Background/Objectives: Despite the 1993 CDC recommendation for routine, voluntary HIV testing in communities with an HIV prevalence >1 %, up to 40% of patients are still diagnosed with CD4 counts less than 200.  Patients have come into contact with the health care system anywhere from 5 to 11 times prior to diagnosis, representing missed opportunities for early diagnosis and intervention. New York City remains the epicenter of the HIV/AIDS epidemic in the United States. This study was designed to better understand physician barriers to HIV testing in a large, urban New York City hospital. 

Methods: Surveys were distributed to 137 Internal Medicine residents and 47 General Internal Medicine attendings from June 16- August 10, 2005. The survey response rate was 64%.

Results: Internal Medicine Residents reported that they ordered a median of 5 HIV tests over the prior year, while General Internal Medicine attendings reported ordering a median of 8 HIV tests. 41% of residents and 84% of attendings were prompted to order an HIV test if the patient was MSM. 64% of residents and 81% of attendings were prompted to order an HIV test if the patient had heterosexual contact with an HIV positive person. 96% of residents and 94% of attendings reported that they were comfortable discussing sexual behavior and HIV status; however, only 54% and 81%, respectively, reported initiating risk behavior discussions. More than half of attendings only discussed sexual activity at specific events, and only 10% of attendings reported that they routinely ask about reasons for engaging in risk behaviors. Primary barriers to discussing risk behaviors identified by all respondents included (1) lack of time, (2) more important priorities, and (3) language barriers. 65% of General Internal Medicine attendings and 70% of Internal Medicine residents reported that an intake questionnaire would help facilitate risk behavior discussions.

Conclusion: Physician barriers to HIV testing exist in a large, urban academic medical center. While physicians reported feeling comfortable discussing risk behaviors, time constraints appear to prevent them from translating this into clinical practice. Routine, voluntary HIV testing should be incorporated in large, urban medical settings to avoid missed opportunities to impact the HIV/AIDS epidemic.