11th International AIDS Conference Vancouver, British Columbia — July 7-12, 1996

Int Conf AIDS 1996 Jul 7-12; 11:25 (abstract no. LB.B.6018)
van Bergen J; Dutch National Society of General Practitioners, Department of Quality Assurance and Continuous Education, Amsterdam, The Netherlands. Fax: 31-50-3182432.

INTRODUCTION: In March 1994 a project was started in order to integrate continuing education for general practitioners (GP's) about HIV in regular continuing education in the Netherlands. The strategy was to create a network of regional GP's with additional knowledge and interest in the field of prevention and care of HIV and sexually transmitted infections. These "regional HIV-consultant GPs" would be available for inter-doctor (peer-)consultation and initiate region-wide professional training on the subject. The viewpoint behind the project was to add to a vertical, rather secondary care oriented and medically biased HIV policy, a more primary care oriented and public health minded focus with more attention to the additional and complementary role of the general practitioner in HIV/STD-prevention and to "Sexual Health" in general. AIDS in Netherlands, a primary care problem? Until 31-12-1995, 3969 AIDS-patients have been diagnosed. There is a stabilization of new cases with a slight decrease in AIDS-patients in the transmission-category homo-bisexual (83% in 1988 to 59% in 1995) and an increase in AIDS-patients reporting IVDU and in persons infected by heterosexual contact (4.9% in 1988 to 20.5% in 1995). Due to the strong concentration of AIDS-patients in Amsterdam, more than 75% of the GP's do not have any experience with AIDS-patients. This causes reservedness for education on the topic. However, every GP is involved in HIV-testing and contraception consultations. The GP's treat approximately 2/3 of all STD's in the country, which is on average 10 patients per GP per year. (The burden of Disease in the Netherlands: annual incidence: approximately 110,000 STDs, of which 500 HIV-infections and 60,000 chlamydial infections with its sequelae of PID: 1500 cases of tubar infertility and 300 cases of ectopic pregnancies). Prevention is of crucial importance, but several surveys indicate a major gap between knowledge and actual preventive sexual behavior. (See Addendum below) The need is expressed for "tailor-made advice" in order to generate realistic individual risk assessments and facilitate a discussion about obstacles to translate correct risk assessment into preventive practice in the actual "on-line" situation. Potentially the general practitioner has many prevention opportunities for problem-oriented counseling and tailored prevention advice on HIV and STD. (Table: see text) Implementation: A national network has been developed of 25 "HIV-consultant GP's" who received training and a manual. Since the inception of the project 2 years ago, more than 1000 GP's (of a total of 7000 Dutch GP's) have participated in continuous education in this area. Easy-to-measure impact indicators, like increased willingness to discuss topics on safer sex and intention to order safe sex education materials for their practice, are increased in pilot sessions, but will be measured after 1 year to see if intention to has any predictive value for actual increase.

DISCUSSION: The GP has potentially several problem-oriented opportunities for prevention advice on safer sex (figure: see text). The proposed strategy model for intervention consist of opening up the discussion on perceived individual vulnerability and inventarisation of personal motivation and barriers in safer sex behavior. With a similar preventive approach on smoking, the "minimal intervention strategy", 10-20% stop-smokers have been recorded. Meaningful counseling requires an open and non-judgmental attitude; insight in personal norms, mores and values and in the way these might interfere within patient-doctor interaction; and appropriate skills in discussing safer sex behavior. Age, gender and cultural differences between doctor and patient can inhibit two-way communication on issues of sexuality. Familiarity with the "family doctor" can interfere with opening up. Continuous education programs for GP's are valuable for the incremental chance they give to open up the "culture of silence" in GP on issues of sexual health. Better use of prevention opportunities during doctor-patient encounters in primary care is one of them.

ADDENDUM: Although condom-use among people with multiple sexual partners (including serial monogamy) has increased, still almost half of them does not use consistent condoms during their sexual encounters. A study among more than 7000 school pupils aged 12-18 years shows that sexual risk-taking has increased between 1990 and 1995 from 6-10% in the total group, and from 20 to 30% in the group with coitus experience. Not-representative studies in homosexual community still record levels of unprotected anal intercourse with non-steady partners in 25% up to 40%. Thus, prevention programs did generate a knowledgeable population, but many individuals who are at risk do not feel as such, or are not equipped with sufficient skills and power to negotiate safer sex. (Figure: see text)

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