Toward a definition of HIV expertise: a survey of experienced HIV physicians

A survey: how periodontists and other dental professionals view the scope of periodontics

BACKGROUND

How do periodontists think of themselves when they define their practices? How do other dental professionals view the scope of the specialty of periodontology? A strong component of periodontal residency programs is extracting teeth and preserving or building bony ridges for the eventual placement of implants. Has the discipline of periodontology moved away from retaining and treating the natural dentition? By the use of a rank-order survey, the practice of periodontology was defined by periodontists and other dental professionals.

METHODS

In a pilot study, respondents were asked to list the answers to the question, "What is a periodontist?" The results were consolidated into eight statements. The eight statements were placed into an anonymous rank-order survey, and more than 1,200 responses were returned. The responses primarily came from periodontists, hygienists, general practitioners, dental students, and dental hygiene students.

RESULTS

"Periodontists surgically treat advanced gum and bone infection problems" was considered the most important statement in all of the cohorts. The least important statement considered by all was, "Periodontists are educators promoting health." Non-periodontist dentists (NPDs) ranked the statement, "Periodontists perform dental implants and related procedures" less importantly (P <0.001) than the periodontists. The non-periodontist cohort (NPC), which includes NPDs and dental hygienists, ranked the statement, "Periodontists' treatments help general dentists and other specialists increase successful therapeutic outcomes" as second most important.

CONCLUSIONS

The results of this survey indicate that periodontists ranked the placement of implants and their related procedures higher than the NPC. NPDs appear to value periodontists in treating the natural dentition for their patients. The NPC appreciates that periodontal therapy done by periodontists increases their therapeutic success for their patients.

The mysteries and demands of HIV care: qualitative analyses of HIV specialists’ views on their expertise

To deepen our understanding of the mysteries and demands associated with HIV care and to inform the debate about HIV specialization, we conducted in-depth interviews with a purposive sample of 20 identified HIV specialists in the San Francisco Bay Area. Participants were from several medical specialties and reported a median of 50% of their time spent in HIV patient care. Through constant comparison, a template of open codes was constructed to identify themes that emerged from the data. Data were analyzed according to the conventions of qualitative research and revealed six interrelated themes: (1) coping with uncertainty and rapid change: being 'comfortable with mystery'; (2) the powerful role of experience; (3) the dual faces of knowledge: 'knowing the patient' and 'knowing the facts'; (4) the dual faces of passion: challenge and calling; (5) stress and burnout; and (6) the relationship between academia and 'the trenches'. The themes underscore the dual dimensions of HIV care: providers must interweave the 'half-baked' science about drug therapies, side effects and drug interactions with the psychosocial and lifestyle factors of the patient. They also provide insight into quantitative findings linking greater HIV experience with better patient outcomes and suggest that providers need skills associated with generalist and specialist training, a phenomenon that argues for a 'special' specialty for HIV care.

Interactive "Video Doctor" counseling reduces drug and sexual risk behaviors among HIV-positive patients in diverse outpatient settings

BACKGROUND

Reducing substance use and unprotected sex by HIV-positive persons improves individual health status while decreasing the risk of HIV transmission. Despite recommendations that health care providers screen and counsel their HIV-positive patients for ongoing behavioral risks, it is unknown how to best provide "prevention with positives" in clinical settings. Positive Choice, an interactive, patient-tailored computer program, was developed in the United States to improve clinic-based assessment and counseling for risky behaviors.

METHODOLOGY AND FINDINGS

We conducted a parallel groups randomized controlled trial (December 2003-September 2006) at 5 San Francisco area outpatient HIV clinics. Eligible patients (HIV-positive English-speaking adults) completed an in-depth computerized risk assessment. Participants reporting substance use or sexual risks (n = 476) were randomized in stratified blocks. The intervention group received tailored risk-reduction counseling from a "Video Doctor" via laptop computer and a printed Educational Worksheet; providers received a Cueing Sheet on reported risks. Compared with control, fewer intervention participants reported continuing illicit drug use (RR 0.81, 95% CI: 0.689, 0.957, p = 0.014 at 3 months; and RR 0.65, 95% CI: 0.540, 0.785, p<0.001 at 6 months) and unprotected sex (RR 0.88, 95% CI: 0.773, 0.993, p = 0.039 at 3 months; and RR 0.80, 95% CI: 0.686, 0.941, p = 0.007 at 6 months). Intervention participants reported fewer mean days of ongoing illicit drug use (-4.0 days vs. -1.3 days, p = 0.346, at 3 months; and -4.7 days vs. -0.7 days, p = 0.130, at 6 months) than did controls, and had fewer casual sex partners at (-2.3 vs. -1.4, p = 0.461, at 3 months; and -2.7 vs. -0.6, p = 0.042, at 6 months).

CONCLUSIONS

The Positive Choice intervention achieved significant cessation of illicit drug use and unprotected sex at the group-level, and modest individual-level reductions in days of ongoing drug use and number of casual sex partners compared with the control group. Positive Choice, including Video Doctor counseling, is an efficacious and appropriate adjunct to risk-reduction efforts in outpatient settings, and holds promise as a public health HIV intervention.

TRIAL REGISTRATION

Clinicaltrials.gov NCT00447707.

Providers' HIV prevention discussions with HIV-seropositive injection drug users

Public health agencies have recommended incorporating HIV prevention counseling into the medical care of persons living with HIV/AIDS. Injection drug users (IDUs) especially need HIV risk-reduction counseling because of their high risk for HIV transmission through both sexual and injection behaviors. The objective of this study was to assess the prevalence of, and patient factors associated with, the delivery of HIV prevention messages to HIV-seropositive IDUs in primary care settings. A majority of participants reported having an HIV prevention discussion with their provider during their most recent primary care visit. Factors significantly associated with report of such discussion were being Hispanic or non-Hispanic Black; high school education or less; and better perception of engagement with provider. Medical providers should provide prevention messages to all HIV-seropositive IDUs, regardless of demographic factors. Effective HIV prevention interventions in primary care settings, including interventions to improve patient-provider communication, are needed for HIV-seropositive IDUs.

Setting and organization of care for persons living with HIV/AIDS

BACKGROUND

Treating the world's 40.3 million persons currently infected with HIV/AIDS is an international responsibility that involves unprecedented organizational challenges. Key issues include whether care should be concentrated or decentralized, what type and mix of health workers are needed, and which interventions and mix of programs are best. High volume centres, case management and multi-disciplinary care have been shown to be effective for some chronic illnesses. Application of these findings to HIV/AIDS is less well understood.

OBJECTIVES

Our objective was to evaluate the association between the setting and organization of care and outcomes for people living with HIV/AIDS.

SEARCH STRATEGY

Computerized searches from January 1, 1980 to December 31, 2002 of MEDLINE, EMBASE, Dissertation Abstracts International (DAI), CINAHL, HealthStar, PsychInfo, PsychLit, Social Sciences Abstracts, and Sociological Abstracts as well as searches of meeting abstracts and relevant journals and bibliographies in articles that met inclusion criteria. Searches included articles published in English and other languages.

SELECTION CRITERIA

Articles were considered for inclusion if they were observational or experimental studies with contemporaneous comparison groups of adults and/or children currently infected with HIV/AIDS that examined the impact of the setting and/or organization of care on outcomes of mortality, opportunistic infections, use of HAART and prophylaxis, quality of life, health care utilization, and costs for patient with HIV/AIDS.

DATA COLLECTION AND ANALYSIS

Two authors independently screened abstracts to determine relevance. Full paper copies were reviewed against the inclusion criteria. The findings were extracted by both authors and compared. The 28 studies that met inclusion criteria were too disparate with respect to populations, interventions and outcomes to warrant meta-analysis.

MAIN RESULTS

Twenty-eight studies were included involving 39,776 study subjects. The studies indicated that case management strategies and higher hospital and ward volume of HIV-positive patients were associated with decreased mortality. Case management was also associated with increased receipt of ARVs. The results for multidisciplinary teams or multi-faceted treatment varied. None of the studies examined quality of life or immunological or virological outcomes. Healthcare utilization outcomes were mixed.

AUTHORS' CONCLUSIONS

Certain settings of care (i.e. high volume of HIV positive patients) and models of care (i.e. case management) may improve patient mortality and other outcomes. More detailed descriptions of care models, consistent definition of terms, and studies on innovative models suitable for developing countries are needed. There is not yet enough evidence to guide policy and clinical care in this area.

Reframing "prevention with positives": incorporating counseling techniques that improve the health of HIV-positive patients

Federal HIV prevention strategy seeks to increase efforts by health care providers to identify and reduce their HIV-positive patients' transmission-related behaviors. Implementation of these recommendations will be hindered if providers perceive these efforts have the potential to harm their relationships with patients. Because transmission-related behaviors (unsafe sex and sharing needles) and the related issues of drug and alcohol use also jeopardize the health of HIV-positive patients, providers can use patient-centered counseling when addressing those behaviors. We suggest efforts to increase provider-delivered transmission-prevention counseling be reframed so that "prevention with positives" includes the goal of protecting HIV-positive patients' health. We review the specific consequences of these risky behaviors on HIV-positive patients' health and review brief counseling strategies appropriate for HIV care providers.

Differences between infectious diseases-certified physicians and general medicine-certified physicians in the level of comfort with providing primary care to patients

BACKGROUND

Human immunodeficiency virus (HIV)-related mortality has decreased because of highly active antiretroviral therapy. As the life expectancy of HIV-infected patients has increased, the management of comorbid disease in such patients has become a more important concern. We examined the level of comfort self-reported by experts in HIV medicine with prescribing medications to HIV-infected patients for hyperlipidemia, diabetes, hypertension, and depression.

METHODS

As part of a larger project (the Veterans Aging Cohort Study), physicians at infectious diseases (ID) clinics and physicians at general medical (GM) clinics were asked to complete a survey requesting information about demographic characteristics, training and certification received, and self-reported comfort with prescribing medications for patients with hyperlipidemia, diabetes, hypertension, and/or depression. Comfort was rated using a 5-point Likert scale, with scores of 4-5 classified as "comfortable."

RESULTS

Of 150 attending physicians surveyed, 51 (34%) were ID certified, 33 (22%) were GM certified but practicing at an ID clinic, and 66 were GM certified and practicing at a GM clinic. Comorbid conditions were common among HIV-infected patients treated at the ID clinics (22% of these patients had hyperlipidemia, 17% had diabetes, 40% had hypertension, and 27% had depression). However, comfort with treating these conditions was less among physicians at the ID clinic. For example, comfort treating patients with hyperlipidemia was greater for GM-certified physicians at GM clinics than for GM-certified physicians and ID-certified physicians at ID clinics (98% vs. 73% and 71%, respectively; P < .0001 for trend). A similar pattern was seen for treating patients with diabetes and hypertension (P < .0001). Comfort with treating patients with depression was generally lower, particularly among physicians at ID clinics (P < .0001).

CONCLUSIONS

We found that ID-certified physicians and GM-certified physicians at ID clinics reported less comfort prescribing medications for common comorbid conditions, compared with generalist physicians at GM clinics, despite a substantial prevalence of these conditions at the ID clinics. Methods are needed to increase physicians' level of comfort for prescribing treatment and/or to facilitate referral to other physicians for treatment.

Knowledge, attitudes, and practices among physicians on HIV/AIDS in Quang Ninh, Vietnam

Health care providers in Vietnam have been facing an increase in the number of HIV patients. However, little is known about physicians' knowledge, attitudes, and practices about HIV/AIDS and their correlates. A cross-sectional survey was conducted in 2003 with 151 physicians who had some contact with HIV-infected people. Anonymous data was collected by physicians' self-administration of the questionnaires. SAS version 8 (SAS, Cary, NC) was used for all descriptive and multivariate statistical analyses. We found that there were misconceptions on some transmission modes: 39.9% thought that good nutrition could protect from HIV/AIDS infection; 12.1% thought sharing the toilet with people living with HIV/AIDS (PLWHA) could transmit HIV infection. Only 41.6% of physicians knew that there was more than one type of HIV. Younger physicians or those with high patient volumes tended to be better informed. The one third of participants who reported positive attitudes regarding their interaction with HIV/AIDS patients were less likely to support mandatory testing or to exclude HIV/AIDS patients from their practices. Older physicians were more likely to have positive attitudes than the younger physicians. Approximately one fourth of the physicians prescribed antiretroviral medications but misuse was common. Among those prescribing antiretroviral medications, physicians working at provincial health care services were 3.1 times more likely to use antiretroviral medications than physicians working in district and commune health care services. In conclusion, even though Vietnamese physicians are providing health care for HIV/AIDS patients, the level of knowledge, attitudes, and practices regarding HIV/AIDS treatment suggest that further training is needed to improve their ability to deliver appropriate treatment to HIV/AIDS patients.

Training family practice residents in HIV care

Although family physicians are likely to encounter patients at risk for or diagnosed with HIV, they rarely are trained in prevention and treatment techniques. From 1997 to 2000, the University of Minnesota developed and evaluated a longitudinal curriculum to train family practice residents in the prevention and comanagement of HIV disease. Five residency programs participated. The core curriculum was based on 18 teaching modules incorporated into the standard 3-year residency program and covers topics in prevention, diagnosis, and treatment of HIV disease. Residents were encouraged to participate in elective rotations of HIV clinical care, service, and research, as well as attend a Sexual Attitude Reassessment Seminar. Baseline and postcurriculum attitude and knowledge surveys were performed and scores were compared before and after completion of the curriculum, as well as between the participants and a historical control group of residents who graduated in 1997. During the 3 academic years from 1997 to 2000, 214 residents participated in the study. Entering classes did not differ in baseline knowledge. Residents' knowledge about HIV disease, attitudes, confidence, and intention to treat HIV-positive patients improved (p < 0.01). The yearly number of HIV enzyme-linked immunosorbent assay (ELISA) tests performed at the residency sites increased from 1145 to 1665 by the project's end. The HIV Curriculum Project provides a useful model of an interdisciplinary program for training family medicine residents in HIV/AIDS. The evaluation data provide an assessment of the curriculum itself and an important look at family practice residents' knowledge, attitudes, and performance related to HIV over time.

Delivery of HIV prevention counseling by physicians at HIV medical care settings in 4 US cities

OBJECTIVES

We investigated physicians' delivery of HIV prevention counseling to newly diagnosed and established HIV-positive patients.

METHODS

A questionnaire was developed and mailed to 417 HIV physicians in 4 US cities.

RESULTS

Overall, rates of counseling on the part of physicians were low. Physicians reported counseling newly diagnosed patients more than established patients. Factors associated with increased counseling included having sufficient time with patients and familiarity with treatment guidelines. Physicians who perceived their patients to have mental health and substance abuse problems, who served more male patients, and who were infectious disease specialists were less likely to counsel patients.

CONCLUSIONS

Intervention strategies with physicians should be developed to overcome barriers to providing counseling to HIV-positive patients.

Hard-to-Reach Providers: Targeted HIV Education by the National AIDS Education and Training Centers

A national system of AIDS Education and Training Centers (AETCs) has received federal funding since 1987 to provide education to health care personnel (HCP) about HIV infection. The purpose of this study is to describe how AETC program personnel define and recognize HCP who are hard to reach and educate about HIV and to clarify the issues that make providers hard to reach. Twenty-three semistructured telephone interviews were used to collect data from AETC faculty and staff. Respondents were asked to identify the types of HCP who are hard to reach and to discuss why they are hard to reach. Themes identified to establish which HCP are hard to reach include specific professional groups (especially physicians and dentists) as well as providers who treated less than 10 HIV-infected clients and some HIV-expert clinicians. Themes identified to establish why they are hard to reach include convenience, isolation, and attitudes. Analysis posits that hard-to-reach HCP fall into identifiable categories: "already know the information," "don't know they don't know the information," "don't think they need to know the information," or "don't want to know the information." Respondents also identified innovative ways to approach hard-to-reach providers.

Effect of physician specialty on counseling practices and medical referral patterns among physicians caring for disadvantaged human immunodeficiency virus-infected populations

Data regarding the care and management of human immunodeficiency virus (HIV)-infected patients provided by infectious diseases (ID)-trained physicians, compared with data for care and management provided by other specialists, are limited. Here, we report results of a self-administered survey sent to 317 physicians (response rate, 76%) in 4 metropolitan areas of the United States who were identified as providing care to disadvantaged HIV-infected patients. ID-trained physicians who responded that they strongly agreed or somewhat agreed that they had enough time to care for their HIV-infected patients were more likely than were non-ID-trained physicians to provide therapy-adherence counseling. Physicians with >or=50 patients in care and ID-trained physicians were less likely to always discuss condom use and risk reduction for HIV transmission. Factors significantly associated with referring rather than treating HIV-infected patients with hypertension or diabetes included having <50 patients in care, being an ID-trained physician, and practicing in a private practice. These results suggest the need for targeted physician training on the importance of HIV transmission prevention counseling, increasing the duration of patient visits, and improving strategies for generalist-specialist comanagement of HIV-infected patients.