HIV and STI testing. 

Apretude (cabotegravir) is the injectable form of PrEP and is taken once every two months. Apretude can be used by people of any gender. 

There is a “lead-in” period of dosing for PrEP medicines to reach protective levels for different routes of HIV exposure. For receptive anal sex (bottoming), oral PrEP reaches protective levels after about seven daily doses. For receptive vaginal sex and injection drug use, oral PrEP reaches protective levels after about 21 daily doses. There is no data available for PrEP effectiveness for insertive anal sex (topping) or insertive vaginal or front-hole sex. Apretude will reach protective levels in the body for most people within seven days after the first injection, according to the manufacturer.

Any licensed prescriber can prescribe PrEP. There are many ways to access PrEP and PrEP services, including through a client’s regular provider, sexual health clinics, local public health departments, and telehealth services. There are also many ways to pay for PrEP, such as through private medical insurance, Medi-Cal, Medicare, Veterans Administration, Tricare, Indian Health Service, and patient assistance programs. 

Doxy-PEP

Doxy-PEP is antibiotic treatment that can reduce the chance of acquiring syphilis, gonorrhea, and/or chlamydia if taken within 72 hours after exposure to these bacteria. Doxy-PEP is recommended for cisgender men, men who have sex with men, and transgender women with a history of bacterial STI diagnosis. Although Doxy-PEP is not recommended for people vaginas at this time, but individuals with vaginas who are sexually active and interested in Doxy-PEP can review fully risk and benefits with a provider as further studies are pending. Learn more on Doxy-PEP here.

References: 

1. San Francisco City Clinic. Doxy-PEP. San Francisco City Clinic. [cited 8/23/2024]. Available from Doxy-PEP | San Francisco City Clinic (sfcityclinic.org)
2. U.S. Centers for Disease Control and Prevention. Preventing STIs with Doxy-PEP. 09/19/24 [cited 11/15/24]. Available from https://www.cdc.gov/sti/prevention/doxy-pep.html. 
3. U.S. Centers for Disease Control and Prevention. HIV Pre-exposure Prophylaxis (PrEP) Care System. U.S. Centers for Disease Control and Prevention. 03/2023 [cited 8/8/2024]. Available from https://www.cdc.gov/hiv/effective-interventions/prevent/prep/index.html
4. U.S. Centers for Disease Control and Prevention. Clinical Guidance for PrEP [Internet]. U.S. Centers for Disease Control and Prevention. 05.2024 [cited 8/8/2024]. Available from https://www.cdc.gov/hivnexus/hcp/prep/index.html
5. U.S. Centers for Disease Control and Prevention. Preventing HIV with PrEP [Internet]. U.S. Centers for Disease Control and Prevention. 01/2024 [cited 8/8/2024]. Available from https://www.cdc.gov/hiv/prevention/prep.html 

Takeaways & tips for case managers

1. Discussing sexual health history and offering partner services to clients is part of a case manager’s job.
2. Be aware of your own limitations and biases. Ask for assistance from others to help you learn and grow. 
3. Be client centered, offer assistance and information, and meet the client where they are at.
4. You do not have to be the expert on everything, just know who and where you can refer clients! 
5. Empower your clients: Give them the information and support them to take part in their care. 
6. Practice self-care: You need to be physically, emotionally, and spiritually fit to best serve your clients. 
7. Learn about and use evidence-based interventions and best practices (harm reduction, trauma-informed care, adverse childhood experiences, etc.).