WASHINGTON — Efforts to make HIV screening an integral part of primary care have created a new set of educational, reimbursement, and workforce challenges for physicians.
In response, the Society of General Internal Medicine (SGIM) is gearing up to help primary care physicians incorporate routine HIV screening into their busy practices, Dr. James M. Sosman said at a meeting on HIV diagnosis and prevention and access to care.
In September, the Centers for Disease Control and Prevention issued recommendations for routine “opt-out” HIV screening of all patients aged 13–64 years. Health care providers should initiate screening unless the prevalence of undiagnosed HIV infection in their patients has been documented to be less than 0.1%. In the absence of such prevalence data, health care providers are advised to initiate voluntary HIV screening until they establish that the diagnostic yield is less than 1/1,000 patients screened, at which point screening is no longer warranted (MMWR 2006;55:RR-14).
Prevention counseling should not be required as part of HIV screening programs, according to the CDC. Although “strongly encouraged” for individuals at high risk for HIV, counseling does not have to be linked to the testing itself, the agency said.
The CDC guidelines have sparked concern that widespread HIV screening will overburden the U.S. health care system by identifying thousands of HIV-positive individuals who will require costly counseling and treatment services. An estimated 252,000–312,000 Americans are unaware that they are HIV-positive.
In anticipation of the guidelines, the SGIM obtained a 3-year grant from the CDC to develop an educational “train the trainer” program aimed at reducing barriers to early diagnosis of HIV infection and increasing patient access to preventive services in primary care settings, Dr. Sosman said at the meeting.
Clinician educators will be recruited from medical school and residency programs, and will then “serve as regional trainers, information resources, and role models for other primary care physicians,” said Dr. Sosman, medical director of the Midwest AIDS Training and Education Center, Madison, Wis. Future training sessions and presentations will include collaborations with groups not directly linked with the SGIM, including local and state medical societies, Area Health Education Centers, and other organizations.
The first half of 2007 will be devoted to information gathering. Focus groups and surveys of SGIM members will be used to ascertain current practices and identify potential barriers to implementation of the CDC guidelines. The information will be used to develop educational materials, such as slide sets, case studies, training scripts, and provider tool kits. The sessions themselves are expected to begin around the country in the latter part of the year. They will not be limited to members of SGIM or specifically to internists, said Dr. Sosman, also with the department of general internal medicine at the University of Wisconsin, Madison.
In a separate presentation at the meeting, Dr. Harvey J. Makadon of the department of medicine at Harvard Medical School, Boston, outlined potential operational challenges to incorporation of routine HIV screening in primary care settings. An informal survey among internists at his hospital revealed “a general sense that routine testing will improve current practices,” but respondents had many questions and concerns, particularly with regard to reimbursement for counseling and the process of counseling itself.
“A lot of doctors have something that they usually say [when counseling patients], and there have been articles written on the topic, but there's no formal curriculum. We're not really taught what to talk about with patients regarding HIV prevention,” Dr. Makadon remarked. “What are the best practices?”
There may be potential legal problems as well. In many states, existing laws regarding informed consent for HIV screening appear to conflict with the CDC “opt-out” guidelines, and these laws would likely need to be amended in order for the guidelines to be implemented. Until that happens, the laws supersede public health guidelines, Dr. Sosman noted.
And then there's the question of what to do with patients identified as HIV-positive, particularly those who are still healthy and asymptomatic. The number of HIV specialists in the country has remained static since the epidemic began 20 years ago, according to another speaker at the conference, Dr. M. Keith Rawlings.
“Where will the newly diagnosed patients get their medical care? I don't foresee the ability of most practitioners to absorb 25%–50% more [HIV-positive] individuals. Available resources in the community will have to be identified,” said Dr. Rawlings, medical director of the AIDS Arms Peabody Health Center, Dallas, speaking on behalf of the National Medical Association.
Dr. Sosman noted that a “team approach” to HIV/AIDS care could be implemented in primary care settings, similar to that currently used for patients with diabetes or for smoking cessation. “It works, but it's expensive,” he remarked.