A 44-year-old man comes to the office to establish medical care. He feels well at this time. The patient has a history of hypertension, stage 3 chronic kidney disease, and generalized anxiety disorder. He is "mostly" adherent to his medications, which include lisinopril, amlodipine, and paroxetine. He is sexually active with both men and women and uses condoms inconsistently. The patient has had 4 sexual partners over the last year. He was recently treated for gonococcal urethritis. HIV testing a year ago was negative. He does not use tobacco or consume alcohol but occasionally smokes marijuana. Blood pressure is 155/90 mm Hg and pulse is 78/min. BMI is 24 kg/m². No jugular venous distension is present. Cardiac auscultation reveals a fourth heart sound but no murmurs. There is no peripheral edema. Laboratory results are as follows: Laboratory screening for syphilis, gonorrhea, and chlamydia is negative. In addition to education on safe sexual practices, which of the following is the most appropriate course of action in this patient?

Question

Quizplus · Accepted Answer

Explanation: This patient with multiple sexual partners is at high risk for hepatitis B virus (HBV) and has no evidence of immunity. He should receive the HBV vaccine. Approximately 2 billion people worldwide have been exposed to HBV. Transmission occurs primarily from mother to child in endemic areas (eg, India) and in those who engage in high-risk sexual practices and intravenous drug use in lower-prevalence areas (eg, United States). Although most infections resolve spontaneously, approximately 5% become chronic, putting patients at risk for cirrhosis, hepatocellular carcinoma, and transmission to others. The Centers for Disease Control and Prevention recommends a 3-dose HBV vaccination for all infants and all children age <19 who have not yet been vaccinated. High-risk adults who have no evidence of prior (positive HBV surface antibody/negative surface antigen) or current (positive HBV surface antigen) infection should also undergo vaccination. In the United States, this high-risk group includes people with >1 of the following: Multiple sexual partners or a history of a sexually transmitted disease Men who have sexual activity with men Intravenous drug users Patients with chronic kidney disease, hepatitis C virus, or HIV Household contacts of patients with chronic HBV In addition, all pregnant women, health care personnel, and inmates who are unvaccinated (and not immune) should also receive HBV vaccination. (Choice B) Approximately 25% of people in the United States have human papilloma virus, and vaccine is recommended for most men until age 21 and women until age 26. Although this patient is at high risk for exposure to human papilloma virus, he is outside of the recommended age range for vaccination. (Choice C) Although HIV pre-exposure prophylaxis is recommended for men who engage in high-risk (eg, unprotected anal sex) sexual activity with men, patients must have normal renal function (unlike this patient). (Choice D) Herpes simplex screening is not recommended for asymptomatic patients due to risk of false positives and lack of evidence that screening alters sexual behavior or reduces risk of transmission. (Choice E) The use of topical microbicides during intercourse can modestly reduce the risk of HIV transmission. Microbicides are currently not widely used; this patient requires HBV vaccination. Educational objective: Adults at high risk for HBV infection should be vaccinated if there is no sign of previous or active HBV infection. Patients at greatest risk are those with multiple sexual partners and a history of intravenous drug use. All pregnant patients, health care personnel, and inmates should also receive HBV vaccination.

A 44-Year-Old Man Comes to the Office to Establish Medical