The STD – HIV Connection: Deficiencies in Knowledge and Practice Patterns among Family Physicians and Gynecologists

Previous studies have shown suboptimal compliance with the Centers for Disease Control and Prevention recommendations for HIV testing in patients with sexually-transmitted disease (STDs). However, the literature is especially sparse with respect to family physicians and gynecologists in private practice. Further, there are no data regarding knowledge among these physicians of the causative relationship between STDs and HIV. All family physicians (238) and gynecologists (131) in private practice in Broward County, Florida were anonymously surveyed for their knowledge of the connection between STDs and HIV and to determine if they translated this into practice. Responses from 57 family physicians and 21 gynecologists were analyzed. Overall, gynecologists showed a greater awareness of the STD-HIV connection (81% vs. 54%, P=0.03), but not in their frequency of testing for HIV. Among physicians in both groups who stated that they “always test” for HIV in patients with STDs, a strong correlation was found between awareness of the STD-HIV connection and testing for HIV (P<0.001). Physicians that only “sometimes test” showed a lesser degree of awareness of this connection and tested less frequently for HIV in patients with seven specific STDs. However, even physicians who claimed to “always test” did not consistently test for HIV with all of these seven STDs. This lack of consistency was especially true for family physicians. Many family physicians and gynecologists in private practice are unaware that STDs facilitate the transmission of HIV and/or do not translate this knowledge into practice. Florida Public Health Review, 2008; 5, 104-112. Introduction Despite great efforts to reduce the scourge of HIV/AIDS in the United States, approximately 40,000 persons become infected with HIV each year (Centers for Disease Control and Prevention [CDC], 1999). Similarly, non-HIV sexually transmitted diseases (hereafter simply referred to as STDs) remain a major public health problem with approximately 19 million new infections occurring each year (CDC, 2006a). Several studies have documented a high rate of co-infection of HIV and other STDs (Quinn et al., 1988; Wasserheit, 1992; Laga et al., 1993; Royce, Seña, Cates & Cohen, 1997; Brown et al., 2007). This is not solely due to the fact that patients with these two diseases engage in the same risky behaviors. Importantly, a direct causal relationship has been identified between STDs and HIV. Through multiple mechanisms, both ulcerative and non-ulcerative STDs can increase the risk of acquisition and transmission of HIV (Fleming & Wasserheit, 1999; LeGoff et al., 2007; Kaul et al., 2008; Levine et al., 1998; Lingappa & Celum, 2007). Information regarding this knowledge among primary care physicians in private practice is lacking. We could find no study that measured this knowledge. There is evidence of a deficiency in compliance with CDC recommendations regarding HIV testing in patients with other STDs. However, most of this research was conducted in emergency departments (CDC, 2001; Weinstock, Dale, Linley & Gwinn, 2002; Burke et al., 2007; Gift & Hogben, 2006; Fincher-Mergi et al., 2002; Wilson, Mitchell, Bradbury & Chavez, 1999; Seña et al., 2005; Montaño, Phillips, Kasprzyk & Greek, 2008). Only one study compared the attitudes and practices of family physicians with those of gynecologists with respect to HIV testing (Montaño et al., 2008). Since among primary care physicians, family physicians and gynecologists see the largest number of STD patients, it is critical that they be aware of the STDHIV connection and that they implement this knowledge by consistently testing STD patients for HIV. Because Broward County, Florida, with 761cases/100,000, has the second highest prevalence of HIV/AIDS in the state (Florida Department of Health [FDH], 2002), and also has very high prevalence rates of other STDs (FDH, 2008), it provides a fertile testing ground in which to assess physician awareness of the STD-HIV connection and the translation of that knowledge into practice. We selected family physicians and gynecologists for our survey because of the paucity of published information regarding their HIV testing knowledge and practice patterns and also because of the frequency with which these physicians see patients with STDs. We were especially interested in determining whether gynecologists, with their more focused training and more frequent contact with STD patients, would demonstrate a greater awareness of the biological connection between STDs and HIV and more consistently implement CDC recommendations for HIV testing. Methods Study Design A 10-question survey of STD practice patterns, approved by the Nova Southeastern University Institutional Review Board for Research with Human Subjects, was mailed or faxed to all 238 practicing family physicians and all 131 practicing gynecologists in Broward County, Florida. Three surveys were returned because of incorrect addresses (one family medicine, two gynecology). Sixty-three surveys were received from family physicians (response rate 26.4%) and 23 from gynecologists (response rate 16.8%). Surveys from six family physicians and one gynecologist were excluded because of incompleteness, leaving for analysis fiftyseven surveys from family physicians and twenty-one surveys from gynecologists. The questionnaires were answered anonymously and returned to the office of the Physician Assistant Program where any identifying information was removed by the department secretary before being given to the investigators for analysis. Statistical Analysis The likelihood ratio chi-squared test (SPSS, Version 15.0) was used to assess the difference between the two specialty groups on each of the characteristics of responding physicians’ practices (Table 1) and on the physicians’ beliefs and testing practices (Table 2). The same test assessed the difference between the ‘always testers’ and the ‘sometime testers’ on their practice of testing for HIV in cases of seven specific STDs. This was conducted both among family physicians (Figure 1) and among gynecologists (Figure 2). Figure 1. HIV Testing Rates for 7 STDs. Comparison of Family Physicians Who State They Always Test for HIV in Patients with STDs vs. Those Who State They Only Sometimes Test Family Physicians Always Test vs. Sometimes Test Groups