HIV Knowledge and Attitudes Among Providers in Aging: Results from a National Survey

Abstract

Within 5 years, half the U.S. HIV-infected population will be over age 50, and providers caring for older adults must deal with this reality. This study assessed attitudes toward people with HIV/AIDS and knowledge of HIV/AIDS among physicians with a geriatrics specialty, and nurses and social workers who specialize in gerontology. A survey mailed in 2008 to a random sample of U.S. providers yielded a 60% response rate. Main outcome measures included: Knowledge of HIV/AIDS, attitudes toward people with HIV/AIDS, and knowledge of issues related to HIV in older adults. General knowledge of HIV/AIDS was good with scores of 89%, 84%, and 81% for physicians, nurses, and social workers, respectively; groups differed significantly (F(2, 483)=18.626, p<0.0005). Attitudes were positive, with a significant main effect of profession on the attitude subscales (F(4, 952)=6.84, p<0.0005). Eighty-three percent of the sample were unaware that dementia due to HIV may be reversible; no significant differences by profession (χ²=4.50, p=0.105). The sample had difficulty ranking the four most common risk factors for HIV infection in older adults, with no significant differences among the professions (F(2, 483)=1.22, p=0.296). Only 6% of the sample correctly ranked all four risk factors. Estimates of the percent of U.S. AIDS cases in people over age 50 varied widely; few answered correctly, with no significant differences by professional group (F(2,319)=2.82, p=0.06). These findings highlight the need for further education among providers who specialize in aging.

Introduction

I t has been estimated that by 2015 half of all HIV-infected individuals in the United States will be over the age of 50.¹ Two factors are contributory to this figure: infection with HIV in later life and increased survival rates that enable adults with HIV to live into older age. The combination of HIV and aging is complex biologically,^1
–3 psychologically,^4
–6 and socially.^7
–9 Increasingly, providers of services to the aging population will see patients with, or at risk for, HIV. It is necessary to understand the preparation that experts in aging have to meet this new demand. To date, studies of provider knowledge of HIV and attitudes toward people living with HIV have not included providers in aging services, likely because HIV was previously seen as a disease of the young. This study was undertaken to understand knowledge and attitudes of providers in geriatrics and gerontology, and to examine variability across professions.

Methods

Study design and sample

This study used a cross-sectional research design to examine knowledge of HIV/AIDS and attitudes toward people with HIV/AIDS in a national sample of physicians, nurses, and social workers who specialize in gerontology or geriatrics. Data were collected systematically in the spring and summer of 2008 via a self-administered survey. Three professional membership organizations—the American Medical Association (AMA), the National Association of Social Workers (NASW), and the American Nursing Credentialing Center (ANCC)—randomly generated lists of approximately 300 members each who specialize in geriatrics (physicians) or gerontology (registered nurses and social workers). These organizations represent the largest national organizations of their kind for the respective professions.

Survey instrument/survey content

The survey instrument included three standardized measures: (1) the HIV Knowledge Questionnaire-45 (HIVKQ-45)¹⁰; (2) the AIDS Attitude Scale (AAS)¹¹; and (3) a short version of the Marlowe-Crowne Social Desirability Scale (MCSDS).^12,13 Demographic questions included retiree status, respondent age, gender, sexual orientation, ethnicity, relationship status, profession, highest degree, years of professional experience, and years of professional experience in gerontology or geriatrics.

Knowledge of HIV was assessed with the HIVKQ-45, a 45-item true/false/I don't know questionnaire. It has been shown to be a reliable, valid measure of HIV-related knowledge,¹⁰ and despite its age was the most psychometrically sound measure of general HIV knowledge available at the time of the study.¹⁴ The HIVKQ-45 has a potential score of 45 if all of the questions are answered correctly. In the current study the measure was found to have good internal consistency reliability (α=0.821).¹⁵

To augment the knowledge construct, the survey included additional questions related to knowledge of HIV/AIDS issues particular to older adults. These questions came from previous studies^16,17 that asked providers about HIV knowledge and included trends in HIV/AIDS in older adults; risk factors for HIV in older adults, and treatment of AIDS dementia. Providers were asked: (1) whether or not they thought dementia due to AIDS was reversible with appropriate treatment¹⁶; (2) whether or not the proportion of older adults contracting HIV through heterosexual transmission was decreasing¹⁶; (3) what percent of all AIDS cases in the United States have occurred in people aged 50 and over¹⁷ (13% of all AIDS cases since the Centers for Disease Control and Prevention [CDC] started tracking through 2006)¹⁸; and (4) to correctly rank the four most common risk factors for HIV transmission in older adults¹⁷ (Correct ranking: first=male to male sex, second=injection drug use, third=heterosexual sex, and fourth=blood transfusion).¹⁹

Attitudes toward persons who have HIV/AIDS were assessed via a modified version of the AAS.^11,20 The AAS was designed to measure health care providers' attitudes, and consists of two subscales: a 14-item avoidance scale and a 7-item empathy scale. The 21 items are rated on a 6-point Likert scale from 1=strongly disagree to 6=strongly agree. Mean scores for the AAS subscales range from 1 to 6, with a score of 6 on empathy representing high levels of empathy, while a 6 on the avoidance subscale represents a high level of avoidance. The AAS was chosen because it has been shown to be a reliable and valid measure of provider attitudes.²¹ In this study, internal consistency reliability was α=0.820 for the AAS avoidance subscale, and α=0.744 for the empathy subscale.

A 13-item version of the MCSDS¹² was used to detect bias on the self-report measures of knowledge and attitudes. This version is psychometrically sound, with reliability of 0.70 (in comparison to 0.75 for the full MCSDS scale),¹² internal consistency of 0.62, and convergent validity of 0.88 with the original MCSDS.²² Internal consistency reliability was found to be α=0.804 in the current study.

Survey procedure

The survey instrument was piloted in a convenience sample of 20 professionals from medicine, nursing, and social work to provide feedback about design and ensure comprehension and face validity. Modifications were made based on this feedback and an initial survey packet was mailed to the entire study sample of 903. The initial packet included a letter of introduction, a $5 Starbucks gift card incentive, the 4-page survey and a postage-paid return envelope. Consent was described in the cover letter and implied by return of the survey. The survey was appropriate for providers who had completed professional training and were not retired at the time of data collection. Survey recipients who were retired were asked to indicate their retiree status on the survey and return it unanswered. The survey method followed a modified tailored design approach.²³ Two weeks after the initial mailing, the entire sample was contacted via a reminder postcard, asking for return of the survey. An additional 2 weeks later a cover letter, replacement survey, and postage-paid return envelope were mailed to members of the sample who had not yet responded. The protocol was approved by the institutional review board at the author's university.

Data analysis

Data were cleaned and examined for non-normality, outliers, missing data, and other irregularities. Assumptions of analysis of variance (ANOVA) and multivariate analysis of variance (MANOVA) were checked and adequately met. Retirees were removed from the database and two cases were dropped due to excessive amounts of missing data (over 20% missing on dependent variable measure). Scores were calculated for the HIVKQ-45: one point for each correct answer; incorrect scores and “I don't know” answers were given a score of zero. Total scores could range from zero to 45. Subscale mean scores for the AAS were calculated. The General Linear Model (GLM) was used to determine the amount of variance in the dependent variables attributable to the multiple independent variables. The question that asked the respondents to rank risk factors was converted to a risk score that allowed them to get credit for relative ranking; while the percent of AIDS cases question was scored as the absolute value of the difference from correct.

Descriptive statistics were computed with the use of SPSS 15.0 software for Windows.²⁴ χ², ANOVA, MANOVA, and GLM were used to examine differences between groups of professionals. MANOVA analysis was performed on the two AAS subscales and ANOVA was performed on HIVKQ-45 scores to determine significance of group differences. Post hoc analysis of group differences followed the recommendations of Stevens.²⁵ Multivariate GLM analysis examined the impact of multiple independent variables (age, gender, highest degree, years of professional experience, years of professional experience in geriatrics/gerontology, relationship status, and profession) on the three dependent variables. Independent variables that were significant were then entered into a blocked regression to determine the effect of each of the independent variables on each dependent variable. Correlation of each of the dependent variables with scores on the MCSDS was calculated to test for the presence of social desirability bias. All statistical tests utilized a p<0.05 level of significance.

Results

Of the 903 surveys mailed to potential participants, 585 surveys were returned to the researcher. After removal of the retirees and two cases that were unusable due to too much missing data, the final sample size used for data analysis was 486, a response rate of 60%. Correlations of the social desirability scale with the dependent variables were all nonsignificant (HIVKQ-45: r=0.027, p=0.551; AAS-empathy: r= 0.002, p=0.962; AAS-avoidance: r=−0.047, p=0.317); therefore, scores from the social desirability measure were dropped from further analysis.

The majority of the sample were female, Caucasian, and heterosexual. Variability in ethnicity was found primarily in the physician subsample where less than 60% of respondents were Caucasian, in comparison to 88.1% of nurses and 87.1% of social workers. The average age of the sample was 51.5 (standard deviation [SD]=10.1), and ranged from 24 to 83 years old. The groups varied significantly on age by profession (F(2, 471)=42.23, p<0.0005), with physicians younger than both nurses and social workers (mean difference=−8.72 years and −9.84 years, respectively; p<0.0005). There was no significant difference in age between nurses and social workers. All groups differed significantly (F(2, 481)=63.52; p<0.0005) with regard to mean years of professional experience. Physicians, nurses, and social workers averaged 13.64 (SD=10.21), 26.31 (SD=9.3), and 23.64 (SD=9.6) respectively, with physicians having on average 12.66 years less professional experience than nurses, 10 years less experience than social workers (p<0.0005), and social workers having 2.67 fewer years of experience than nurses (p<0.0005). Years of experience in gerontology/geriatrics differed significantly by profession as well (F(2, 480)=45.27, p<0.0005). Physicians had 9.56 fewer years in geriatrics/gerontology than nurses and 7.32 fewer years than social workers (both significant differences at p<0.0005). Social workers had 2.27 fewer years experience in gerontology than the nurses. Sample demographics are detailed in Table 1.

Table 1.

Sample Demographic Characteristics (n =486)

	MDs n (%) ^a	RNs n (%) ^a	SWs n (%) ^a
Variable	M (SD)	M (SD)	M (SD)	F(df), p; χ² (p)
Age	111 (23)	190 (39)	173 (36)	42.23 (2, 471), <0.0005
	44.02 (9.15)	52.74 (7.87)	53.86 (10.88)
Years of professional experience	112 (23)	195 (40)	177 (36)	63.52 (2, 481), <0.0005
	13.64 (10.21)	26.31 (9.33)	23.64 (9.65)
Years of professional experience in geriatrics/gerontology	112 (23)	194 (40)	177 (36)	45.27 (2, 480), <0.0005
	9.68 (7.92)	19.27 (8.15)	17.00 (9.47)
Gender				79.92 (<0.0005)
Female	64 (57.1)	188 (96.9)	149 (84.2)
Male	48 (42.9)	6 (3.1)	28 (15.8)
Ethnicity				77.34 (<0.0005)
Caucasian	66 (59.5)	171 (88.1)	155 (87.1)
African American	5 (4.5)	7 (3.6)	9 (5.1)
Asian/Pacific Islander	33 (29.7)	11 (5.7)	4 (2.2)
Hispanic/Latino	2 (1.8)	4 (2.1)	7 (3.9)
Native American	0 (0.0)	0 (0.0)	1 (.6)
Other	5 (4.5)	1 (0.5)	2 (1.1)
Sexual orientation				20.78 (0.002)
Heterosexual	100 (93.7)	192 (100)	164 (92.7)
Bisexual	0 (0.0)		4 (2.3)
Gay/lesbian	6 (5.4)		9 (5.1)
Other	1 (0.9)		0 (0.0)
Relationship status (currently in a committed romantic relationship)				2.07 (0.356)
Yes	97 (86.6)	156 (80.4)	145 (81.0)
No	15 (13.4)	38 (19.6)	34 (19.0)
Highest degree earned				676.45 (<0.0005)
Doctorate	112 (100)	3 (1.6)	18 (10.1)
Master's		26 (13.9)	153 (85.5)
Bachelor's		106 (56.7)	8 (4.5)
Associate's/RN		52 (27.8)	0 (0.0)
Diploma

Percentages do not add up to 100 due to rounding; numbers do not add to a total of 486 due to missing values.

MDs, physicians; RNs, registered nurse; SWs, social workers; SD, standard deviation.

Scores on the outcome measures of HIV knowledge, as measured by the HIV KQ-45, and attitudes, as measured by the AAS, were compared across profession. Group means, standard deviations, and results of group comparisons are presented in Table 2. Multivariate analysis via GLM found that the independent variables of gender (F(3, 405)=4.31, p=0.005) and profession (F(3,405)=5.27, p<0.0005) had an effect on the combination of all dependent variables. When results were broken out by dependent variable, significant effects were only found for age, gender and profession on the HIVKQ-45; significant effects for profession were also found on the avoidance subscale of the AAS.

Table 2.

Group Means and Standard Deviations on Standardized Outcome Measures (Knowledge and Attitudes)

	MD (n=111)	RN (n=194)	SW (n=177)
Dependent variable	M (SD)	M (SD)	M (SD)	F(df), p
HIVKQ-45 Score^a	39.94 (4.17)	37.81 (4.42)	36.50 (5.22)	18.63 (2, 483), <0.0005
AAS-Avoidance^a,b	1.72 (0.69)	1.90 (0.70)	1.56 (0.60)	6.841 (4,952), <0.0005^c
AAS- Empathy^a,b	5.46 (0.69)	5.47 (0.71)	5.66 (0.69)	6.841 (4,952), <0.0005^c

Potential range of scores on HIVKQ-45=0 to 45; on AAS-A=1 to 6; on AAS-E=1 to 6.

Mean scores on subscale.

For set of AAS subscales.

MD, physician; RN, registered nurse; SW, social worker; HIVKQ-45, HIV Knowledge Questionnaire-45; AAS-E, AIDS Attitute Scale-Empathy; AAS-A, AIDS Attitude Scale-Avoidance.

Knowledge of HIV/AIDS

Significant differences were found between all groups on the measure of HIV knowledge (F(2, 483)=18.626, p<0.0005). Physicians scored significantly higher than nurses and social workers, while nurses scored significantly higher than social workers. Physicians scored on average 2.1 points higher than nurses, and 3.4 points higher than social workers. Nurses scored 1.3 points higher than the social workers on this measure. Scores on the HIVKQ-45 are number correct out of a possible total of 45; physicians scored on average 88.6% correct, compared to 84% correct for the nurses and 81% correct for social workers. Profession was found to have an effect on knowledge (F=7.152, p=0.001), it is a shared effect with age (F=7.59, p=0.006) and gender (F=9.148, p=0.003). Blocked regression found that profession contributes to the variance in knowledge above and beyond that contributed by age and gender (Model 1(age, gender) R ²=0.103; Model 2(age, gender, profession) R ²=0.121), by about 2%.

Knowledge of issues related to older adults and HIV/AIDS

Eighty-three percent of the sample (n=401) did not know that dementia due to AIDS may be reversible with appropriate treatment. There were statistically significant differences in who answered correctly: 30.4% of physicians, 11.8% of nurses, and 15.6% social workers (χ²=17.66, p<0.0005).

When asked if HIV infection due to heterosexual transmission is increasing in adults over age 50, two thirds of the sample correctly answered yes. Three quarters of the physicians (n=85) answered correctly compared to two thirds of the nurses (n=128) and the social workers (n=116). No significant difference was found between professions and the likelihood of answering this question correctly (χ²=4.50, p=0.105).

Participants were asked about the percent of AIDS cases in the United States in adults over age 50. Scores were calculated as the absolute difference from correct (13% of all AIDS cases, as measured by the CDC, from the start of the epidemic through 2006).¹⁸ The whole sample averaged 13.64 points off of correct (SD=12.43; range, 0–69), with physicians averaging 11.2 points from correct, nurses averaging 15.3 points from correct, and social workers averaging 14.0 points from correct. There were no statistically significant differences found between the groups of professionals (F(2, 319)=2.824, p=0.061).

Participants were asked to rank in order of frequency the top four risk factors for HIV infection in adults over 50. A ranking score was created that reflected correct position and relative ranking, with a total of 6 points given for correctly ranking all four risk factors. Ranking scores ranged from 0 to 6, with a mode at four correct responses (25.9% of the sample). Forty-nine percent of the sample got a score of 3 or below, and 51% scored a 3 or above. Six percent of the sample answered all four risk-ranking questions correctly. There were no statistically significant differences found between groups of professionals (F(2, 483)=1.22, p=0.296) on this question.

Attitudes toward people with HIV/AIDS

When looking at attitudes, the profession main effect was significant for the set of two dependent variables, AAS-Empathy and AAS-Avoidance (Wilks' λ=0.945; F(4, 952)=6.841; p<0.0005; partial η²=0.028), indicating that the three groups of professionals differ significantly on the two attitude subscales. Post hoc analysis via Tukey's test²⁵ was conducted to see where the differences were between groups. Statistically significant differences between nurses and social workers were found on the avoidance and empathy subscales of the AAS. Significant group differences were not found between the physicians and either of these groups on either subscale. Nurses mean scores for avoidance were 0.35 points higher than social workers (p<0.0005). The empathy subscale results are similar in that mean scores for nurses were 0.18 points lower than their social work counterparts (p=0.043). In the GLM multivariate analysis profession was the only independent variable that had an independent effect on the attitude construct, and that occurred for the avoidance subscale only (F=7.152, p=0.001).

Discussion

Results of this study show that in this group of providers general HIV knowledge was good, as measured by the HIVKQ-45. However knowledge of issues related to HIV and older adults was not as good. Attitudes were generally positive and when differences were found they were small. The results related to general HIV knowledge and provider attitudes toward caring for people with HIV/AIDS are consistent with results from previous studies. To date there have been very few studies of provider knowledge about HIV issues related to older adults; these results add to that small body of literature.

Knowledge of HIV/AIDS

This study is consistent with prior studies that assessed knowledge of HIV/AIDS in physicians and nurses^26

–29 in that general HIV knowledge was good for the sample as a whole. It was expected that professional providers would perform very well on this measure as it was created for the general public, and was somewhat surprising that providers did not have higher scores. The HIVKQ-45 is a test of knowledge that the average American might have of the disease; several of the questions deal directly with myths about HIV transmission.¹⁰ Physicians scored the highest of all three professions; this may be reflective of their more recent professional education in comparison to the other providers. The results may, in part, reflect measurement error as the HIVKQ-45 is an older measure that includes some items that are outdated.

Knowledge of issues related to older adults and HIV/AIDS

Consistent with previous studies,^16,17 provider knowledge of issues specific to older adults in this study was low. In the current study, physicians did not correctly rank the four most common risk factors for HIV infection in the older adult population, and this is consistent with previous findings from a study of primary care physicians.¹⁷ Almost half (47%) of physicians in the current study were unable to correctly rank any of the four most common risk factors. Part of the difficulty with this question may have been its format. Ranking can be difficult for respondents in that it asks not only for content awareness but also some manipulation of that content. It was also identified that providers had trouble estimating the percentage of AIDS cases in the United States that have occurred in the over-50 population. This may be due to measurement error in that the item could be interpreted in different ways, all of which yield different answers. However, even with this in mind, provider responses covered a broad range, indicating in some instances that over 70% of AIDS cases occurred in those over 50. This is suggestive of providers guessing at the correct answer and a knowledge deficit of the trends of HIV infection.

It is vital for providers of geriatric and gerontology services to be aware that dementia due to HIV may be reversible. The presentation of dementia or cognitive concerns is prevalent in geriatrics and gerontology practices. The vast majority of providers in this study were not aware of this issue, indicating a lack of awareness of the power of antiretroviral medications, and a missed opportunity to reverse a devastating condition. In a 1998 study,¹⁶ it was found that the majority of health care providers in the sample did not know that dementia due to HIV was reversible; a finding repeated in the current study in which 83% of all respondents did not have this knowledge.

When looking at knowledge specific to older adults and HIV, it appears that the majority of this sample of professionals needs further education on these issues. The exception for all professionals was the awareness that HIV was increasingly being spread among older adults via heterosexual contact, with two-thirds of the sample responding correctly to this item. However, these results may not be indicative of specific knowledge about HIV and older adults. Providers may have been aware of trends indicating increased heterosexual transmission in other populations, or general transmission trends in the United States.³⁰ Providers may have been inferring that this is also true in the older adult population.

Attitudes toward people with HIV/AIDS

Attitudes were generally positive across the sample. This is consistent with past literature that indicates a lack of extreme attitudes on the parts of providers.^{26

–29,31
–33} When differences were found, such as those between nurses and social workers, the differences were small. While significant statistically, the effect size of this relationship was weak and the practical significance of these differences may not be that important. It was found that nurses tend toward more negative attitudes in comparison with social workers and physicians. Previous research on physician and nurse attitudes toward people with HIV/AIDS has shown that, in general, physicians tended to have more positive attitudes than nurses.^26,27,32,33 There are no recent studies of social worker attitudes to examine in comparison.

Results of this study should be considered along with its limitations. The cross sectional nature of this research does not allow causal inferences to be made. The use of self report measures does not allow participants to clarify responses or ask any questions about survey content, which can increase the total survey error.³⁴ Measurement issues for some survey items may have contributed to minor loss of data or uninterpretable responses. The HIV knowledge measure is dated and some of the items are outdated and do not have one clear answer. The items used to measure knowledge of issues related to older adults and HIV/AIDS lacked clarity in some cases that may have contributed to confusion in responses. As well, the answer formats for the items asking providers to rank risk factors and give the percentage of all AIDs cases in those over age 50 may have contributed to their difficulty in answering the questions. These factors should be considered when looking at the findings regarding HIV knowledge. With a response rate of 60% it must also be considered that the study sample may not fully represent providers in geriatrics and gerontology. Information was not collected from nonresponders so it is unclear in what ways the sample differs from the source population. Finally, the findings may not be generalizable to providers outside of geriatrics/gerontology.

Despite these limits, the study provides valuable information on some previously unstudied phenomena. It is quite common for social workers, nurses, and physicians to work together in providing both gerontological health services and HIV services. Different professionals contribute unique strengths to the team and good working relationships are essential. In the area of HIV care, attitudes have been shown to impact care that is given.³⁵ Knowing that team members share generally positive attitudes toward caring for people with HIV and AIDS eliminates one hurdle in providing excellent patient care. However this attitudinal preparation, while necessary, is not sufficient to provide competent clinical care to older adults at risk for, or infected with, HIV. Studies of older adults with HIV or AIDS show the complexity of aging with HIV or AIDS.^36,37 Comorbidity with other illnesses is common,^38,37 thus complicating the clinical picture. In addition, HIV-infected individuals on treatment have been found to experience “accelerated aging” in multiple bodily systems.^39

–42 These complications and complexities will continue to challenge all providers, and geriatric/gerontology providers will need to be prepared to manage these patients. The management of complex care is not new to providers of gerontological and geriatric care, however the HIV/AIDS arena may be. This research identifies the need for provider training in the area of HIV/AIDS and the older adult. Professional continuing education could potentially address the identified knowledge gap.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

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