Abstract
Context: An estimated 252,000 to 312,000 individuals have undiagnosed human immunodeficiency virus (HIV) infection in the United States. To date, little has been known about osteopathic physicians' attitudes and practices regarding routine HIV testing.
Objectives: To understand osteopathic primary care physicians' attitudes and practices toward HIV testing and sexual history taking and to examine factors associated with osteopathic physicians' recommendations of HIV testing at the initial patient visit.
Methods: A cross-sectional survey of osteopathic physicians was conducted at the 106th Annual Convention of the Florida Osteopathic Medical Association in February 2009. Survey participants were asked 36 questions about osteopathic physician and patient sociodemographic factors and osteopathic physician attitudes and office practices regarding HIV testing and sexual history taking.
Results: A total of 233 osteopathic physicians completed the survey, but only 160 respondents (69%) met inclusion criteria of working in primary care and spending more than 50% of their time with patients. Almost two-thirds of participants were men, 80% were white, and the age range was 28 to 83 years. Twenty-two percent of participants recommended HIV testing at the initial patient visit, and 18% recommended annual HIV testing for all patients. Eighty-seven percent obtained a separate consent form for HIV testing, and 19% included HIV testing in general consent forms. About two-thirds of participants recommended annual HIV testing for homosexual men. Three factors were associated with recommending HIV testing at the initial patient visit: (1) recommending an annual HIV test for sexually active patients (odds ratio [OR], 12.82; 95% confidence interval [CI], 3.97-41.67); (2) having an agree/strongly agree attitude toward HIV testing (OR, 5.59; 95% CI, 1.63-19.23); and (3) obtaining a general consent form that included permission for HIV testing (OR, 3.25; 95% CI, 1.07-9.90).
Conclusion: Osteopathic physicians who practice primary care medicine can play a crucial role in reducing the number of individuals with undiagnosed HIV infection. More concerted efforts are needed to help osteopathic physicians incorporate HIV testing as part of routine care for all patients.
The United States Centers for Disease Control and Prevention (CDC) estimates that 1 million to 1.2 million people are living with human immunodeficiency virus (HIV) infection in the United States, and about one-quarter of these individuals are not aware of their infections.
1-3 The CDC recently changed its estimates of the annual number of new HIV infections in the United States from 40,000 to more than 56,000.
4 Moreover, the transmission rate among individuals who have undiagnosed HIV infection is estimated to be 3.5 times higher than among those who know of their serostatus.
1,5
Because many individuals are diagnosed as having HIV infection late in the course of their disease, after development of symptoms, the CDC issued revised recommendations to promote routine HIV testing in healthcare settings.
1,3 Some key changes made in CDC recommendations to promote widespread HIV screening are as follows: HIV screening for all patients between 13 and 64 years of age in all healthcare settings (after patients are notified that testing will be performed unless they decline, known as
opt-out testing); annual HIV testing for individuals who engage in high-risk behaviors; and incorporation of permission for HIV testing into general consent forms (instead of using a separate consent form for HIV testing).
6
Early diagnosis enables individuals to know their HIV status and to receive timely access to antiretroviral therapy, as well as access to preventive treatment for opportunistic infections. Such treatment can improve health and extend life.
1,7,8 The high proportion of undiagnosed and late-diagnosed HIV infection supports the need for routine screening of HIV infection. In a 1999-2000 survey of more than 4100 US physicians by Bernstein et al,
2 only 28% of respondents reported HIV screening of asymptomatic men or nonpregnant women. The data showed that women, African American, and Hispanic physicians were more likely than their counterparts to routinely screen patients for HIV infection.
2 Physicians working in large cities were more likely than those in smaller cities or rural areas to conduct routine HIV screening.
2 Furthermore, specialists in emergency medicine, internal medicine, and pediatrics were less likely than family/general practitioners to offer HIV screening.
2
Despite the benefits of early diagnosis, a number of factors impede physicians from routinely screening for HIV infection in primary care settings. According to a comprehensive review conducted by Burke et al,
9 physicians commonly cited the following barriers to HIV screening: insufficient time, burdensome consent processes, competing priorities, lack of knowledge and training, lack of patient acceptance, inadequate reimbursement, and pretest counseling requirements. In addition to these factors, Burke et al
9 described other behavior-oriented barriers to routine HIV testing that had not previously been examined. For example, physicians' reluctant attitudes and practices regarding taking of sexual histories and routine vs targeted updates of patients' sexual histories may result in missed opportunities to provide prevention information, HIV diagnosis, or treatment for asymptomatic sexually transmitted infections (STIs). Similarly, the practice of routinely recommending HIV testing only to patients from “high-risk” groups may represent a missed opportunity of diagnosis for “low-risk” patients.
Furthermore, structural barriers in the form of state laws or statutes may impede implementation of routine HIV testing and incorporation of consent for testing into the general consent-for-care form. For example, Florida Statute 381.004
10 requires patients to sign a separate written consent form for HIV testing—except for participants in anonymous epidemiologic surveys and for healthcare professionals who have had needlestick exposures to patients' body fluids.
For several decades, a large number of osteopathic physicians have been trained as primary care providers. Consequently, many osteopathic physicians play vital roles in all aspects of primary care medicine, including the treatment of patients with HIV infection or AIDS. Because of their important roles, osteopathic physicians are in position to promote early diagnosis of HIV infection. In order to assist osteopathic primary care physicians in routinely screening patients for HIV infection, it is essential to understand osteopathic physicians' attitudes, beliefs, and practices regarding routine HIV testing and the revised HIV screening recommendations from the CDC.
1,3 To date, no such data are available.
In response to this need, we conducted a cross-sectional survey to understand osteopathic physicians' attitudes and practices toward HIV testing and sexual history taking. We also analyzed factors associated with osteopathic physicians' recommendations of HIV testing at the initial patient visit.
We recruited participants at the registration kiosk, and we made announcements at numerous sessions requesting participation in the study. Convention attendees were told that the survey was anonymous, with no personal identifiers. This information was also in the cover letter included with the survey packets, which were distributed at the registration kiosk, at the Nova Southeastern University College of Osteopathic Medicine (NSU-COM) alumni table, and in the rooms where the sessions were held.
Participants were instructed to complete the survey and return it to the research assistants. The survey required approximately 10 minutes to complete. Participants were informed that by completing the survey they were providing their consent to be part of the study. The Institutional Review Board at NSU approved the study in January 2009.
Although most osteopathic physicians recommend annual HIV testing for patients in high-risk groups (eg, men who have sexual intercourse with other men, injection drug users), more concerted efforts are needed to help osteopathic physicians incorporate HIV testing as part of routine care for all of their patients. Osteopathic physicians can play a crucial role in reducing the numbers of individuals with undiagnosed HIV infection and in helping to ensure that individuals who are diagnosed with HIV infection receive proper treatment. Further research is needed on potential changes in osteopathic medical education to improve osteopathic physicians' understanding of HIV screening practices and to encourage more favorable medical and legal perspectives among osteopathic physicians regarding routine HIV screening.
Copies of the survey questionnaire are available from Dr Fernandez upon request.
Financial Disclosures: Student Doctor Gongidi received funding for this study through an NSU-COM research fellowship. Student Doctor Sierakowski and Drs Bowen, Jacobs, and Fernandez have no relevant financial relationships to disclose. All authors have no relevant conflicts of interest to disclose.
We would like to thank NSU-COM Dean Anthony J. Silvagni, DO, PharmD, for his continued support of the research fellowship. We would also like to thank Robert T. Hasty, DO, and Nilda Hernandez, AA, at NSU-COM. We are indebted to Michelle Winn, CMP, at the Florida Osteopathic Medical Association (FOMA) for her assistance in coordinating the study during the FOMA convention. Most important, we appreciate the participation of all the osteopathic physicians who took the time to complete our survey.
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