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Is Experience With Human Immunodeficiency Virus Disease Related to Clinical Practice?
A Survey of Rural Primary Care Physicians
Cynthia L. Willard, MD;
Petra Liljestrand, PhD;
Ronald H. Goldschmidt, MD;
Kevin Grumbach, MD
Arch Fam Med. 1999;8:502-508.
Background Human immunodeficiency virus (HIV) disease is spreading to the rural United States, and medical care is increasingly provided by local primary care physicians. A volume-outcome relationship might exist in HIV care. However, little is known about the HIV experience and practices of rural primary care physicians.
Objectives To estimate the HIV experience of rural primary care physicians, and to determine whether experience is associated with use of newer management strategies, confidence in care, and consultation needs.
Design Telephone survey of a random sample of primary care physicians.
Setting Primary care sites in nonmetropolitan California.
Participants One hundred twenty eligible primary care physicians in nonmetropolitan California, with 102 respondents (85.0%).
Main Outcome Measures Physicians' HIV experience, use of protease inhibitors and viral load tests, familiarity with vertical HIV transmission prophylaxis, confidence in HIV care, and consultation needs.
Results Most physicians were low-volume providers of HIV care and had limited knowledge of newer management strategies. Experience with protease inhibitors and viral load tests was significantly related to number of recent patients with HIV; 25.0% of those with 1 to 3 patients but 75.0% of those with 4 or more patients had prescribed protease inhibitors (P = .01), whereas 20.8% of those with 1 to 3 patients but 83.3% of those with 4 or more patients had used a viral load test (P = .001). Only 59.8% of all respondents, but 100.0% of those with 4 or more patients, were familiar with vertical HIV transmission prophylaxis (P = .001). After adjustment for other characteristics, HIV experience remained significantly associated with use of newer management strategies (P = .01) and familiarity with vertical HIV transmission prophylaxis (P = .007). Physicians' confidence in HIV care increased with experience (P = .006), and consultation needs decreased (P = .006).
Conclusions Primary care physicians in rural California lacked in-depth experience with HIV disease. Experience was significantly associated with use of newer HIV management strategies, confidence, and consultation needs. Treating 4 or more patients with HIV or acquired immunodeficiency syndrome may be the threshold above which primary care physicians rapidly adopt new strategies and have confidence in their care.
From the Department of Family and Community Medicine, San Francisco General Hospital Family Practice Residency Program (Drs Willard, Goldschmidt, and Grumbach) and the Community Provider AIDS Training Project (Drs Liljestrand and Goldschmidt), and the Primary Care Research Center (Dr Grumbach), University of California–San Francisco. Dr Willard is now with the Community Health Foundation of East Los Angeles, Los Angeles, Calif.
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