SEXUALLY TRANSMITTED INFECTIONS (STIs), including HIV, have major health consequences among patients and populations.1–3 In the United States, it is estimated that over 1 million individuals have HIV, and an estimated 40,000 new infections occur every year.1 An estimated 19 million new cases of sexually transmitted diseases (STDs) occur each year,2 with about half occurring in youth aged 15 to 24.4 STDs and HIV cause important morbidity, mortality, and have many costs, both economic and human.3,5,6 Primary and secondary prevention are both strategies to control the spread of HIV and other STDs. Prevention efforts can effectively reduce incidence, transmission, and complications of STDs and HIV,3,7,8 and STD and HIV prevention have been shown to be cost-effective and necessary.9,10 Primary prevention focuses on risk assessment to identify behaviors that put patients at increased risk of infection, and prevention counseling to help patients change their behavior and reduce their risks. Secondary prevention includes testing for screening, diagnosis, and case finding, to aid in early treatment and in reducing transmission to others.
Clinicians are in a unique position to offer these preventive services to patients. It has long been known that patients view physicians as trusted sources of health information,11 but physicians have low rates of providing these services.12 Given the scope of the problem and the effectiveness of preventive measures, it is important to determine factors affecting these measures, and to identify and minimize any missed opportunities for prevention of STDs and HIV in clinical practice.13–16
Opportunities for STD and HIV prevention exist in primary care (PC), where most people get most of their health care, including clinical preventive services.17 A large majority of STI prevention, diagnosis, and treatment occurs in PC settings.18–21 The PC clinician is in a key position to affect patient behavior through effective risk assessment and prevention counseling. Research shows that clinicians can effectively encourage patients to reduce their sexual risk behavior.22–25
Recent trends show that HIV and other STIs are increasing in the general population, including in individuals without traditionally recognized risk factors.26 A patient does not need to be in a traditional risk group (e.g., men who have sex with men, injecting drug users) to be at risk of major illness. Unfortunately, most of our information on STD/HIV risk status and prevention practices comes from STD clinics and other settings where patients are often assumed to be at high risk.27
Testing is also important in the PC control of STDs and HIV and can aid in reducing high-risk behaviors.28 New CDC guidelines recommend that clinicians initiate HIV testing in all patients, regardless of risk factors for STI/HIV.29 Thus, the full array of HIV prevention services a clinician may offer include risk assessment, prevention counseling, and offering testing to patients in PC clinical settings. Research shows that it is possible to change providers’ behavior in managed care settings to increase risk assessment and discussions regarding STD or HIV risk among patients,30,31 but we know little about how risk is identified and reduced in typical PC settings. No studies have examined how PC clinicians deliver these services to patients within the context of a typical PC practice, and what these services may consist of among patients coming in for regular health maintenance examinations.
To address these needs, we conducted a comprehensive study, including both qualitative and quantitative methods, to describe the current practices of PC clinicians in the 3 key clinical activities: risk assessment, prevention counseling, and testing.32 We sought to document the variety, prevalence, and patterns of current practices among a representative sample of PC clinicians in Washington State. We also sought to study the associated characteristics of clinicians, practice settings, and patient populations. This information can help us understand and influence clinician behaviors, and thereby improve their practices in prevention of STDs and HIV.
We used formal qualitative methods to identify the variety of approaches PC clinicians use in these 3 STD/HIV control activities. Using these findings, we constructed a quantitative questionnaire and surveyed the population of PC clinicians in Washington State. The study was approved by the Battelle Institutional Review Board and other IRBs relevant to the participating clinicians.
We conducted an initial series of open-ended, qualitative, in-depth interviews to understand the variety of approaches to STD/HIV prevention practices in PC. One goal of these wide-ranging interviews was to elicit from clinicians information about their approaches to providing their patients with 3 services: 1) Assessing risk for STD/HIV by asking specific questions about sexual behavior, 2) STD/HIV prevention counseling, and 3) Offering STD and HIV testing. In developing the interview guide, we consulted with regionally recognized experts of each of the 5 clinician types. Discussion began by asking clinicians to describe their approach to adult health maintenance exam (HME) patient visits and progressed to asking whether, how, and under what circumstances they provide each of the 3 key STD/HIV control services.33 [Using the Integrated Behavioral Model,34 as a framework, we also asked clinicians about their related beliefs, attitudes, perceived facilitators and barriers, and their beliefs about patient attitudes, but we will address these factors in separate reports.]
We conducted these interviews with 64 PC clinicians in Washington, randomly selected from each clinician type [13 family physicians (FP), 12 internists (IM), 12 obstetrician–gynecologists (OB), 17 nurse practitioners (NP), and 10 certified nurse midwives (CNM)]. For geographic balance, we selected 3 quarters from King County (mostly urban on the western side of the state) and 1 quarter in Yakima County (mostly rural on the eastern side).
We audiotape recorded all interviews and transcribed them verbatim. Using the qualitative analysis program NUD*IST version 4 (from QSR International), we coded meaningful comments and conducted content analysis to sort them into thematic lists of the strategies clinicians use for each of the 3 control services. As the themes emerged from the interview data, the multidisciplinary research team and the clinician experts, reviewed, discussed, and refined the lists in an iterative process. This analysis produced lists of: (a) 14 risk assessment strategies, (b) 12 prevention counseling strategies, and (c) 13 STD/HIV test offering strategies.
Using these qualitative data, we designed a quantitative questionnaire, which presented all strategies identified for each service. It asked the clinician to rate how often during HMEs with established adult patients he or she uses each of the strategies, on a 5-point scale: Never, Sometimes, Half the Time, Usually, or Always. The questionnaire instructed clinicians to focus on their practices in: (a) asking patients specific questions about their sexual history and behavioral risk for acquiring STDs including HIV, (b) providing advice and counseling about prevention of STD and HIV, and (c) offering STD and HIV testing to patients. It also collected data on characteristics of the clinicians, their practices and patients, and their STD/HIV diagnosis and screening practices.
Sampling frames for the clinician survey represented physicians and nurses. For physicians (FPs, IMs, and OBs), we used the American Medical Association (AMA) Physician Master File, the most comprehensive listing of physicians in the United States. It includes both members and nonmembers of the AMA, and includes information on specialty and clinical practice. We included physicians if they practiced in Washington State, reported that they spent the majority of their professional time in direct patient care, and listed a primary specialty of family or general practice (FP), obstetrics and gynecology (OB), or internal medicine (IM). Internal medicine physicians were included only if they listed no secondary specialty, to ensure that they practiced general internal medicine rather than a subspecialty. The sampling frame of eligible physicians consisted of 1800 FPs, 471 OBs, and 662 IMs.
For nurses (NPs and CNMs), we used the Washington State licensure list. Because this list does not provide any information on clinical practice, we included all nurses who listed a specialty of Adult or Family NP or CNM. The sampling frame of nurses included 987 NPs and 276 CNMs.
We drew a stratified random sample of 200 subjects from each of the 5 clinician types. To each of these 1000 clinicians, we sent an advance letter to introduce the survey and request a response on a prepaid postcard if the clinician was no longer providing PC. The advance letter helped identify any clinicians who were ineligible, had moved out of Washington State, or had an invalid address. After excluding 74 clinicians due to ineligibility (26), undeliverable or out-of-state address (45), or request to be excluded (3), we sent survey packets to 926 clinicians by FedEx, with a cover letter explaining the purpose of the study and $50 in cash. A postcard reminder went out to all clinicians about 10 days after the initial survey mailing. To nonresponders, we sent by FedEx a second survey at 3 weeks and a third survey at 5 weeks after the initial mailing. All survey collection was completed by June 2000.
To examine the clinician and practice characteristics associated with risk assessment, prevention counseling, and test offering, we present both bivariate- and multivariate-adjusted results. We conducted these analyses in 4 steps. First, we reported mean and percent distributions of clinician and practice characteristics across the 5 clinician types (Table 1). Second, we examined differences in percent distributions across clinician types in the strategies used to provide key STD/HIV control services: risk assessment, prevention counseling, and test offering (Tables 2, 4, and 6). In these first 2 steps, significance testing for overall between group differences was conducted with Pearson chi-square for percentages and ANOVA for means. Significant differences between clinician types were determined by 95% confidence intervals.
In the third step, we conducted bivariate logistic regression to determine the unadjusted association of clinician and practice characteristics with the reported use of 3 STD/HIV control services (Tables 3, 5, 7, and 8). Fourth, we applied forward stepwise logistic regression to determine which characteristics were most closely associated with the report of control services. Each clinician and practice characteristic that was significant at P < 0.05 in the bivariate logistic regression was eligible for entry into the multivariate stepwise procedure. Stepwise inclusion into the multivariate model was stopped when there were no additional variables, which had a significant association of P < 0.05. Odds-ratios, 95% confidence intervals, and P-value estimates are presented for logistic regression models.
Because the probability of selection for the survey varied across the clinician types, we calculated sample weights (the inverse of the probability of selection, based on the number of clinicians selected and the total number in the sampling frame for that clinician type). To adjust for sampling weights in the stratified sample design, analyses that combined clinician types were conducted using the survey modules in Stata Version 9.35
Of the 1000 clinicians sampled, 710 clinicians responded, 45 were ineligible (moved, deceased, or no longer in practice), 73 surveys were undeliverable, and 172 refused or did not respond. After adjusting for ineligible clinicians and undeliverable surveys, the overall response rate was 80%. Adjusted response rates varied by clinician type, with the highest for nurse practitioners (89%) and certified nurse midwives (84%), and lowest for obstetrician–gynecologists (72%). Of the 710 respondents, 519 indicated that they provide HMEs and completed the survey section that assessed their STD/HIV control practices. All results are based on these 519 clinicians (113 NP, 95 CNM, 92 OB, 107 IM, 112 FP).
We describe the survey respondents and their practice settings, by clinician type, in Table 1. More NPs and CNMs are women. More NPs had practiced less than 10 years. More OBs, CNMs, and FPs provide prenatal care than IMs and NPs. More NPs than OBs, IMs, and FPs worked in public clinics. There were no major differences in geographic location of practices.
Patient mix differed among clinician types, with NPs, CNMs and OBs seeing more females and more patients aged 13 to 40 years. Across all clinician types, about 26% of patients were nonwhite. CNMs see more patients with public-subsidized insurance. CNMs and OBs saw greater percentages of patients for HMEs.
IMs and FPs generally report more experience with HIV than the other clinician types. However, as many NPs as FPs report making new diagnoses of HIV within the last 2 years. IMs (56%) are least likely to have seen a case of STD in the past year. Many OBs (73%), CNMs (76%), and NPs (61%) report having never seen a new case of HIV.
All clinician types reported receiving training on STD risk assessment (95%) and prevention counseling (91%), though the percents were slightly lower for IMs. Nurses were more likely to have received this training in school and physicians later in their careers.
In the qualitative phase of the study, we identified the variety of approaches PC clinicians used to assess risk of STD and HIV infection. The clinical actions and the words to describe them came directly from the clinicians. In this survey, we presented each activity to the clinician and asked: How often do “you take each approach when you see established patients for health maintenance exams?” Table 2 summarizes the percent of clinicians by clinician type who reported they use each strategy usually or always. Clinicians may use multiple approaches, and different approaches with different patients.
Most PC clinicians ask about risks when patients request contraception (87%). Most ask specific HIV risk questions with patients who have a history or current case of other STDs (83%). Many clinicians of all types select the patients in whom they do a formal risk assessment. Many ask only those patients in recognized high risk groups (63%). Many rely on some combination of clinical clues apparent at the visit (51%), their background knowledge about the patient (36%), and their own clinical intuition (23%). Some clinicians (24%), most commonly IMs, use a passive approach, waiting for the patient to raise concerns. Another common approach is to use a written (38%) or verbal (26%) intake form to identify patients for further risk assessment.
Practices for risk assessment differed among the types of clinicians. In general, IMs are least likely to use active strategies (e.g., strategies 6, 7, 11, 12, 14) to elicit concerns and identify risks. FPs and OBs are intermediate in their use of active strategies. Both NPs and CNMs are most likely to routinely ask patients specific questions to identify risks.
We considered clinicians to be universal risk assessors if they reported that they usually or always follow either of 2 universal approaches (Table 2). Approach A, “Regardless of apparent risk, I ask specific questions to see if the patient engages in behaviors that put him or her at increased risk” (strategy 6), was reported by 34% of all clinicians. Approach B, “I ask questions about sexual and behavioral risk as a routine part of the patient history” (strategy 7), was reported by 53% of all clinicians. Other strategies that involve the use of screening questions (strategies 11, 12, 13) were not considered universal approaches because they do not necessarily lead to risk assessment with all patients regardless of apparent risk. Among all clinicians, 56% were classified as Universal Risk Assessors, by either approach A or B. This proportion ranged from 80% for CNMs to 39% for IMs. CNMs are significantly more likely than all 3 physician types to be Universal Risk Assessors, followed by NPs, OBs, FPs, and IMs.
We used multivariate analyses to investigate the associations between universal risk assessors and clinician characteristics (Table 3). Bivariate logistic regression found significantly higher odds of being a universal risk assessor were associated with: being a nurse (CNM or NP); female gender; practice less than 10 years; having diagnosed at least 1 STD in the past year (but not HIV); training in STD/HIV risk assessment during school; training in STD/HIV prevention counseling during school or in postgraduate training and continuing education; percent of patient visits devoted to HMEs; and proportions of patients who are female, on public insurance, and young. Multivariate logistic regression with all significant variables found independent associations for only 3 characteristics: being a CNM (OR: 3.14), practicing less than 10 years (OR: 2.34), and having had continuing education in STD/HIV prevention counseling (OR: 2.56).
We identified the strategies PC clinicians use to provide counseling about STD and HIV prevention, using the same qualitative methods. We presented each strategy to the clinician and asked: How often do “you take each of the following STD/HIV prevention counseling actions when you see established patients for HMEs?” Table 4 summarizes the percent of clinicians by clinician type, who reported they use each strategy usually or always,
Most clinicians provide prevention counseling to patients with STD symptoms (95%), and those requesting contraception (82%). Most also provide counseling to patients they identified as at increased risk, based on clinical cues, demographics, or questions about sexual practices (77%). Sixty-nine percent of clinicians have brochures available for patient education on risks, but only 9% give them routinely to all patients. Sixteen percent give a standard verbal “speech” to all patients. The routine practice of counseling all patients regardless of apparent risk was reported by 44% of all clinicians. Nurses, both CNMs and NPs, are significantly more likely to counsel all patients than all 3 types of physicians.
We considered clinicians to be universal counselors if they reported either of 2 approaches (Table 4). Approach A represents clinicians who reported they usually or always use strategy 7c: “Regardless of apparent risk, I do personalized, interactive prevention counseling with all patients.” Approach B required meeting both of 2 standards, B1 and B2. Standard B1 required classification as a universal risk assessor by the criteria described above and listed in Table 2. Standard B2 required a clinician to report usually or always using strategy 8c: “Once I have identified patients at increased risk, I do personalized, interactive prevention counseling with them.” Other approaches that link prevention counseling with clinical services that are not always provided (e.g., strategies 3 and 4) were not considered universal approaches. Approach A was reported by 44% and Approach B by 48% of all clinicians. Overall, 60% of clinicians were classified as universal counselors, highest in CNMs (85%) followed by NPs, OBs, and FPs, and lowest in IMs (48%). CNMs and, to a lesser extent, NPs were more likely to be universal counselors than were physicians of all types.
We used multivariate analyses to investigate the associations between universal counseling and clinician characteristics (Table 5). Bivariate logistic regression found significantly higher odds of being a universal counselor were associated with: being a nurse (CNM or NP); female gender; practice less than 10 years; practicing in a public clinic; having diagnosed at least 1 STD in the past year (but not HIV); training in STD/HIV prevention counseling during school or continuing education; percent of patient visits devoted to HMEs; and proportions of patients who are female, on public insurance, and young. Clinicians whose most recent diagnosis of HIV was more than 2 years ago had significantly lower odds of being a universal counselor. Multivariate logistic regression with all significant variables documented independent associations for 5 characteristics: being a CNM (OR: 2.94), being an NP (OR: 2.52), practicing in a public clinic (OR: 2.36), having diagnosed at least 1 STD in the past year (1.97), and percent of female patients (OR: 1.02).
STD and HIV Test Offering
We asked clinicians: How often do “you take each of the following STD/HIV testing actions when you see established patients for health maintenance exams?” The options were drawn from the qualitative study and represent the variety of approaches used in PC practice. Table 6 summarizes testing practices by clinician type.
Almost all clinicians offer STD testing to patients with STD signs or symptoms (91%), or concerns about sexual practices (96%). We considered clinicians to be universal STD test offerers (30%) if they reported they usually or always use strategy 11: “Regardless of apparent risk, I routinely offer STD testing to patients, as it eliminates the need to make assumptions about individuals.” The proportion of universal STD test offerers was significantly highest in CNMs (74%) and lowest in IMs (12%), with nurses generally higher than physicians.
Almost all clinicians offer HIV testing to patients who report partners positive for STDs/HIV (98%), express concerns about sexual practices (96%), have suspicious opportunistic infections (94%), or test positive for other STDs (89%). We considered clinicians to be universal HIV test offerers (19%) if they reported they usually or always use strategy 12: “Regardless of apparent risk, I routinely offer HIV testing to patients, as it eliminates the need to make assumptions about individuals”. The proportion of universal HIV test offerers was significantly highest in CNMs (55%) and lowest in IMs (8%).
Generally, more clinicians of all types report that they offer STD and HIV testing selectively rather than universally. Most commonly, they select patients for testing based on high-risk groups (62%), clinical cues (63%), and sexual behaviors (53%).
Results of multivariate analyses for universal STD test offering (Table 7) show that strategy is associated with multiple characteristics of clinicians, their patients, and practices. Multiple logistic regression, using forward stepwise entry of all of the significant variables, demonstrated that odds of being a universal STD test offerer were higher for CNMs (OR: 10.24), those in practice less than 10 years (OR: 1.84), and those seeing larger percentages of nonwhite patients (OR: 1.02 for each 1% increase). Results of similar multivariate analyses to identify characteristics associated with universal HIV test offering showed generally similar patterns (Table 8). Multiple logistic regression shows again that the odds of being a universal HIV test offerer were higher for CNMs (OR: 6.77) and those in practice less than 10 years (OR: 2.25).
This is the largest published description of these STD/HIV control services among PC clinicians. Our statistical sample is likely to represent practice among these clinician types in Washington State in 2000, but may not accurately represent other regions or evolving practice patterns.
Despite the relatively high survey response rate of 80%, response bias is a possible limitation. We compared respondents to nonrespondents but found no significant differences between the groups on characteristics available in the sampling databases, including sex, region of the state, community size, and years since graduation from professional school.
These data are limited by reliance upon self-report. Furthermore, different clinician types may feel different degrees of social acceptability bias in reporting their professional practices. The goal of these services is to reduce risky behaviors and ultimately rates of infection in patients and partners, but this study was not designed to measure patient-oriented or public health outcomes.
No single approach is best for every patient. The data in Tables 2, 4, and 6 document the variety of clinical strategies these PC clinicians report they take in their practices at the time of HMEs with established patients. In our mixed-methods study design, the items presented to the survey subjects resulted from formal qualitative analysis. The options were not designed to be exhaustive and mutually exclusive. They represent the ways clinicians provide this care to their patients in their own words. We selected the criteria for universal practices after review of the clinical strategies that led most reliably to provision of the service to all patients, regardless of apparent risk. We repeated analyses with alternative definitions of universal practices and found little change in the results.
Our study used formal qualitative methods to understand and design measures of actual practice. As a result, the format of our survey items does not allow direct comparison of these data with clinical practice guidelines. However, it is clear from these findings that many PC clinicians do not follow guidelines published by public health authorities that recommend universal questioning and counseling of all patients regardless of probable risk for STD/HIV.15,36–38 The majority of PC clinicians do assess risk, counsel patients, and offer testing to patients who seem to them to be at high risk for STD/HIV. These current practices undoubtedly miss opportunities to detect and reduce risks. However, it may be that these practices actually identify appropriate patients for whom counseling is provided in a way that has a positive impact on personal and public health. How well these clinicians are able to make these judgments to select patients for targeted counseling is an important empirical question that deserves further study.
Our research focused primarily on PC services for primary prevention of STD/HIV. The new CDC guidelines on HIV testing recommend clinicians initiate testing in patients regardless of risk factors, thus emphasizing secondary prevention and case finding.29 Our finding of 19% universal HIV test offerers during HME indicates that the recommendation to test all patients is far from current practice. Although many PC clinicians offer HIV tests, fewer do so universally.
As a general pattern of practice, nurses were more likely than physicians to be routine in their provision of all 3 services to all patients. Many CNMs and NPs work in clinical settings where more of the care they provide is organized around clinical protocols, e.g., health maintenance examination (particularly female HMEs) and prenatal care. OBs and FPs tend to spend more of their time providing this type of care than do IMs, who were least likely to provide the STD/HIV control services routinely. The way to deliver services routinely may be to make them part of a protocol, and this may be done more effectively by nurses than physicians. However, the key factor may be something more than just the proportion of a clinician’s patient encounters spent in routine preventive care. Nurses may see their professional role more intimately linked to preventive services than do IMs and, to a lesser degree, other physicians. These are questions that further studies could investigate to better understand the specialty differences we observed. Such understanding about specialty differences, particularly between nurses and physicians, may help determine intervention strategies to increase provision of these preventive services.
Because HIV is moving from risk groups into the general population,29 universal risk assessment, prevention counseling, and HIV test offering are becoming more important. Interventions are clearly needed to increase provision of these preventive services. Efforts to improve STD/HIV prevention services may be aimed at clinicians, delivery systems, or communities. Our findings suggest that different approaches might be most effective depending upon the type of clinicians. Nurses differ from physicians, even when they practice as PC clinicians. Health maintenance care, women’s health care, and illness care might all present opportunities for improvement, but each will likely require a tailored strategy for change.
The design of effective interventions will require understanding the factors that motivate or hinder provision of these services. These include clinician beliefs and attitudes toward providing each services as well as environmental facilitators and barriers.34 Clinician motivation may be affected by beliefs about whether PC clinicians can impact STD/HIV incidence. An important belief about adoption of universal STD/HIV control services may be clinicians’ concern that their efforts are not likely to produce the desired result. Many physicians in our qualitative interviews voiced the opinion that patients are unlikely to change behavior, even if the clinician did identify risks and offer counseling. This was also voiced as a negative belief in Dodge and colleagues’ managed care intervention to increase risk assessment and prevention counseling among PC clinicians.30 Many other beliefs are likely to be important in determining a clinician’s motivation to provide these services, including beliefs about time constraints and patient response. A systematic identification of the most important beliefs affecting provision of STD/HIV preventive services, including differences between specialties, will be critical to developing effective interventions.
Practice environmental factors impose important facilitators and barriers to provision of preventive services. In the setting of PC, where the task is comprehensive health care of patients as individuals, the clinician must prioritize the full complement of risks, services and net benefits. Clinical judgment is an important tool in striking this balance. STD/HIV control services, just as with all preventive services and other care, must be delivered in an environment of competing demands.39 Thus, minutes spent on routine STD questions are not available for smoking cessation, immunization education, domestic violence screening, or other preventive services. Routine use of patient intake questionnaires with specific behavioral risk questions that require less clinician time may help optimize the delivery of clinical services.30,40,41 Currently, our research shows that not many PC clinicians use such instruments (38%). Similarly, routine use of patient education materials might reduce the need for clinician–patient counseling, but routine distribution of such material is not common (9%).
If competing demands can interfere with delivery of preventive services, it might follow that those clinicians who provide STD/HIV control services selectively rather than universally might be those with a broader scope of practice and more responsibility for illness care. IMs may provide more illness care and have less time for preventive services than the other specialties in our survey. IMs had the most experience with care of HIV patients, an indicator of providing more illness care. This may partially explain why IMs were least likely to be universal risk assessors or counselors.
Further research to identify the beliefs underlying clinician motivation to provide risk assessment, prevention counseling and HIV/STD testing, and to identify practice environmental facilitators and barriers to these services will provide important information to inform interventions to increase their provision. Specialty differences may provide critical information to tailor the intervention strategies to different specialty groups and practice settings. Our findings suggest approaches to delivering interventions to increase PC STD/HIV prevention behaviors. For example, continuing education might be most fruitfully provided to clinicians who have been in practice longer than 10 years, because years in practice predicted lower rates of risk assessment and prevention counseling, and recent training was associated with higher rates. Additional research findings about beliefs, attitudes, facilitators, and barriers are needed to determine the content and target messages for such training to be most effective.
PC is a complex endeavor and control of STD/HIV is an important challenge. These data are drawn from a large mixed-methods study of PC clinicians and their patients on STD/HIV prevention practices. Subsequent reports will examine clinician and patient experiences and attitudes regarding STD/HIV prevention, and how these are related to provision of these services among PC clinicians.
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