Special Coverage of 41st IDSA Conference

Primary care doctors fail to offer tests, survey says

Medical students need additional training

A new survey shows that most primary care practitioners often fail to offer HIV testing to their sexually active patients, and many even neglect to offer the test to pregnant patients.

With estimates that the HIV epidemic in the United States affects nearly 1 million people and one-third of these people are undiagnosed, testing and counseling should be a routine part of physicals and physician-patient care as is recommended by the Centers of Disease Control and Prevention (CDC), says Curt G. Beckwith, MD, infectious disease fellow at Brown University School of Medicine in Providence, RI.

"Right now, testing is done on a targeted basis," he says. "If a patient presents with some kind of disease syndrome consistent with HIV, or if the physician is suspicious the patient has HIV, then that’s how they do testing."

The current CDC and medical community push is for HIV testing to become as routine as a Pap smear, where it’s given routinely without first going through a risk assessment, Beckwith says. "That way you will diagnose more people with HIV because it’s a routine part of medical care."

Beckwith and co-investigators decided to see if medical practitioners were doing routine HIV testing by surveying 108 family practitioners and 63 internal medicine house officers from Rhode Island. They also surveyed 516 fourth-year medical students from 19 states.1

Physicians were asked whether they routinely offer HIV testing to patients, and a separate question asked whether they routinely offered the test to pregnant patients. "That is one setting where the recommendations are stronger," he adds. "With-out exception, every pregnant woman should be offered an HIV test."

The survey found that 86% of practitioners did not routinely offer HIV testing to all sexually active patients, and about half were not routinely offering it to their pregnant patients, Beckwith says. The family physicians surveyed may be providing obstetrical care, but that distinction wasn’t made in the survey.

Since the survey clearly showed that HIV testing isn’t being done routinely, perhaps because of time and financial constraints, investigators separated the answers from medical students and residents to see if they are offering the HIV testing often enough, given that most of these physicians are in hospital settings, he explains.

"We looked at medical students to see how much they were being educated on HIV testing and counseling; and basically, they were not being educated enough," Beckwith says.

For instance, 81% of the medical students had not received formal training in HIV testing and counseling, and 94% of the medical students believed HIV testing should be a part of the medical school curriculum to provide them with formal training, he points out.

"Residents aren’t doing enough HIV testing, and they are not being trained enough," Beckwith says. "So we’re saying we need to concentrate more on teaching medical students how to do it and teach residents how to do HIV testing and counseling."

Residents should be encouraged to ask themselves of every patient, "Should I test this patient for HIV?" he states. "Right now, they’re not thinking about it."

In the outpatient settings, primary care physicians should consider suggesting to all patients, ages 18-55, that they have an HIV test every year if they are sexually active," Beckwith says. "Patients who are sexually active with multiple partners should get a test every six months."

If a patient is married and opts out of the test, then that’s OK, because it’s the fact that the physician is thinking about it that’s important. he says. "If you offer the test in that way, then the patient will begin to expect it, and it will be a more acceptable thing. And they don’t have to be asked about their drug use and sex life if you make testing routine." And that really is the whole point: to make HIV testing so routine that it eventually will lose the social and political stigma, he adds.

Reference

1. Beckwith CG, Boutwell A, Simmons E, et al. Barriers to routine HIV testing and counseling. Presented at the 41st annual meeting of the Infectious Diseases Society of America. San Diego; Oct. 9-12, 2003: Abstract 611.