HIV prevention: Doctors asked to take bigger role

The CDC would like physicians to use their power to influence patients' behavior to help stop the spread of AIDS.

By Susan J. Landers, amednews staff. Aug. 11, 2003.

Washington -- Physicians must ask their HIV-positive patients more probing questions about their sex lives and needle-using habits in order to slow the spread of AIDS, according to guidelines released last month by the Centers for Disease Control and Prevention.

The document aims to help physicians and others who care for people infected by the AIDS virus to initiate conversations on sensitive subjects -- not always an easy task for time-strapped physicians intent upon treating these patients with an ever-changing battery of medications.

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"It's time we merge prevention services for HIV-infected persons into the mainstream of medical care," said CDC Director Julie L. Gerberding, MD, MPH. "These guidelines provide a much-needed road map for medical professionals ... to work more closely with their HIV-infected patients to reduce HIV transmission."

The new guidelines, published in the July 18 issue of Morbidity and Mortality Weekly Report, resulted from a collaboration of the CDC, the National Institutes of Health, the Health Resources and Services Administration, and the HIV Medicine Assn. of the Infectious Diseases Society of America.

The document calls for:

Screening patients to assess risky behaviors that could spread the disease to sexual or needle-sharing partners. It also recommends that AIDS patients be tested for other sexually transmitted diseases and that the possibility of pregnancy be raised with female patients to help prevent mother-to-child HIV transmission.
Delivering prevention messages, providing condoms and, when appropriate, referring patients to outside prevention services.
Encouraging patients to notify partners of their infections and to help patients contact health departments to arrange for notification of partners who are not already informed.

The guidelines do have a downside, said John Bartlett, MD, professor of medicine and chief of the Division of Infectious Diseases at Johns Hopkins School of Medicine, Baltimore. Although Dr. Bartlett helped draft them, he noted that the guidelines add to an already onerous workload for doctors caring for this growing population.

However, all agree that additional prevention efforts must be launched to stop the spread of AIDS, and the guidelines represent a long overdue effort to include people who already have AIDS in prevention strategies, said Thomas Farley, MD, PhD, chair of the Community Health Sciences Dept. at Tulane University's School of Public Health and Tropical Medicine in New Orleans.

An estimated 900,000 people in the United States are living with HIV, noted Harold Jaffe, MD, director of the CDC's National Center for HIV, STD and TB Prevention. "Health care professionals provide a critical link to HIV prevention information and services."

Spreading the word

The guidelines make good sense, considering what is known about the HIV-infected population, said Dr. Farley. "We know that the majority of identified HIV-positive people are in contact with health care providers. We also know that an awful lot of those HIV-positive people continue to be sexually active and to spread the infection to others."

Additional research has shown that patients pay attention to their physicians' advice, and even the simplest messages can have an important impact on patients' health practices. But until now, said Dr. Farley, physicians have focused on treating their patients' disease.

900,000 people in the United States are living with HIV.

"They really don't talk about whether a patient is using condoms when having sex, or whether they are having sex at all, or whether they are sharing needles," said Dr. Farley. Up to now, treatment and prevention of AIDS existed in two different worlds, he said. "And they have been talking past each other for a long time."

Those focused on treatment have paid closer heed to which of the latest triple therapies to use, and those involved in prevention have concentrated more on broad community education, said Dr. Farley.

The guidelines also serve to spread the type of counseling and care provided by university-based treatment centers to the general practice of AIDS care in clinics and offices, said Margaret Fischl, MD, professor of medicine and director of the AIDS Clinical Research Unit at the University of Miami School of Medicine.

Clinicians at the university see about 1,000 patients for testing, counseling or research studies, she said.

"We are used to asking those questions," said Dr. Fischl, though she admits it was difficult in the beginning to train staff members to even say the word condom.

Yet the staff soon learned they had to be prepared to answer such questions as where to get a dental dam. "That's not necessarily something a physician in practice would have at their fingertips."

Dr. Fischl is amazed at the influence physicians wield over their patients' health behaviors.

"I don't know whether it is the aura of being a doctor or whatever, but it is an important position you have with your patients, and I think the CDC is trying to say you should use that in communicating to patients so you empower them to practice safer sex, for example."