HIV/STD Prevention in General Practice

This thesis examines aspects of the prevention of sexually transmitted diseases (STDs) in the Australian community, with a particular emphasis on HIV/AIDS in the context of general practice (or primary care settings). The work has four broad aims: i) To describe the primary prevention of sexually transmitted diseases, following from the arrival of the HIV/AIDS pandemic in Australia ii) To describe HIV/STD risk behaviour iii) To summarise previously known evidence of interventions to reduce risk and to raise awareness of HIV and other sexually transmitted diseases iv) To contribute new evidence addressing the potential of the general practitioners' role in HIV/STD prevention The first chapter gives a brief review of the history of HIV/AIDS from its discovery in the United States of America to its appearance in Australia and New Zealand, and discusses the Australian response strategies, both initial and continuing, to confine the epidemic. Specifically, the arrival of HIV/AIDS gave rise to increasing awareness of sexually transmitted diseases, which hitherto, although sometimes chronic, were rarely fatal. The public health risk of HIV necessitated swift government action and led to wider acceptance of publicity about sexual behaviour. Although the thesis does not concentrate solely on HIV, this is still an emphasis. This chapter provides useful background to ensuing chapters. Chapter Two provides an overview of behavioural risk in sexually transmitted diseases. It gives a review of risk factor prevalence studies, and introduces risk behaviour and cognitive models of behaviour change, as applied to STD risk. Sexual behaviour is a complex social interaction, usually involving more than one person, and relying on the personality and behaviour patterns intrinsic to the individuals taking part. It is therefore perhaps more challenging to alter than behaviour which is undertaken alone, being dependent on the behaviour and intentions of both parties. Moreover, comprehensive assessment of sexual risk behaviour requires very detailed information about each incident. Its private nature makes accurate data difficult to obtain, and sexual risk behaviour is, correspondingly, difficult to measure. Chapter Three reviews the effectiveness of interventions tested in primary health care settings to reduce sexual risk behaviour. The candidate uses a replicable method to retrieve and critique studies, comparable with standards now required by the Cochrane Collaboration. From 22 studies discussed, nine health interventions were short, 'one-shot', efforts owing to limited time, resources and other practical constraints. This review demonstrates the scarcity of interventions with people who may be perceived as 'low-risk'. Only four interventions were carried out in community health centres and two in university health clinics. One of the university interventions showed no change in sexual behaviour in any of three arms of the intervention (Wenger, Greenberg et al 1992) while the other showed an increase in condom use in both groups, although the intervention group's self-efficacy and assertiveness also improved (Sikkema, Winett & Lombard 1995). The rationale for the intervention, where given, is described. Chapter Four analyses the content, format and quality of sexual health information brochures available in New South Wales at the time of the candidate's own planning for an interventional study. One of the most effective ways to disseminate information widely is by the use of educational literature, especially when the subject material is potentially sensitive or embarrassing to discuss in person. In this chapter, the candidate reviews the literature available at the time of designing the intervention used in Chapter Five. Readability, attractiveness, clarity and the accurate presentation of facts about sexually transmitted disease risk are examined for each pamphlet. Forty-seven pamphlets were scored according to the Flesch formula, and twenty-four of these scored in the 'fairly' to 'very difficult' range. There was, therefore, a paucity of easy-to-read material on these subjects. Chapter Five evaluates a general practitioner-based counselling intervention to raise awareness of sexually transmitted diseases and to modify HIV/STD risk behaviour. While adults aged 18-25 are less likely than older cohorts to have a regular general practitioner or to visit often, most people visit a general practitioner at least once a year. This could provide an opportunity for the general practitioner to raise preventive health issues, especially with infrequent attendees. As the effectiveness of an opportunistic intervention about sexual risk behaviour was yet to be tested, the candidate designed an innovative randomised controlled trial to raise awareness of risk and increase preventive behaviour. The participation rate was 90% and 76% consented to followup; however the attrition rate meant that overall only 52% of the original participants completed the follow-up questionnaire. The intervention proved easy and acceptable both to GPs and to patients, and risk perception had increased at three months' follow-up; however this occurred in both the control (odds ratio 2.6) and the intervention group, whose risk perception at baseline was higher (odds ratio 1.3). In order to establish some markers of risk in the general population, Chapter Six analyses data resulting from questions on sexual behaviour asked in the Central Sydney section of the NSW Health Survey. The candidate advocated for inclusion of relevant questions to determine some benchmarks of sexual risk behaviour and to provide an indication of condom use among heterosexuals. Although limited in scope as a result of competing priorities for questions in the survey, results demonstrate that, while a small percentage of people were at risk, those with higher levels of partner change or of alcohol use were the most likely to always use condoms. Specifically, 100% of those with more than four new partners in the last 12 months had used condoms with every new partner. In addition, 'heavy' alcohol users were more likely to report condom use every time with new partners (odds ratio 0.34). To furnish data to inform future planning of educational activities for general practitioners, Chapter Seven presents the results of a survey of Central Sydney general practitioners' opinions and current practices in HIV risk reduction with in the broader context of sexually transmitted disease prevention. The general practitioner is in an ideal position to provide information and advice, especially if future research affirms the impact of such advice on STD risk behaviour. General practitioners in this study said they would be slightly more likely to discuss sexual health matters with young patients than with older ones (p=0.091), but this was not significant. The most cited barrier to discussing sexual health was inadequate remuneration for taking time to do so (over 50% gave this reason). The next most cited obstacle was difficulty in raising the subject of STDs or HIV in routine consultations, but this reason was given by less than half the sample. Forty-six percent had participated in continuing medical education programs in STDs, HIV/AIDS, or hepatitis diagnosis or management; 32% of GPs had patients with HIV, and 55% of all GPs indicated they would like more training in management and continuity of care of HIV patients. Approximately half (51%) wanted more training in sexuality issues, including sexual dysfunction. Chapter Eight reviews the whole thesis and discusses future directions for the research agenda

The relationship between self-reported alcohol intake and the morbidities managed by GPs in Australia

BACKGROUND: One in five Australians consume alcohol at risky or harmful levels. Most (85%) attend a general practitioner at least once a year, giving opportunity for detecting and providing brief interventions for reducing alcohol-related harm. Historically, detection rates of problem drinking have been low in general practice, producing lower prevalence estimates of heavy drinking than expected from population surveys. METHOD: The BEACH program collects data from 100 consecutive patient consultations with 1000 GPs annually. For 40 consecutive encounters, GPs ask adult patients three questions on alcohol consumption (AUDIT-C). This paper reports the problems managed and treatments provided at encounters with heavy and non-heavy drinkers, grouped by their response to the 3rd question, and compares the two groups before and after standardisation for age and sex. Heavy drinking was defined as having 6 or more standard drinks at least once a week or more often. RESULTS: Heavy drinking was reported by 7.3% patients overall; more prevalent among men (13.8%) than women (3.9%); and among Indigenous patients (18.5%). Prevalence was highest in young adults (18–24 years)(12.7%) and decreased with age. Patients from a non-English speaking background were less likely to be heavy drinkers. Heavy drinkers had more problems managed at encounters, more chronic problems, physical injuries and psychological problems (particularly depression) managed than non-heavy drinkers. They were less likely to have respiratory complaints, ischaemic heart disease or diabetes managed. CONCLUSION: Heavy drinkers are more likely than non- or light drinkers to see their GP for management of chronic problems, psychological problems and physical injuries. However, the wide range of morbidity managed in heavy drinkers means that relying on clinical impression alone to detect this group will not suffice and should be augmented with routine screening. Given the pressures of general practice, finding efficient methods of screening for alcohol problems remains a priority

Should adjustment for covariates be used in prevalence estimations?

Background Adjustment for covariates (also called auxiliary variables in survey sampling literature) is commonly applied in health surveys to reduce the variances of the prevalence estimators. In theory, adjusted prevalence estimators are more accurate when variance components are known. In practice, variance components needed to achieve the adjustment are unknown and their sample estimators are used instead. The uncertainty introduced by estimating variance components may overshadow the reduction in the variance of the prevalence estimators due to adjustment. We present empirical guidelines indicating when adjusted prevalence estimators should be considered, using gender adjusted and unadjusted smoking prevalence as an illustration. Methods We compare the accuracy of adjusted and unadjusted prevalence estimators via simulation. We simulate simple random samples from hypothetical populations with the proportion of males ranging from 30% to 70%, the smoking prevalence ranging from 15% to 35%, and the ratio of male to female smoking prevalence ranging from 1 to 4. The ranges of gender proportions and smoking prevalences reflect the conditions in 1999–2003 Behavioral Risk Factors Surveillance System (BRFSS) data for Massachusetts. From each population, 10,000 samples are selected and the ratios of the variance of the adjusted prevalence estimators to the variance of the unadjusted (crude) ones are computed and plotted against the proportion of males by population prevalence, as well as by population and sample sizes. The prevalence ratio thresholds, above which adjusted prevalence estimators have smaller variances, are determined graphically. Results In many practical settings, gender adjustment results in less accuracy. Whether or not there is better accuracy with adjustment depends on sample sizes, gender proportions and ratios between male and female prevalences. In populations with equal number of males and females and smoking prevalence of 20%, the adjusted prevalence estimators are more accurate when the ratios of male to female prevalences are above 2.4, 1.8, 1.6, 1.4 and 1.3 for sample sizes of 25, 50, 100, 150 and 200, respectively. Conclusion Adjustment for covariates will not result in more accurate prevalence estimator when ratio of male to female prevalences is close to one, sample size is small and risk factor prevalence is low. For example, when reporting smoking prevalence based on simple random sampling, gender adjustment is recommended only when sample size is greater than 200

The association between intimate partner violence, alcohol and depression in family practice

Background: Depressive symptoms, intimate partner violence and hazardous drinking are common among patients attending general practice. Despite the high prevalence of these three problems; the relationship between them remains relatively unexplored. Methods: This paper explores the association between depressive symptoms, ever being afraid of a partner and hazardous drinking using cross-sectional screening data from 7667 randomly selected patients from a large primary care cohort study of 30 metropolitan and rural general practices in Victoria, Australia. The screening postal survey included the Center for Epidemiological Studies Depression Scale, the Fast Alcohol Screening Test and a screening question from the Composite Abuse Scale on ever being afraid of any intimate partner. Results: 23.9% met criteria for depressive symptoms. A higher proportion of females than males (20.8% vs. 7.6%) reported ever being afraid of a partner during their lifetime (OR 3.2, 95%CI 2.5 to 4.0) and a lower proportion of females (12%) than males (25%) were hazardous drinkers (OR 0.4; 95%CI 0.4 to 0.5); and a higher proportion of females than males (20.8% vs. 7.6%) reported ever being afraid of a partner during their lifetime (OR 3.2, 95%CI 2.5 to 4.0). Men and women who had ever been afraid of a partner or who were hazardous drinkers had on average higher depressive symptom scores than those who had never been afraid or who were not hazardous drinkers. There was a stronger association between depressive symptoms and ever been afraid of a partner compared to hazardous drinking for both males (ever afraid of partner; Diff 6.87; 95% CI 5.42, 8.33; p < 0.001 vs. hazardous drinking in last year; Diff 1.07, 95% CI 0.21, 1.94; p = 0.015) and females (ever afraid of partner; Diff 5.26; 95% CI 4.55, 5.97; p < 0.001 vs. hazardous drinking in last year; Diff 2.23, 95% CI 1.35, 3.11; p < 0.001), even after adjusting for age group, income, employment status, marital status, living alone and education level. Conclusions: Strategies to assist primary care doctors to recognise and manage intimate partner violence and hazardous drinking in patients with depression may lead to better outcomes from management of depression in primary care

Effectiveness of skills-based training using the Drink-less package to increase family practitioner confidence in intervening for alcohol use disorders

BACKGROUND: Misuse of alcohol is second only to tobacco as a leading cause of preventable death in Australia. There is an opportunity in family practice to detect problems and intervene with people at risk of alcohol-related harm before complications occur. However, family practitioners (FPs) report low levels of confidence in managing patients with drinking problems. The aim of this study was to determine whether the interactive training session using the 'Drink-less' package led to improvement in FPs' self-reported level of confidence in detecting and providing interventions for risky alcohol consumption. METHOD: FPs in urban and rural New South Wales were invited to training sessions in their local area. An introductory overview preceded a practical skills- based session, using the Drink-less package. Participants completed before and after evaluation forms. RESULTS: While 49% (CI 43 – 55) of the attending FPs indicated at baseline that they felt confident in identifying at-risk drinkers, this proportion rose to 90% (95% CI: 87 – 93) post-session, and they also reported increases in confidence from 36% (95% CI: 31 – 41) to 90% in their ability to advise patients. Urban FPs reported lower levels of confidence than rural FPs, both pre- and post-session. CONCLUSION: Training sessions in the Drink-less intervention resulted in increased self-reported confidence in detection and brief intervention for alcohol problems. Further research is needed to determine the duration of this effect and its influence on practice behaviour

Barriers and enablers to the provision of alcohol treatment among Aboriginal Australians: A thematic review of five research projects

Introduction and Aims: To review the results of five research projects commissioned to enhance alcohol treatment among Aboriginal Australians, and to highlight arising from them. Design and Methods: Drafts of the papers were workshopped by project representatives, final papers reviewed and results summarised. Lessons arising were identified and described. Results: While the impact of the projects varied, they highlight the feasibility of adapting mainstream interventions in Aboriginal Australian contexts. Outcomes include greater potential to: screen for those at risk; increase community awareness; build capacity and partnerships between organisations; and co-ordinate comprehensive referral networks and service provision. Discussion: Results show a small investment can produce sustainable change and positive outcomes. However, to optimise and maintain investment, cultural difference needs to be recognised in both planning and delivery of alcohol interventions; resources and funding must be responsive to and realistic about the capacities of organisations; partnerships need to be formed voluntarily based on respect, equality and trust; and practices and procedures within organisations need to be formalised. Conclusions: There is no simple way to reduce alcohol-related harm in Aboriginal communities. However, the papers reviewed show that with Aboriginal control, modest investment and respectful collaboration, service enhancements and improved outcomes can be achieved. Mainstream interventions need to be adapted to Aboriginal settings, not simply transferred. The lessons outlined provide important reflections for future research

‘Making the invisible visible’ through alcohol screening and brief intervention in community pharmacies: an Australian feasibility study

Background: Screening and brief interventions (SBI) for alcohol related problems have been shown to be effective in health settings such as general practice or emergency departments. Recent data from the United Kingdom and New Zealand suggest that SBI can be delivered through community pharmacies, but this approach has not been tested in Australia. This study assesses the feasibility of delivering alcohol SBI via community pharmacists. Method: We recruited five pharmacies and developed an SBI training package to be delivered by pharmacy staff, who screened consumers and delivered the brief intervention where appropriate. Consumers also completed a questionnaire on the process. At three months consumers were telephoned to enable ‘retention’ to be quantified. After completing recruitment, a semi-structured interview was conducted with pharmacists on the process of delivering the intervention, potential improvements and sustainability. Results: Fifty consumer participants were screened, ten from each pharmacy. There were 28 (57 %) men and 21 (43 %) women with one not responding. Most (67 %) were aged 25-55 years. Their AUDIT scores had a range of 0 to 39 (mean 10.9, SD 9.8) with 11 categorised as ‘hazardous (8-15)’, four as ‘harmful (16-19)’ and eight as ‘probably dependent (20+)’ consumers of alcohol. Reactions to the process of SBI were generally favourable: for example 75 % agreed that it was either appropriate or very appropriate being asked about their alcohol consumption. With respect to follow-up interviews, 23 (46 %) agreed that they could be contacted, including five from the highest AUDIT category. Subsequently 11 (48 %) were contactable at three months. Three of the five non-low risk drinkers had reduced their level of risk over the three months. Ten pharmacists participated in semi-structured telephone interviews. Overall these pharmacists were positive about the intervention and five main themes emerged from the interviews: 1) flexibility applied in recruitment of participants, 2) easiness in use of AUDIT score to facilitate discussions, 3) perceived positive intervention impact, 4) enhanced role of community pharmacists and 5) facilitators and challenges experienced. Conclusions: Pharmacy-based SBI appears to be acceptable to consumers and feasible for pharmacy staff to deliver. Challenges remain in translating this potential into actual services

A web-based Alcohol Clinical Training (ACT) curriculum: Is in-person faculty development necessary to affect teaching?

<p>Abstract</p> <p>Background</p> <p>Physicians receive little education about unhealthy alcohol use and as a result patients often do not receive efficacious interventions. The objective of this study is to evaluate whether a free web-based alcohol curriculum would be used by physician educators and whether in-person faculty development would increase its use, confidence in teaching and teaching itself.</p> <p>Methods</p> <p>Subjects were physician educators who applied to attend a workshop on the use of a web-based curriculum about alcohol screening and brief intervention and cross-cultural efficacy. All physicians were provided the curriculum web address. Intervention subjects attended a 3-hour workshop including demonstration of the website, modeling of teaching, and development of a plan for using the curriculum. All subjects completed a survey prior to and 3 months after the workshop.</p> <p>Results</p> <p>Of 20 intervention and 13 control subjects, 19 (95%) and 10 (77%), respectively, completed follow-up. Compared to controls, intervention subjects had greater increases in confidence in teaching alcohol screening, and in the frequency of two teaching practices – teaching about screening and eliciting patient health beliefs. Teaching confidence and teaching practices improved significantly in 9 of 10 comparisons for intervention, and in 0 comparisons for control subjects. At follow-up 79% of intervention but only 50% of control subjects reported using any part of the curriculum (p = 0.20).</p> <p>Conclusion</p> <p>In-person training for physician educators on the use of a web-based alcohol curriculum can increase teaching confidence and practices. Although the web is frequently used for disemination, in-person training may be preferable to effect widespread teaching of clinical skills like alcohol screening and brief intervention.</p

Guidelines for the treatment of alcohol problems.

Summary of recommendations vii 1. Introduction 1 • Purpose of the guidelines 1 • Structure of the guidelines 1 • Evidence-based health care 3 • Community and population approaches to alcohol problems 4 • A note on terminology 4 2. Prevalence of alcohol consumption and related harms in Australia 7 • Prevalence of alcohol use 7 • Alcohol-related harm 8 3. Screening, assessment and treatment planning 13 • Screening 13 • Comprehensive clinical assessment 21 • Treatment planning 32 4. Brief interventions 41 • Who to target for brief interventions 41 • How to deliver brief interventions 42 • Who can deliver brief interventions? 43 • Where should brief interventions be delivered? 43 • Limitations of brief intervention 45 5. Alcohol withdrawal management 49 • Alcohol withdrawal syndrome: Clinical presentation 49 • Assessment and treatment matching 51 • Supportive care 57 • Medications for managing alcohol withdrawal 61 • Treating severe withdrawal complications 68 • Wernicke–Korsakoff’s syndrome 76 6. Psychosocial interventions for alcohol use disorders 81 • Overview of psychosocial interventions 81 • When to use psychosocial interventions 82 • Choosing psychosocial interventions: a stepped care approach 82 • Motivational interviewing 85 • Cognitive behavioural interventions 86 • Relapse prevention strategies 89 • Residential rehabilitation programs 89 7. Pharmacotherapies for alcohol dependence 93 • Naltrexone 93 • Acamprosate 96 • Combined acamprosate and naltrexone 98 • Disulfiram 98 • Other medications 101 • Integration with psychosocial treatments 102 • Increasing medication adherence 102 • Selecting medications for individual patients 103 8. Self-help programs 107 • Alcoholics Anonymous 107 • SMART RecoveryR 110 • Self-help for families 111 9. Specific populations 115 • Adolescents and young people 115 • Pregnant and breastfeeding women 121 • Indigenous Australians and people from other cultures 130 • Older people 135 • Cognitively impaired patients 138 10. Comorbidities 145 • Physical comorbidity 145 • Co-occurring mental and alcohol-use disorders 147 • Polydrug use and dependence 153 11. Aftercare and long-term follow-up 161 • Aftercare 161 • Working with the persistent problem drinker 161 Appendixes 165 • Appendix 1 Screening and diagnostic instruments 167 • Appendix 2 Diagnostic criteria for alcohol use disorders 195 • Appendix 3 Withdrawal scales 197 • Appendix 4 Alcohol and drug interactions 202 • Appendix 5 Getting through alcohol withdrawal: A guide for patients and carers 205 • Appendix 6 A guide for people with alcohol-related problems 208 • Appendix 7 Disulfiram Agreement 213 • Appendix 8 Treatment guidelines for mental disorders 214 • Appendix 9 Standard drinks 215 Glossary 221 Acronyms 225 References 22