Prevention counseling should be ongoing
More education for docs needed
In rural Southern states such as South Carolina, the HIV/AIDS epidemic primarily affects low-income African American people who live miles from an urban health care clinic and the high-tech prevention services available in large cities.
Also, these states are badly affected by a growing epidemic and inadequate funding for prevention and treatment, says Wayne Duffus, MD, PhD, clinical assistant professor at the University of South Carolina School of Medicine, division of infectious diseases in Columbia. Duffus also is the medical director for the HIV/STD/Hepatitis division at the South Carolina Department of Health and Environmental Control in Columbia.
"We don’t get Title I funding from the Ryan White Care Act because we don’t have a city that’s impacted so badly to be eligible for it," he says. "The consequences of not having Title I funding is we have an epidemic that’s growing and growing and spread out across the state."
One way to improve HIV prevention in rural states is to better educate physicians and other health care providers who serve rural areas, Duffus suggests.
Duffus and co-investigators from Florida, Alabama, and Georgia conducted a recent survey into prevention services among rural and urban providers in Florida and South Carolina, including physicians, nurse practitioners, and physician assistants, in Southern states for a comparison study.
"We asked about the number of HIV-positive patients they took care of, and there was no statistically significant difference between urban and rural providers," he reports.
Survey respondents also reported having a lot of experience treating HIV patients with more than half saying they’ve cared for HIV patients for more than eight years, Duffus notes.
Respondents were asked about their prevention practices with newly diagnosed and established patients, including these types of questions:
- What percentage of time does the provider spend discussing condom usage?
- Does the provider discuss risk reduction counseling?
- Does the provider discuss illicit drug use?
- Does the provider discuss HIV disclosure to the patient’s partner?
Their responses were surprising, Duffus notes.
More than 72% of the providers said they discuss HIV risk behaviors and prevention with newly diagnosed patients, but fewer than 27% of providers said they discuss these issues with established patients, he says.
"Once the patient becomes established, they say they don’t talk about prevention anymore," Duffus explains. "They argue that maybe someone else in their practice probably does, but studies show it doesn’t seem to be as important to a patient until a physician discusses it."
This finding is worrisome because a patient who is newly diagnosed may be monogamous initially, but return to sexual risk behaviors six months or more after the diagnosis, Duffus says.
"They might get a diagnosis and be abstinent this month, but a year later they might not," he adds.
In a similar study, Duffus also found that infectious disease doctors were more likely than other physicians treating HIV patients to limit discussions to medicines and opportunistic infections.
"Infectious disease physicians were less likely to talk about prevention, and noninfectious disease doctors were the opposite," Duffus says.
These findings highlight the importance of stressing more frequent and continual prevention counseling among providers working with HIV patients, he says.
"I think that providers need to put prevention counseling on the same parity with medications," Duffus suggests. "We emphasize how patients must take their medications 95% of the time, and we talk about the side effects of medications, and we monitor medications and treatment."
But HIV prevention education is just as important because it’s sexually transmitted and can be fatal, so simply focusing on one aspect of care is not sufficient, he explains.
"We need to learn how to talk about sex," Duffus says.
Since this is a common problem, it would be helpful to give providers a set of standard questions to ask patients, along with training about how to approach this topic, he suggests.
"It’s more important now that we have medications available that help patients live longer because patients are sexually active and are searching for answers," Duffus says. "Patients want to know what safe sex is, and we need to address their concerns."
For example, Duffus had one patient who told him that he was having safe sex. When Duffus asked him what he meant, he replied, "I don’t tell my wife I’m messing around with men."
Although it sounds like a punch line to a joke, the patient honestly thought that safe sex meant that he wouldn’t tell his wife about his sexual risk behaviors, so she wouldn’t get mad and kill him.
"I said, I think it’s unfortunate that you are HIV-positive, but now that you are we have to learn how to live with it, and there are certain things you’re going to need to do or not do now that you have HIV,’" Duffus recalls.
After the man explained his own interpretation of "safe sex," Duffus explained how the man’s wife may not know he is HIV-positive, but she is at risk of becoming infected with the virus from him.
He told the patient: "How would she feel if she finds out that you knew you were positive, but you never told her? If she loves you and cares about you, she might accept you for being honest."
Finally, Duffus told the man how wearing condoms during sexual intercourse with his wife will lower the likelihood that she becomes infected, and if the man takes the HIV medications and lowers his viral load, this also will reduce transmission risk.
"I told him, It’s similar to if you had diabetes, and I’d tell you to watch your sugar intake or if you had hypertension, I’d tell you to watch your salt intake; so like any chronic illness, you have to take care of yourself,’" Duffus adds. "Then I said, So from now on, you will have to have safe sex.’"
"The patient thought there was nothing he could do, so I made him comfortable with the idea of using condoms and with disclosure and faithful monogamy," he recalls.
Experience working in an STD clinic has convinced Duffus that many sexually active people, even some who are college-educated, do not even know how to put on a condom.
"I see a lot of college students who don’t know that you can’t have a condom in your car in South Carolina heat for three to four months, and now the girlfriend is pregnant or HIV-infected," he reports.
Physicians need to put as much emphasis on risk prevention counseling as they do on medicines, Duffus says.
"They need to learn appropriate questions to ask and make themselves comfortable with sexual practices and substance abuse," he says. "They will realize that by talking about it, they’ll become more comfortable, and patients will tell them what they’re doing."
Patients appreciate having these kinds of discussions with their providers because they trust their doctors and want to learn the truth about sexual risk behaviors, he adds.
Providers who would some guidance in how to ask patients about their sexual risk behaviors could refer to Table 4 in the "Primary Care Guidelines for HIV," published Sept. 1, 2004, in Clinical Infectious Diseases.1
The questions were designed to be open-ended and include, "Tell me about your sex life."1
The article is available for free at www.journals.uchicago.edu/CID/journal/issues.
"These questions give an opportunity for patients to say things they wouldn’t ordinarily volunteer," Duffus says. "A lot of times, physicians want to ask these questions but aren’t sure they’re appropriate."
- Aberg JA, et al. Primary care guidelines for the management of persons infected with human immunodeficiency virus: recommendations of the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis 2004; 39(5):609-629.