Letters to the Editor
The Changing Role of Family Physicians in HIV Care
TO THE EDITOR: The article1 and editorial2 on care of patients with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) in the January 15, 2006, issue of American Family Physician emphasized the important medical services that family physicians can provide for patients infected with HIV, including health care maintenance, baseline evaluation and laboratory studies, and monitoring to guide the initiation of antiretroviral therapy and prophylaxis against opportunistic infections.
The role of family physicians will need to shift toward routine HIV screening for nearly all of our patients. The Centers for Disease Control and Prevention (CDC) recently released new guidelines that recommend making HIV testing routine.3 The new federal guidelines will recommend one-time HIV testing for everyone between 13 and 64 years of age, with annual testing for those with risk factors. The new CDC guidelines are not consistent with those issued by the U.S. Preventive Services Task Force, which did not find enough evidence to recommend for or against routine HIV screening.4 The guidelines also are in conflict with some state HIV testing laws. Nevertheless, it is likely that routine testing for HIV will soon become the standard of care.
Family physicians will need to dedicate additional time to discussing various aspects of HIV testing with patients, nearly all of whom will not be infected. It will be important to explain to patients that HIV now will be considered a routine test, one that they may refuse (the so-called "opt-out" option). Physicians can expect a fair number of false-positive tests in low-prevalence populations and should advise their patients about this possibility. In addition, physicians will need to be able to clarify certain test results, such as indeterminate tests and the meaning of a positive rapid HIV test before confirmation.
Routine HIV screening will give family physicians more opportunities to impede the spread of HIV and impact its clinical course in infected patients. In addition to referral to local experts, up-to-the-minute telephone consultation is available to assist the busy family physician in this important role.
One resource for advice on testing and other clinical issues is the National HIV/AIDS Clinicians' Consultation Center (NCCC). Many family physicians use the NCCC hotlines as a source of HIV consultation in providing primary care for HIV. The NCCC, located in the University of California-San Francisco Department of Family and Community Medicine, has three free and confidential telephone consultation lines: (1) the National HIV Telephone Consultation Service (800-933-3413) offers assistance to all clinicians, from those with limited experience with HIV to those with complex antiretroviral resistance dilemmas; (2) the National Clinicians' Post-Exposure Prophylaxis Hotline (888-448-4911), which provides guidance in managing occupational exposures to HIV and hepatitis B and C; and (3) the National Perinatal HIV Consultation and Referral Service (888-448-8765), which provides advice on HIV testing and antiretroviral use in the prenatal, intrapartum, postpartum, and neonatal periods. In addition, there are 11 regional AIDS Education and Training Centers with more than 140 local sites that provide training and consultation for primary care clinicians nationally (http://www.aidsetc.org).
REFERENCES
1. Khalsa AM. Preventive counseling, screening, and therapy in the patient with newly diagnosed HIV infection. Am Fam Physician 2006;73:271-80.
2. Kirchner J. Who should care for patients with HIV/AIDS? Am Fam Physician 2006;73:215-16.
3. Branson BM, Handsfield HH, Lampe MA, Janssen RS, Taylor AW, Lyss SB, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep 2006;55(RR-14):1-17. Accessed online September 21, 2006, at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm.
4. U.S. Preventive Services Task Force. Screening for Human Immunodeficiency Virus Infection. July 2005. Accessed May 9, 2006, at: http://www.ahrq.gov/clinic/uspstf/uspshivi.htm.
Connection Between Religion and Health Is Complicated Issue
TO THE EDITOR: The editorial by Drs. Weaver and Koenig in the April 15, 2006, issue of American Family Physician provides a helpful synopsis of recent studies regarding the relationship between religion and health.1 However, other literature suggests that this relationship is more nuanced than can be described by even high-quality studies.
Religious practice is heterogeneous. The beliefs, practices, and lifestyle of a Seventh-Day Adventist, for example, are different from those of a devout Muslim or orthodox Jew; yet, much of the medical literature on religion and health presumes a Christian context.2 Physicians generally lack the training to engage in in-depth conversations with patients about spiritual concerns.2 Differences in religious content become especially problematic when family physicians are urged to encourage and support their patients in religious activities.3 Despite the growing body of research linking religion to better health, certain religious practices may have negative health effects, as demonstrated by the ascetics and martyrs from the world's religions. If evidence eventually were to suggest that some religious denominations offer better health than others, should physicians guide patients toward those religions?
Attempts to quantify the effects of religion upon health may misrepresent religious practice. An instrumental approach to religion-that is, viewing religion as an intervention similar to antibiotics or surgery-may be deeply offensive to some people.2 Shuman and Meador assert that a utilitarian understanding of religion distorts the very nature of religion.4 A person who prays regularly solely because of purported health benefits may be involved in a substantively different activity from that of a person who follows the tenets of a particular religion out of faithfulness and humility. They further suggest that religious faith is not a commodity that can be exchanged for health.4
Physicians should have a basic knowledge of existing research on religion and health. Religious practice, however, is qualitatively different from other health behaviors such as quitting smoking5; research findings should be applied cautiously, if at all, to clinical practice.
REFERENCES
1. Weaver AJ, Koenig HG. Religion, spirituality, and their relevance to medicine: an update. Am Fam Physician 2006;73:1336-7.
2. Sloan RP, Bagiella E, VandeCreek L, Hover M, Casalone C, Jinpu Hirsch T, et al. Should physicians prescribe religious activities? N Eng J Med 2000;342:1913-6.
3. Matthews DA, McCullough ME, Larson DB, Koenig HG, Swyers JP, Milano MG. Religious commitment and health status: a review of the research and implications for family medicine. Arch Fam Med 1998;7:118-24.
4. Shuman JJ, Meador KG. Heal Thyself: Spirituality, Medicine, and the Distortion of Christianity. Oxford, U.K.: Oxford University Press, 2003.
5. Sloan RP, Bagiella E, Powell T. Religion, spirituality, and medicine. Lancet 1999;353:664-7.
in reply: Dr. Garrison addresses some important points about the relationship between religion and health and the potential applications of this relationship to clinical practice. Most of the current research does occur in a Christian context, mainly because approximately 80 percent of the population of the United States is Christian; however, a handful of studies in other religions have reported similar findings related to the effects of religion on health. Although physicians generally lack training on how to address spiritual issues in clinical practice, more than 85 of the 126 medical schools in the United States now offer elective or required training regarding these issues. Medical students are not being trained to "engage in in-depth conversations with patients regarding spiritual concerns," but rather to take a brief spiritual history and refer patients to chaplains or pastoral counselors if appropriate. Supporting a patient's religious beliefs is straightforward and does not depend on concordance between the beliefs of the patient and physician. However, the physician should not feel required to do so.
In general, prescribing which religion to belong to or whether to be religious at all for health reasons is ethically out of bounds for physicians, and we do not encourage this practice. On the other hand, understanding the role that a patient's religious beliefs plays in coping with illness, medical decision making, and medical outcomes (i.e., taking a spiritual history), and supporting healthy coping behaviors falls squarely within the scope of what good whole-person medical care is all about.
The article "Medications for Migraine Prophylaxis" (January 1, 2006, page 72) contained an error in the section titled "Pregnancy" on page 77. The second sentence of this section incorrectly listed fluoxetine (Prozac) as a U.S. Food and Drug Administration (FDA) pregnancy category B drug, and that it could be considered for preventive therapy of chronic migraine in women who are pregnant. In March 1997, the FDA reclassified fluoxetine as a pregnancy category C drug, and it should be used with the same caution as all pregnancy category C drugs in women who are pregnant. The online version of this article has been corrected.
The Point-of-Care Guides "Treating Adult Women with Suspected UTI" (January 15, 2006, page 293) contained an error in the patient encounter form on page 295. Under the Treatment Plan section, the dosage for levofloxacin (Levaquin) was incorrectly listed as 500 mg twice per day. The correct dosage is 250 mg once daily. The corrected encounter form is reprinted on page 1686 of this issue, and the online version of this article has been corrected.
Suspected Urinary Tract Infection in Women Encounter Form
Send letters to Kenny Lin, M.D., Contributing Editor, American Family Physician, e-mail: afplet@aafp.org. Letters submitted via regular mail should be sent to: 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-6272.
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