Behavioral risk assessment is a necessary and important component of HIV prevention.⁶ Clinicians should incorporate screening for behavioral risk factors into the routine office visit with every new patient as part of an initial intake and on a regular basis with existing clients. The results can aid in clinical intervention, provide a focus for risk reduction strategies or referrals, and provide opportunities for education and counseling. For patients, a behavioral risk assessment provides an opportunity to ask questions and discuss concerns, which may increase positive changes in their behavior.

A thorough behavioral risk assessment includes a frank discussion about sexual and drug (including alcohol) use behaviors. This can only happen after good rapport between clinician and patient has been established. Given the sensitive nature of these topics, it is important to discuss the purpose of the assessment with the patient and to reassure him or her that information gathered will remain confidential. Table 39.1 includes risk assessment techniques recommended by the National Network of STD/HIV Prevention Training Centers.⁶

A thorough clinical risk assessment elicits symptoms of early HIV infection and other sexually transmitted infections (STIs). The clinician assesses for signs or symptoms consistent with chronic infection and problems associated with STIs (e.g., genital ulcers, warts, blisters, or other lesions) or HIV infection (e.g., headaches, diarrhea, fatigue, fever, chills, night sweats, skin lesions, rash, weight loss, oral thrush). When conducting a drug use risk assessment, the clinician must gather specific information about the types of drugs injected and whether clean needles were or are used.

When conducting a sexual risk assessment, the primary goal is to elicit accurate clinical and behavioral information, including the identification of specific risk behaviors. First, and
most important, the clinician must determine if the patient has been having sex. Although this seems obvious, the clinician must clarify definitions of sexual practice. For example, some patients may not report oral sex when responding to questions about whether or not they have been sexually active. Therefore it is important for the clinician to clarify what the patient means by “having sex.” Once it has been established that the patient has been sexually active, it is important to determine the number and gender of sexual partners, both current and past. Avoid assumptions; it is not enough for clinicians to ask patients about their marital status or sexual identity. Marriage between heterosexuals does not preclude same-sex behavior among one or both partners. Furthermore, some who identify themselves as “heterosexual” may have same-sex partners and others who identify themselves as “homosexual” may have opposite- sex partners. Therefore the clinician must assess behaviors and avoid making inferences based on labels or self-descriptions.

Clinicians must inquire about the HIV status and history of STIs among sexual partners, keeping in mind that this information may be unknown. In completing the risk assessment, the clinician also may ascertain how the patient meets sexual partners (e.g., the Internet, bars, bathhouses, circuit parties, public venues, etc.). The clinician should then inquire about the various types of sexual activity in which the patient engages (i.e., oral, anal, vaginal) and the extent to which condoms or other barrier contraceptives are used, if at all. Further inquiry about condom use may involve questions such as the following⁶:

If conducting these assessments is too time-consuming for regular office visits, consider prescreening. The use of self-administered questionnaires or computer-, audio-, or video- assisted questionnaires are appropriate for the prescreening process. In addition, ancillary staff may conduct brief interviews with patients. The clinician can use the results of the pre- screening to more efficiently conduct a thorough risk assessment. Clinicians may consider using the HIV-risk screening instrument (HSI), which is a 10-item scale designed to discriminate between low- and high-risk behaviors associated with HIV infection.⁸ Questions on the HSI elicit information about whether or not patients have engaged in specific risky behaviors, as opposed to the frequency with which patients engage in those behaviors, based on research that suggests participants are likely to respond more accurately when responses required are categorical in nature (i.e., yes, no, don’t know). The specific risk factors assessed on the HSI include history of sexual intimacy with more than one sexual partner, history of anal sex and the extent to which condoms were used during anal sex, history (or sexual partner with history) of STIs, history of bartering for sex, history (or sexual partner with history) of injection drug use, and history of sexual intimacy with men who have had sex with men. Many questions on the HSI are phrased to elicit information about whether or not the behaviors listed have occurred within the past 10 years.

Besides time constraints, it is important to recognize certain barriers to effective risk assessment. Patients’ perceptions that they are being stigmatized by a clinician certainly is one barrier. However, many patients may not only be comfortable discussing their sexual behavior, but may actually expect clinicians to gather such information. The discomfort associated with discussing sexual behavior often lies with the clinician. Clinicians not only report discomfort asking personal questions about sexual behavior, as well as discomfort
responding to issues that arise in response to these questions.⁹,¹⁰ Clinicians sometimes lack confidence in their ability to make the client comfortable, especially when discussing same- sex relationships. Finally, misconceptions held by the clinician regarding sexual behavior and level of risk act as barriers to effective risk assessment. These barriers can be addressed by developing specific policies and procedures for conducting risk assessments. This may include identifying specific questions to be asked during the assessment, developing a plan for responding to information that might surface, determining how information will be integrated into the patient’s overall care, and training staff how to perform prescreenings or thorough risk assessments. Practice and experience will increase clinician comfort levels.

HIV infection prevention must become a high priority for all mental health professionals. Clinicians must educate teenagers and young adults who do not know how to properly use and remove a condom. We must educate pregnant women about mother-to-child transmission. We should teach our patients to take the necessary personal precautions to minimize the possibility of transmission of this deadly disease. This requires a frank and open discussion of sex and drug use with our patients and members of the community with whom we come in contact. A clinician might find it useful to use a model of a penis or an educational chart to provide patients with an explicit demonstration of the proper use of condoms. The correct procedure for removing the condom without spilling the contents should be emphasized. Clinicians should also be able to demonstrate the proper use of a female condom. It is important that clinicians gain proficiency in these demonstrations and overcome any barriers they have in terms of their comfort level with providing this type of experiential education. Clinicians should also keep in mind the sensitive nature of this educational material. Some patients, especially those suffering from certain mental illnesses, may become anxious or agitated in response to this type of explicit demonstration. Good clinical training and sound professional judgment will be imperative when confronting these issues. Furthermore, normalizing these behaviors is likely to help put patients at ease, which is why it is so important for clinicians to increase their proficiency and comfort levels.