visits than any other specialty; (2) a significant proportion of family physicians include obstetrics and pediatrics in their practices (30.5% provide obstetric care and 91.5% pediatric care); and (3) preventive health services are a high priority for AAFP.

Incorporation of Guidelines

AAFP policies regarding HIV disease have closely followed those set forth by PHS. The academy recommends universal HIV counseling and voluntary testing for all pregnant women, and has adopted as policy the section "Guidelines for Counseling and Testing for HIV Antibody" from the CDC statement "Public Health Service Guidelines for Counseling and Antibody Testing to Prevent HIV Infection and AIDS." In addition, the AAFP supports the enactment of state laws providing for (1) reporting to the appropriate public health authorities of all individuals testing positive for HIV, and (2) public health agencies to conduct appropriate confidential contact identification, notification, and counseling. This does not preclude the physician or patient from notifying the contacts. Finally, HIV education is part of state association meetings, and the two AAFP publications also cover HIV issues.

Implementation

Data from the National Ambulatory Medical Care Survey indicate that in 1993, HIV accounted for only 0.12% of all family practice office visit conditions, and that counseling on HIV transmission was included in 0.54% of office visits. While Dr. Kubota noted that these data are somewhat old, he still felt they reflected important trends. Dr. Kubota offered several observations about why family practice physicians may not be offering counseling and testing. First, he said, family practice physicians' standards are high, so if they include HIV testing they would want to do appropriate pre- and post-test counseling; yet the yield—the number of HIV-positive patients—is low. Time pressures are even greater now with the move to a highly penetrated managed care market. Although other tests, such as phenylketonuria (PKU) and galactosemia, also have a low yield, they do not require intensive pre-test counseling. There is also an issue of mixed messages about whom to test: while in the past, the model has been risk-based testing, suddenly in the area of prenatal care, risk stratification does not matter. This is a contradiction. The rapid changes in HIV treatment also add a new complexity to counseling, so that the models of treatment and care are moving much faster than the average family physician can keep up with. Finally, in many towns there is a lack of expert backup help should a patient test positive. All of these factors mediate against family physicians routinely providing testing and counseling for HIV.



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