Racial/Ethnic Attitudes towards HIV Testing in the Primary Care Setting: DISCUSSION

RacialEthnic Attitudes towards HIV Testing in the Primary Care Setting DISCUSSION

The April 2003 guidelines for HIV testing from the CDC advocated routine offering of HIV tests in both inpatient and outpatient settings in order to increase the number of patients who are aware of their serostatus. The implementation of this recommendation in the primary care setting is difficult. It is cumbersome, especially in a time-restricted encounter, for a primary care provider to bring up a sensitive or embarrassing topic that could potentially lead to a prolonged discussion simply to screen for the “traditional” risk factors associated with HIV infection.

The current risk-based approach to HIV testing is fraught with hindrances due to the frequent inability of both healthcare providers and patients to talk openly about sensitive personal topics. Research has shown that many physicians feel uncomfortable asking sensitive risk histories, even among OB-GYN providers where sexual histories should be routine. Additionally, many patients feel uncomfortable with being asked questions about their sexual history. Ironically, when not asked, assessed or tested for their HIV risk behavior, many patients may reason that they must not be at risk for HIV if their physician did not offer testing to them. Two major reasons for patients not obtaining an HIV test are an unrealistic risk perception and fear of a positive test result. Eliminating some of the more unpleasant aspects of risk-based testing by offering routine testing, coupled with brief discussion, could present an opportunity to engage more patients. In addition, more frequent testing opportunities may allow a patient to become more aware of their personal risk for contracting the disease. female viagra online

Routine testing is a viable alternative to risk-based testing and has the potential to identify many people who are unaware of their HIV serostatus. Routine testing represents an equitable testing approach of all sexually active adults in order to increase detection of unknown HIV infections and to reduce AIDS.

The April 2003 HIV testing recommendations by the CDC and others have questioned the necessity of routine pretest counseling. However, brief pretest discussion should remain a necessary component of HIV testing in order to ensure that the patient is aware of HIV testing and what HIV testing entails. This discussion provides an opportunity for questions by the patient prior to testing and offers information and education on HIV prevention. This conversation should be tailored to the patient and the nature of the office visit and may be very brief in the routine encounter.

The results of our questionnaire suggest that patients are engaging in behaviors that could place them at risk for HIV infection, although they don’t consider themselves to be at “traditional” risk for HIV Only 14% percent of male respondents considered themselves to be at significant risk for HIV, although self-reported risk factors would have suggested that 62% were at high risk for HIV infection. A similar pattern was observed among the female respondents: only 5% reported high-risk behavior, but 53% were at increased risk by history of multiple heterosexual encounters. In this study, Latina and white females more accurately perceived their risk for HIV, while black females significantly underestimated their risk . buy viagra soft tabs

Patients in this sample, by self-report, received HIV testing at a higher rate than the national average. Nationally, 51.6% of blacks, 43.6% of whites and 39.5% of Latinos had consented to HIV testing, whereas we found that 71% of blacks, 86% of whites and 83% of Latinos in the current study were previously tested. It may be that our respondents falsely assumed that they had been HIV tested simply because they had some other laboratory testing. However, the high response rate at all three clinics makes selection bias unlikely. The providers at these community health centers may be more aggressive in HIV testing than their peers at either private offices or other health centers in areas outside of Providence.

Little is known about the potential impact of introducing routine testing into the primary care outpatient setting. Although many patients in our study reported that they are interested in routine testing for HIV disease, real and perceived barriers to its implementation exist. Doctors are not efficiently identifying those people infected with HIV. It is also very interesting that only the white and Hispanic women in this sample were tested because it was recommended by their provider. This racially discrepant offering of HIV tests may be associated with a fear of the provider of being perceived as a “racial profiler” or a desire to not alienate their African-American and black patients. There were no white males in the sample, which limits our ability to fully determine the extent of any racial and/or gender bias. cialis soft tabs online

Barriers and facilitators, both real and perceived, at the individual provider and at the systems level need to be identified in order to develop effective change. Logistically, the actual time requirement to implement routine testing should be less than that required for “risk-based” testing. It should be more efficient because the awkward exchange of initial unproductive, unsolicited probing into patients’ private social and personal lifestyles is eliminated. Routine testing would capture those patients who are too embarrassed to state that they have been or continue to engage in risky behavior.

Limitations of this study include the small sample size as well as the limited male data. The convenience design of the survey also limits generalizabili-ty. The racial composition was not representative of the general population; minorities were overrepre-sented. Internal validity was checked by asking different questions on the same concepts. Although patients could have provided socially acceptable answers, this was probably less likely in the setting of an anonymous self-administered survey. Specifically, the response to the questions addressing perceptions towards HIV testing was similar to the answers provided in other surveys. This study sought to determine both lifetime and recent (six-month) risk factors; however, other important factors, such as duration of the relationship and the possibility of infidelity, were not assessed and were determined to be beyond the scope of this study.

Some might argue that identification via routine testing of those who are HIV infected might overwhelm the primary and tertiary healthcare system. This is not a valid argument for a chronic progressive infection. Simply waiting until a patient shows clinical signs and symptoms of AIDS represents a lost opportunity for secondary and tertiary prevention of the affected patient and primary prevention of a partner. The financial efficacy of routine testing in the outpatient setting has been presented by Phillips and Fernyak. The costs saved by identifying HIV infection prior to development of opportunistic infections or prior to the development of symptoms are immeasurable not only financially but also personally and socially. Since the majority of patients with HIV are infected prior to the age of 50 and the fastest increasing mode of transmission is via the heterosexual route, routine testing could be age-restricted for practical reasons. The ages of 18 (or age of onset of sexual activity) through the age of 50 are reasonable ranges for initial implementation.
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Earlier detection of the virus that causes AIDS is the goal of routine testing. This allows for treatment decisions to be made in conjunction with the health provider and the patient. Routine testing for HIV is a reasonable option to identify more infections at a potentially earlier stage in a primary care setting. The respondents in this survey clearly indicated their desire to be tested routinely for HIV by their primary care providers. In addition to advocating further research, it is time to begin implementing this policy to improve the nation’s health.

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Tags: attitudes, HIV testing, minorities, primary care setting, risk factors

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