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Talking to patients about AIDS.

Most physicians would agree that acquired immunodeficiency syndrome (AIDS) is the most pressing public health problem facing America today. As of November 30, 1990, the Centers for Disease Control has documented 154,791 cases of AIDS in adults and adolescents in the United States, and this number is steadily rising.

AIDS is no longer confined to the large urban populations, and the care of AIDS patients is no longer limited to specialized urban clinics. Many persons with AIDS are leaving the cities and returning to the rural areas from where they came, to die. Because of this, rural areas now report AIDS in dimensions that parallel the rate in the general population. Forty-one percent of the AIDS cases reported in the Ambulatory Sentinal Practice Network (ASPN) study in this issue of the Journal were from rural sites. [1] As the AIDS epidemic has spread, the site of care has mvoed into the offices of primary care physicians.

The reasons AIDS is such a threat to our population are both simple and complex. People get AIDS by doing things that most people do not do and do not approve of other people doing. Prevention, therefore, requires changes in behavior--changes in moral behavior. This makes health education difficult, but education is our only weapon. There can be no law passed, nor passive restraint invented, to save lives as has been done with seat belts.

Like it or not, prevention is our only hope, so we had better tackle it with all we've got. And who better to do this than the family physician? You must assume the role of leader in prevention education. Why? Because society has given you that mandate. As shown by Epstein et al, 47% of all of your patients and 67% of those who are adolescents want to talk to you about AIDS. [2] They expect to hear the answers from you. They prefer to hear them from you. They think that you are the most competent individual to answer their questions.

Although it is uncomfortable for some physicians--myself included--to discuss sexual issues with patients, sexual transmission must be the focus of your prevention efforts, because this is the most common mode of contracting AIDS. Tell your patients these basic facts:

1. There is no vaccine and no cure for AIDS. This should be the number one deterrent to engaging in high-risk behavior, but surprisingly, almost one third of the respondents surveyed by Epstein did not know that a cure was not available.

2. Recommend sexual abstinence to the young and mutually faithful monogamy to adjults. Condoms are a poor third, but we have little else to offer those who continue to be sexually active with multiple partners. You should remind your patients that condoms are not 100% effective. Be sure to stress that latex condoms are preferable and should be used in conjunction with a water-soluble lubricant containing at least 65 mg of the spermacide nonoxynol 9, which kills the human immunodeficiency virus (HIV). It is also important to emphasize that to use condoms correctly, they must be used from start to finish. Some of you will find it unpleasant to recommend condoms to young people. So do I, but AIDS is an unpleasant disease, and recommending condoms to those who need protection is preferable to treating AIDS.

3. Dispel the myths about AIDS. Acquired immunodeficiency syndrome cannot be transmitted by casual, nonsexual contact, which you should define for the patient. Questions from your patients may signal their unreasonable fears.

4. Tell patients not to engage in anal intercourse. The rectal mucosa bleeds easily and provides an entry for HIV. Since the AIDS epidemic began, the majority of cases of AIDS in the United States have probably occurred by way of anal intercourse. Condoms provide some protection, but anal intercourse is simply too dangerous a practice.

5. Advise patients to abstain from sex, including oral sex, unless their partner is known to be HIV-seronegative and has practiced safe sex for at least 6 months before and any time after negative testing. They should have doubts about anyone who has had sex with anyone else. Beware of people who belong to organizations that offer "sexual safety" because they issue a health card. Such cards are always out of date and such people usually have a reason for being tested.

6. If a patient in doubt about his or her HIV status, recommend an HIV antibody test. Tell the patient that you will keep these test results confidential, sharing the information only with other health professionals who need to know. If the patient is HIV-seropositive, discuss the advisability of notifying the spouse or other sexual contacts.

7. Women who test positive for HIV antibodies often transmit AIDS to the children they conceive.

8. Tell your patients never to shoot drugs. If they are hooked, they should not share needles or other drug paraphernalia. AIDS is spread by tiny amounts of blood that may be in syringes and needles.

If the public will heed and practice your advice, I believe that the AIDS epidemic can be contained. Please do your part now in making sure that this happens.


[1] Calonge BN, Miller RS, Dennis LK, Joffe LS. AIDS in primary care: a report from the Ambulatory Sentinel Practice Network. J Fam Pract 1991; 32(3):369-372.

[2] Epstein R. Patient attitudes and knowledge about HIV infection and AIDS. J Fam Pract 1991; 32(3):373-377.
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Author:Koop, C. Everett
Publication:Journal of Family Practice
Article Type:editorial
Date:Apr 1, 1991
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