Ensign Joshua Mondloch, a nurse assigned to Naval Medical Center San Diego, takes notes in the cardiology in-patient ward. More than 1,000 active duty and civilian nurses provide patient care throughout the medical center. (U.S. Navy photo by Mass Communication Specialist 2nd Class John O'Neill Herrera/ Released)

Doc – can we talk? The Conscience Check and the Navy Healthcare Provider

By Michael R. (Bob) MacDonald, MS, CHES, manager, Sexual Health and Responsibility Program (SHARP), Navy and Marine Corps Public Health Center

Ensign Joshua Mondloch, a nurse assigned to Naval Medical Center San Diego, takes notes in the cardiology in-patient ward. More than 1,000 active duty and civilian nurses provide patient care throughout the medical center. (U.S. Navy photo by Mass Communication Specialist 2nd Class John O'Neill Herrera/ Released)
Ensign Joshua Mondloch, a nurse assigned to Naval Medical Center San Diego, takes notes in the cardiology in-patient ward. More than 1,000 active duty and civilian nurses provide patient care throughout the medical center. (U.S. Navy photo by Mass Communication Specialist 2nd Class John O’Neill Herrera/ Released)

Navy health care providers, from physicians to hospital corpsmen, from time to time, may be confronted with a patient seeking a “conscience check”. This shipmate, perhaps returning to home port, may present as worried about the potential of having acquired a sexually transmitted infection (STI) acquired as a result of a sexual encounter while on liberty. He/she asks to be “tested” for an infection. This can be a very challenging scenario, especially in the resource-constrained settings in which the Navy must operate.

How should the provider respond? Some may be tempted to say “come back when you’re sick”, or “come back when you grow a conscience.” But doing so would constitute a missed opportunity to identify and treat a current infection, protect a future partner from that infection, and protect the patient from a future infection.

The provider should immediately recognize that this shipmate has risk in his/her life. The request for a “conscience check” is an early warning, not only that a potential exposure may have occurred, but also that a shipmate engages in behavior that may result in serious consequences in the future. The provider should welcome this opportunity to intervene and assist. Be glad this shipmate feels he/she can trust and rely on the provider. This credibility with the crew is an essential asset to the medical professional. Retain and reinforce this relationship by responding in a caring and confidential manner.

Often, the first question – and concern – a provider may ponder is “should I order tests?” Testing capabilities and supplies are very limited in many of the settings in which the Navy operates. For the asymptomatic patient, immediate STI testing may not be warranted. A high sense of suspicion is warranted if the exposure was unprotected (no condom), the partner had symptoms of, or is known to have, an STI, or if there were multiple partners.

If the patient is asymptomatic, inform them that if they used a condom correctly (before any penetration) and every time they had sex, then infection risk is low. Inform them about symptoms and the approximately two-week incubation period for gonorrhea, chlamydia and genital herpes. They should also be informed about the acute symptoms of primary HIV infection (flu-like symptoms and/or skin rash) which occurs in 50-80% of people within about three-weeks of infection. Inform them that many men infected with HPV, HIV and chlamydia may develop no obvious symptoms in the short term, yet they may in fact be infected and be infectious to others. Even primary syphilis may go unnoticed if the primary chancre is rectal, because these lesions are typically painless.

HIV testing at the time of the conscience check (and at least annually) is appropriate for men who have sex with men and for people who have sex without condoms with casual partners. HIV post-exposure prophylaxis should be initiated within 72 hours of exposure for patients who had unprotected sex with a person likely to have HIV. If HIV infection risk is high (unprotected sex with a person at high risk of having HIV) then a follow-up HIV test 90-days post exposure is indicated. All females up to age 24, and older women who have risk, should receive an annual chlamydia test. Other immediate testing or treatment for the asymptomatic patient is probably not warranted.

Regardless of testing, the provider should welcome this opportunity to provide prevention counseling:

1. Assess the patient’s current risk:

  • Why is he/she worried? What happened?
  • Does the patient have symptoms?
  • Did the partner(s) have symptoms or a known infection?
  • Was a condom used? Were other contraceptives used?
  • Did the patient have sex with men, women or both?
  • Were partner(s) new or likely to have HIV?
  • Is HIV post-exposure prophylaxis appropriate?
  • Is emergency contraception appropriate and desired?

2. Assess the patient’s future risk. Determine risk behaviors and circumstances:

  • How many people has the patient had sex with in the past year?
  • Are partners typically anonymous, casual, or steady?
  • Where and when does he/she typically meet sex partners?
  • Does he/she use condoms every time, or only with some partners?
  • What other forms of contraception are used?
  • Does alcohol use influence his/her sexual risk behavior?
  • “What is the riskiest thing you do, that might result in getting HIV or a pregnancy?”

Assess patient’s risk-perception and sense of vulnerability — “What would happen / how would it affect you if you have HIV or if a pregnancy occurred”.

3. Counsel the patient about reducing future risk:

  • Identify the patient’s safer goal behaviors: “What would you like to do to protect yourself in the future?”
  • Identify the patient’s perceived benefits and barriers to the chosen safer goal behavior. “What would be the hardest thing about being safer in the future?” “What would be the best thing about being safer in the future?”
  • Reinforce benefits of safer behavior; discuss potential solutions for barriers.
  • Assess/teach correct condom and contraception use, if appropriate.
  • Assess future plan for condom / contraception access, if appropriate.
  • Help the patient develop a simple action plan.
  • Conduct or refer for testing and/or treatment, if appropriate.
  • Schedule follow-up to assess the action plan and risk-reduction success.

4. Conduct sexual partner referral counseling (if the patient is definitively infected).

  • Counsel patient about the importance of partner treatment (for select STIs only)
  • Offer to assist with partner referral, if appropriate.

The role of the Navy health care provider is to treat illness and injury – but also to protect and preserve the health of the crew. As the saying goes, “To cure disease is glory; to prevent disease is victory”.

__________________

Helpful resources:

Sexual risk assessment guide:

http://www.med.navy.mil/sites/nmcphc/Documents/health-promotion-wellness/reproductive-and-sexual-health/sexual-risk-assessment-brief-counseling-guide.pdf

Sexual partner counseling and referral guide:

http://www.med.navy.mil/sites/nmcphc/Documents/health-promotion-wellness/general-

The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, nor the U.S. Government.