PrEP Provider Toolkit

Patient-centered approach

Sexual and substance use history

The CDC created a helpful framework for taking a sexual history termed “The 5 P’s”. (6)  The National Coalition for Sexual Health expanded this to “The 6 P’s” which includes a “Plus” category that encompasses topics such as pleasure, problems, and pride. (7).  This coalition also created a helpful video series to improve your approach when taking a sexual history. (8)

The 6 P’s of a Sexual History

  1. Partners
  2. Practices
  3. Past History of STIs
  4. Protection
  5. Pregnancy
  6. Plus: Pleasure, Problems, & Pride

Given the rising incidence rate of HIV among people who inject drugs (PWIDs), it is important to expand on the second “P” in this framework: Practices.
Although this approach raises the question of drug and alcohol use in the context of sex, a simple follow-up question to further assess these habits could be…

“Have you ever used injection drugs that were not prescribed by a doctor such as heroin, cocaine, meth, or others?”

If the patient answers “yes,” ask further about the frequency of use and most recent use. Most importantly, ask if they ever share drug injecting equipment of any sort. This includes needles, syringes, cookers, filters, etc. A common misconception is that the patient is not at risk for acquiring transmissible infections as long as different injection needles are used. Ask carefully and provide risk reduction strategies when applicable.

Relatedly, bloodborne infections such as HIV, Hepatitis B, and Hepatitis C can also be transmitted through needles used for tattoos, particularly in correctional facilities. (42)  Inquire about any tattoos the patient has or plans on getting to tailor your care and patient education.

It may not always be feasible to ask every question mentioned in this section; the point of this framework is to help you progressively improve your history-taking skills. Remember that it may take several conversations about PrEP before a patient decides that it is right for them. Even if typical risk factors are not made apparent, it is always worthwhile to at least ask your patients if they have heard of PrEP. A patient will never take something into consideration if they don’t have an awareness of it at all.