HIV and STI risk reduction through physician training
Authors: Zunyou Wu
Journal: The Lancet Global Health (2015)

UNAIDS has set ambitious targets to end the epidemic of HIV/AIDS by 2030 through the 90-90-90 strategy—ie, 90% of HIV infected individuals diagnosed, 90% diagnosed being treated, and 90% treated achieving viral suppression.1UNAIDS90-90-90 an ambitious treatment target to help end the AIDS epidemic.http://www.unaids.org/sites/default/files/media_asset/90-90-90_en_0.pdfDate: 2014Google Scholar Physicians will contribute immensely to the achievement of each of these targets. In a randomised controlled trial (the Ai Shi Zi study) in The Lancet Global Health, Don Operario and colleagues2Operario D Wang D Zaller ND et al.Intervention to reduce HIV risk and sexually transmitted reinfections among high-risk patients in China: a cluster randomised trial.Lancet Glob Health. 2015; 4: e29-e36Google Scholar have shown the potentially pivotal role of physicians in treatment and prevention of sexually transmitted infections (STIs) in China. In the study, physicians were trained in HIV and STI knowledge, treatment, and risk reduction counselling, and were motivated to integrate prevention and treatment into routine care. Patients of the physicians who were randomly assigned to training experienced 38% lower odds of combined gonorrhoea and chlamydia reinfection and 32% lower odds of gonorrhoea reinfection alone than patients of physicians in a delayed control group after 9 months' follow-up. Their findings call for a scale-up of physician training in HIV and STI knowledge, treatment, and risk reduction counselling, as an important strategy to prevent HIV risk and STI transmission in China as well as around the world. China is among the world's top 15 countries in terms of HIV incidence and total number of people living with HIV/AIDS and will be a crucial contributor to global efforts towards ending the epidemic.3UNAIDSThe GAP Report.http://www.unaids.org/sites/default/files/media_asset/UNAIDS_Gap_report_en.pdfDate: 2014Google Scholar HIV/AIDS in China has shifted its primary transmission mode from infection through needle sharing and injectable drug use to one mainly attributable to sexual contact, and with staggering magnitude.4Zheng N Guo Y Padmadas S Wang B Wu Z The increase of sexually transmitted infections calls for simultaneous preventive intervention for more effectively containing HIV epidemics in China.BJOG. 2014; 121: 35-44Crossref PubMed Scopus (20) Google Scholar, 5Zhang L Chow EP Jing J et al.HIV prevalence in China: integration of surveillance data and a systematic review.Lancet Infect Dis. 2013; 13: 955-963Summary Full Text Full Text PDF PubMed Scopus (218) Google Scholar The proportion of newly diagnosed HIV cases acquiring HIV through sexual contact increased from 60·4% in 2010 to 92·4% in 2014.6National Center for AIDS/STD Control and Prevention. 2014 National AIDS/STD Prevention and Treatment Statistics in China Beijing: National Center for AIDS/STD Control and Prevention. China CDC, 2014.Google Scholar The national average HIV prevalence among men who have sex with men increased from 1·4% in 2005 to 8·0% in 2015.7National Center for AIDS/STD Control and Prevention. 2015 National HIV/HCV/syphilis sentinel surveillance report in China Beijing: National Center for AIDS/STD Control and Prevention. China CDC, 2015.Google Scholar Control and prevention of the HIV epidemic as transmitted through sexual contact has become a top priority in China, yet it remains a great challenge. The scaling up of such a physician training programme could encounter various hurdles. Broad dissemination and implementation of this type of programme calls for an understanding of the specific key components that contribute to the positive impact seen. The Ai Shi Zi intervention study involved a programme consisting of 1-week group training and two additional booster sessions, incorporating didactic sessions with practical skills acquisition exercises. Individual-level interaction—ie, between physician and patient—is important to understand specifics affecting successful patient outcomes. In addition to the high rate of patient attrition reported, the scarce data collected regarding clinical encounters makes specification and thereby replication of effective programme components difficult.2Operario D Wang D Zaller ND et al.Intervention to reduce HIV risk and sexually transmitted reinfections among high-risk patients in China: a cluster randomised trial.Lancet Glob Health. 2015; 4: e29-e36Google Scholar Feasibility is yet to be determined; the authors did not report costs of such a training programme, which was already demanding in terms of time, study design, and implementation. The country-wide scale-up of a similar programme involves a complex interplay not limited to institutional support and training resources. The training programme's reported effectiveness in reducing gonorrhoea and chlamydia reinfection was apparent, although it might not be well generalisable to the case of HIV. In national sentinel surveillance of men who have sex with men in China, the average HIV prevalence saw an increase from 5·0% in 2008 to 8·0% in 2015, whereas the national average prevalence of syphilis among the same sample of MSM declined from 13·0% to 5·3% during the same time period.7National Center for AIDS/STD Control and Prevention. 2015 National HIV/HCV/syphilis sentinel surveillance report in China Beijing: National Center for AIDS/STD Control and Prevention. China CDC, 2015.Google Scholar Despite the existence of a few studies reporting the effectiveness of physician training programmes to increase knowledge, improve counselling skills, reduce stigma, and reduce sexually transmitted infections,2Operario D Wang D Zaller ND et al.Intervention to reduce HIV risk and sexually transmitted reinfections among high-risk patients in China: a cluster randomised trial.Lancet Glob Health. 2015; 4: e29-e36Google Scholar, 8Wu Z Detels R Ji G et al.Diffusion of HIV/AIDS knowledge, positive attitudes, and behaviors through training of health professionals in China.AIDS Educ Prev. 2002; 14: 379-390Crossref PubMed Scopus (51) Google Scholar, 9Li L Wu Z Liang LJ et al.Reducing HIV-related stigma in health care settings: a randomized controlled trial in China.Am J Public Health. 2013; 103: 286-292Crossref PubMed Scopus (72) Google Scholar few clinical trials have shown similar results in reduction of HIV incidence. Such studies should be considered in the near future, perhaps extending to the Chinese men who have sex with men population, since this group experiences enormous stigma and alienation from health-care providers as well as the general public. In view of the crucial role of physicians in HIV diagnosis and treatment, future training programmes should emphasise improving the rate of HIV diagnosis through several strategies including promoting provider initiation of HIV testing among patients seeking any medical services, or mandating HIV screening on clinical visits, with an opt-out option.10Wu Z Sun X Sullivan SG Detels R Public health. HIV testing in China.Science. 2006; 312: 1475-1476Crossref PubMed Scopus (131) Google Scholar Physician training programmes would see benefit from courses in public health to build knowledge and strengthen skills in the identification and prevention of HIV within the clinical setting using approaches such as partner tracing, partner notification, and partner treatment. Recent guidelines issued by WHO encourage treating all HIV-infected individuals with antiretroviral therapy regardless of their CD4 cell level.11WHOGuideline on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV.http://www.who.int/hiv/pub/guidelines/earlyrelease-arv/en/Date: 2015Google Scholar This new policy will undoubtedly be beneficial in achieving the goal of 90% treatment among those with known diagnoses. Improved training programmes emphasising this approach will help China and the world to achieve the 90-90-90 targets towards ending AIDS by 2030. I declare no competing interests. The opinions expressed in this comment reflect the views of the author and do not necessarily represent the official position of the National Center for AIDS/STD Control and Prevention, Chinese Center for Diseases Control and Prevention. Effect of a knowledge-based and skills-based programme for physicians on risk of sexually transmitted reinfections among high-risk patients in China: a cluster randomised trialIntegrating HIV and STI training into medical education in China could be an effective strategy to reduce the country's growing HIV risk and STI epidemics. Full-Text PDF Open Access