Prospects for improvement in physicians' communication skills and in prevention of HIV infection
Authors: Peter A Selwyn
Journal: The Lancet (1998)

Although certain features of HIV and its life-cycle have worked to its advantage in chillingly effective ways, behavioural factors have also helped greatly to promote the global extension of the pandemic of HIV infection. Public-health measures to stem the transmission of this infection by influencing behaviour are challenging because the transmission is effected largely by individual private acts that have important social consequences. A complicating factor is that some of these behaviours may be illegal (eg, injecting drug use) or socially unacceptable in some cultural contexts (eg, homosexuality). Some of the behaviours are also socially valued (eg, childbearing). Moreover, HIV-prevention efforts have been limited by social acceptability (eg, condom use and contraception). Despite these difficulties, a good physician-patient relationship in routine clinical care should should contribute substantially to risk reduction and hence the prevention of this infection. In the USA most individuals visit a physician at least twice a year. Although many physicians may think that they counsel their patients about HIV risk effectively,1Makadon HJ Silin JG Prevention of HIV infection in primary care: current practices, future possibilities.Ann Intern Med. 1998; 123: 715-719Crossref Scopus (39) Google Scholar it has been shown that even the most experienced clinicians sometimes exhibit discomfort or difficulty when discussing sexuality and substance-use behaviours with their patients.1Makadon HJ Silin JG Prevention of HIV infection in primary care: current practices, future possibilities.Ann Intern Med. 1998; 123: 715-719Crossref Scopus (39) Google Scholar, 2Epstein RM Morse DS Frankel RM Frarey L Anderson K Beckham HB Awkward moments in patient-physician communication about HIV risk.Ann Intern Med. 1998; 128: 435-442Crossref PubMed Scopus (133) Google Scholar A national survey of physicians in the USA1Makadon HJ Silin JG Prevention of HIV infection in primary care: current practices, future possibilities.Ann Intern Med. 1998; 123: 715-719Crossref Scopus (39) Google Scholar found that fewer than 1% of visits to primary-care physicians involved counselling or advice about HIV transmission.1Makadon HJ Silin JG Prevention of HIV infection in primary care: current practices, future possibilities.Ann Intern Med. 1998; 123: 715-719Crossref Scopus (39) Google Scholar Another study2Epstein RM Morse DS Frankel RM Frarey L Anderson K Beckham HB Awkward moments in patient-physician communication about HIV risk.Ann Intern Med. 1998; 128: 435-442Crossref PubMed Scopus (133) Google Scholar found, in a convenience sample of physicians in outpatient practice in Rochester, New York, that physicians did not elicit adequate information for determination of patients' risk status in nearly three-quarters of all encounters, which were videotaped and reviewed by both physicians and patients. Much of the difficulty physicians experienced in this context was attributed to their own emotional discomfort with these issues, or to financial disincentives against in-depth counselling of patients during routine clinic visits. The same study found, as have other studies,1Makadon HJ Silin JG Prevention of HIV infection in primary care: current practices, future possibilities.Ann Intern Med. 1998; 123: 715-719Crossref Scopus (39) Google Scholar that patients expressed an interest in discussing HIV with their physicians, and expected that their physicians would broach the topic with them. Another study,3Fallowfield L Lipkin M Hall A Teaching senior oncologists communication skills: results from phase I of a comprehensive longitudinal program in the United Kingdom.J Clin Oncol. 1998; 16: 1961-1968Crossref PubMed Scopus (299) Google Scholar this time from the UK and of senior oncologists, has found that the oncologists expressed discomfort or a perceived lack of expertise in communicating with patients and families about difficult clinical issues in the context of life-threatening illness. The oncologists then underwent a brief communications-skills training course consisting of a combination of didactic teaching, structured feedback, videotape review of interviews with standardised patients, and small-group discussion. Immediately after the course, confidence ratings for key communication areas improved significantly. Importantly, these changes were sustained in 95% of physicians at 3 months of follow-up. These encouraging findings suggest that a focused measure to improve communications skills for clinicians might be expected to have an important potential impact on discussions between doctor and patient on HIV-risk behaviour. Other reports also suggest that problem-based teaching methods can help address difficult attitudinal and communication issues more appropriately than can traditional didactic methods alone.1Makadon HJ Silin JG Prevention of HIV infection in primary care: current practices, future possibilities.Ann Intern Med. 1998; 123: 715-719Crossref Scopus (39) Google Scholar The findings of another recent study4Stein MD Freedberg KA Sullivan LM et al.Sexual ethics: disclosure of HIV-positive status to partners.Arch Intern Med. 1998; 158: 253-257Crossref PubMed Scopus (122) Google Scholar also support the need for improving physicians' communication skills: a survey of HIV-infected patients in outpatient HIV clinics in Boston, Massachusetts, and Providence, Rhode Island, found that 40% of patients had not informed their primary sexual partners of their HIV infection, and slightly more than half of these had used condoms less than half the time.4Stein MD Freedberg KA Sullivan LM et al.Sexual ethics: disclosure of HIV-positive status to partners.Arch Intern Med. 1998; 158: 253-257Crossref PubMed Scopus (122) Google Scholar This finding was consistent with those of other studies, in which, despite making some effort to modify behaviour, a significant minority of HIV-infected patients continued to engage in unsafe sexual or drug-use behaviours.5Lemp GF Hirozawa AM Givertz D et al.Seroprevalence of HIV and risk behaviours among young homosexual and bisexual men.JAMA. 1994; 272: 449-454Crossref PubMed Scopus (252) Google Scholar, 6McKusker J Bigelow C Frost R Hindin R Vickers-Lahti M Zorn M The relationship of HIV status and HIV risky behavior with readiness for treatment.Drug Alcohol Depend. 1994; 34: 129-138Summary Full Text PDF PubMed Scopus (16) Google Scholar, 7Metsch LR McCoy CB Lai S Miles C Continuing risk behaviors among HIV seropositive chronic drug users in Miami, Florida.AIDS Behavior. 1998; 2: 161-169Crossref Scopus (42) Google Scholar Thus, it is fair to surmise that many physicians interacting daily with patients who are at potentially high risk of HIV transmission or re-acquisition are not taking the opportunity to promote behaviour change, whether for primary prevention or for the prevention of further transmission from those already infected. On a global scale, it will not be changes in physician consultations that will contribute in a significant way to the slowing and eventual retreat of the HIV epidemic, but rather an effective vaccine against HIV, improvements in the social and economic status of women in developing countries, prevention and treatment of drug addiction, and more systematic treatment and prevention of sexually transmitted diseases in high-risk populations. However, caregivers should not avoid or overlook opportunities to help patients protect themselves against disease, especially when some of the communication barriers are due to their own emotional discomfort or lack of expertise in discussing sensitive issues.