PREVALENCE AND DETECTION OF HIV RISK BEHAVIOR IN PRIMARY-CARE - IMPLICATIONS FOR CLINICAL PREVENTIVE SERVICES

Despite their potential to reduce the incidence of HIV infection through primary prevention, family physicians report low levels of routine identification of patients at risk and counseling. This may reflect perceptions that few of their patients are at risk, that patients at risk will self-disclose during consultations, or that a physician-initiated approach is unacceptable to patients presenting for non-HIV-related problems. Our aim was to determine the prevalence of risk factors for HIV infection and HIV testing among patients in general practice, the acceptability to patients of opportunistic identification of risk during routine consultations and the accuracy of general practitioners' assessment of HIV risk. Our setting included randomly selected general practitioners' surgeries in metropolitan Sydney, Australia. We conducted a self-administered survey about risk factors in a consecutive sample of patients 18-50 years of age and compared it to a checklist about patient's risk factors completed by general practitioners unaware of the patients' answers. Of 1,030 patients, 43 (4%) were at risk of HIV infection having received blood transfusions between 1980 and 1985 and seven (1%) had injected intravenous drugs in the previous 12 months. In the previous 12 months, 133 (21%) female and 110 (28%) male patients had been in nonmutually monogamous heterosexual relationships. Only 26% always used condoms. While the majority of patients indicated they were heterosexual, 42 (4%) were homosexual and 23 (2%) bisexual. Of those men who had had sex with other men, 39% always used condoms. Of all patients, 303 (29%) had had a previous HIV test: 2 (< 1%) tests were positive although 10 (3%) of those who had been tested did not know their results. Questions about specific HIV risk factors were acceptable although 12% would mind if their doctor asked about number of sexual partners. Using 1,021 matching checklists, we found that the specificity of physicians' judgment of sexual preference was high but sensitivity was poor. Physicians detected 38% at most of those at risk. The prevalence of risk factors for HIV infection is not insubstantial. Physicians do not judge HIV risk accurately. Their detection of risk needs to be reconsidered in the light of these findings. A physician-initiated approach to risk assessment appears acceptable to patients although some questions were less acceptable than others. We recommend a rigorous trial of risk detection and counseling in family practice to evaluate its cost-effectiveness in changing risk behavior and to monitor any potential for negative impact on patient satisfaction.