Evaluating primary care physician STI/HIV counseling practices

Background

Pretest and posttest counseling guidelines for HIV antibody testing were first adopted in British Columbia in 1985; revised sexually transmitted disease (STD) guidelines were published by Health Canada in 1998.[1] In 2002 and 2003, the STD/AIDS Control Division of the BC Centre for Disease Control (BCCDC) and the Sexual Health and Sexually Transmitted Infections Section of the Division of Community Acquired Infections Health Canada, collaborated on a study to assess current counseling practices in order to ensure that the educational and training needs of health care practitioners throughout the province were being met.

The pretest counseling guidelines currently in use in BC[1] were designed to promote physician-patient dialogue on issues including HIV antibody test capabilities, transmission and prevention, risk-reduction behaviors, support systems, and personal readiness to test. This process was deemed necessary to ensure informed patient consent to proceed with testing.

The questionnaire used in this study asked whether primary care physicians use the Canadian STD Guidelines and, if so, how they interpreted them in practice. The study sought to evaluate which components of the counseling guidelines were considered useful and whether the current BCCDC training curriculum reflects practice needs.

Cross-sectional survey questionnaires have been the primary method used in the past to collect data on HIV and sexually transmitted infections (STIs).[2-4] Other studies have used focus groups to assess the relevance, clarity, and practicality of HIV counseling guidelines used in Canada.[5]

Research focusing on primary health care practitioners reveals that practices concerning HIV test counseling may not be optimal. Common shortcuts in counseling—giving brief information before and after the HIV test—are seriously flawed as a strategy to prepare patients for effective coping.[6] A qualitative review of the Canadian Medical Association HIV testing guidelines indicated that 41% of primary care physician participants reported not having a copy of the CMA HIV testing guidelines.[5] Studies from the early 1990s suggested that fewer than 50% of Canadian physicians surveyed routinely obtained sexual histories.[2]

A person with an existing, untreated STI is more susceptible to HIV infection, and transmissibility of HIV increases with concurrent STI and HIV infection.[7] This information has mobilized health care practitioners to link STI screening with HIV antibody testing.

Methods

As of October 2002, the total number of family medicine practitioners in the BC College of Physicians and Surgeons database was 4715. Physicians whose practices were in metropolitan areas of more than 100 000 residents (according to the 2001 Canadian census) were classified in this study as urban. This included physicians in the Greater Vancouver Regional District, Victoria, Abbotsford, and Kelowna. The sample obtained for this study reflected the urban/nonurban split in the BC College of Physicians and Surgeons family medicine membership (64.5% urban and 35.5% nonurban).

The required sample size was determined to be approximately 400 respondents. It was anticipated that response to a questionnaire delivered by post with appropriate follow-up and reminder phone calls would be between 30% to 50%. To achieve such a sample, the survey was distributed to 1200 randomly selected family practitioners in the province, including 780 urban physicians and 420 nonurban physicians.

The questionnaire used by participating physicians included multiple-choice questions and attitudinal and time measurement scales. Two questions were directed to only those practitioners with HIV-positive patients currently in their care. The remaining 21 questions were answered by all respondents. Returns were accepted by fax or post from November 2002 to January 2003.

Results

Of the 1200 family physicians contacted, 407 completed their questionnaires, for a response rate of 34%. Male practitioners accounted for 62.1% of the total and female practitioners for 37.9%. The median age of respondents was 45 years, with an age range of 27 to 83 years. The median value for years of professional experience was 18, with a range of 1 to 61 years. About 83% of participants identified their practice setting as private, either solo or group. The next most frequent practice setting was urgent care/walk-in clinic (12%).

The median number of HIV test requests received as well as ordered by respondents in the previous 3 months was 10. Seventy-five percent of respondents reported ordering more than five HIV tests in the last 3 months. A median number of 1.5 patients who received HIV tests in the previous 3 months did not return for follow-up.

Guidelines

The Canadian STD Guidelines provide recommendations for the prevention, diagnosis, management, and treatment of STIs, including HIV, when a person first presents to the health care system.

More than half of respondents (57.9%) said that they had a copy of the Canadian STD Guidelines on hand (Table 1). The Canadian STD Guidelines were felt to be more useful for STI counseling than for HIV counseling. Seventy percent of respondents felt they were either “very important” or “important” for STI counseling; 55% felt the guidelines were either “very important” or “important” for HIV counseling (P<.001). Some practitioners felt the guidelines were “not at all important” for HIV counseling (7.2%) or STI counseling (4.6%; P<.001).

Comments about the guidelines included, “The Canadian STD Guidelines are more helpful in treatment than in counseling” and “the guidelines are useful for prenatal testing, for methadone treated patients, and in management of accidental exposure to HIV.”

Pretest counseling

The largest range of responses from respondents concerned the discussion of HIV testing with patients (Table 2). When providing pretest counseling, the STD/AIDS Control Division of the BCCDC suggests the health care practitioner follow the Canadian STD Guidelines and cover the following topics: the patient-physician relationship, description of the tests available, the window period, transmission, personal risks and concerns, risk reduction, benefits of testing, risks of testing, support, consent, and the need to return for retest and posttest counseling. The guidelines do not prioritize issues to be addressed.

The study sought to determine how much time physicians were devoting to pretest and posttest HIV counseling. The median time physicians said they spent on pretest HIV counseling was 6 minutes. The median time spent on discussing a nonreactive result was 4 minutes. Patients with positive or reactive results to an HIV test were given a median time of 20 minutes according to respondents.

The study also sought to learn which patients physicians thought should be offered HIV testing (Table 3), and how physicians viewed the interrelationship between HIV testing and STI testing. Most respondents (92%) said that when screening for STI risk they “always” or “usually” discuss HIV risk. Fewer respondents (79.4%) “always” or “usually” screen for or offer STI testing when offering HIV testing.

Impediments to counseling

More respondents identified impediments to HIV counseling than to STI counseling (Table 4). When physicians were asked whether they felt they were able to meet patient needs for HIV counseling, 72% answered either “usually” or “always.” However, only about 25% of these answered “always.”

Responses of urban and nonurban physicians

Urban physicians were significantly more likely than their nonurban counterparts to feel that they are “always” or “usually” able to meet their patient’s needs for HIV counseling (P = .03). Nonurban respondents were significantly more likely to indicate that they did not have sufficient information about risk and prevention when providing patient counseling for HIV testing (P = .008). As well, urban physicians were significantly more likely to respond that they had HIV-positive patients in their current practice (P = .02).

Study limitations

The sample of 407 physicians surveyed for this study is generally representative of the split between urban and nonurban practice settings in BC. It is difficult, however, to generalize from this sample, primarily because of the issue of self-selection. Physicians who are more involved in sexual health care, STI or HIV testing, or who serve high-risk patients are likely to be more motivated than others to respond to such a survey, and we would expect these practitioners to be more aware than the general medical population of the Canadian STD Guidelines and other clinical practice guidelines for HIV pretest and posttest counseling.

Conclusions

The results of the study described here provide a snapshot of some important practice issues and support several recommendations (see box). Many primary care physicians in BC were found to have a copy of the Canadian STD Guidelines on hand and many indicated the guidelines were useful, especially for counseling about STIs. Physician awareness of the importance of HIV testing was high, with most “always” or “usually” offering it to patients who disclose high-risk behavior.

When providing pretest counseling, most practitioners surveyed discussed prevention/risk reduction, personal risks and sexual history, window period/most recent risk event, and significance of and preparation for positive/negative results. Notably, almost half of practitioners identified insufficient time as an impediment to HIV counseling.

Practitioners do not consistently recognize the interrelationship between HIV testing and STI screening. It appears that when STIs are being investigated, physicians “always” or “usually” discuss HIV testing (92%), but when patients present primarily for HIV testing, fewer physicians “always” or “usually” discuss the need for STI screening (79.4%).

Another concern is that 11% of respondents said they either “never” offer or “sometimes” offer HIV testing to patients who present for prenatal care. This is significant considering the 1998 recommendations that pregnant women be universally offered HIV testing. Of additional concern is that fewer than one out of three practitioners indicated they routinely offer both nominal and non-nominal options for testing.

These preliminary findings warrant further research and interpretation to investigate and address barriers to better integrated HIV/STI screening, testing, and counseling.

Competing interests
None declared.

Additional reading

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Beardsell S. Should wider HIV testing be encouraged on the grounds of HIV prevention? AIDS Care 1994;6:5-19.

Canadian Task Force on Preventive Health Care. Counseling for Risky Health Habits: A Conceptual Framework for Primary Care Practitioners. Technical Report #01-7, November 2001.

Carter AO, Battista RN, Hodge MJ, et al. Report on activities and attitudes of organizations active in the clinical practice guidelines field. CMAJ 1995;153:901-907.

Edwards P. Increasing response rates to postal questionnaires: Systematic review. BMJ 2002;324:118-131.

Eichler M, Ray SM, del Rio C, et al. The effectiveness of HIV post-test counselling in determining healthcare-seeking behavior. AIDS 2002;16:943-945.

Grosskurth H, Mosha F, Todd J, et al. Impact of improved treatment of sexually transmitted diseases on HIV infection in Zupal, Tanzania: Randomized, controlled trial. Lancet 1995;346:530-536.

Gully PR. How well do family physicians manage sexually transmitted diseases? Can Fam Physician 1995;41:1890-1896.

HIV Prevention Through Early Detection and Treatment of Other Sexually Transmitted Diseases — United States Recommendations of the Advisory Committee for HIV and STD Prevention. CDC MMWR Recommendations and Reports. 31 July 1998;47(RR12):1-24. www.cdc.gov/mmwr/preview/mmwrhtml/00054174.htm (accessed 26 August 2004).

Jurgens R, Palles M. HIV testing and confidentiality. The Canadian HIV/AIDS Legal Network, 1997.

Kerr SH, Valdiserri RO, Loft J, et al. Primary care physicians and their HIV prevention practices. AIDS Patient Care STDS 1996;10:227-235.

Lewis CE, Montgomery K. The AIDS-related experiences and practices of primary care physicians in Los Angeles. Am J Public Health 1990;80:1511-1513.

Moses S, Elliott L. Sexually transmitted diseases in Manitoba: Evaluation of physician treatment practices, STD drug utilization, and compliance with screening and treatment guidelines. Sex Trans Dis 2002;29:840-846.

Samson L, King S. Evidence-based guidelines for universal counselling and offering of HIV testing in pregnancy in Canada. CMAJ 1998;158:1449-1457.

Table 1. Practitioner use of Canadian STD Guidelines.

 Table 2. Physicians who “usually” or “always” discuss the following topics with patients.

 Table 3. Physicians who “usually” or “always” offer HIV testing.

 Table 4. Physician-identified impediments to HIV/STI counseling.

J. Barnett, RN, MA, D. Spencer, RN, T. Beer, MA, M. Rekart, MD, FRCPC, DTM&H, L. Hansen, MSc, MHSc, T. Wong, MD, MPH, FRCPC, and J. Mann, MD

Ms Barnett is a nursing education administrator at the BC Centre for Disease Control. Ms Spencer is a surveillance nurse for HIV Surveillance, BC Centre for Disease Control. Ms Beer is an independent consultant for the BC Centre for Disease Control. Dr Rekart is director of STD/AIDS Control, BC Centre for Disease Control. Ms Hansen is a senior STD prevention and control officer, Community Acquired Infections Division, Health Canada. Dr Wong is director of Community Acquired Infections Division, Health Canada. Dr Mann is a senior public health analyst, Community Acquired Infections Division, Health Canada.