AIDSWEEKLY Plus, September 11, 1995
Daniel J. DeNoon, Senior Editor

AIDS is the leading cause of death among U.S. men aged 15 to 44 years and the fourth leading cause of death among 15-to-44-year-old women, noted researchers J. Randall Curtis, Paul G. Ramsey, and colleagues of the University of Washington, Seattle, in the journal Archives of Internal Medicine (Physicians' Ability to Provide Initial Primary Care to an HIV-Infected Patient," Arch Int Med, August 7/21, 1995;155(15):1613-8).

But when Curtis et al. conducted a study of primary-care physicians, they discovered an appalling inability to provide adequate basic HIV preventive and primary care. Most doctors in the study not only failed to recommend appropriate Pneumocystis carinii pneumonia (PCP) prophylaxis, but also failed to recommend appropriate vaccinations and screening for hepatitis and syphilis. Nearly half failed to recommend indicated tuberculosis prophylaxis.

"Basic HIV preventive and primary care may not be adequately performed by many primary care physicians," Curtis et al. concluded.

The researchers designed an ingenious study using 17 individuals trained to represent a "standardized patient (SP)" with HIV infection. This standardized patient was an asymptomatic 39-year-old homosexual man presenting four weeks after a positive HIV test and seeking a new primary care physician three months after moving to a new city. He brought with him a letter from a previous physician indicating 1) a positive tuberculin skin test (14 mm) performed two years previously; 2) a chest radiograph taken at that time showed no abnormalities; and 3) no prior tuberculosis prophylaxis.

Physicians were recruited for the study by a letter of introduction sent to internists and family practitioners listed in the American Medical Association directories for five northwestern U.S. states. Physicians were eligible if 1) 50 percent of their time was spent providing primary care; 2) they graduated from medical school in 1967 or later; and 3) they specialized in internal medicine, family practice, or general practice. Of the 2308 physicians that responded to a questionnaire about their practice, 31 percent did not meet eligibility criteria, 20 percent provided insufficient information, 23 percent declined participation, and 26 percent agreed to participate.

Of the 599 eligible physicians, 134 were randomly selected, stratifying for experience with HIV, year of graduation from medical school, and specialty. The 121 physicians who actually participated in the study received eight category I continuing medical education credits and were reimbursed $500 for time and travel expenses. All gave informed consent.

Even though selection bias would be expected to choose those physicians with the most confidence in the primary-care skills, the findings showed a lack of knowledge about how to treat the standardized patient.

According to current recommendations, the patient should have received assessment of CD4 cell count, adequate PCP prophylaxis, screening for prior TB exposure with preventive isoniazid for exposure, screening for syphilis and hepatitis, administration of pneumococcal and influenza vaccinations, assessment of HIV risk behaviors and provision of counseling to reduce risk of HIV transmission (Jewett et al., JAMA, 1993;269:1144-53; El-Sadr et al., in Clinical Practice Guideline No. 7, 1994, Rockville, Maryland: Agency for Health Care Policy and Research, HHS publication 94-0572; "Physician Guidelines," AMA, 1994; Francis et al., JAMA, 1989;262:2572-6).

Curtis et al. found:

• Only 23 percent of physicians recommended pneumococcal vaccination.
• Only 32 percent recommended syphilis screening.
• Only 35 percent recommended viral hepatitis screening.
• Only 50 percent recommended appropriate PCP prophylaxis, even though 87 percent would obtain CD4 counts.
• Only 53 percent recommended prophylactic isoniazid, and only a fifth recommended an appropriate course of isoniazid prophylaxis.
• Although 75 percent of the physicians asked the standardized patient about his HIV risk, fewer than a third queried about condom use, number of sexual partners, or contact with previous sexual partners.
• The physicians with the most experience in treating patients with HIV were more likely to recommend PCP and TB prophylaxis, hepatitis and syphilis screening, and pneumococcal vaccination. However, the most experience care providers did no better than their less experienced peers at assessing the patients risk of infecting others or at counseling condom use.

"Provision of preventive health measures and basic primary care to HIV-infected individuals represents the major method physicians have to decrease the morbidity and mortality of HIV infection for those already infected," Curtis et al. concluded. "Our results suggest that basic HIV preventive and primary care may not be adequately performed by many primary care physicians. ... An important step in minimizing the morbidity and mortality for those already infected with HIV and preventing further spread of HIV infection will be the education of primary-care physicians in the provision of primary care to the asymptomatic HIV-infected individual."

The corresponding author for this study is Paul G. Ramsey, Department of Medicine, University of Washington, RG-20, Seattle, Washington 98195.

This project was supported by grant HS 06454-03 from the Agency for Health Care Policy and Research, Rockville, Maryland. Dr. Curtis was funded by the Robert Wood Johnson Clinical Scholars Program, University of Washington, Seattle.

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