Are patients willing to discuss HIV?
Yes. Patients want to hear about AIDS from their doctors. Most adults believe physicians to be desirable and credible sources of information about AIDS. Teenagers also prefer to hear about HIV risks from their doctors.(1)
Yet in a nationwide survey of adults, only 15% of patients had discussed HIV risks with their doctors in the previous five years, although 94% had seen a physician during that time. Nearly three-quarters (72%) of the discussions about HIV that did take place were at the patients' urging.(2)
Clinicians have incorporated many important aspects of disease prevention and health promotion into daily practice. A study by the Centers for Disease Control and Prevention (CDC) reported that the overwhelming majority of primary care physicians "usually" or "always" asked their adult patients about cigarette smoking (94%) and alcohol use (84%). In areas most directly related to HIV risks physicians were more reticent. Many fewer inquired about illicit drug use (49%), condom use (31%), number of sexual partners (22%), or sexual orientation (27%).(3) These findings underscore the substantial number of physicians who are missing opportunities to counsel during encounters with patients.
What can clinicians do?
Opportunities for health caregivers to help foster the behavior changes needed to stem the spread of HIV infection are myriad. Physicians see about 78% of adults each year (excluding institutionalized populations).(4) Visits with physicians or other encounters with the health care system are "teachable moments"Ñopportunities for discussing sexual and drug-use risks in a manner relevant to individual patients' lives.
One-on-one AIDS prevention education is not necessary for each and every patient, as HIV risks are not spread evenly among the population. For primary care practitioners, the main goal should be to learn which patients are at high risk and to focus prevention efforts on them. Individualized risk assessment and counseling is a hallmark of good prevention practice. "The physician who would provide the same counseling to all patients would be serving none well."(5)
The federal government's national health promotion and disease prevention plan, Healthy People 2000, includes the following goals: to increase to 80% the proportion of persons with HIV infection who have been tested and to increase to at least 75% the proportion of primary care and mental health providers who provide age-appropriate counseling on the prevention of HIV and other STDs.(6)
What are clinicians' barriers to discussing HIV risks?
Barriers to greater clinician involvement can be grouped under a few headings, each of which needs to be addressed: narrow conceptions of medical care; clinicians' discomfort with discussions about sexuality, drug use and attitudes about HIV/ AIDS; constraints of time and resources; and the ambiguity of prevention messages.(7,8,9,10)
Some physicians may lack the knowledge or the skills to deal with HIV risks; many health care providers practicing today were trained before HIV disease was known.(11) The ability to integrate HIV concerns into clinical practice requires substantive knowledge about the epidemiology of HIV and the risk of transmission.
Why are clinicians reluctant to discuss HIV risks?
HIV prevention requires the ability to talk about sexuality and drugs in a non- judgmental way, something that may be difficult.(12) More education and training opportunities in both undergraduate and continuing medical education can help shore up clinicians' knowledge of HIV risk issues.(13) Such training can also go beyond the didactic and focus on practical skills needed to assess risks, counsel patients and make referrals. Innovative ways to help foster these skills include simulated patient instructors for role-play and feedback on clinical performance.
Clinicians need to be apprised of the most recent epidemiologic data on risks of HIV transmission, including aspects where the evidence is not clear cut, such as the risks for gay men of oral sex without condoms, anal intercourse with condoms, and HIV transmission between women. Ambiguity regarding the appropriate content of the prevention message is part of the challenge for clinicians. Uncertainties in areas such as these can be an occasion for discussion with patients about their values, their understanding of risk, and how much risk they are willing to assume.
What support do clinicians need?
The lack of time is an enormous barrier for primary care clinicians, who, when they are not providing acute care, have a panoply of disease prevention concerns and screening topics such as depression, smoking cessation, alcohol and drug use, diet and cholesterol, exercise, and seat belt wearing.(14) In recent years, primary caregivers have also been urged to address topics with broader social ramifications, such as domestic violence. No wonder clinicians might balk when asked to add yet another sensitive topic, especially when straining under the yoke of cost containment.
Clinicians may overestimate what it will take to make a useful contribution to HIV prevention efforts. For skilled practitioners, interventions involving only a few HIV screening questions as part of a larger battery for a history and physical exam will serve to identify high-risk individuals who can then become the focus of more targeted efforts and receive referrals to community-based public health programs.
Administrative structures can be built to encourage and reward geater attention to HIV risks in clinical practice. Such systems have already proven useful in other health promotion efforts. They typically include reminder notices, follow-up appointments, telephone counseling, labels and identifiers for patient records and other ways to help caregivers work with patients to help achieve behavioral goals. The establishment of such systems has been shown to increase significantly physicians' participation in smoking cessation campaigns.(15)
Administrative systems should also be put in place that foster reliance on a broader range of health professionals, including nurses, physicians' assistants, community health educators, and reception staff. Greater use should be made of videos, brochures, questionnaires and other written materials to teach patients about HIV risks and to elicit information about risk histories.
Will enhancing clinician involvement be enough?
Enhancing clinicians' involvement is only one aspect of a broad prevention policy. A comprehensive HIV prevention strategy uses multiple elements to protect as many people at risk of HIV infection as possible. HIV prevention is not a "one-shot" effort; it is an ongoing process that demands the involvement of many sectors of society. This includes the physicians, nurses, health educators and other health caregivers to whom people look for advice on how to stay healthy.
References:
Prepared by Harvey Makadon and Jeff Stryker
Reproduction of this text is encouraged; however, copies may not be sold. The Center for AIDS
Prevention Studies at the University of California San Franciso is the source of this
information. For additional copies of this and other HIV Prevention Fact Sheets, please call the
National AIDS Clearinghouse at 800/458-5231. Comments and questions about this Fact Sheet may
be e-mailed to prevention_factsheets@quickmail.ucsf.edu. ©1996, University of California
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