Lack of education, knowledge, and supplies are barriers to cryptococcal meningitis care among nurses and other healthcare providers in rural Uganda: A mixed methods study.

BACKGROUND: Cryptococcal meningitis (CM) is one of the deadliest opportunistic infections related to HIV/AIDS. A research gap exists surrounding the barriers to CM diagnosis, treatment delivery, and care from the healthcare provider's perspective. OBJECTIVES: The purpose of this study was to elucidate provider's behaviors, to identify barriers and facilitators to diagnose and treat CM, and to assess their knowledge of CM, cryptococcal screening, and treatment. DESIGN, SETTING, AND PARTICIPANTS: A convergent mixed-methods study among twenty healthcare providers who provided CM patient referrals to Lira Regional Referral Hospital in Lira, Uganda. METHODS: Surveys and interviews were conducted to obtain information from healthcare providers who referred CM patients to Lira Regional Referral Hospital from 2017 to 2019. Questions related to provider education, knowledge, barriers to CM care, and patient education were inquired to understand the providers' perspectives. RESULTS: Nurses had the least amount of CM knowledge with half knowing the cause of CM. Approximately half the participants knew about CM transmission, but only 15 % knew the duration of CM maintenance therapy. Most participants (74 %) last had education regarding CM during didactic training. In addition, 25 % disclosed they never educate patients due to time constraints (30 %) and lack of knowledge (30 %). Nurses (75 %) were least likely to provide patient education. Most participants acknowledged their lack of CM knowledge and attributed it to a lack of education and perceived inexperience with CM. CONCLUSIONS: Providers' gaps in knowledge due to the lack of education and experience contributes to decreased patient education, and the lack of access to appropriate supplies affects their provision for CM diagnosis, treatment, and care. These results can guide evidence-based interventions to improve health providers' knowledge. Recommendations for standardized CM education should be developed for both providers and patients in collaboration with professional boards and the Uganda Ministry of Health.

High satisfaction among patients at HIV clinics in Harare, Zimbabwe: a time and motion evaluation and patient satisfaction study.

Patient satisfaction is an important component of health and healthcare utilization, which measures the perceived needs and expectations for healthcare services. Patient satisfaction surveys are effective in improving health outcomes by informing health facilities on service and provider gaps and guiding the development of effective action plans and policies for quality improvement within a healthcare organization. Although patient satisfaction and patient flow analyses have been conducted in Zimbabwe, the combination of these two quality improvement measures in the context of Human Immunodeficiency Virus (HIV) clinics has not previously been evaluated. This study assessed and evaluated patient flow and patient satisfaction to enhance care quality and improve HIV service delivery to optimize patient health. We collected time and motion data from HIV patients who attended three purposively selected City of Harare Polyclinics in Harare, Zimbabwe. All patients who sought care at the clinic were given time and motion forms to track their movement and the time spent at each service area. After services were completed, patients were invited to participate in a satisfaction survey regarding their services and care. The average waiting time from clinic arrival to see the provider was 2 hr and 14 min. The areas with the longest waiting time and bottlenecks occurred at registration (49 min) and the HIV clinic waiting area (44 min). Despite these extended times, the overall patient satisfaction for HIV services was high at 72%, with over half (59%) reporting that there was nothing they did not like about their services. Patients were most satisfied with services provided (34%), timely service (27%), and antiretroviral medications (19%). The areas of least satisfaction were related to time delays (24%) and cashier delays (6%). Despite prolonged waiting times, patients' overall satisfaction with their clinic experience remains high. Perceptions of satisfaction are influenced by experience, culture, and context. However, there are still several areas of recommendations to improve service, care, and quality. Specifically, reducing or eliminating service fees, increasing clinic hour times, and having available medication were most cited. Support from the Zimbabwe Ministry of Health and Child Care, City of Harare, and other decision-makers is needed to improve patient satisfaction and address patients' recommendations within the City of Harare Polyclinic organization in accordance with the 2016-20 National Health Strategies for Zimbabwe.

Delays in Cryptococcal Meningitis Diagnosis and Care: A Mixed Methods Study in Rural Uganda.

Background: Cryptococcal meningitis (CM) remains a major cause of mortality for HIV-infected persons in sub-Saharan Africa, despite widespread access to antiretroviral therapy. Delays in CM diagnosis and treatment contribute to high mortality, with patients often arriving "too late" for treatment to be effective. Little is known about patient-related delays and their experiences with CM. Objectives: This study seeks to identify the factors related to delays in diagnosis and care among patients with cryptococcal meningitis. Methods: A convergent mixed-methods approach was used to understand delays related to diagnosis and treatment of CM among patients admitted to Lira Regional Referral Hospital in rural northern Uganda. We collected data from February to March 2020 using surveys followed by semi-structured interviews from 20 CM patients who survived hospitalization and 20 family members of deceased patients during February 2017-November 2019. Interviews were audio-recorded, transcribed, and thematically coded for analysis. Findings: Delays to CM care were related to 1) self-medication, 2) lack of CM education, 3) seeking treatment multiple times at health centers with 4) missed/misdiagnosis, and 5) cultural factors. Among patients who died, 70% sought care ≥3 times, while those who survived, 35% of sought care ≥3 times before CM diagnosis. Only 10% of patients and 40% of family members knew what caused CM, indicating a lack of knowledge. Conclusions: Patients sought medical care for CM symptoms, but several factors contributed to CM diagnosis and care delays. Many of these factors relate to a lack of CM education and knowledge among patients and providers. A CM awareness campaign for the general public, targeted education for HIV patients, and continuing medical education for healthcare providers can decrease delays and improve outcomes.

Impact of a Cryptococcal meningitis diagnosis and treatment program at Lira Regional Referral Hospital in rural, Northern Uganda.

In rural areas of sub-Saharan Africa, infrastructure and resources for treatment of cryptococcal meningitis (CM) are often lacking. We introduced a CM diagnosis and treatment program (CM-DTP) at Lira Regional Referral Hospital (LRRH) in rural Uganda to determine if implementing high-quality standard of care protocols would improve outcomes. Information extracted from hospital charts and clinical record forms at LRRH were used to compare diagnoses, treatments, and outcomes for all patients diagnosed with meningitis (n = 281) over a two-year period after initiation of the CM-DTP in February of 2017 to all patients diagnosed with meningitis (n = 215) in the two preceding years. After implementation of the CM-DTP, we observed increased confirmed diagnoses of CM from 22.2% (48 of 215) to 35.2% (99 of 281), (p = 0.002) among all patients diagnosed with meningitis. Among all patients treated for CM, the proportion who received standard of care treatment with amphotericin B plus fluconazole increased from 63 of 127 (49.6%) to 109 of 146 (74.7%), (p <0.001) and mortality improved from 66 of 127 (52.0%) to 57 of 146 (39.0%), (p = 0.04) after implementation of the CM-DTP. Implementation of the CM-DTP was associated with increased number of lumbar punctures and decreased use of antibiotics in patients with CM, as well as decreased mortality among patients with meningitis from all causes. Improved diagnosis, treatment, and mortality were observed following implementation of the CM-DTP. Our results demonstrate that quality treatment of CM in rural Uganda is feasible.

Field-based evaluation of malaria outbreak detection and response in Mudzi and Goromonzi districts, Zimbabwe - 2017.

National-level evaluations may fail to identify capacity improvements for detecting and responding to outbreaks which begin and are first detected at the local level. In response to this issue, we conducted a field-based assessment of the malaria outbreak surveillance system in Mashonaland East, Zimbabwe. We visited eleven clinics in Mudzi and Goromonzi districts. Twenty-one interviews were conducted with key informants from the provincial (n = 2), district (n = 7), and clinic (n = 12) levels. Interviews focused on surveillance system activities, preparedness, data quality, timeliness, stability, and usefulness. Main themes were captured utilising standard qualitative data analysis techniques. While the surveillance system detects malaria outbreaks at all levels, we identified several gaps. Clinics experience barriers to timely and reliable reporting of outbreaks to the district level and staff cross-training. Stability of resources, including transportation (33% of informants, n = 7) and staff capacity (48% of informants, n = 10), presented barriers. Strengthening these surveillance barriers may improve staff readiness to detect malaria outbreaks, resulting in timelier outbreak response and a reduction in malaria outbreaks, cases, and deaths. By focusing at the local level, our assessment approach provides a framework for identifying and addressing gaps that may be overlooked when utilising tools that evaluate surveillance capacity at the national level.

Identification of Key Beliefs Explaining Male Circumcision Motivation Among Adolescent Boys in Zimbabwe: Targets for Behavior Change Communication.

Male circumcision (MC) significantly reduces HIV acquisition among men, leading WHO/UNAIDS to recommend high HIV and low MC prevalence countries circumcise 80% of adolescents and men age 15-49. Despite significant investment to increase MC capacity only 27% of the goal has been achieved in Zimbabwe. To increase adoption, research to create evidence-based messages is greatly needed. The Integrated Behavioral Model (IBM) was used to investigate factors affecting MC motivation among adolescents. Based on qualitative elicitation study results a survey was designed and administered to a representative sample of 802 adolescent boys aged 13-17 in two urban and two rural areas in Zimbabwe. Multiple regression analysis found all six IBM constructs (2 attitude, 2 social influence, 2 personal agency) significantly explained MC intention (R2 = 0.55). Stepwise regression analysis of beliefs underlying each IBM belief-based construct found 9 behavioral, 6 injunctive norm, 2 descriptive norm, 5 efficacy, and 8 control beliefs significantly explained MC intention. A final stepwise regression of all the significant IBM construct beliefs identified 12 key beliefs best explaining intention. Similar analyses were carried out with subgroups of adolescents by urban-rural and age. Different sets of behavioral, normative, efficacy, and control beliefs were significant for each sub-group. This study demonstrates the application of theory-driven research to identify evidence-based targets for the design of effective MC messages for interventions to increase adolescents' motivation. Incorporating these findings into communication campaigns is likely to improve demand for MC.

Evidence-Based Identification of Key Beliefs Explaining Infant Male Circumcision Motivation Among Expectant Parents in Zimbabwe: Targets for Behavior Change Messaging.

Slow adult male circumcision uptake is one factor leading some to recommend increased priority for infant male circumcision (IMC) in sub-Saharan African countries. This research, guided by the integrated behavioral model (IBM), was carried out to identify key beliefs that best explain Zimbabwean parents' motivation to have their infant sons circumcised. A quantitative survey, designed from qualitative elicitation study results, was administered to independent representative samples of 800 expectant mothers and 795 expectant fathers in two urban and two rural areas in Zimbabwe. Multiple regression analyses found IMC motivation among fathers was explained by instrumental attitude, descriptive norm and self-efficacy; while motivation among mothers was explained by instrumental attitude, injunctive norm, descriptive norm, self-efficacy, and perceived control. Regression analyses of beliefs underlying IBM constructs found some overlap but many differences in key beliefs explaining IMC motivation among mothers and fathers. We found differences in key beliefs among urban and rural parents. Urban fathers' IMC motivation was explained best by behavioral beliefs, while rural fathers' motivation was explained by both behavioral and efficacy beliefs. Urban mothers' IMC motivation was explained primarily by behavioral and normative beliefs, while rural mothers' motivation was explained mostly by behavioral beliefs. The key beliefs we identified should serve as targets for developing messages to improve demand and maximize parent uptake as IMC programs are rolled out. These targets need to be different among urban and rural expectant mothers and fathers.

A Phase II Randomized Controlled Trial Comparing Safety, Procedure Time, and Cost of the PrePex™ Device to Forceps Guided Surgical Circumcision in Zimbabwe.

BACKGROUND: The World Health Organization (WHO) and the Joint United Nations Program on HIV/AIDS promote MC (male circumcision) as a key HIV prevention strategy where HIV prevalence and incidence are high and MC prevalence is low. In Zimbabwe, to achieve the 1.26 million circumcisions needed to be performed by 2015 to achieve optimal MC coverage, a new approach was needed. The primary objective of the current trial was to assess the performance (safety, procedure time, and cost) of the PrePex device compared to forceps-guided surgical circumcision. METHODS AND FINDINGS: This Phase II, randomized, open-label trial in Zimbabwe involved healthy, non-circumcised adult male volunteers who were randomly assigned to the PrePex device (n = 160) or surgical arm (n = 80). Three doctors and 4 nurses, all certified on both circumcision methods, performed the procedures. The PrePex device procedure involves a plastic ring with a rubber O-ring that necrotizes the foreskin to facilitate easy and minimally invasive removal. Total procedure time was the primary endpoint. Adverse event (AE) data were also gathered for 90 days post-procedure. All 80 participants in the surgical arm and 158 participants in the PrePex arm achieved complete circumcision. The total procedure time for the PrePex device was approximately one-third of the total surgical procedure (4.8 minutes, Standard Deviation [SD]: 1.2 versus 14.6 minutes; SD: 4.2; p<0.00001). There were 2 AEs for 2 participants (rate of 1.3%, 95% Confidence Interval: 0.0025-4.53%), which were resolved with simple intervention. The AEs were device related, including 1 case of pain leading to device removal and 1 case of removal of the device. CONCLUSIONS: The trial supports previous studies' conclusions that the PrePex procedure is safe, quick, easy to apply, and effective in terms of procedure time as an alternative to traditional surgical circumcision. The PrePex device has great potential for use in overburdened health systems and in resource-limited settings and is recommended for use in rapid scale-up of adult MC in Zimbabwe. TRIAL REGISTRATION: ClinicalTrials.gov NCT01956370.

Psychosocial Results from a Phase I Trial of a Nonsurgical Circumcision Device for Adult Men in Zimbabwe.

Male circumcision (MC), an effective HIV prevention tool, has been added to Zimbabwe's Ministry of Health and Child Care HIV/AIDS Prevention Program. A Phase I safety trial of a nonsurgical male circumcision device was conducted and extensive psychosocial variables were assessed. Fifty-three men (18 and older) were recruited for the device procedure; 13 follow-up clinical visits were completed. Interviews conducted three times (before the procedure, at 2 weeks and 90 days post-procedure) assessed: Satisfaction; expectations; actual experience; activities of daily living; sexual behavior; and HIV risk perception. Using the Integrated Behavioral Model, attitudes towards MC, sex, and condoms, and sources of social influence and support were also assessed. Men (mean age 32.5, range 18-50; mean years of education = 13.6; 55% employed) were satisfied with device circumcision results. Men understand that MC is only partially protective against HIV acquisition. Most (94.7%) agreed that they will continue to use condoms to protect themselves from HIV. Pain ratings were surprisingly negative for a procedure billed as painless. Men talked to many social networks members about their MC experience; post-procedure (mean of 14 individuals). Minimal impact on activities of daily living and absenteeism indicate possible cost savings of device circumcisions. Spontaneous erections occurred frequently post-procedure. The results had important implications for changes in the pre-procedure clinical counseling protocol. Clear-cut counseling to manage pain and erection expectations should result in improved psychosocial outcomes in future roll-out of device circumcisions. Men's expectations must be managed through evidence-based counseling, as they share their experiences broadly among their social networks.

Evidence-based identification of key beliefs explaining adult male circumcision motivation in Zimbabwe: targets for behavior change messaging.

Male circumcision (MC) reduces HIV acquisition among men, leading WHO/UNAIDS to recommend a goal to circumcise 80 % of men in high HIV prevalence countries. Significant investment to increase MC capacity in priority countries was made, yet only 5 % of the goal has been achieved in Zimbabwe. The integrated behavioral model (IBM) was used as a framework to investigate the factors affecting MC motivation among men in Zimbabwe. A survey instrument was designed based on elicitation study results, and administered to a representative household-based sample of 1,201 men aged 18-30 from two urban and two rural areas in Zimbabwe. Multiple regression analysis found all five IBM constructs significantly explained MC Intention. Nearly all beliefs underlying the IBM constructs were significantly correlated with MC Intention. Stepwise regression analysis of beliefs underlying each construct respectively found that 13 behavioral beliefs, 5 normative beliefs, 4 descriptive norm beliefs, 6 efficacy beliefs, and 10 control beliefs were significant in explaining MC Intention. A final stepwise regression of the five sets of significant IBM construct beliefs identified 14 key beliefs that best explain Intention. Similar analyses were carried out with subgroups of men by urban-rural and age. Different sets of behavioral, normative, efficacy, and control beliefs were significant for each sub-group, suggesting communication messages need to be targeted to be most effective for sub-groups. Implications for the design of effective MC demand creation messages are discussed. This study demonstrates the application of theory-driven research to identify evidence-based targets for intervention messages to increase men's motivation to get circumcised and thereby improve demand for male circumcision.

Alcohol use and abuse among rural Zimbabwean adults: a test of a community-level intervention.

BACKGROUND: Understanding what factors contribute to alcohol abuse in resource-poor countries is important given its adverse health consequences. Past research shows that social peers influence substance abuse, suggesting that the social environment may be an effective target for reducing alcohol abuse across a population. This study investigates the determinants of alcohol use and abuse in rural Zimbabwe and tests a community popular opinion leader (CPOL) community-based intervention partly directed at reducing alcohol abuse. METHODS: Tests were conducted on the impact of the CPOL intervention on alcohol use patterns across communities in rural Zimbabwe over three waves from 2003 to 2007, including community- and individual-level tests using data based on in-person interviews of adult men and women (ages 18-30; N=5543). Data were analyzed using paired-sample t-tests, as well as logistic and ordinary least-squares regression with random effects. RESULTS: Higher drinking (any use, more frequent use, greater quantity, and/or frequent drunkenness) was generally associated with being male, older, not married, more highly educated, of Shona ethnicity, away from home frequently, employed, having no religious affiliation, or living in areas with a higher crude death rate or lower population density. Over the study period, significant declines in alcohol use and abuse were found in intervention and control sites at relatively equal levels. CONCLUSIONS: Although no support was found for the effectiveness of the CPOL study in reducing alcohol abuse, Zimbabwe is similar to other countries in the impact of socio-demographic and cultural factors on alcohol use and abuse.

Concurrent partnerships, acute infection and HIV epidemic dynamics among young adults in Zimbabwe.

This paper explores the roles of acute infection and concurrent partnerships in HIV transmission dynamics among young adults in Zimbabwe using realistic representations of the partnership network and all published estimates of stage-specific infectivity. We use dynamic exponential random graph models to estimate partnership network parameters from an empirical study of sexual behavior and drive a stochastic simulation of HIV transmission through this dynamic network. Our simulated networks match observed frequencies and durations of short- and long-term partnerships, with concurrency patterns specific to gender and partnership type. Our findings suggest that, at current behavior levels, the epidemic cannot be sustained in this population without both concurrency and acute infection; removing either brings transmission below the threshold for persistence. With both present, we estimate 20-25% of transmissions stem from acute-stage infections, 30-50% from chronic-stage, and 30-45% from AIDS-stage. The impact of acute infection is strongly moderated by concurrency. Reducing this impact by reducing concurrency could potentially end the current HIV epidemic in Zimbabwe.

Colorectal cancer screening use among insured primary care patients.

OBJECTIVE: To compare colorectal cancer (CRC) screening use, including changes over time and demographic characteristics associated with screening receipt, between 2 insured primary care populations. STUDY DESIGN: Clinical and administrative records from 2 large health systems, one in New Mexico and the other in Michigan, were used to determine use of CRC screening tests between 2004 and 2008 among patients aged 51 to 74 years. METHODS: Generalized estimating equations were used to evaluate trends in CRC screening use over time and the association of demographic and other factors with screening receipt. RESULTS: Rates of CRC screening use ranged from 48.1% at the New Mexico site to 68.7% at the Michigan site, with colonoscopy being the most frequently used modality. Fecal occult blood test was used inconsistently by substantial proportions of patients who did not meet the definition of screening users. Screening use was positively and significantly associated with older age, male sex, and more periodic health examinations and other types of primary care visits; at the Michigan site, it was also associated with African American race, married status, and higher annual estimated household income. CONCLUSIONS: Among insured primary care patients, CRC screening use falls short. Further research is needed to determine what factors are barriers to routine fecal occult blood test or colonoscopy use among insured patients who have access to and regularly use primary care and how those barriers can be eliminated.

What about the partners of women with abnormal Pap or positive HPV tests?

BACKGROUND: Because high-risk HPV is highly prevalent in the general population, usually transient, and rarely causes clinical symptoms, and because diagnostic and treatment options for HPV in men are lacking, partner notification is not useful for preventing transmission or protecting the health of male partners. METHODS: We conducted a nationally representative survey of clinicians in 7 specialties that perform cervical cancer screening. Providers were asked whether they recommend that women with an abnormal Pap or positive HPV test inform sex partners of the infection or refer partners to a clinician. RESULTS: A large proportion of providers in all 7 specialties encourage women with either an abnormal Pap or a positive HPV test to tell their sex partners to see a clinician, ranging from 48% to 73% across specialties. Providers who perform reflex HPV testing were more likely to recommend that patients with an ASCUS Pap inform their partners of test results if an HPV test was positive than if it was negative (66%-83% vs. 29%-50%); providers who perform adjunct HPV testing were more likely to recommend that patients with a normal Pap inform their partners if an HPV test was positive than if it was negative (72%-92% vs. 30%-52%). CONCLUSIONS: Most providers advise patients with cervical cancer screening tests suggestive of HPV infection to notify their sex partners and to refer them to a clinician. Guidelines are needed for providers to clarify any rationale for clinical evaluation of male partners, including that informing partners has a limited role in the control of HPV transmission or in preventing adverse health outcomes in the male partner.

Access of Black, Hispanic, and nonprivately insured women to liquid-based cytology, human papillomavirus DNA testing, and on-site colposcopy in the United States.

OBJECTIVE: To determine whether patient race, ethnicity, or insurance status was associated with access to cervical cancer screening with liquid-based cytology (LBC) and with human papillomavirus (HPV) DNA testing and with access to on-site colposcopy at the provider's principal practice site. MATERIALS AND METHODS: We conducted a nationally representative survey of clinicians in specialties that provide cervical cancer screening. Adjusted odds ratios (OR) were estimated for the associations between race, ethnicity, and insurance status of patients and provider use of LBC, HPV DNA testing, and on-site colposcopy. RESULTS: Providers who cared for >or=20% Hispanic patients were less likely to use LBC (OR 0.60, 95% CI=0.42-0.84). Providers who cared for >or=25% black women (OR 0.71, 95% CI=0.51-0.98) and providers who cared for <75% privately insured patients (OR 0.66, 95% CI=0.46-0.95) were less likely to use HPV DNA testing. Providers who cared for <75% privately insured patients were less likely to have on-site colposcopy (OR 0.57, 95% CI=0.37-0.89), but those who cared for >or=20% Medicaid patients were more likely to have on-site colposcopy (OR 1.86, 95% CI=1.26-2.73). CONCLUSIONS: Given the high rates of cervical cancer in minority women, access to cervical cancer screening and diagnostic follow-up must be ensured. It may also be beneficial to ensure affordable access to technologies such HPV DNA testing that increases the sensitivity of disease detection and to on-site colposcopy that facilitates follow-up of abnormal cytology.

STD/HIV prevention practices among primary care clinicians: risk assessment, prevention counseling, and testing.

OBJECTIVE: To describe current practices of primary care (PC) clinicians for STD/HIV control services: risk assessment, prevention counseling, and offering tests. STUDY DESIGN: We identified clinical strategies through qualitative interviews. We then surveyed by mail a random sample of Washington State family physicians, general internists, obstetrician-gynecologists, nurse practitioners, and certified nurse midwives. We identified characteristics of clinicians and their practices associated with each strategy and universal provision of each service. RESULTS: We report on 519 clinicians (80% adjusted response rate). Clinicians provided services to selected patients they considered high risk. Universal practices were less common: risk assessment (56%), prevention counseling (60%), STD tests (30%), and HIV tests (19%). Universal services were more common among nurses, those recently trained, and those seeing more STD patients. CONCLUSION: Different types of PC clinicians use widely differing clinical strategies and many use selective rather than universal approaches to STD/HIV control services. Further research is needed to develop tailored interventions to improve provision of these services.

Use of DNA tests for human Papillomavirus infection by US clinicians, 2004.

Since 1999, human papillomavirus (HPV) DNA tests have been approved only for abnormal cervical cytology management and as an adjunct to cervical cytology screening. To assess HPV DNA testing practices, we mailed surveys to 6906 randomly selected clinicians in mid-2004. Awareness (87%) and ever use (67%) of HPV DNA tests was high. Test users were more likely than nonusers to be obstetricians/gynecologists or midwives, to be female, and to serve mainly privately insured patients. Respondents reported ever using HPV DNA tests for both approved and nonapproved indications, which included testing for HPV infection in women with anogenital warts or other sexually transmitted diseases, in their sex partners, and in men. Interventions are needed to discourage HPV DNA test use for nonapproved indications.

Anogenital warts knowledge and counseling practices of US clinicians: results from a national survey.

OBJECTIVES: To examine messages US clinicians use when counseling patients diagnosed with anogenital warts. STUDY DESIGN: In mid-2004, we conducted a confidential mail survey of nationally representative samples of physicians practicing internal and adolescent medicine, family/general practice, obstetrics/gynecology, urology, or dermatology; nurse midwives; physician assistants; and nurse practitioners. The survey assessed knowledge and counseling practices of clinicians who had diagnosed anogenital warts. RESULTS: After adjusting for survey eligibility, 81% responded. Most (89%) were aware that human papillomavirus (HPV) causes anogenital warts, but only 48% were aware that oncogenic and wart-related HPV genotypes usually differ. Most (>95%) clinicians reported telling patients with warts that warts are an STD, are caused by a virus, or that their sex partners may have or may acquire warts. Many clinicians (>/=85%) also reported discussing STD prevention or assessing STD risk with such patients. Most reported addressing ways to prevent HPV (89%), including using condoms; limiting sex partners or practicing monogamy; or abstinence. Many also reported recommending prompt (82%) or more frequent (52%) Pap testing to female patients with anogenital warts. Potential barriers to counseling included providing definitive answers on how HPV infection was acquired, dealing with patients' psychosocial issues, and inadequate reimbursement. CONCLUSIONS: Most surveyed clinicians appropriately counseled patients about the cause and prevention of anogenital warts. However, many clinicians were unaware that oncogenic and wart-related HPV types usually differ, and this may explain why many reported recommending more aggressive cervical cancer screening for female patients with warts.

Cervical cancer screening, abnormal cytology management, and counseling practices in the United States.

OBJECTIVE: We assessed clinician knowledge and practices since the marketing of tests for sexually transmitted human papillomavirus (HPV) and the release of HPV testing guidelines for two indications: 1) as an adjunct to cytologic screening and 2) to guide colposcopic triage of patients with atypical squamous cells of undetermined significance (ASC-US) cytology results. METHODS: In mid-2004, we surveyed nationally representative, random samples of clinicians practicing specialties that provide cytologic screening. Mail surveys addressed HPV-related knowledge, screening, abnormal cytology management, HPV testing, and counseling practices. RESULTS: The overall adjusted response rate was 82%. Of the 2,980 (89%) clinicians providing cytologic screening, 99% knew that HPV infection increases cervical cancer risk, and 91% were aware of HPV tests. Of the 21% who reported ever using HPV tests as an adjunct to cytology, more reported usually testing patients aged less than 30 years (which guidelines do not recommend) than older patients (which guidelines do recommend). Of the 63% of clinicians who ever ordered HPV tests for abnormal cytology results, 84% usually ordered tests for ASC-US results and preferentially advised colposcopy if HPV tests were positive, as guidelines recommend. However, more than 60% usually ordered HPV tests for higher-grade abnormalities, which is not recommended for colposcopy triage. Although few sought HPV test consent, most discussed sexually transmitted HPV with patients with abnormal cytology or positive HPV tests despite potentially negative psychosocial consequences. CONCLUSION: New HPV tests and testing guidelines have transformed screening, abnormal cytology management, and counseling practices. Although many U.S. clinicians reported using HPV tests according to guidelines, many also reported inappropriate use.

Family physicians' knowledge of genital human papillomavirus (HPV) infection and HPV-related conditions, United States, 2004.

BACKGROUND AND OBJECTIVES: Information about human papillomavirus (HPV) has evolved rapidly and HPV DNA tests are now available. Little is known about family physicians' knowledge about HPV and how it relates to HPV test use and counseling practices. METHODS: In mid-2004, confidential surveys were mailed to a nationally representative sample of 760 family physicians. We assessed and analyzed relationships between knowledge about HPV, HPV test use, and counseling messages provided when collecting cervical cytology and managing anogenital warts. RESULTS: The adjusted response rate was 68% (n=368). Ninety-one percent provided cervical cancer screening, and 90% had managed genital warts. Responses indicated that more than 90% had up-to-date knowledge about several issues: HPV infection is common, persistent infection increases risk of cervical neoplasia, and treatment does not eliminate the causative infection. However, fewer than 50% were aware that HPV infections may clear spontaneously and that the HPV types associated with warts and cervical neoplasia differ. Only 57% had ever used HPV tests. Some HPV knowledge varied by clinician characteristics, and knowledge was associated with HPV test use but not counseling messages. CONCLUSIONS: Most physicians were aware of new information about HPV infection, but some were unaware of important information relevant for patient counseling. These topics have been highlighted in new clinical training and patient education materials.