Sexual Health Counseling in Daily Practice: Applying Intervention Frameworks and Behavioral Theory to Increase and Improve Sexual Health Discussions

Over recent decades, life expectancy for people with Human Immunodeficiency Virus (HIV) has greatly improved due to the success of combination antiretroviral therapy (cART). With proper treatment, HIV has shifted from a fatal disease to a manageable chronic condition, and life expectancy is now nearly equal to that of the general population. The World Health Organization (WHO) set ambitious goals to reduce the global HIV epidemic. These “90-90-90” targets were revised in 2020 to the “95-95-95” goals, aiming for 95% of people with HIV to be diagnosed, 95% to receive effective treatment, and 95% to have suppressed viral loads (UNAIDS, 2023). While these targets help normalize life expectancy, HIV still significantly impacts quality of life, with co-morbidities such as heart disease, diabetes, and depression being more prevalent in HIV-positive individuals. Moreover, HIV not only affects physical health but also influences mental and social well-being, which are integral to overall quality of life. A shift toward person-centered care in HIV treatment has focused on improving not just health outcomes but overall quality of life. This led to a fourth "90" goal to optimize physical, social, and psychological functioning, with sexuality being a key aspect. An HIV diagnosis can significantly alter one’s experience of sexuality, often resulting in sexual, relational, and intimacy difficulties. Since HIV is primarily transmitted through sexual contact, the prevention of other sexually transmitted infections (STIs) remains essential, particularly in HIV-positive men who have sex with men (MSM). Addressing sexuality in HIV care is crucial for improving quality of life and preventing risky sexual behavior. This dissertation investigates the factors influencing how healthcare providers discuss sexuality with HIV patients. It examines differences in how doctors and nurses approach the topic and explores both verbal and non-verbal communication during consultations. A pilot training intervention was developed to improve the frequency and quality of sexuality discussions in HIV care. Chapter 2 describes a survey of HIV care in the Netherlands, showing that nurses are more likely than doctors to discuss sexuality, focusing on psychosocial issues, while doctors address medical concerns like erectile dysfunction. Barriers to discussing sexuality included time pressure and the presence of third parties. Chapter 3 presents a qualitative study using focus groups to explore how HIV nurses address sexual risk behavior with MSM. Barriers such as shame, role changes, and time constraints were identified. Chapter 4 further investigates how factors like attitude, knowledge, and perceived control influence nurses' willingness to discuss sexual risk behavior. Chapter 5 analyzes video recordings of routine consultations to reduce bias in self-reported behavior. Findings showed that discussions about sexuality were often limited to medical issues and lacked consistency in communication skills. Finally, Chapter 6 details the development and evaluation of a pilot training program aimed at improving sexuality discussions. The evaluation indicated positive changes in knowledge, attitudes, and confidence in discussing sexuality. This dissertation offers valuable insights into discussing sexuality in HIV care. It highlights the need for structured training for both nurses and doctors to improve these conversations in routine HIV consultations.