At a time when cases of sexually transmitted infections (STIs) in the United States are at an all-time high, many physicians are uncomfortable even discussing sex and sexuality, particularly with people who identify as lesbian, gay, bisexual, transgender, or queer. Despite this, there’s no requirement for health care providers to understand even the basics of a public health issue of sexual health. Newly proposed legislation in New York State could change that.
In January, New York State Assemblymember Linda B. Rosenthal introduced Bill A3864, which, if passed, would require state-licensed health care providers to complete course work or training in sexual health, including how to open a dialogue about sex, STIs, and HIV.
Terri Wilder recently spoke with Kathleen Bernock, FNP-BC, a family nurse practitioner and the president of the Greater NY Association of Nurses in AIDS Care; Michelle Collins-Ogle, M.D., a clinical HIV specialist and national leader in developing best practices for comprehensive rural HIV care; and Amir Sadeghi, M.A., the national policy and partner strategist at the Center for HIV Law & Policy (CHLP), about the new legislation and how it will support Ending the HIV Epidemic (EtE) efforts.
“A Very Simple Proposal”
Terri Wilder: Can you start off by telling me about the details of Bill A3864?
Amir Sadeghi: Absolutely. I think it’s precisely that role that medical providers play in ending the HIV and STI epidemics that New York State Assembly Bill 3864 seeks to address. It’s altogether a very simple proposal. It’s a continuing medical education (CME) bill that would improve and add to the already existing continuing medical education credits that physicians and other medical professionals have to take already. It improves that by adding training on HIV and STI testing, basic elements about sexual health, including sexual orientation and gender identity.
Other training that this bill seeks to provide medical providers includes training on discussing the roots and risks of HIV and STI transmission, the importance of, for example, informed consent prior to an HIV test. Currently under New York State Public Health Law Section 2781, physicians are required to put patients on verbal notice prior to an HIV test because of the history and the legacy of medical mistrust and stigma affecting patients, both living with HIV and vulnerable to HIV acquisition.
The bill, we think, is a simple proposal to help give providers the tools that they need to have robust conversations with all patients about sexual health, sexual health history, sexual health risk, and just open a dialogue, especially between [providers and] LGBTQ patients and other marginalized patients who might be subject to discrimination in medical settings. They might also be affected by those legacies of medical mistrust where they put off or altogether avoid care because they’re afraid of being discriminated against in a medical setting, they’re afraid of being deadnamed or called the wrong pronoun, or having other kinds of assumptions that providers might make about them, about who they are, and maybe other aspects of their lives and experiences that could drive patients away—and in fact do, do drive patients away.
That, in essence, is what the bill does. It will require that physicians, physician assistants, and special assistants practicing in the state take this kind of continuing education on sexual health literacy.
Wilder: There are lots of HIV conferences around the world. There are certainly a number of offerings in New York State around HIV, hep C, and sexual health. Why is it important that this medical education be required and tied to licensing, versus depending on people to voluntarily take these kinds of trainings?
Michelle Collins-Ogle: It’s kind of two different paths because there are education courses that we take voluntarily that are based on our interests, or based on our practice, that also have to do with our competency. For example, I provide gender-affirming care. So, it’s not a requirement that I have any kind of education credits towards that. However, if I’m going to be competent and able to perform those medical services in a competent manner, I have to take courses, trainings, etc. in order to be competent in that area. There’s nothing that requires me to do that.
That continuing medical education is a requirement because we have to prove ongoing learning and competence. Every state has their own sort of topics that have to be covered in their CMEs. For example, New York’s has child abuse. You have to have so many credits on child abuse and maltreatment. And then every four years, you have to do CMEs on infectious and communicable diseases, and then another one on pain management, and so on. So, every state kind of has their own topics that they require you to have in order to fulfill your CME requirements.
The licensing issue is kind of separate. The CME requirements are how I’m able to have my privileges at a hospital. It’s how I’m able to be credentialed with insurance companies. Those CMEs overall are requirements that I have to have for that. But there’s nothing within those CMEs other than some of the topics that some states require that says I have to have CMEs towards a certain topic or a certain discipline in medicine in order to be credentialed with an insurance company or be credentialed with my hospital, if that makes sense.
So, it’s one of two different conversations around CMEs, and then what’s required for you to be able to perform your services in your specific area of expertise.
For example, for what I do, I have to have a certain amount of education credits towards HIV care, transgender care, and STI instruction and training. But nothing mandates that I do that.
Wilder: If this bill passes, it will be the first in the country to actually tie medical licensing and certification to continuing medical education regarding sexual health and, particularly, HIV-related, disease-related prevention, diagnosis, and engagement in care.
Katy, you’re a nurse, and nurses are obviously critical to ending the HIV epidemic in New York State. Why do you think it’s important for nurses to be included and singled out in this piece of legislation?
Kathleen Bernock: It’s incredibly important for nurses to be involved. They are often the first point of contact with the person coming into the medical center. Nurses often are working in triage and asking the patient their medical histories. They’re getting that initial front-end information from somebody who’s coming in for care.
So, it’s really important that nurses across the spectrum, wherever they are, understand how to be able to speak with people about gender identity, about preferred pronouns, and also to be able to get to the gist of what’s concerning them and what they’re coming in for care for. Nurses are often the ones who are taking this history and writing it down in order for the medical provider to know how to direct that visit. Nurses decide, who are they going to be seeing? Is this an emergency so they need to be seen today? All of those things. So it’s so important that nurses are included.
Nurses also provide so much health care education to patients coming into the clinic. I’m a nurse practitioner now, and I get so busy that I sometimes miss working in that nursing role, because I don’t always have as much time to really talk to people and provide the education that I did back then. It’s so important, and I try to make a point to work with all the nurses I’m working with in all of my clinics, that they understand the transmission of STIs, and that they understand three-point testing.
A lot of times, nurses are able to have more robust conversations with patients about what’s going on with their health. So, if nurses aren’t aware of this, as well as the physicians, then there are still going to be quite a few gaps in care.
Strengthening People-Centered, Affirming Care
Wilder: This piece of legislation is an amendment to a public health law. Amir, how did this idea come to be? How did Assembly [member] Rosenthal get involved? What was the spark that led to this legislation being introduced?
Sadeghi: That’s a great question. The background about State Assembly Bill 3864 is rooted in conversations that different members of the community and different New York and national organizations have been having regarding a reform to the HIV testing bill in 2019. In that year, there was a proposal to change the testing requirements here in New York that a patient be provided direct verbal notice prior to administering an HIV test. That legislative proposal was seeking to address some distressing data out there on late HIV diagnoses and concurrent HIV/AIDS diagnoses. The idea was that maybe if we try to provide notice indirectly to patients prior to an HIV test—hopefully that proposal was seeking to connect patients with care once they’ve been identified as living with HIV. However, there was a lot of concern about the proposal. Current CDC testing guidelines advised direct verbal notice prior to an HIV test. That is the letter of the law currently in New York State, that patients do have to be given direct verbal notice. I think that there are a lot of good reasons for that.
New York State Assembly Bill 3864, introduced by Assemblymember Rosenthal, seeks to encourage and strengthen the relationship between patients and providers, especially marginalized patients who might be worried about the collateral legal consequences to an HIV diagnosis, and might be worried about how an HIV diagnosis would change their lives, affect their romantic and sexual relationships, affect their immigration or asylum status, or affect every aspect of their lives. We think that by encouraging and strengthening those relationships between patients and providers, we can truly seek to bring all patients into an affirming and competent health care system.
So, a lot of conversations that were happening in 2019 about how perhaps balancing some of these issues on the backs of patients and potentially testing them without direct verbal notice could have drastic repercussions for the progress that the New York State Department of Health has made in bending the curve and working to end the HIV epidemic. We’ve known for years that there are still some pretty shameful disparities in HIV and STI diagnoses in patients of color and LGBTQ patients being tested and connected to lifesaving care.
There’s a good argument here that balancing anything on the backs of patients and perhaps putting the conditions at play for a scenario where someone comes into a medical setting with a hangnail and then is informed that they’ve been diagnosed with HIV could actually create a lot of public health harm. I think a lot of the proponents of Assemblymember Rosenthal’s Bill 3864 see it as an important alternative response to the same data.
To the same issue of patients maybe feeling alienated from care, patients subject to certain discriminatory experiences, or subject to assumptions that providers might be making about their sexual activity, patients and data seem to suggest that providers aren’t really fulfilling their legal obligation of offering and verbally engaging a patient prior to an HIV test. That bill in 2019 that would have changed the HIV testing requirements in New York State is actually what led to a lot of advocates and public health experts and providers coming together and thinking of an alternative proposal that doesn’t balance this issue on the backs of patients, doesn’t strip them of their rights, and actually is guided by a lot of values and principles grounded in patient-centered care, people-centered care, and affirming and culturally competent care.
Wilder: The New York State HIV testing law requires medical providers to offer HIV testing to anyone 13 and older. Could you shed some light on why there’s this failure by medical providers to actually offer HIV testing, when we have a governor who has a plan to end the AIDS epidemic in New York State?
Collins-Ogle: It’s not just providers in New York and New York State—this is across the country. The CDC put out those guidelines that anyone between the ages of 13 and 64 should be offered an HIV test at least once during an encounter with a medical provider or a clinician. That’s a guidance and guidelines for clinicians across the country. It’s not just in New York State. So that’s one thing.
Across the country, there’s no mandate, there’s no teeth behind not offering an HIV test. Now, let’s say I want to go to a provider and have a discussion about HIV testing or my risks for HIV, there is a code for HIV counseling. So, I can put in a code that says this person came in today to see me for HIV counseling. But it’s not really reimbursed. If people come in to see me for counseling for HIV, if they want to come in for testing for HIV, I’m not really reimbursed for that service.
If you come in to see me for something else, however—as Amir was saying, if you come in to see me for a hangnail and I use that opportunity to talk to you about HIV testing or to say to you, “Hey, have you ever had the test? You have the right to have one,” there’s still no reimbursement. There’s no real incentive for me as a clinician to do that. And that takes time. Talking with someone about HIV is not a five-minute talk, if you do it well—and depending on the person’s risk for exposure to HIV. So that’s not a five-minute conversation.
We don’t really get reimbursed for the time that it takes to do that in order to do the next step. This is why I’ll bring it back around to New York, because New York is kind of unique in this sense. In New York, instead of offering opt-out, you’ve got to opt in—so to bring that back around to clinicians in New York, there’s no real incentive to do it.
I don’t want to look at it as consequences because that’s not the way to look at this. The way to look at this is that with all the other things on clinicians, all the other counseling and services that we must provide in a visit in order to get reimbursed, HIV is just not a priority because there’s no real incentive for us to take the time necessary to do that.
Building Sex Ed Into the Medical School Curriculum
Wilder: The bill, in addition to targeting practicing medical providers in receiving this education and training, it also targets medical students. Why were medical students’ educational needs included in the bill?
Bernock: I think it’s fantastic to include medical students in the bill. For students going into the health care professions across the board, it’s important for this to begin to be integrated into education—because historically, it has not been a part of education. And so, going into a clinic and starting to work, a lot of medical students have to learn this from the people they’re working with. If they’re not working with a physician or in a residency program where this is something that is taught, then it’s not something they’re going to learn, and it’s not something they see as a priority or as important. Whereas, if it’s integrated into the curriculum for medical students, then it’s already ingrained that “this is something that I need to know, and this is something that I’m going to have to utilize once I go out into practice.”
That’s going to turn a whole new generation of providers over who, hopefully, will then have the competency and understand the importance of this moving forward, without having to backtrack and provide this mandatory education for those that haven’t yet received it.
Collins-Ogle: A lot of what medical students receive in terms of education is what our actual experiences are at the time. For example, students now that were in medical school for the past year during COVID are probably going to know more about COVID than anybody else on the planet, because of their proximity to COVID during their training.
I was a resident and then a fellow in infectious diseases during the height of the HIV epidemic in the early to mid-’80s. We were trained. We worked hard because we actually cared for patients that were in the hospital. So, since those patients aren’t in the hospital anymore, since we don’t have whole wards with babies or young children or adults dying from complications of AIDS, since that’s really not part of the clinical experience right now, that’s why it may appear that students aren’t really getting the education they need. But it has to do with your proximity to what’s going on in the health care system at the time you’re doing your training, if that makes sense.
I had plenty of training in HIV care. That was during the time we needed to have the training because we were caring for so many people that were sick with HIV. So, I wanted to make that background, that that’s sort of how education and the curriculum works for medical students.
And then, there’s HIV curricula out here. There’s a national HIV curriculum. The American Academy of HIV Medicine has a certification that you can take, which I have. I’m an HIV specialist. I took the training and I’m certified to provide that care. So it’s out here. There’s no lack of resources and there’s no lack of agencies that provide education around HIV. So I want to make sure I put that out there—that it’s definitely out there for people who want to get the education.
This Bill, in the Real World
Wilder: If this bill passes, which I hope it does, what does the implementation look like? Who’s the organization that’s going to take the lead to make sure this happens in the real world?
Sadeghi: As Michelle noted, there is already an abundance of curricula out there. One of our partners on this campaign actually puts together curriculum on LGBTQ cultural sensitivity and sexual health literacy. The Hetrick-Martin Institute has been doing that for years and years, and they’re collaborating with us on this campaign to advance State Assembly Bill 3864.
But it’s not really typically the job of a continuing medical education bill to spell out or direct the implementation or assign certain agencies or organizations to take up fleshing out what the curricula looks like. I think a good example of that is the bills advanced here in New York that are now law to require that medical professionals be competent in identifying signs of child abuse or pain management and addiction issues. These proposals seek to improve the continuing medical education requirements that physicians and other medical professionals need and are really about shifting the conversation away from personal responsibility and thinking about the responsibilities that providers have in engaging their patients. They’re also about making sure that they have the toolkit that they need to have the conversations with patients about sexual health history and sexual health risk.
Wilder: I’d like to close by asking each of you to talk about your big vision or big hope for this bill. Ultimately, what is the outcome that you would like to see?
Collins-Ogle: You know, I’ve been around a while, and I really don’t look at this as being a big, huge lift. I look at this as being a request made to the health care community to, as lifelong learners, to educate ourselves on the changes that are occurring now in the health care field and providing more comprehensive care around sexual health—which is the way I really like to look at this. I kind of put it all together: gender-affirming care, high-risk STIs, and high risk for HIV exposure—all of those are topics that are centered around sexual health.
As this bill says, it gives an opt-out for clinicians who are dead set against it.
But it requires—like my infectious-disease components that New York State CME requires—that you have two or three CMEs focused on sexual health. It’s mandating that you do take time to educate yourselves and be competent in basic sexual health, for people that you want to provide services for in a health care center.
I look at it as a small step to make sure that we remain competent and that we remain current in what people that we provide health care for, in what they need to receive complete services around health care.
Sadeghi: You’re right. There absolutely is a provision in this bill, as there would be in most continuing medical education bills, that provides an exception for these requirements if you can demonstrate that you have satisfied competency on this by, for example, proving that you’ve taken training with a different medical organization or society that offered training over this topic.
Bernock: In health care, it’s often the simplest things that are the hardest to change. So, I think just focusing on the simple idea that maybe this bill can create primary care centers, urgent care centers, and emergency room centers where, when someone walks in the door, it starts to become the norm for asking about sexual orientation and gender identity to be organized into the intake—and for providers to be able to take a comprehensive sexual health history and understand how to test for different STIs with patients.
Just having those two simple things will open the door to a lot, as well as the specifications for HIV testing and the recognition that it’s important that this is integrated into care. The bill focuses on some really simple things that weren’t being done. And I think that the comfort level of people accessing care will just be vastly improved if these simple things can start to be implemented.
I’m really excited about this bill. I hope it’s passed and that this is mandated, so that these things start becoming the norm instead of a learning in clinical practice.
Sadeghi: It’s so hard to follow Katy and Michelle. But I actually would just add to the idea that the task captured by State Assembly Bill 3864 is actually quite a simple one. I think state, local, and federal agencies have been calling for this kind of cultural sensitivity and competency training for years. The original blueprint to end the HIV epidemic in New York identified this type of patient-centered cultural competency training as a fundamental element of the response to the HIV epidemic. Following that, the New York State AIDS Institute identified priorities in 2019 and 2020 that also touched on the necessity for this kind of training.
Lastly, one of the most recent plans from the federal Department of Health and Human Services also made it clear that basically medical staff, anyone delivering direct care to patients, the importance for them to understand the experiences of everyone seeking care, and understanding how every patient might identify so that we can make it easier and more comfortable and more welcoming for all patients to connect to the care—especially the patients that the State Department of Health and different medical and public health stakeholders are desperately trying to reach.
My vision is that simple one of honoring what experts and leaders across disciplines have been identifying as something that’s very much needed for a long time. Sexual health is truly one of the nearly universal health issues that unites nearly all of us. I agree with Michelle that it’s not asking too much that providers take some basic sexual health literacy, HIV, and STI training to make sure that we can successfully and equitably respond to disparities and negative health outcomes that are still affecting a lot of marginalized patients.