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HIV Prevention Practices of Primary-Care Physicians -- United States, 1992

Primary-care physicians can be important providers human immunodeficiency virus (HIV)-prevention services to their patients. In 1991, 15% of U.S. adults reported having been tested for HIV antibody; of these, 55% reported their most recent HIV test had been in a physician's office or a hospital (1). During 1992, CDC and the Health Resources and Services Administration (HRSA) commissioned a national survey to characterize the types of HIV prevention services provided by primary-care physicians and barriers to the provision of these services. This report summarizes the results of the survey.

In October 1992, a questionnaire was mailed to 4011 * primary-care physicians who were randomly selected from the American Medical Association (AMA) Physician Masterfile, which comprises all physicians in the United States. The sample was stratified by location, race/ethnicity, and specialty. Two categories of location were defined on the basis of the prevalence of acquired immunodeficiency syndrome (AIDS) in metropolitan statistical areas (MSAs): 1) physicians practicing in the 20 MSAs with the highest prevalence and 2) those practicing in the remaining MSAs. Physicians were asked about their risk assessment of new patients; HIV counseling, testing, and treatment practices; and basic understanding of and attitudes about HIV infection and persons with HIV disease. The data were weighted to adjust for unequal probabilities of selection and for the variability of response rates among the strata.

Of the 3735 eligible ** physicians, 2545 (68%) responded; of these, 802 were general/family practitioners; 360, pediatrician/adolescent medicine physicians; 683, obstetrician/gynecologists (OB/GYNs); and 700, general internal medicine physicians. Of the 2545 respondents, 1931 (76%) were men. Three hundred eighty (15%) were aged less than 35 years; 1042 (41%), 35-44 years; and 1123 (44%), greater than 44 years. Of 2496 respondents for whom primary practice was known, 1487 (60%) were based in private, single-specialty practices; 442 (18%), in private, multispecialty practices; 299 (12%), in hospitals, public clinics, and community health centers; and 267 (11%), from academia and other institutions. Six hundred two (24%) of the physicians were located in areas with high prevalences of AIDS.

Almost all (94%) respondents indicated they "usually" or "always" asked new adult (aged greater than or equal to 19 years) patients about cigarette smoking; however, sexual history-taking was less frequently reported (Table_1): 49% asked about sexually transmitted diseases (STDs), 31% about condom use, 27% about sexual orientation, and 22% about number of sex partners. In comparison, 84% of all physicians asked new adolescent (aged 13-18 years) patients about cigarette smoking, 56% about STDs, 52% about condom use, 34% about number of sex partners, and 27% about sexual orientation. One fourth (25%) of all physicians believed their patients would be offended by questions about their sexual behaviors.

The percentage of physicians who indicated they would "likely" or "very likely" encourage HIV testing varied by patient risk category (Table_2) and ranged from 95% (homosexual men with multiple partners and injecting-drug users) to 40% (sexually active adolescent patients).

Most physicians (66%) indicated that if HIV testing were indicated for a patient, they would probably provide the test counseling themselves. Factors that either "moderately" or "strongly" influenced physicians to refer for counseling and testing rather than provide it themselves were that counseling was too time consuming (55%), information was insufficient to enable counseling (45%), and they preferred anonymous testing for their patients (42%). Most respondents indicated that their decision to refer was not influenced by inadequate reimbursement (86%) or discomfort with counseling (85%).

Ninety-two percent of physicians indicated that they would counsel an HIV-positive patient to reduce the risk for transmitting HIV. In addition, 76%-81% indicated they would counsel the patient to notify sex partners, refer the patient to the local health department for assistance with the notification, or both.

Of physicians in OB/GYN practices, 85% indicated they would provide contraceptive services and 47% would provide prenatal care to all women, regardless of their HIV status (Table_3). In comparison, 73% would provide contraceptive services and 29% would provide prenatal care to women with HIV.

Physicians who reported they would refer patients with HIV for medical services indicated the primary reasons for referring were their lack of experience with HIV (83%) and the availability of other providers with more expertise in treating HIV infection (94%). Overall, 68% of physicians indicated they believed they had an obligation to take care of someone infected with HIV, and 87% indicated that professional training could help "increase their comfort in caring for AIDS patients." Reported by: J Loft, PhD, W Marder, PhD, Abt Associates, Inc., Chicago. L Bresolin, PhD, R Rinaldi, PhD, American Medical Association. Div of Medicine, Bureau of Health Professions, Health Resources and Svcs Administration. National AIDS Information and Education Program, Office of HIV/AIDS; Women's Health and Fertility Br, Div of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion; Div of Sexually Transmitted Diseases and Human Immunodeficiency Virus Prevention, and Behavioral Studies Section, Behavioral and Prevention Research Br, Div of Sexually Transmitted Diseases and HIV Prevention, National Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: Although primary-care physicians may contribute to the prevention of HIV transmission by counseling patients who are at risk, the findings in this report underscore the substantial number of physicians who are missing opportunities to counsel during encounters with patients. To more effectively use these encounters as a means of prevention, physicians first must be knowledgeable about HIV infection and its transmission (2). In addition, they should be made aware of the importance of assessing patients' risk for HIV infection and prepared to counsel patients, based on their risk (3). Therefore, medical schools and professional organizations should continue to emphasize HIV/AIDS prevention and treatment as priorities in training new and practicing physicians.

The findings in this report can assist in the development of HIV prevention policies and programs. For example, the reluctance of some physicians to assess the risky sex practices of patients underscores the importance for public health agencies to assist physicians in improving risk assessment and risk-reduction counseling efforts for their patients and patients' partners. These findings may be used by HRSA to improve training strategies and programs for health-care professionals and AMA and other professional organizations to develop training objectives for primary-care physicians.

Finally, these findings can assist in efforts to achieve the national health objectives for the year 2000 regarding HIV prevention (4). These objectives include increasing to at least 80% the proportion of persons with HIV infection who have been tested (objective 18.8); increasing to at least 75% the proportion of primary-care and mental health-care providers who provide age-appropriate counseling on the prevention of HIV and other STDs (objective 18.9); and increasing to at least 50% the proportion of primary-care clinics who screen, diagnose, treat, counsel, and provide (or refer for) partner notification services for HIV infection and bacterial STDs (objective 18.13).

References

  1. Hardy AM. Advance data -- AIDS knowledge and attitudes for 1991: data from the National Health Interview Survey. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1993. (Advance data no. 225).

  2. Gerber AR, Valdiserri RO, Holtgrave DR, et al. Preventive services guidelines for primary care clinicians caring for adults and adolescents infected with the human immunodeficiency virus. Archives of Family Medicine 1993;2:969-79.

  3. Valdiserri RO, Holtgrave DR, Brackbill RM. American adults' knowledge of HIV testing availability. Am J Public Health 1993;83:525-8.

  4. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.

* Represents 3% of the total primary-care physician population. 

** Physicians who were not practicing in one of the primary-care specialties, were practicing out of the country, retired, or deceased were deemed ineligible.
Table_1
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TABLE 1. Percentage* of primary-care physicians who would "usually" or "always" assess risks for new adult and adolescent
patients, by risk behavior and physician specialty -- United States, 1992
==================================================================================================================================================================================================================
                                                                 Pediatrician/Adolescent                                                         General internal
                        General/Family practitioner                medicine physician                 Obstetrician/Gynecologist                medicine physician                            Total
                     ---------------------------------     ----------------------------------     ---------------------------------     ---------------------------------      ---------------------------------
                          Adult           Adolescent            Adult            Adolescent           Adult            Adolescent           Adult            Adolescent            Adult            Adolescent
                         (n=765)           (n=723)             (n=78)             (n=327)            (n=676)            (n=653)            (n=669)            (n=492)            (n=2188)            (n=2195)
                     ---------------    --------------     ---------------     --------------     --------------     --------------     --------------     --------------      --------------     --------------
Risk behavior         %   (95% CI +)     %    (95% CI)      %     (95% CI)      %    (95% CI)      %    (95% CI)      %    (95% CI)      %    (95% CI)      %    (95% CI)       %    (95% CI)      %    (95% CI)
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cigarette
  smoking            93 &  (+/-1.9)     81    (+/-2.9)     89     (+/-7.0)     75    (+/-4.1)     93    (+/-2.3)     92    (+/-2.6)     96 &  (+/-1.3)     89    (+/-2.7)      94 &  (+/-1.0)     84    (+/-1.6)
Alcohol use          79 &  (+/-2.9)     69    (+/-3.4)     74     (+/-9.8)     67    (+/-4.4)     80    (+/-3.8)     80    (+/-3.9)     92    (+/-1.9)     84    (+/-3.1)      84 &  (+/-1.6)     75    (+/-1.9)
Contraceptive
  use                53    (+/-3.6)     58    (+/-3.7)     65    (+/-10.8)     62    (+/-4.6)     97    (+/-1.7)     96    (+/-1.8)     49    (+/-3.6)     59    (+/-4.2)      61    (+/-2.1)     66    (+/-2.0)
STDs @               34 &  (+/-3.4)     43    (+/-3.6)     44    (+/-11.3)     49    (+/-4.7)     82    (+/-3.7)     85    (+/-3.4)     45 &  (+/-3.5)     54    (+/-4.3)      49 &  (+/-2.2)     56    (+/-2.1)
Other illicit
  drugs              36 &  (+/-3.4)     43    (+/-3.6)     64    (+/-10.8)     53    (+/-4.7)     59    (+/-4.7)     65    (+/-4.6)     54 &  (+/-3.5)     66    (+/-4.0)      49 &  (+/-2.2)     55    (+/-2.1)
Illicit IV drugs     37    (+/-3.5)     38    (+/-3.6)     57    (+/- 1.1)     46    (+/-4.7)     60    (+/-4.6)     65    (+/-4.6)     55 &  (+/-3.5)     63    (+/-4.1)      50 &  (+/-2.2)     51    (+/-2.1)
Condom use           21 &  (+/-2.9)     41    (+/-3.6)     50 &  (+/- 1.1)     56    (+/-4.7)     60 &  (+/-4.6)     75    (+/-4.2)     23    (+/-3.0)     45    (+/-4.3)      31 &  (+/-2.0)     52    (+/-2.1)
High-risk sex
  partner            22 &  (+/-2.9)     29    (+/-3.3)     21 &  (+/- 9.3)     32    (+/-4.4)     39 &  (+/-4.6)     46    (+/-4.8)     28 &  (+/-3.2)     40    (+/-4.2)      28 &  (+/-2.0)     36    (+/-2.1)
No. sex
  partners           16 &  (+/-2.6)     17    (+/-3.2)     24 &  (+/- 9.5)     30    (+/-4.4)     37 &  (+/-4.6)     52    (+/-4.8)     18 &  (+/-2.7)     33    (+/-4.0)      22 &  (+/-1.8)     34    (+/-2.0)
Sexual orienta-
  tion               18    (+/-2.7)     18    (+/-2.8)     13    (+/- 7.6)     28    (+/-4.2)     36 &  (+/-4.6)     36    (+/-4.6)     33    (+/-3.3)     32    (+/-4.0)      27    (+/-1.9)     27    (+/-1.9)
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
* Percentages are based on the number of physicians who indicated that they see adult or adolescent patients in their practice.
+ Confidence interval.
& p<.001 (McNemar test comparing physicians' assessment of adults and adolescents).
@ Sexually transmitted diseases.
==================================================================================================================================================================================================================


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Table_2
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TABLE 2. Percentage of primary-care physicians who would "likely" or "very likely" encourage HIV testing, by risk behavior
and physician specialty -- United States, 1992
============================================================================================================================================
                         General/Family      Pediatrician/Adolescent       Obstetrician/        General internal
                          practitioner         medicine physician          Gynecologist        medicine physician            Total
                      --------------------   -----------------------    -------------------    -------------------    --------------------
Risk behavior         No.  (%)   (95% CI*)     No.  (%)   (95% CI)      No.  (%)   (95% CI)    No.  (%)   (95% CI)    No.   (%)   (95% CI)
------------------------------------------------------------------------------------------------------------------------------------------
Homosexual men
  with multiple
  partners            768  (96)  (+/-1.5)      230  (94)  (+/-3.1)       74  (88)  (+/-7.4)    755  (95)  (+/-1.6)    1827  (95)  (+/-1.0)
Injecting-drug use    760  (95)  (+/-1.6)      283  (91)  (+/-3.3)      380  (96)  (+/-2.0)    750  (96)  (+/-1.5)    2174  (95)  (+/-.94)
Homosexual men        771  (92)  (+/-1.9)      238  (85)  (+/-4.5)       73  (88)  (+/-7.4)    700  (92)  (+/-1.9)    1839  (91)  (+/-1.3)
Current/Past STD +    784  (76)  (+/-3.0)      373  (63)  (+/-4.9)      431  (71)  (+/-4.3)    764  (79)  (+/-2.9)    2352  (74)  (+/-1.8)
Heterosexual men
  with multiple
  partners            787  (66)  (+/-3.3)      340  (53)  (+/-5.3)      426  (70)  (+/-4.3)    769  (72)  (+/-3.2)    2322  (67)  (+/-1.9)
Other drug and
  alcohol users       783  (52)  (+/-3.5)      355  (50)  (+/-5.2)      416  (66)  (+/-4.5)    769  (57)  (+/-3.5)    2321  (57)  (+/-2.0)
Sexually active
  adolescents         755  (38)  (+/-3.5)      433  (32)  (+/-4.4)      427  (40)  (+/-4.6)    637  (46)  (+/-3.9)    2253  (40)  (+/-2.0)
------------------------------------------------------------------------------------------------------------------------------------------
* Confidence interval.
+ Sexually transmitted disease.
============================================================================================================================================


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Table_3
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TABLE 3. Percentage * of primary-care physicians who would provide obstetric/gynecologic services for all adult female patients
and for all adult female patients with HIV infection, by service and physician specialty -- United States, 1992
=========================================================================================================================================================================================================
                             General/                     Pediatrician/Adolescent                   Obstetrician/                       General internal
                   Family practitioner (n=515)           medicine physician (n=74)               Gynecologist (n=675)              medicine physician (n=277)                  Total (n=1541)
                 --------------------------------     --------------------------------     --------------------------------     --------------------------------     ----------------------------------
Service          All  (95% CI +)   HIV   (95% CI)     All   (95% CI)    HIV   (95% CI)     All   (95% CI)    HIV   (95% CI)     All   (95% CI)    HIV   (95% CI)     Total   (95% CI)    HIV   (95% CI)
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Contraceptive    91 &  (+/-2.5)    76    (+/-3.7)     55    (+/-1.2)    50    (+/-1.2)     99 &  (+/-1.1)    86    (+/-3.3)     60 &  (+/-6.0)    51    (+/-6.1)       85 &  (+/-2.0)    73    (+/-2.5)
Postpregnancy    61 &  (+/-4.3)    50    (+/-4.4)      5    (+/-5.6)     5    (+/-5.6)     93 &  (+/-2.5)    76    (+/-4.2)     16    (+/-4.4)    12    (+/-4.0)       59 &  (+/-2.7)    48    (+/-2.8)
Emergency
  gynecology     22    (+/-3.6)    20    (+/-3.5)      4    (+/-4.9)     4    (+/-4.9)     95 &  (+/-2.0)    85    (+/-3.5)      6    (+/-2.7)     5    (+/-2.7)       42 &  (+/-2.7)    37    (+/-2.7)
Elective
  gynecology     26 &  (+/-3.8)    19    (+/-3.5)     12    (+/-8.0)    12    (+/-8.0)     95 &  (+/-2.2)    72    (+/-4.3)      7    (+/-3.0)     5    (+/-2.6)       44 &  (+/-2.8)    33    (+/-2.6)
Prenatal         40 &  (+/-4.3)    22    (+/-3.6)      5    (+/-5.2)     5    (+/-5.1)     89 &  (+/-3.0)    58    (+/-4.8)      5    (+/-2.6)     3    (+/-1.9)       47 &  (+/-2.8)    29    (+/-2.5)
Delivery         35 &  (+/-4.2)    20    (+/-3.5)      9    (+/-5.6)     9    (+/-7.0)     87 &  (+/-6.7)    59    (+/-4.8)      3    (+/-3.2)     1    (+/-1.3)       44 &  (+/-2.8)    28    (+/-2.5)
Sterilization on
  request        12    (+/-2.9)    10    (+/-2.7)      0       -         0       -         93 &  (+/-2.4)    81    (+/-3.8)      1    (+/-1.0)     0       -           36 &  (+/-2.7)    31    (+/-2.6)
Abortion          3    (+/-1.4)     3    (+/-1.5)     <1    (+/-1.5)    <1    (+/-1.1)     27    (+/-4.3)    25    (+/-4.2)      0       -         0       -           10    (+/-1.7)     9    (+/-1.6)
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
* Percentages are based on the number of physicians who indicated that they provide obstetric/gynecologic services.
+ Confidence interval.
& p<.001 (McNemar test comparing services physicians would provide to all women and to women with HIV).
=========================================================================================================================================================================================================


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