HIV Risk Screening in the Primary Care Setting: Assessment of Physicians’ Skills

Early identification and treatment of HIV infection is important to reduce morbidity and to prevent HIV-related complications and hospitalizations, and spread of infection to others.1–6 The U.S. Preventive Task Force recommends that primary care physicians take a complete sexual and drug-use history from all adolescents and adults as a means of identifying behaviors associated with risk of HIV infection and other sexually transmitted diseases (STDs).7 In a busy practice setting, however, it may be difficult for clinicians to screen all patients, especially in appointments for acute illness during which the majority of care occurs. In fact, surveys suggest that primary care physicians do not routinely perform risk assessments for HIV infection. Primary care physicians estimate that they take sexual histories from one quarter to one half of their patients.8–10 The accuracy of HIV risk assessment data is difficult to evaluate because of limitations in the Methods used. The physician-patient interaction is a private one between two individuals, and information about that interaction is not easily obtained. Medical record audits are not reliable sources of information about what occurs in these private interactions,11 and self-report by physicians may not accurately portray actual practice activities.12,13 Two different approaches to quantify risk assessment for HIV are patient report 14,15 and the use of standardized patients (SPs)16. Patient report suggests low levels of HIV risk screening, but the reliability of patient report is unknown. The most important patients to screen are those who have HIV infection or are at risk of HIV infection to reduce morbidity and mortality associated with the disease, counsel to reduce risk, and prevent transmission. It remains unclear to what extent primary care physicians perform HIV risk assessments with patients at risk of HIV infection. In addition, little is known about what questions constitute a typical HIV risk assessment among primary care physicians, particularly with patients who have HIV risk behaviors. Studies that present physicians’ self-reported estimates of HIV risk assessment suggest that some physician characteristics appear to be associated with increased HIV risk screening. Younger physicians, women physicians, and physicians who say they do not experience a great deal of discomfort with homosexuals may take sexual histories more often.17 Physicians who had diagnosed HIV-related problems in their practices also appear to be more likely to take routine histories of AIDS-related risk factors.8 Standardized patients provide an opportunity to study primary care physicians’ skills in interactions that are similar to their interactions with real patients.16,18 In this study, 17 SP cases were used to test 134 primary care physicians. The overall purpose of the study was to assess the skills of primary care physicians at identifying and managing patients with or at risk of HIV infection as well as assessing their overall clinical skills. In nine of the cases, patients were at high risk of HIV infection as indicated by risk behaviors that were not initially identified to physicians who saw them. The remainder of cases tested physicians’ skills in other clinical areas, and one case assessed physicians’ skills in an initial interview with a patient with known HIV infection.19 Physicians were not informed that one focus of the study was their identification of HIV risk behaviors. The study described here was designed to assess the extent to which primary care physicians perform an HIV risk assessment with a diverse panel of acute care patients at high risk of HIV infection and the content of the risk assessment. The influence of physician demographic characteristics on performance of HIV risk assessment was also assessed.