Although national recommendations call for screening all patients for risks of HIV infection, these recommendations may be difficult to follow in the context of brief appointments with patients. Failing to screen patients may have few or no consequences in patients with few or no risks of HIV; however, failing to screen a patient at high risk may result in inadequate or misdirected patient management and adversely influence the course of disease. Although previous studies suggest that primary care physicians do not routinely perform HIV risk assessment with their patients, practice-based data for patients with known risks are not available. Therefore, little is known about the content of HIV risk assessment, the consistency of questioning, or the extent to which physicians identify patients’ HIV risk behaviors. We assessed physicians’ skills in detecting HIV risk using a panel of standardized patients with primary care presentations and unidentified risk behaviors for HIV infection. The context of risks and cues available to physicians varied considerably, as would be true in the practice setting. The SPs had features of their history or physical examination that should have directed physicians to perform an HIV risk assessment. Our data suggest that there is great variability in the performance of HIV risk assessment across different patients at risk of HIV infection. There was also considerable variation within individual cases in the frequency of covering HIV risk assessment topics. These data suggest that primary care physicians are inconsistent and sporadic in their practices related to screening for and identification of HIV risk behaviors in brief visits and frequently miss important HIV risk behaviors. Systematic screening for HIV risks would reduce variability and increase detection of HIV risk behaviors.
Relative to self-reported estimates of HIV risk assessment from previous studies,8–10
physicians did better than expected in this study in performing a minimal HIV risk assessment. However, physicians still did not ask any HIV risk assessment questions of 40% of SPs who had HIV risk behaviors and, more importantly, missed clinically important HIV risk behaviors in 50% of SPs they saw who were at risk. As a result, physicians did not identify HIV as a potential consideration in more than half of these cases in which SPs were at high risk of HIV infection. The discrepancies in all cases between initiating screening (screening in at least one of the five HIV screening topic areas) and identifying the patient's risk behavior suggests that even among physicians who initiate screening, basic risk behaviors may not be covered, resulting in missed opportunities to detect HIV risk and to intervene to decrease risk.
Physicians performed substantially better with four of the nine SPs (cases 3, 5, 8, and 9) at initiating HIV risk screening and identifying the risk behaviors. Although speculation concerning what differentiated these four from the other five SPs cannot adequately consider all the factors that led to screening, the four SPs who were screened more comprehensively appear to be distinguished by their symptoms. All described symptoms consistent with possible HIV-related disease (prolonged diarrhea, dyspnea and fever, sore throat with white spots on the tongue, and fatigue and weight loss). Symptoms of other patients may have been less overtly suggestive of HIV infection, although they had symptoms, histories, or clues that should have led to consideration of HIV infection. It appears that physicians appropriately ask questions about HIV risk behavior when the presenting symptoms indicate a higher probability of HIV infection. Many HIV-positive individuals are asymptomatic, however, and others may not have classic, obvious, or well-known presentations associated with the disease. In addition, patients with risk behaviors for HIV infection may not be easily identified by their medical, physical, or social presentations. In general, it appears that primary care physicians do not routinely screen patients without obvious symptoms of HIV infection, and our findings highlight the need for better screening processes to identify risk behaviors.
Several physician demographic characteristics appear to influence performance in screening patients for HIV risk behaviors. Board-certified internists performed better at initiating screening and identifying risk behaviors than board-certified family practitioners. In addition, medical school graduation year was significantly associated with performance in these areas. The findings concerning the influence of number of years since training on performance in HIV risk screening are similar to previous findings.17
The findings concerning performance by general internists compared with family practitioners, however, are new.
This study has several limitations. Physician participants were volunteers and may not be representative of all primary care physicians. Individuals who are willing to have their skill levels tested might be expected to have more confidence in their skills. In addition, performance in a known SP setting may be better than in actual practice settings because physicians know they are being tested. Thus, our data may overestimate average practice performance at HIV risk behavior screening by primary care physicians. Second, the number of SPs seen who had HIV risk behaviors was disproportionate to what most primary care physicians would actually see in practice. Although all patients had common primary care presentations (e.g., cough, fatigue), a typical case load would not consist of so many patients with HIV risk behaviors, decreasing the likelihood that physicians would consider HIV so frequently. Finally, this type of SP assessment provides information only about what happens in an initial, relatively brief visit. Follow-up visits and test information could result in further insights about HIV risk behaviors. However, for the patient who is generally healthy and seen only infrequently and for patients with acute illness, the initial visit assumes added importance. For these patients, missed history and physical examination items and missed diagnoses may increase morbidity because of treatment delays for a patient with underlying disease and may delay important preventive counseling for the well patient with risk behaviors.
Unidentified HIV infection or risk of infection presents an important opportunity to prevent morbidity and mortality. Our findings document the need for improvement in HIV risk screening by primary care providers. However, although guidelines for primary care physicians emphasize the importance of routine HIV risk screening, there is little recognition of the difficulty of covering multiple diverse screening topics in a limited amount of time. Our data suggest the need for new Methods that will systematically incorporate HIV risk screening questions into practices. A brief set of standardized HIV risk screening questions, such as exists for alcoholism through the CAGE questions,23,24
is one approach that might improve HIV risk behavior screening in primary care. In one study using a single SP, physicians who used an HIV risk questionnaire performed better at assessing HIV risks than physicians who did not use the questionnaire.25
Research is needed to determine what questions perform best at identifying HIV risks in a written screening questionnaire. Overall, our data suggest that physicians do not routinely address HIV risk assessment with patients who are at risk of HIV infection and, when they do perform screening, the content of risk assessments is variable and limited. As a result, many HIV risk behaviors among patients remain unidentified.