HIV pretest and posttest counseling: still missing from medical school curriculum.

I t has been almost 20 years since the first report about a disease that we now call AIDS (acquired immu-nodeficiency syndrome) was published in the Morbidity and Mortality Weekly Report. Shortly thereafter, se-rological testing to detect evidence of infection with human immunodeficiency virus (HIV) was developed, and guidelines were published for HIV counseling and testing. Today, the majority of HIV testing is performed in a broad range of medical care settings and not at publicly funded testing sites. 1 With the availability of more effective therapies, HIV testing has become even more important in preventive intervention. The major benefits of HIV testing are (1) the referral of HIV-seropositive persons for medical evaluation and treatment and other social services and (2) counseling to promote the necessary changes in behavior to reduce HIV transmission. Physicians play an essential role in this public health effort: as the principal providers of primary health care, the general public most frequently names them as the desired source for HIV testing. 2 Despite the accumulated information on the importance of HIV testing, the majority of recent medical school graduates have had no training on HIV pretest and post-test counseling. It is not surprising then that, as Freed-berg and Samet recently wrote, " a passive approach to HIV testing prevails in many clinical settings. " 3 In June 2000, we surveyed the incoming internal medicine interns (categorical, primary care, transitional, and preliminary programs) of Emory University about their experience with and knowledge of HIV testing. Among these 71 recent graduates from 41 medical schools, only 13% had received any formal training on HIV pretest and posttest counseling as part of their medical school curriculum. The majority of these trainings were brief, lasting only a couple of hours. Additionally, their clinical rotations did not prepare them with the necessary skills and experience. Only 24% had ever given a patient an HIV-positive result, with most having done so only once (range, 1-3 patients). While most responded that they felt comfortable discussing HIV and offering an HIV test to a patient , no one felt " completely comfortable " giving positive test results, and 37% felt uncomfortable doing so. Knowledge of HIV testing guidelines was also weak. In January 1993, the Centers for Disease Control and Prevention recommended that HIV testing should be offered to all hospitalized patients, aged 15 to 54 years, at hospitals with an HIV seroprevalence rate …