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Physicians' Ability to Provide Initial Primary Care to an HIV-Infected Patient

Physicians' Ability to Provide Initial Primary Care to an HIV-Infected Patient Abstract Background: Primary care physicians are providing care for an increasing number of persons infected with the human immunodeficiency virus (HIV). This study assesses the ability of primary care physicians to provide initial care for a patient with recently diagnosed HIV infection. Methods: A standardized patient (SP) was trained to portray an asymptomatic person with HIV infection seeking a primary care physician. Physicians took a medical history and counseled the SP; their performances were assessed by the SP and through a brief written examination. In addition, physicians distributed questionnaires to HIV-infected patients in their practices to assess actual performance. The study participants consisted of 121 primary care physicians. Results: A minority of physicians recommended standard primary care screening tests and vaccinations, including viral hepatitis screening (35%), syphilis serologic testing (32%), and pneumococcal vaccination (23%). While most physicians (87%) indicated they would obtain CD4 cell counts, only 50% indicated they would start appropriate Pneumocystis carinii pneumonia prophylaxis. Although this patient presented documentation of a positive tuberculin skin test and no prior therapy for tuberculosis, only 53% of the physicians recommended prophylactic isoniazid. While 75% of the physicians asked this SP about his HIV risk (sex with men), less than a third asked about condom use, number of sexual partners, or contact with previous sexual partners. Physicians with the most HIV experience were more likely to recommend P carinii pneumonia prophylaxis, coinfection screening, pneumococcal vaccination, and isoniazid prophylactic therapy. However, physicians' HIV experience was not associated with assessing this SP's risk of infecting others or with counseling regarding condom use. Questionnaires distributed to HIV-infected patients of these physicians generally confirmed these findings. Conclusions: Basic HIV preventive and primary care may not be adequately performed by many primary care physicians. Physicians' HIV experience was associated with better performance of HIV primary care tasks, but not with screening and counseling concerning the spread of HIV infection.(Arch Intern Med. 1995;155:1613-1618) References 1. Centers for Disease Control and Prevention. Update: mortality attributable to HIV infection among persons aged 25-44—United States, 1991 and 1992. MMWR Morb Mortal Wkly Rep . 1993;42:869-872. 2. Jewett JF, Hecht FM. Preventive health care of adults with HIV infection. JAMA . 1993;269:1144-1153.Crossref 3. Gallant JE, Moore RD, Chaisson RE. Prophylaxis for opportunistic infections in patients with HIV infection. Ann Intern Med . 1994;120:932-944.Crossref 4. Osmond D, Charlebois E, Land W, Shiboski S, Moss A. Changes in AIDS survival time in two San Francisco cohorts of homosexual men, 1983 to 1993. JAMA . 1994;271:1083-1087.Crossref 5. El-Sadr W, Oleske JM, Agins BD, et al. Evaluation and management of early HIV infection. In: Clinical Practice Guideline No. 7 . Rockville, Md: Agency for Health Care Policy and Research; 1994. US Dept of Health and Human Services publication 94-0572. 6. American Medical Association. HIV early intervention. In: Physician Guidelines . 2nd ed. Chicago, III: American Medical Association; 1994. 7. American College of Physicians and Infectious Diseases Society of America. Human immunodeficiency virus (HIV) infection. Ann Intern Med . 1994;120:310-319.Crossref 8. State of the Art Conference on AZT Therapy for Early HIV Infection. Recommendations for zidovudine: early infection. JAMA . 1990;263:1606-1607.Crossref 9. Saag MS. What to do when zidovudine fails. N Engl J Med . 1994;330:706-707.Crossref 10. Francis DP, Anderson RE, Gorman ME, et al. Targeting AIDS prevention and treatment toward HIV-1-infected persons: the concept of early intervention. JAMA . 1989;262:2572-2576.Crossref 11. Lewis CE, Montgomery K. The AIDS-related experiences and practices of primary care physicians in Los Angeles: 1984-1989. Am J Public Health . 1990; 80:1511-1513.Crossref 12. Wenrich MD, Ramsey PG. Patterns of primary care of patients infected with human immunodeficiency virus. West J Med . 1991;155:380-383. 13. Stillman PL, Swanson DB, Smee S, et al. Assessing clinical skills of residents with standardized patients. Ann Intern Med . 1986;105:762-771.Crossref 14. Stillman PL, Swanson DB, Regan MB, et al. Assessment of clinical skills of residents utilizing standardized patients: follow-up study and recommendations for application. Ann Intern Med . 1991;114:393-401.Crossref 15. Curtis JR, Paauw DS, Wenrich MD, Carline JD, Ramsey PG. Internal medicine residents' skills at identification of HIV risk behavior and HIV-related disease. Acad Med . 1994;69:S45-S47.Crossref 16. Carney PA, Dietrich AJ, Freeman DH, Mott LA. The periodic health examination provided to asymptomatic older women: an assessment using standardized patients. Ann Intern Med . 1993;119:129-135.Crossref 17. Bowman MA, Russell NK, Boekeloo BO, Rafi IZ, Rabin DL. The effect of educational preparation on physician performance with a sexually transmitted disease-simulated patient. Arch Intern Med . 1992;152:1823-1828.Crossref 18. Ramsey PG, Wenrich MD, Carline JD, Curtis JR, Paauw DS. Primary Care of Patients With or At-Risk for HIV Infection . Rockville, Md: Agency for Health Care Policy and Research; 1994. 19. American Medical Association. Directory of Physicians in the United States . 33rd ed. Chicago, III: American Medical Association; 1992. 20. Centers for Disease Control. Pneumococcal polysaccharide vaccine. MMWR Morb Mortal Wkly Rep . 1989;38:64-76. 21. Centers for Disease Control. Prevention and control of influenza. MMWR Morb Mortal Wkly Rep . 1988;37:361-373. 22. Hirschmann JV, Lipsky BA. The pneumococcal vaccine after 15 years of use. Arch Intern Med . 1994;154:373-377.Crossref 23. Nelson KE, Clements ML, Miotti P, Cohn S, Polk BF. The influence of HIV infection on antibody responses to influenza vaccines. Ann Intern Med . 1988; 109:383-388.Crossref 24. Pinching AJ. Antibody responses in HIV infection. Clin Exp Immunol . 1991; 84:181-184. 25. Selwyn PA, Hartel D, Lewis VA, et al. A prospective study of the risk of tuberculosis among intravenous drug users with HIV infection. N Engl J Med . 1989;320:545-550.Crossref 26. Selwyn PA, Sckell BM, Alcabes P, Friedland GH, Klein RS, Schoenbaum EE. High risk of active tuberculosis in HIV-infected drug users with cutaneous anergy. JAMA . 1989;268:504-509.Crossref 27. Curtis JR, Hooton TM, Nolan CM. New developments in tuberculosis and HIV infection: an opportunity for prevention. J Gen Intern Med . 1994;9:286-294.Crossref 28. Aboulker JP, Swart AM; the Concorde Coordinating Committee. Preliminary analysis of the Concorde trial. Lancet . 1993;341:889-890.Crossref 29. Cooper DA, Gatell JM, Kroon S, et al. Zidovudine in persons with asymptomatic HIV infections and CD4 cell counts greater than 400 per cubic millimeter. N Engl J Med . 1993;119:786-793. 30. Hamilton JD, Hartigan PM, Simberkoff MS, et al. A controlled trial of early versus late treatment with zidovudine in symptomatic human immunodeficiency virus infection: results of the Veterans Affairs Cooperative Study. N Engl J Med . 1992;326:437-443.Crossref 31. Sande MA, Carpenter CJ, Cobbs CG, Holmes KK, Sanford JP. Antiretroviral therapy for adult HIV-infected patients: recommendations from a state-of-the-art conference. JAMA . 1993;270:2583-2589.Crossref 32. Higgins DL, Galavotti C, O'Reilly KR, et al. Evidence for the effects of HIV antibody counseling and testing on risk behaviors. JAMA . 1991;266:2419-2429.Crossref 33. Wenger NS, Linn LS, Epstein M, Shapiro MF. Reduction of high-risk sexual behavior among heterosexuals undergoing HIV antibody testing: a randomized clinical trial. Am J Public Health . 1991;81:1580-1585.Crossref 34. Landis SE, Schoenbach VJ, Weber DJ, et al. Results of a randomized trial of partner notification in cases of HIV infection in North Carolina. N Engl J Med . 1992;326:101-106.Crossref 35. Pavia AT, Benyo M, Niler L, Risk I. Partner notification for control of HIV: results after 2 years of a statewide program in Utah. Am J Public Health . 1993; 83:1418-1424.Crossref 36. Van der Vleuten CPM, Swanson DB. Assessment of clinical skills with standardized patients: state of the art. Teach Learn Med . 1990;2:58-76.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Physicians' Ability to Provide Initial Primary Care to an HIV-Infected Patient

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Publisher
American Medical Association
Copyright
Copyright © 1995 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1995.00430150083009
Publisher site
See Article on Publisher Site

Abstract

Abstract Background: Primary care physicians are providing care for an increasing number of persons infected with the human immunodeficiency virus (HIV). This study assesses the ability of primary care physicians to provide initial care for a patient with recently diagnosed HIV infection. Methods: A standardized patient (SP) was trained to portray an asymptomatic person with HIV infection seeking a primary care physician. Physicians took a medical history and counseled the SP; their performances were assessed by the SP and through a brief written examination. In addition, physicians distributed questionnaires to HIV-infected patients in their practices to assess actual performance. The study participants consisted of 121 primary care physicians. Results: A minority of physicians recommended standard primary care screening tests and vaccinations, including viral hepatitis screening (35%), syphilis serologic testing (32%), and pneumococcal vaccination (23%). While most physicians (87%) indicated they would obtain CD4 cell counts, only 50% indicated they would start appropriate Pneumocystis carinii pneumonia prophylaxis. Although this patient presented documentation of a positive tuberculin skin test and no prior therapy for tuberculosis, only 53% of the physicians recommended prophylactic isoniazid. While 75% of the physicians asked this SP about his HIV risk (sex with men), less than a third asked about condom use, number of sexual partners, or contact with previous sexual partners. Physicians with the most HIV experience were more likely to recommend P carinii pneumonia prophylaxis, coinfection screening, pneumococcal vaccination, and isoniazid prophylactic therapy. However, physicians' HIV experience was not associated with assessing this SP's risk of infecting others or with counseling regarding condom use. Questionnaires distributed to HIV-infected patients of these physicians generally confirmed these findings. Conclusions: Basic HIV preventive and primary care may not be adequately performed by many primary care physicians. Physicians' HIV experience was associated with better performance of HIV primary care tasks, but not with screening and counseling concerning the spread of HIV infection.(Arch Intern Med. 1995;155:1613-1618) References 1. Centers for Disease Control and Prevention. Update: mortality attributable to HIV infection among persons aged 25-44—United States, 1991 and 1992. MMWR Morb Mortal Wkly Rep . 1993;42:869-872. 2. Jewett JF, Hecht FM. Preventive health care of adults with HIV infection. JAMA . 1993;269:1144-1153.Crossref 3. Gallant JE, Moore RD, Chaisson RE. Prophylaxis for opportunistic infections in patients with HIV infection. Ann Intern Med . 1994;120:932-944.Crossref 4. Osmond D, Charlebois E, Land W, Shiboski S, Moss A. Changes in AIDS survival time in two San Francisco cohorts of homosexual men, 1983 to 1993. JAMA . 1994;271:1083-1087.Crossref 5. El-Sadr W, Oleske JM, Agins BD, et al. Evaluation and management of early HIV infection. In: Clinical Practice Guideline No. 7 . Rockville, Md: Agency for Health Care Policy and Research; 1994. US Dept of Health and Human Services publication 94-0572. 6. American Medical Association. HIV early intervention. In: Physician Guidelines . 2nd ed. Chicago, III: American Medical Association; 1994. 7. American College of Physicians and Infectious Diseases Society of America. Human immunodeficiency virus (HIV) infection. Ann Intern Med . 1994;120:310-319.Crossref 8. State of the Art Conference on AZT Therapy for Early HIV Infection. Recommendations for zidovudine: early infection. JAMA . 1990;263:1606-1607.Crossref 9. Saag MS. What to do when zidovudine fails. N Engl J Med . 1994;330:706-707.Crossref 10. Francis DP, Anderson RE, Gorman ME, et al. Targeting AIDS prevention and treatment toward HIV-1-infected persons: the concept of early intervention. JAMA . 1989;262:2572-2576.Crossref 11. Lewis CE, Montgomery K. The AIDS-related experiences and practices of primary care physicians in Los Angeles: 1984-1989. Am J Public Health . 1990; 80:1511-1513.Crossref 12. Wenrich MD, Ramsey PG. Patterns of primary care of patients infected with human immunodeficiency virus. West J Med . 1991;155:380-383. 13. Stillman PL, Swanson DB, Smee S, et al. Assessing clinical skills of residents with standardized patients. Ann Intern Med . 1986;105:762-771.Crossref 14. Stillman PL, Swanson DB, Regan MB, et al. Assessment of clinical skills of residents utilizing standardized patients: follow-up study and recommendations for application. Ann Intern Med . 1991;114:393-401.Crossref 15. Curtis JR, Paauw DS, Wenrich MD, Carline JD, Ramsey PG. Internal medicine residents' skills at identification of HIV risk behavior and HIV-related disease. Acad Med . 1994;69:S45-S47.Crossref 16. Carney PA, Dietrich AJ, Freeman DH, Mott LA. The periodic health examination provided to asymptomatic older women: an assessment using standardized patients. Ann Intern Med . 1993;119:129-135.Crossref 17. Bowman MA, Russell NK, Boekeloo BO, Rafi IZ, Rabin DL. The effect of educational preparation on physician performance with a sexually transmitted disease-simulated patient. Arch Intern Med . 1992;152:1823-1828.Crossref 18. Ramsey PG, Wenrich MD, Carline JD, Curtis JR, Paauw DS. Primary Care of Patients With or At-Risk for HIV Infection . Rockville, Md: Agency for Health Care Policy and Research; 1994. 19. American Medical Association. Directory of Physicians in the United States . 33rd ed. Chicago, III: American Medical Association; 1992. 20. Centers for Disease Control. Pneumococcal polysaccharide vaccine. MMWR Morb Mortal Wkly Rep . 1989;38:64-76. 21. Centers for Disease Control. Prevention and control of influenza. MMWR Morb Mortal Wkly Rep . 1988;37:361-373. 22. Hirschmann JV, Lipsky BA. The pneumococcal vaccine after 15 years of use. Arch Intern Med . 1994;154:373-377.Crossref 23. Nelson KE, Clements ML, Miotti P, Cohn S, Polk BF. The influence of HIV infection on antibody responses to influenza vaccines. Ann Intern Med . 1988; 109:383-388.Crossref 24. Pinching AJ. Antibody responses in HIV infection. Clin Exp Immunol . 1991; 84:181-184. 25. Selwyn PA, Hartel D, Lewis VA, et al. A prospective study of the risk of tuberculosis among intravenous drug users with HIV infection. N Engl J Med . 1989;320:545-550.Crossref 26. Selwyn PA, Sckell BM, Alcabes P, Friedland GH, Klein RS, Schoenbaum EE. High risk of active tuberculosis in HIV-infected drug users with cutaneous anergy. JAMA . 1989;268:504-509.Crossref 27. Curtis JR, Hooton TM, Nolan CM. New developments in tuberculosis and HIV infection: an opportunity for prevention. J Gen Intern Med . 1994;9:286-294.Crossref 28. Aboulker JP, Swart AM; the Concorde Coordinating Committee. Preliminary analysis of the Concorde trial. Lancet . 1993;341:889-890.Crossref 29. Cooper DA, Gatell JM, Kroon S, et al. Zidovudine in persons with asymptomatic HIV infections and CD4 cell counts greater than 400 per cubic millimeter. N Engl J Med . 1993;119:786-793. 30. Hamilton JD, Hartigan PM, Simberkoff MS, et al. A controlled trial of early versus late treatment with zidovudine in symptomatic human immunodeficiency virus infection: results of the Veterans Affairs Cooperative Study. N Engl J Med . 1992;326:437-443.Crossref 31. Sande MA, Carpenter CJ, Cobbs CG, Holmes KK, Sanford JP. Antiretroviral therapy for adult HIV-infected patients: recommendations from a state-of-the-art conference. JAMA . 1993;270:2583-2589.Crossref 32. Higgins DL, Galavotti C, O'Reilly KR, et al. Evidence for the effects of HIV antibody counseling and testing on risk behaviors. JAMA . 1991;266:2419-2429.Crossref 33. Wenger NS, Linn LS, Epstein M, Shapiro MF. Reduction of high-risk sexual behavior among heterosexuals undergoing HIV antibody testing: a randomized clinical trial. Am J Public Health . 1991;81:1580-1585.Crossref 34. Landis SE, Schoenbach VJ, Weber DJ, et al. Results of a randomized trial of partner notification in cases of HIV infection in North Carolina. N Engl J Med . 1992;326:101-106.Crossref 35. Pavia AT, Benyo M, Niler L, Risk I. Partner notification for control of HIV: results after 2 years of a statewide program in Utah. Am J Public Health . 1993; 83:1418-1424.Crossref 36. Van der Vleuten CPM, Swanson DB. Assessment of clinical skills with standardized patients: state of the art. Teach Learn Med . 1990;2:58-76.Crossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Aug 7, 1995

References