Ⓒ2020 The Japanese Society for AIDS Research

The Journal of AIDS Research

Note

Educational Program for General Physicians to Promote
Early Diagnosis and Initiation of Treatment of
Human Immunodeﬁciency Virus Infection
Hiromizu Takahashi1, Yoshiyuki Yokomaku2, Kunihisa Tsukada3,
Fumio Otsuka4, Hiroyuki Morita5 and Toshio Naito1
12

Department of General Medicine, Juntendo University Faculty of Medicine,
Department of Infectious Diseases and Immunology, Clinical Research Center, Nagoya Medical Center,
3
AIDS Clinical Center, National Center for Global Health and Medicine,
4
Department of General Medicine, Okayama University Graduate School of Medicine,
Dentistry and Pharmaceutical Sciences,5
Department of General Internal Medicine, Gifu University Graduate School of Medicine
Background : Early-stage human immunodeficiency virus (HIV) infection is often missed,
primarily because the symptoms are non-speciﬁc, and treatment is therefore delayed. To address
this, we developed an educational program for general physicians to better understand the likely
presentations and the importance of conﬁrming early-stage HIV infection.
Methods : Special sessions were organized twice at the Japanese Society of Hospital General
Medicine conference, where the attendees learned that HIV-infected patients frequently present
with non-speciﬁc symptoms similar to those caused by other types of infection, and therefore
physicians should not disregard the likelihood of HIV infection from the apparent presentations
to ensure early diagnostic confirmation. Session attendees were surveyed with a 6-item
questionnaire before and after each session.
Results : The session attendees reported being more confident and positive in diagnosing/treating early-stage HIV infection. There was also a decrease in the percentage of physicians
who think that HIV infections should be handled exclusively by specialist physicians.
Conclusion : Early diagnostic conﬁrmation of HIV infection is important for both physicians
and patients. This educational program can help physicians control the infection at its early stage.
Key words：human immunodeficiency virus, HIV awareness, general physicians
The Journal of AIDS Research 22 : 46⊖50, 2020

Introduction
Human immunodeﬁciency virus (HIV) infection causes
serious symptoms and may lead to death if untreated. It is
important that the diagnosis of infection be conﬁrmed andthat appropriate treatments be provided at an early stage
post-infection to prevent wide dissemination of the virus
through sexual contact of the infected person with noninfected individuals1, 2）. One of the problematic issues isthat the early-stage infection is frequently missed in thereal-world setting despite an increasing prevalence of HIV
infection in Japan, primarily because the prevalence in Japan
Correspondence：Toshio Naito, Department of General Medicine, Juntendo University Faculty of Medicine,2⊖1⊖2 Hongo, Bunkyo-ku, Tokyo 113⊖8421,
Japan
E-mail : naito@juntendo.ac.jp
Received February 18, 2019 ; Accepted September 27, 201946 （ 46 ）is still relatively low and the symptoms of infection are
non-speciﬁc, including fever, pharyngitis, lymphadenopathy,
rash, oral and/or genital ulcerations, and gastrointestinal
symptoms, which may not be considered related to possible
HIV infection by primary care physicians3, 4）. It is importantfor physicians to remember and not exclude the possibilityof HIV infection based on the patients＇ symptoms, which
are occasionally less distinguishable from those of certain
opportunistic infections. HIV infection is also frequently
overlooked in patients with syphilis, acute hepatitis B andherpes zoster. To address these issues, we planned an
educational program for general physicians to better
understand the likely presentations and the importance ofdiagnostic conﬁrmation of HIV infection at its early stage.
The preliminary results of this program are reported here.

Methods
Special sessions were organized twice at the conference

The Journal of AIDS Researchof the Japanese Society of Hospital General Medicine(March 2017 and September 2018), titled ＂General physicians learn more about HIV infection＂ and ＂General
physicians can judge HIV infection＂, where session
attendees learned that : (1) patients with acute HIV
infections usually present with non-specific symptoms(see Introduction) ; (2) patients with HIV infections
frequently have previous or concurrent syphilis, acutetype B hepatitis, herpes zoster, and other infections ; (3)acute hepatitis B may occur through sexual contact ; and(4) physicians should remember that apparently nonspeciﬁc presentations and the previous/concurrent episodes
mentioned above may indicate possible HIV infection.
The importance of HIV-RNA testing in highly suspectedcases with negative antigen/antibody results in patients at
an early stage of infection was also emphasized at thesessions.
The session attendees were surveyed with a questionnaire before and after each session, as summarized inTable 1. The questionnaire included questions about theimportance of early-stage HIV tests in patients withpresentations similar to those caused by other infections
and about attendees＇ mentality regarding HIV diagnosis
and treatment. The attendees replied to the questionnaire
using a self-response system (Turning Point Audience
Response SystemⓇ in combination with Response WareⓇ ;Keepad Japan, Osaka). They were further encouraged to
ask free questions at the end of the session.

Results
Figure 1 summarizes the survey results obtained fromthe two sessions. The ﬁrst session had 75 attendees, 50 ofwhom responded to at least 1 of the 6 questions listed inTable 1Vol. 22

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Table 1. To the first question (Q1), 24% answered Yes,
and 76% answered No. The session clearly improved the
HIV awareness of the attendees, i.e. the survey performed
before and after the session indicated an increase in thepercentage of attendees answering Yes to Q2⊖Q5 (6 to12%, 41 to 90%, 88 to 100%, and 67 to 83%, respectively)
and a decrease in the percentage of attendees answeringYes to Q6 (65 to 50%). The percentage answering No to
Q2⊖Q5 decreased, and that to Q6 increased in a concomitant manner.
The second session was performed a year and a halflater with 64 attendees, and all of them responded to atleast 1 of the 6 questions. Of the 35 attendees who
responded to Q1, 21 (60%) answered Yes, and 14 (40%)
answered No. Increased HIV awareness was demonstrated
again by the ＇before＇ vs. ＇after＇ survey comparison, withincreased percentages of Yes answers to Q2⊖Q5 (3 to23%, 35 to 90%, 67 to 95%, and 15 to 52%, respectively)
and a decreased percentage of Yes answers to Q6 (79 to43%), with a concomitant decrement of No answers to
Q2⊖Q5 and an increment of No answers to Q6.

Discussion
Antiretroviral therapies have greatly improved theprognosis of patients with HIV infections in the clinicalsetting. However, there are still a substantial number ofcases of infected patients who present with characteristic
AIDS complications at the time of ﬁrst diagnosis. Early
diagnosis and treatment initiation for the disease are thus
quite important for both physicians and infected patients1, 2）.
The present program＇s aim was to promote the awarenessof HIV and AIDS in general physicians, many of whom
are less familiar with the diagnosis and treatment of thisQuestionnaire on HIV infection

Q1：Have you ever made a diagnosis of HIV infection ? a（HIV 感染症の診断をしたことがありますか？）Q2：Are you conﬁdent in diagnosing and treating HIV infection ?（HIV 感染症の診療に自信がありますか？）Q3：If a patient in their 30s with herpes zoster visits your clinic, will you suggest an HIV test
for this patient ?（30 代の帯状疱疹患者が来院しました。HIV 検査をしますか？）Q4：If a patient with acute type B hepatitis visits your clinic, will you suggest an HIV test forthis patient ?（急性 B 型肝炎患者が来院しました。HIV 検査をしますか？）
Q5：Do you want to diagnose and treat patients with HIV infection ?（HIV 感染症の診察をしたいですか？）Q6：Do you think HIV infection should be treated by an appropriate specialist physician ?
（HIV 感染症は専門医が治療をするべき？）a: All questions were presented before and after the session except for this question, which was only asked
before the session.

47 （ 47 ）H Takahashi et al : Promoting Early Diagnosis of HIV

Fig. 1 Survey results from the two sessions.
At each session, the attendees were encouraged to reply to Q1 to Q6 (Table 1) using the self-response system. Q2 to Q6
were asked before and after each session. The percentage of the answer ＇Yes＇ (or ＇No＇ or ＇not sure＇) was calculated for eachquestion based on the total responders. Panels (a) to (f) correspond to Q1 to Q6, respectively. In each histogram, the dark
box represents ＇Yes＇, the grey box ＇No＇, and the crosshatch ＇not sure＇. The percentages are rounded off to the closest integers
and hence do not necessarily sum up to exactly 100%.

48 （ 48 ）The Journal of AIDS Research

infection. Educational sessions were provided twice, ayear and a half apart, during both of which the attendees
learned the importance of diagnostic confirmation andtreatment initiation at an early stage post-infection.
While the presented data (Fig. 1) have certain limitations,as the same physicians did not attend each session, andthe same attendees did not answer each question of thesurvey, the attendees learned non-specific symptoms
usually presented at an early stage of HIV infection andbecame more conﬁdent and positive in the early diagnosis
and treatment of the infection. Another significant
achievement of the sessions was a decrease in the percentageof physicians who think that HIV infections should be
handled exclusively by specialist physicians. In addition,
the attendees raised many questions via the self-response
system, and answers to the questions have further promoted
their HIV awareness.
HIV-infected patients had a greater burden of comorbidities
and comedications with increasing age than people without
HIV in Japan5, 6）. In this clinical setting, general physicians
will have more opportunities to examine patients with HIV
infection. We have recently established a Web training
system in which general physicians can learn more about
HIV and gain practical skills for the diagnosis and treatment of the disease. Using this system, the physicians
may further ask a specialist physician for case consultation.
While limited to the member physicians of the JapaneseSociety of Hospital General Medicine at present, thebeneﬁt of this system may be widely provided to generalpractitioners nationwide in the future.
Acknowledgments : This work was funded by a Healthand Labour Sciences Research Grant for AIDS Control
Measures (H30-AIDS-General program-008). The authors
acknowledge ViiV Healthcare (Tokyo, Japan) for its Independent Medical Education program that sponsored theVol. 22

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two special sessions organized at the conference of theJapanese Society of Hospital General Medicine. The
authors would also like to thank Forte Science Communications (Tokyo, Japan) for preparation and editing of thepresent report.
Conﬂict of Interest : T.N. and Y.Y. have received honoraria
for lectures from MSD K.K.

References
1 ）Schacker T, Collier AC, Hughes J, Shea T, Corey L :Clinical and epidemiologic features of primary HIV
infection. Ann Intern Med 125 : 257⊖264, 1996.
2 ）U.S. Department of Health and Human Services :Symptoms of HIV. HIV.gov. https://www.hiv.gov/hivbasics/overview/about-hiv-and-aids/symptoms-of-hiv(Accessed November 21, 2018).
3 ）Naito T, Mizooka M, Mitsumoto F, Kanazawa K, Torikai K,
Ohno S, Morita H, Ukimura A, Mishima N, Otsuka F,
Ohyama Y, Nara N, Murakami K, Mashiba K, Akazawa K,
Yamamoto K, Senda S, Yamanouchi M, Tazuma S, Hayashi
J : Diagnostic workup for fever of unknown origin : amulticenter collaborative retrospective study. BMJ Open 3 :e003971, 2013.
4 ）Rosenberg ES, Caliendo AM, Walker BD : Acute HIV
infection among patients tested for mononucleosis. N Engl
J Med 340 : 969, 1999.
5 ）Ruzicka DJ, Imai K, Takahashi K, Naito T : Comorbidities
and the use of comedications in people living with HIV on
antiretroviral therapy in Japan : a cross-sectional study usinga hospital claims database. BMJ Open 8 : e019985, 2018.
6 ）Ruzicka DJ, Imai K, Takahashi K, Naito T : Greater burdenof chronic comorbidities and co-medications among people
living with HIV versus people without HIV in Japan : ahospital claims database study. J Infect Chemother 25 : 89⊖
95, 2019.

49 （ 49 ）H Takahashi et al : Promoting Early Diagnosis of HIV

総合診療医に向けた HIV 感染症の早期発見と早期治療推進のための教育プログラム
高橋

宏瑞1，横幕

能行2，塚田訓久3，大塚文男4，森田浩之5，内藤俊夫1

順天堂大学医学部総合診療科学講座
国立病院機構名古屋医療センター臨床研究センター感染免疫研究部
3
国立研究開発法人国立国際医療研究センターエイズ治療・研究開発センター
4
岡山大学大学院医歯薬学総合研究科総合内科学
5
岐阜大学大学院医学系研究科総合病態内科学
1

2

背景：HIV 感染症は，早期段階では主として非特異的な症状を呈するためしばしば見逃され，治療開始の遅延につながる。この問題に取組むため，われわれは，総合診療医が早期の段階で HIV
感染症によくみられる兆候を理解し，また早期診断の重要性を認識するための教育プログラムを企画した。
方法：日本病院総合診療医学会学術総会で特別セッションを 2 度開催し，参加者に対し各セッションの前後で 6 項目からなるアンケート調査を行った。
結果：アンケートに対する回答から，各セッション後には HIV 感染症に対する早期の診断/診療に対し，「自信あり」，「積極的に取組みたい」とする医師の割合が増大したことが分かった。さらに，HIV 感染症には「専門医が取り組むべき」と考える医師の割合が低下した。
結論：HIV 感染症に対して早期診断による確認が医師，患者双方にとり重要である。本教育プ
ログラムは医師が同感染症を早期にコントロールする一助となる。
キーワード：HIV 感染症，HIV 感染症の啓蒙，総合診療医

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