Racial/Ethnic Attitudes towards HIV Testing in the Primary Care Setting Emma M. Simmons, MD; Michelle L. Rogers, PhD; Georita M. Frierson, PhD; Curt G. Beckwith, MD; and Timothy P. Flanigan, MD Pawtucket and Providence, Rhode Island
Purpose: To determine attitudes of patients towards routine HIV testing in the prmary care setting.
Methods: Cross-sectional survey on the risk factors, beliefs, attitudes and knowledge of HIV/AIDS administered to 101 individuals present in urban primary care clinics in Providence, RI. Results: Previous HIV testing was done most frequently for those respondents requirng prenatal services and for those who were curious about their HIV status. Patients' perceptions of their personal risk for HIV infection and their self-identified risk factors were frequently discordant. Patients wanted to be tested routinely for HIV by their primary care providers, even when they did not feel that they were at high risk for HIV acquisition. Conclusions: Patients in this study clearly indicated their desire to be tested for HIV routinely by their primary care providers. Routine HIV testing is a reasonable option to identify HIV infections in the primary care setting, as it is nondiscriminatory, allows increased awareness of actual risk for infection, and provides an opportunity for eardier detection of HIV.
Key words: HIV testing * minorities * attitudes * risk factors U primary care setting
© 2005. From MHRI (Simmons), Lifespan (Frierson, Beckwith, Flanigan) and Brown Medical School (Simmons, Frerson, Beckwith, Flanigan, Rogers), Providence, RI. Send correspondence and reprnt requests for J NatI Med Assoc. 2005;97:46-52 to: Emma Simmons, Center for Prmary Care and Prevention, Medical Hospital of RI, Pawtucket, RI 02860; phone: (401) 729-2866; fax: (401) 729-2894; e-mail:
[email protected]
46 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
INTRODUCTION The Centers for Disease Control and others estimate that up to one million people in the United States are HIV infected.1 2 Approximately one-third of those infected are unaware of their HIV status.3 Heterosexual transmission is increasing, especially among young men and women without traditional risk factors, such as substance abuse or same-sex relationships.4 The outpatient primary care setting represents an ideal place to identify those who are HIV infected by offering routine testing for HIV This setting could easily provide earlier identification of HIV infection and immediate linkage to healthcare of those infected. The current risk-based approach to HIV testing has failed to identify approximately one-third of those who are HIV positive nationally.5 Routine testing for HIV has the potential to pick up thousands of patients who have been unknowingly infected or who were too fearful to find out the test results. This method of testing for HIV may reduce the barrier of risk-based inquiry prior to testing. While risk assessment is eliminated in routine testing, patient consent and appropriate discussion remain important components of testing. In a recent study6 in Providence, RI, 29 patients admitted to urban hospitals were newly diagnosed with HIV during their hospitalization, and the majority had severe opportunistic infections. Although 45% percent of the patients had a primary care provider and 69% had received recent medical care, they had not been previously tested for HIV The majority of those who tested positive during their hospitalization (65 %) did not have easily identifiable "traditional" risk factors for HIV This study underscores the not-so-rare "missed opportunities" for HIV testing that occur each day in primary care. Routine testing for HIV indirectly influences the patient encounters by allowing avoidance of personal subjects that traditionally require more time, effort and energy to discuss or to manage. This leaves the larger, more detailed and invasive risk VOL. 97, NO. 1, JANUARY 2005
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assessment to be done in the event of an HIV diagnosis. A recent inpatient study7 conducted in Boston, MA identified 19 additional HIV infections during a nine-month study period among low-risk patients by offering routine testing instead of risk-based testing. A similar study8 in Atlanta, GA assessed routine HIV testing among predominately underserved minority patients attending a primary care health center in a large urban setting. By offering routine HIV testing, 27 more patients were diagnosed and educated about HIV-double the previous year's linkage to care. Although the CDC has recently advocated routine HIV testing,9 there has been very little published information on this practice and even less information on routine testing within the primary care setting. Our study sought to determine the attitudes towards routine testing for HIV in a primary care outpatient setting serving impoverished underserved minorities, particularly African Americans and Latinos, who are disproportionately affected by HIV/AIDS.
METHODS An anonymous, self-administered cross-sectional survey of primary care outpatients was conducted from April until August 2002 at a group of community health centers affiliated with Providence Ambulatory Community Health Centers, Inc. (PACHC) located in Providence, RI.
Sites and Subjects A convenience sample of 101 respondents attending the health centers was obtained. PACHC clinics were chosen because they are multidisciplinary sites that primarily serve impoverished underserved minorities in a primary care outpatient setting. All adults present in the waiting rooms of the clinic were approached for participation in the survey by a single recruiter. The only exclusionary criteria for participation were age less than 18 years old and inability to speak/read either in Spanish or English. Patients were compensated in the form of a $10 gift certificate to a local supermarket chain. The study was approved by both Lifespan's and PACHC's institutional review boards.
Instrument Respondents were invited to complete a 45-item pen-and-paper instrument with questions on demographics, personal risk factors as well as beliefs, attitudes and knowledge about HIV/AIDS. The FleschKincaid grade level for the questionnaire was 5.9. The instrument was self-administered anonymously for 99 of the respondents. To be more inclusive, the questions were translated into Spanish approximately halfway through the study. An independent interpreter checked the translation of the original instrument for accuracy and readability.
Table 1. Distribution (%) of Demographic Characteristics for Survey Respondents, by Self-Reported Race/Ethnicity
Female Married Stable housing Employed Insurance coverage Private Public Uninsured Education Less than high school High school graduate or equivalent Attended or completed college/graduate school
Total (N=101)
Black (N=21)
White (N=14)
Latino (N=49)
Other' (N=16)
79 42 92 76
76 29 81 76
100 29 93 57
82 47 96 79
62 53 94 80
19 53 28
20 50 30
27 27 46
16 59 25
20 53 27
25 34
10 38 52
43 36 21
29 27 45
19 50 31
42
"Other" refers to individuals who self-identified as American Indian/Alaskan Native, Asian and Pacific Islander, Cape Verdian or mixed race/ethnicity.
a
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Data Collection
know," "prevention" or "physical examination" (Table 2). Only 9.2% of the respondents stated that they obtained an HIV test specifically on the advice of their physician/healthcare provider, and all of these respondents were either Latina or white females. No males were tested as a result of health provider recommendation. There was no difference in the mean number of times tested among the four racial categories (Table 3). Examining the reasons for previous HIV testing based on racial/ethnic identification, we found that 27% of blacks were tested because of personal curiosity, whereas 23% ofwhites and Hispanics were tested because their provider suggested it. Females in the study consented to HIV testing more frequently than the male respondents and were tested primarily as a result of prenatal testing. The women respondents were also more likely to be insured (p
