Primary care physicians and their HIV prevention practices

A national random-sample survey of 4011 primary care physicians was conducted to determine the extent to which they are providing HIV prevention and clinical services, and to learn what characteristics and attitudes might impede the provision of such services. Physicians were asked about their history-taking practices for new adult and adolescent patients, including asking about the use of illicit drugs (injection and noninjection), the number of sexual partners, use of condoms and contraceptives, past episodes of sexually transmitted diseases (STDs), sexual orientation, and sexual contact with partner(s) at high risk for HIV. A preliminary analysis was conducted and reported earlier by the Centers for Disease Control and Prevention (CDC), focusing on the HIV-prevention services being provided by primary care physicians. This report provides additional analyses from this study, focusing on characteristics and attitudes that may prevent physicians from providing these services. Male physicians and the physicians' belief that patients would be offended if asked questions about their sex behaviors were strongly predictive of not asking new patients about their sex and drug behaviors. The physician's specialty was also a strong predictor-OB/GYNs were predictive of asking these questions and GP/FPs were predictive of not asking the questions. Physicians who indicated that a majority of their patients were white were less likely to report asking patients about their sex and drug behaviors. The authors conclude that a substantial number of primary care physicians are missing important opportunities to prevent HIV transmission by not adequately assessing patients' risks and not providing necessary risk-reduction counseling during their physician-patient encounters. Physician's attitudes and beliefs about their patients, as well as their level of experience with HIV, may help to explain these observations.     

Physicians' transmission prevention assessment and counseling practices with their HIV positive patients.

Physicians can help prevent transmission of HIV by assessing HIV positive patients for risky sexual and needle-sharing behaviors, and by providing risk reduction counseling. From 1995 to 1997, we gathered data on the HIV transmission prevention assessment and counseling practices of 44 San Francisco Bay area physicians in face-to-face, semistructured interviews. A refined coding scheme and constant comparative analytic method were used. Although physicians varied in their responses to coded items, two styles of engagement, at the extremes, emerged from the data: "consultant" and "collaborator." Consultants conducted transmission prevention assessment and counseling during initial visits or upon medical cues (e.g., presence of sexually transmitted diseases) and viewed themselves primarily as information sources, whereas collaborators regularly conducted transmission prevention counseling and viewed themselves as actively helping patients reduce transmission risk. Physicians who fell between the two styles generally did not conduct regular counseling themselves, but many used referrals to health educators. The findings suggest that consultant and collaborator styles may influence patients differently, and offer insight into the role that physicians can play in transmission prevention with HIV positive patients.     

Do physicians provide counseling with HIV and STD testing at physician offices or hospital outpatient departments?

OBJECTIVES: To estimate the frequency of HIV/sexually transmitted disease (STD) counseling among patients tested for HIV or STD infection at physician offices and hospital outpatient departments and to describe the factors associated with HIV/STD counseling in private settings in the USA. DESIGN: Cross-sectional study of patients served by physicians in private settings in the USA. METHODS: We analyzed 1997-1998 data from two representative national surveys of ambulatory care visits in private settings by persons aged 18-64 years. RESULTS: During 1997-1998, 12.7 million ambulatory care visits included HIV or STD testing. HIV/STD counseling was documented in 35% of all visits and in 28% of visits by pregnant women at the time HIV or STD tests were done. Counseling was less common when only HIV tests (21%) or STD tests (37%) alone were carried out than when both HIV and STD tests (50%) were performed. Counseling was more common (65%) if the patient's reason for visit was related to HIV, STD, or genitourinary complaints than if the visit was for other reasons. CONCLUSIONS: Private physicians often counseled about HIV/STD when testing patients with symptoms. The proportion of other visits in which counseling accompanied HIV or STD tests was variable. This suggests the need for a better understanding of the reasons why clinicians in private settings decide whether to counsel patients about HIV and STD when they order testing, barriers to offering counseling, and interventions to increase counseling when appropriate.     

Sexually transmitted diseases in travelers

International travelers engaging in casual sex are at risk for acquiring sexually transmitted diseases (STDs), including HIV. The frequency of international travel emphasizes the need for a travel sexual activity history to be included in the clinical assessment of any returned traveler. When formulating a differential diagnosis, the STD prevalence rates at the travel destination and the risk profile of the traveler and the sexual partner need to be considered. Casual sex with host country nationals residing in tropical and subtropical areas of the developing world increases the traveler’s risk for acquiring STDs rarely seen in industrialized countries, particularly bacterial genital ulcer diseases. Pretravel counseling needs to include education on STD prevention. A post-travel STD diagnostic evaluation is indicated when casual sexual activity has occurred during travel, regardless of whether symptoms are present.     

The link between sexually transmitted disease clinics and HIV counseling and testing centers: who is not getting referred?

A total of 236 clients attending human immunodeficiency virus (HIV) counseling and testing (C&T) centers and sexually transmitted disease (STD) clinics were interviewed to evaluate who is being reached by C&T services and if STD clients are being referred to HIV C&T centers. Respondents receiving HIV C&T reported significantly more sexual risk based on characteristics of their partners, whereas STD clinics respondents more frequently reported previous STD diagnoses and sex with prostitutes. Over 50% of the high-risk individuals attending STD clinics were not referred to HIV C&T centers. The differences in perceived risk of current and future infection between STD and HIV C&T centers and the low referral rates of high-risk individuals for HIV C&T indicate a need for increased education efforts, more effective risk-assessment policies in STD clinics, and a tightening of the link between STD clinics and HIV C&T centers.     

Characteristics of Individuals and Couples Seeking HIV-1 Prevention Services in Nairobi, Kenya: The Voluntary HIV-1 Counseling and Testing Efficacy Study

This paper describes the recruitment and baseline characteristics of men, women, and couples who enrolled in the Voluntary Counseling and Testing Efficacy Study at the study site in Nairobi, Kenya. The purpose of this study was to test the effectiveness of Voluntary HIV Counseling and Testing (HIV VCT) to reduce sexual risk behavior. Between June 1995 and March 1996, 500 individual men, 500 individual women, and 515 couple members were recruited for a total sample of 1,515 participants. Participants were young (average age 29 years) and of low income. High levels of risk behavior and self-reported STD symptoms and a high rate of HIV seropositivity among those tested at baseline (15% of men and 27% of women) indicate that an at-risk sample was recruited. Women and participants reporting symptoms of a sexually transmitted infected were significantly more likely to be infected with HIV. Findings suggest that HIV VCT services combined with STD diagnosis and treatment and economic development services could motivate more at-risk individuals and couples to receive counseling and testing.     

Treatment delay and reliance on private physicians among patients with sexually transmitted diseases in China.

We examined health-care seeking practices among patients with sexually transmitted diseases (STDs) in south China. In 1995, we recruited a consecutive sample of 939 STD patients attending the STD clinics of the Municipal STD Control Centers of Guangzhou and Shenzhen, 'special economic zones' near Hong Kong. Attending physicians interviewed patients face-to-face using a standard survey questionnaire. Twenty-seven per cent of all subjects had sought treatment elsewhere for their presenting complaints, before visiting a study clinic. The main sources of prior treatment were private physicians followed by public clinics and drugstores. Women were more likely than men to delay in presenting their current symptoms to a study clinic (32% vs 25%, P=0.046). Factors associated with treatment delay differed by gender. Among men, seeking prior treatment from private physicians (OR=3.31; 95% CI=1.70, 6.43), having no urethral discharge (OR=4.00; 95% CI=2.33, 6.85), having engaged in sex trade (OR=1.64; 95% CI=1.03, 2.63), or being a resident in Shenzhen (OR=1.80; 95% CI=1.12, 2.89) were more likely to delay seeking treatment. Among women, only living in Shenzhen (OR=2.86; 95% CI=1.56, 5.25) was associated with treatment delay. Promotion of appropriate health-seeking behaviours and better management of STDs must be a top priority to slow a rapid spread of STD/HIV in China. Health education, improvement of STD care in the public and private sectors, and regulations of unauthorized private physicians, may help with STD control and HIV prevention.     

Estimating dissemination of Centers for Disease Control and Prevention Sexually Transmitted Disease Treatment Guidelines from a survey of physicians

Periodically, the Centers for Disease Control and Prevention (CDC) produce guidelines for the treatment of sexually transmitted diseases (STDs) in the USA. To date, few evaluations of the dissemination of these guidelines exist. A paper and pencil survey was distributed via priority mail to a sample of Atlanta-area physicians, 416 (34%) of whom responded with complete data. Physicians were drawn from private practice, managed-care settings and public settings. In all, 85% of respondents treated STD, with a further 10% referring cases. Of those treating STD, 56% owned a copy of the 2002 CDC Treatment Guidelines, and 26% knew how to access them. The corresponding figures for physicians not treating STD were 25% and 30%. Of the physicians who did have copies, half had accessed the internet for their copies. Acquisition of, or the knowledge of how to acquire, the CDC STD Treatment Guidelines was widespread. The internet may be an effective and cost-saving means of disseminating the guidelines, although the continued need for print distribution should not be discounted.     

Adherence counseling practices of generalist and specialist physicians caring for people living with HIV/AIDS in North Carolina

CONTEXT: National guidelines recommend that practitioners assess and reinforce patient adherence when prescribing antiretroviral (ART) medications, but the extent to which physicians do this routinely is unknown. OBJECTIVE: To assess the adherence counseling practices of physicians caring for patients with HIV/AIDS in North Carolina and to determine characteristics associated with providing routine adherence counseling. DESIGN: A statewide self-administered survey. SETTING AND PARTICIPANTS: All physicians in North Carolina who prescribed a protease inhibitor (PI) during 1999. Among the 589 surveys sent, 369 were returned for a response rate of 63%. The 190 respondents who reported prescribing a PI in the last year comprised the study sample. MAIN OUTCOME MEASURES: Physicians reported how often they carried out each of 16 adherence counseling behaviors as well as demographics, practice characteristics, and attitudes. RESULTS: On average, physicians reported spending 13 minutes counseling patients when starting a new 3-drug ART regimen. The vast majority performed basic but not more extensive adherence counseling; half reported carrying out 7 or fewer of 16 adherence counseling behaviors "most" or "all of the time." Physicians who reported conducting more adherence counseling were more likely to be infectious disease specialists, care for more HIV-positive patients, have more time allocated for an HIV visit, and to perceive that they had enough time, reimbursement, skill, and office space to counsel. After also controlling for the amount of reimbursement and availability of space for counseling, physicians who were significantly more likely to perform a greater number of adherence counseling practices were those who 1). cared for a greater number of HIV/AIDS patients; 2). had more time allocated for an HIV physical; 3). felt more adequately skilled; and 4). had more positive attitudes toward ART. CONCLUSIONS: This first investigation of adherence counseling practices in HIV/AIDS suggests that physicians caring for patients with HIV/AIDS need more training and time allocated to provide antiretroviral adherence counseling services.     

The effect of educational preparation on physician performance with a sexually transmitted disease-simulated patient.

BACKGROUND--Simulated patients are used with increased frequency for medical students and residents, but have not been used very often with practicing physicians. We hypothesized that educational materials could improve primary care physicians sexual practices history taking and counseling as assessed by a simulated patient in the physician's office. METHODS--Simulated patient (SP) visits were made to 232 (75% of eligible) primary care physicians. The patient simulated was a sexually active young woman with vaginitis and sexually transmitted disease/human immunodeficiency virus risk behaviors. In advance of the visit, physicians were provided educational materials (monograph, pamphlet, and audiotape) developed for the study, including a risk assessment questionnaire that could be used with patients. RESULTS--Most physicians randomly allocated to the intervention participated. Twenty-one percent of physicians refused to schedule an SP visit. Physicians who received an SP rated the experience highly. Physicians who prepared for the visit with the educational materials performed significantly better than those who did not. About two thirds of physicians reviewed the materials, many for the second time, after the SP visit. Physicians who used the study risk assessment questionnaire performed better. Many physicians (24.9% to 39.8%) did not meet each of the four goals for the visit, as assessed subjectively by the SP. Physician performance was better for measures of general patient interaction than for measures of sexual practices history taking and counseling techniques. CONCLUSION--The SP visit was acceptable to most physicians practicing in a community and was evaluated by them as an appealing and an effective educational experience. The SP, however, has limited feasibility because of cost. The SP led to review of materials by nearly all physicians either before or after the visit. Physicians who prepared before the visit performed better on every dimension, eliciting more information, displaying better patient interaction skills, and meeting more of the educational goals. Even with educational preparation, however, many physicians were not perceived as being effective counselors.     

Cardiac Risk Underestimation in Urban, Black Women

BACKGROUND: Because sexually transmitted chlamydial infections are common among young women, it is critical that providers screen and manage these infections appropriately. OBJECTIVE: To assess the Chlamydia care practices of California primary care physicians and nurse practitioners. DESIGN: Cross-sectional, self-report mail survey. PARTICIPANTS: A stratified random sample of primary care physicians and a convenience sample of primary care nurse practitioners in California. MEASUREMENTS AND MAIN RESULTS: Survey content included 5 topic areas: sexual history taking, management of cervicitis, management of a nonpregnant Chlamydia-infected patient, availability of onsite STD services, and Chlamydia screening practices and attitudes. Main outcome measure was the reported frequency of Chlamydia screening of sexually active women age 25 and younger. Respondents included 708 physicians (49% response rate) and 895 nurse practitioners (63% response rate). Nearly half of physicians (47%, 95% confidence interval [CI], 42% to 51%) and a majority of nurse practitioners (79%, 95% CI, 77% to 82%) reported routine Chlamydia screening of women under age 20; similar proportions reported routinely screening women aged 20 to 25 years. Independent predictors of screening among physicians were adolescent medicine specialty, female gender, practicing in a nonprivate setting, and having a higher volume of female patients. Additional findings included the overscreening of women over age 25 by nurse practitioners and the shared concern among providers that Chlamydia screening may not be reimbursed. CONCLUSIONS: The Chlamydia care practices of many California primary care providers are inconsistent with current guidelines. Targeted provider education and improved reimbursements are potential strategies for improvement.     

New challenges in HIV care: prevention among HIV-infected patients

The HIV-infected population has been understudied and underserved with respect to risk reduction and prevention interventions. Increases in high-risk sex practices and sexually transmitted diseases (STDs) have prompted considerable concern and have led to initiatives to implement routine STD screening and risk reduction counseling among the HIV-infected population. Available evidence indicates that risk reduction counseling can be effective. Improved attention to risk reduction counseling in the HIV medical care setting in needed, and efforts to improve access and maintain linkage to care must be increased. This article summarizes a presentation given by Carlos del Rio, MD, at the March 2003 International AIDS Society-USA course in Atlanta.     

<Emphasis Type="Italic">Chlamydia</Emphasis> screening and management practices of primary care physicians and nurse practitioners in California

BACKGROUND: Because sexually transmitted chlamydial infections are common among young women, it is critical that providers screen and manage these infections appropriately.
OBJECTIVE: To assess the Chlamydia care practices of California primary care physicians and nurse practitioners.
DESIGN: Cross-sectional, self-report mail survey.
PARTICIPANTS: A stratified random sample of primary care physicians and a convenience sample of primary care nurse practitioners in California.
MEASUREMENTS AND MAIN RESULTS: Survey content included 5 topic areas: sexual history taking, management of cervicitis, management of a nonpregnant Chlamydia -infected patient, availability of onsite STD services, and Chlamydia screening practices and attitudes. Main outcome measure was the reported frequency of Chlamydia screening of sexually active women age 25 and younger. Respondents included 708 physicians (49% response rate) and 895 nurse practitioners (63% response rate). Nearly half of physicians (47%, 95% confidence interval [CI], 42% to 51%) and a majority of nurse practitioners (79%, 95% CI, 77% to 82%) reported routine Chlamydia screening of women under age 20; similar proportions reported routinely screening women aged 20 to 25 years. Independent predictors of screening among physicians were adolescent medicine specialty, female gender, practicing in a nonprivate setting, and having a higher volume of female patients. Additional findings included the overscreening of women over age 25 by nurse practitioners and the shared concern among providers that Chlamydia screening may not be reimbursed.
CONCLUSIONS: The Chlamydia care practices of many California primary care providers are inconsistent with current guidelines. Targeted provider education and improved reimbursements are potential strategies for improvement.     

Sexually transmitted infections in female rape victims

Sexual assault is a common occurrence that carries significant physical and mental health morbidity. Some of the most common concerns expressed by sexual assault victims can be allayed by addressing the risks of rape-related sexually transmitted infections. Although exact risks cannot be accurately quantified, it is important that health-care professionals provide counseling as well as prophylaxis and/or treatment as indicated. Screening and treatments should follow established guidelines, and follow-up care is indicated to confirm successful prevention or treatment. Continued support, surveillance, and medical attention should be offered as needed. This article will address important clinical issues regarding the prevalence and consequences of sexual assault, and will summarize current recommendations for the prophylaxis and treatment of sexually transmitted infections in adolescent and adult rape victims. Some of the logistical issues surrounding HIV testing, counseling, and prevention for rape victims will also be addressed.     

Missed opportunities for HIV testing in health care settings among young African American men who have sex with men: implications for the HIV epidemic

Limited health care access and missed opportunities for HIV and other sexually transmitted infection (STI) education and testing in health care settings may contribute to risk of HIV infection. In 2008, we conducted a case-control study of African American men who have sex with men (MSM) in a southeastern city (Jackson, Mississippi) with an increase in numbers of newly reported HIV cases. Our aims were to evaluate associations between health care and HIV infection and to identify missed opportunities for HIV/STI testing. We queried 40 potential HIV-infected cases and 936 potential HIV-uninfected controls for participation in this study. Study enrollees included HIV-infected cases (n=30) and HIV-uninfected controls (n=95) who consented to participate and responded to a self-administered computerized survey about sexual risk behaviors and health care utilization. We used bivariate analysis and logistic regression to test for associations between potential risk factors and HIV infection. Cases were more likely than controls to lack health insurance (odds ratio [OR]=2.5; 95% confidence interval [CI]=1.1-5.7), lack a primary care provider (OR=6.3; CI=2.3-16.8), and to not have received advice about HIV or STI testing or prevention (OR=5.4; CI=1.3-21.5) or disclose their sexual identity (OR=7.0; CI=1.6-29.2) to a health care provider. In multivariate analysis, lacking a primary health care provider (adjusted odds ratio [AOR]=4.5; CI=1.4-14.7) and not disclosing sexual identity to a health care provider (AOR=8.6; CI=1.8-40.0) were independent risk factors for HIV infection among African American MSM. HIV prevention interventions for African American MSM should address access to primary health care providers for HIV/STI prevention and testing services and the need for increased discussions about sexual health, sexual identity, and sexual behaviors between providers and patients in an effort to reduce HIV incidence and HIV-related health disparities.     

Messages HIV clinicians use in prevention with positives interventions

Prevention with Positives (PwP) is a component of the US HIV prevention strategy that targets HIV-infected persons who are aware of their seropositive status. This paper examines the use of prevention messages by clinical providers during the PwP intervention period of the US Health Resources and Services Administration's Special Projects of National Significance program. Quantitative approaches were used to learn which prevention topics were most discussed and qualitative interviews were also utilized to better understand the clinician perspective in providing prevention counseling. At 12-month follow-up, there was a significant increase in the percent of patients receiving all PwP counseling messages (p<0.01). Providers reported discussing safer sex with 91% of patients when sexually transmitted infection (STI) screening was conducted during a visit, an increase from baseline (83.5%). The percent of providers reporting they regularly explained the risk of superinfection to their clients also increased from 75% at baseline to 90% at 12-month follow up (p<0.001). Qualitative data suggest that providers prioritize individual care over public health approaches to PwP in counseling. Discussing superinfection offered providers a way to discuss HIV prevention from a non-judgmental clinical perspective while focusing on a patient-centered philosophy of care. However, the threat of superinfection may not be the best counseling option. Examples such as STI screening, giving messages to reduce the number of sexual partners and adherence to medication, are more evidence-based approaches to changing HIV transmission risk behavior and may be more important in PwP. Findings suggest that in order for HIV care providers to incorporate HIV prevention discussions into their practice, acceptable approaches to speaking about risk behavior and prevention of HIV transmission must be developed.     

Assessment of emergency department health care professionals' behaviors regarding HIV testing and referral for patients with STDs

The objective of this study was to evaluate human immunodeficiency virus (HIV) counseling, testing, and referral practices of emergency department health care professionals (i.e., medical doctors [MD], physician assistants [PA], nurse practitioners [NP], and registered nurses [RN]) for patients presenting with other sexually transmitted diseases (STD). All health care professionals from 10 emergency departments in a northeastern county were asked to complete an anonymous survey. The surveys were returned by 154 (41%) health care professionals (RN = 99, NP = 5, PA = 7, MD = 39, other = 4). The average years in practice were 11. Only 7% of respondents were certified to provide state mandated HIV pretest counseling (certification not required for MD). Respondents reported caring for an average of 13 patients per week with suspected STD. Fifty-five percent of respondents reported that they always or usually warn STD patients of their HIV risk, yet only 10% always or usually encouraged these patients to consent to HIV testing in their emergency department (RN = 7%, NP = 25%, PA = 0%, MD = 16%). Reasons for not offering HIV testing in their emergency department were follow-up concerns (51%), not certified to provide pretest/posttest counseling (45%), and too time consuming (19%). Twenty-seven percent of respondents indicated HIV testing was not available in their emergency department despite all hospital laboratories reporting HIV testing capability. Ninety-three percent of respondents were aware that confidential testing sites were available, but only 35% always or usually referred patients not tested in the emergency department elsewhere for testing. Emergency department health care professionals frequently fail to provide HIV counseling, testing, and/or referral for patients with suspected STD.     

Women's HIV transmission risk perceptions and behaviors in the era of potent antiretroviral therapies.

The availability of potent antiretroviral medications has raised new concerns regarding continued HIV transmission risk behavior among seropositive persons. Relatively little is known about how women with HIV perceive secondary transmission risk in the context of HIV treatment advances. This study describes sexual risk perceptions and behaviors of 80 women enrolled in HIV outpatient care in 1999. Participants completed structured interviews assessing sexual risk perceptions, attitudes regarding severity of HIV disease, sources of HIV prevention information, and sexual practices during the previous 6 months. Medical histories including 6-month cumulative incidence of sexually transmitted diseases (STDs) were obtained from a clinic database. Thirty-five percent of the sample had engaged in unprotected intercourse or had been diagnosed with an STD in the past 6 months. Only 5% of women believed that medication-related reductions in viral load signify safer sex is unimportant, but 15% indicated they practice safer sex less often since the advent of new HIV treatments and 40% believed AIDS is now a less serious threat. These data suggest women's perceptions of diminished disease severity may be more influential than beliefs regarding diminished infectivity. Study results have implications for framing prevention messages for women and suggest that close integration of secondary prevention and clinical HIV services may be beneficial.