Austria currently has a “low incidence” of AIDS cases, ranking 12th among 32 European countries (World Health Organization [WHO], 1990). The Austrian Federal Ministry of Health had recorded 474 AIDS cases by the end of September, 1990. The Ministry estimates that, among the Austrian population of 7.6 million people, 6,000 to 8,000 persons are infected with human immunodeficiency virus (HIV) (Möse, 1991).

As a global increase in the rate of HIV infection must be expected, further educational efforts will be needed to promote safe behaviors of persons at risk and help them maintain consistent behavioral change. Several studies have focused on possible predictors of behavioral change of persons at risk, for example, Allard, 1989; Klein, Sullivan, Wolcott, Landsverk, & Fawsey, 1987; Montgomery et al., 1989.

Until recently, in considering the history of sexually transmitted diseases (Brandt, 1988), little attention has been focused on the critical role that physicians have always played as health educators and opinion leaders in their communities. Facing the HIV epidemic today, there is increasing evidence that physicians are a highly trusted source of AIDS-related information (Freimuth, Edgar, & Hammond, 1987; Manning & Balson, 1989) and much is expected of them in this arena. There is little doubt that suitably prepared physicians could play an increased, key role in educating and motivating their patients to apply HIV-risk-reducing behaviors.

The involvement of physicians in HIV prevention counseling not only provides them opportunities to assess a patient’s risk of HIV infection in a private setting and offer adequate counseling and education to large parts of the population, but also is a way to reduce the physicians’ own risk of HIV infection. Certainly, if physicians and their patients were more open about AIDS specifically and sex behavior in general, patients would be more likely to be honest in discussing high-risk and other questionable activities. Unfortunately, many physicians seem unwilling or unable to provide general or HIV-related sex and disease counseling (Mime & Keen, 1988), and not all patients expect or would welcome it.

Several studies have evaluated the AIDS-related knowledge, attitudes, clinical experience, and practices of primary care physicians (Lewis, Freeman, & Corey, 1987; Searle, 1987; Shultz, MacDonald, Heckert, & Osterholm, 1988; Sibbald & Freeling, 1988). Other studies have focused on more personal factors experienced by physicians when dealing with persons with AIDS. These factors included the individual’s sense of responsibility. the desire to help others in need, fear of infection, homophobia. discomfort in dealing with drug addicts, and feelings of helplessness and grief (Frierson & Lippmann 1987; Richardson, Lochner, McGuigan, & Levine, 1987).

Lately, there has been increasing interest in those factors that influence physicians’ readiness to work as health educators with their patients at risk (Fredman, Rabin, & Bowman, 1989; Milne & Keen, 1988). Recent studies also described different factors as having impact on physicians’ readiness to treat persons with AIDS (Richardson et al., 1987; Somogyi, Watson-Abady, & Mandel, 1990). Since most, if not all, of these reports are of physicians in English-speaking countries, we conducted a questionnaire study to determine AIDS-related knowledge, attitudes, and practices (K-A-P) among Austrian physicians and to assess which of several factors are related to their readiness and willingness to provide HIV-related health education.



In Austria, health care is nationalized and general practitioners, internists, and dermatologists are the “family” physicians available to all citizens. They are usually among the first to be consulted by someone with illness and are in a good position to detect symptoms of HIV disease. They are also in a good position to educate their patients about HIV prevention. For these reasons, we chose these three groups of physicians for our survey. For our sample, we selected all physicians in the abovementioned specialties whose practices were in the city of Graz (240,000 inhabitants), the second largest city in Austria1. A minimum time of at least 6 official practice hours per week was also set for inclusion in the study. Using these criteria, 148 physicians were available for our survey.

In June, 1990, all 148 physicians were informed by letter that a colleague would personally bring them an anonymous questionnaire designed to help assess general awareness of HIV disease/AIDS and designed to probe their training needs and desires regarding these problems. During this personal contact, the physicians were further informed of the purpose of the study, allowed to ask any questions they might have, and were asked to full out the questionnaire within 2 weeks and send it back anonymously. Of the physicians that were contacted, 16 (9%) did not want to participate because of lack of time or lack of interest. Of the 132 questionnaires distributed, 78 were returned for a response rate of 59%. In regard to all 148 physicians contacted, the response rate was 53%. Since there was personal contact originally and the returns were anonymous, there was no follow-up request. We also think the personal contact enhanced response reliability.

Among Graz physicians working in the specialties of general practice, internal medicine, and dermatology, our survey respondents, in comparison with data provided by the Austrian Medical Association, were a representative sample regarding gender, marital status, and specialty (Table 1). In regard to age distribution, more respondents than expected were below 40 years of age (n = 33) and fewer were above 60 years of age (n = 11) [Χ2 (2, N = 148) = 15.30, p <0.01.] For our respondents, this and other aspects of their practice are indicated in Table I.


The questionnaire included approximately 100 questions grouped into different sections. The first section dealt with demographic and professional details of the physicians and their practices. This included questions on gender, age, marital status, specialty, years in practice, average number of patients per month, and so on. The second section asked specifically of experience with HIV-positive patients. Following questions asked how the physician dealt with aspects of HIV risk assessment, HIV disease assessment, HIV counseling, and the use of referrals.

There were several open-ended and four direct and specific HIV-related knowledge questions to be answered either Yes, No, or Don’t know. Another section also contained items that dealt with matters that might pose potential conflict or stress for physicians. These items were rated on a 5-point I.ikert scale (“Strongly disagree” to “Strongly agree”).

Participants were furthermore asked to give their estimates of their own professional risk of HIV infection on a 5-point rating scale (“No risk” to “Absolute risk”) and how they might deal with the situation of themselves being HIV-positive. Lastly, we included questions regarding interest in continuing medical education.

Table 1. Responder Characteristics (%)

Population of
all physicians
(N = 118)
(N = 78)
 General practice
61 2
 Internal medicine
29 5
21 8
25 6
Married: yes
 Younger than 40
 Older than 60

Characteristics of their Practices
No. of patients per month
 Mean = 529
 Median = 400
 Mode = 500
 Range = 20-3200

No. of HIV tests ordered within last year
 Sum = 568
 Mean = 7.3
 Median = 3.0
 Mode = 0
 Number of physicians ordering tests = 55 (71%)

No. of HIV-positive patients seen in the office:
 Total sum = 53 by 19 (24%) of 78 physicians
 Asymptomatic patients: sum = 20: mean = 0.26
 Symptomatic patients: sum = 28: mean = 0.37
 Patients with AIDS: sum = 5: mean = 0.07

No. of patients having themselves asked of HIV risk factors within last month:
 Sum = 219
 Mean = 2.8
 Median = 1.0
 Mode = 0

Perceived % of their own patients they think have no risk of HIV infection within next 5 years:
 Mean = 81.6
 Median = 94.0
 Mode = 95.0


All data were analyzed with the SPSS computer package. In most cases, simple percentages are indicated in our tables. They are based on the number of available responses, usually 78, for each particular question. HIV tests for significance utilized were Χ2, t-tests, and ANOVA. Pearson coefficients were used to evaluate correlation (Bortz, 1989).

After a review of the responses, factor analysis of the principal components revealed relevant groups of pertinent questionnaire items: “factors.” The factors were rotated through orthogonal and oblique procedures. Since the oblique rotation, which enables factors to be correlated, produced uncorrelated results, orthogonal rotation served as a preferred basis for the construction of the subscales. Two subscales were computed by adding the scores of the items loading on one of the factors. Coefficient alpha (0 to 1) was calculated for these subscales as a measure of internal consistency. High values indicate high internal consistency (homogeneity). Factor analysis revealed attitudes related to how the respondents dealt with the HIV epidemic.



Our respondents estimated they saw from 20 to 3,200 patients per month, with an average of 529 (Table 1). Nineteen physicians (24%) indicated experience with at least one HIV-infected patient in their office. Fourteen of these 19 physicians reported that the HIV-infected patients had informed them about their HIV status, whereas 5 of the 19 physicians had diagnosed persons as HIV-positive. Only 7 patients were diagnosed by these physicians as HIV-positive. The maximum number of HIV-positive patients seen by any one physician was 17. Most HIV-positive patients themselves informed the physicians of their HIV condition. Our physicians reported seeing 20 asymptomatic and 28 symptomatic patients with HIV disease and an additional 5 with full AIDS (Table 1).

Respondents who reported experience with an HIV-positive patient had higher estimates of their own professional risk, on a 5-point scale, than respondents who reported no experience with an HIV-infected patient. The respective means for these groups were 2.47 vs. 2.05, t(76) = 2.76, p < .01. Furthermore, there were significantly more male than female physicians reporting experience with an HIV-infected patient; only one female physician had such an experience [Χ2 (1, n=78) = 5.47, p < .05]. No such correlation existed between experience and age group or specialty.

Only 12% of our respondents used protective gloves when doing routine blood work, but 35% said they used them under special circumstances, for example, when they knew the patient was infectious with HIV or hepatitis B (13%); suspected HIV or hepatitis B (13%); or knew the patient to have a high-risk medical history (9%).

Among our physicians, 55 (71%) ordered a total of approximately 568 HIV antibody tests in the previous year (mean/physician = 7.3). No such tests were ordered by 29% of the physicians.

As part of a generalized HIV health education campaign in Austria, 2 of our responding physicians had HIV information posters in their offices, 41 (53%) had HIV brochures available, and 9 (22%) had both posters and pamphlets available. No significant correlation was found between having such material available and having patients spontaneously ask of HIV risk factors.

About 91% of the respondents could correctly identify a list of common symptoms associated with HIV disease: fever, weight loss, diarrhea, lymphadenopathy, weakness, and night sweats. However, only 58% of the respondents knew that HIV is less infectious than hepatitis B virus, and only 40% of the respondents knew that a medical treatment for asymptomatic HIV-infected persons is available; 27% were uncertain, and 32% thought there were none. Only 12% of the respondents knew that the ELISA test does not minimize the number of false-positive results.

When physicians were asked, in an open-ended question, how many years it takes “according to current medical opinion” until 50% of HIV-infected persons get full-blown AIL)S. the overall estimate was a mean of 6.1 years (mode = 5.0; median = 5.0). Regarding this question. those physicians who reported experience with HIV-infected persons had significantly lower estimates of the number of years than those without this experience (mean = 5.1 vs. mean = 6.4, t(72) = 2.47, p < .05).


The attitudes of our physicians to various components of HIV/AIDS medical practices that might pose potential conflict or stress to the physician are given in Table 2. We can see that basically our respondents are concerned with their professional obligations and competence, their personal safety, and the personal background of their patients.

In regard to “whether they can really help an HIV-positive individual” and “whether a physician should have the option of refusing to treat an HIV-positive individual,” they are fairly evenly spread in their opinion. They almost uniformly agree that patients would stop seeing them if they were known to treat many HIV-infected persons. and that all society should be aware that the HIV epidemic is a major health problem in the general community.

Eight items listed in Table 2, dealing with potential areas of stress for physicians, were determined by factor analysis to probe prime attitudes reflective of the way physicians cope with the HIV epidemic. Two factors with eigen value > 1 were extracted, thereby explaining 43% of the variance. These factors are indicated by (R) or (I) in Table 2. We labeled these factors “Reluctance,” a measure of the physician’s attitude in dealing with high-risk individuals or sex-relative issues and also showing a close connection with underlying emotions (Factor 1), and “Infection” (Factor 2) which reflects the physician’s fears toward dealing directly with HIV. Reluctance accounted for 25% of the total variance (coefficient alpha = .70). Infection accounted for an additional 18% of the total variance (coefficient alpha = .64).

Neither of the two scales were related to personal variables of the respondents such as gender, marital status, and age group or to their specialty. Both subscales were, however, related to several variables of the physicians’ HIV -behavior patterns as described below.

Table 2. General Attitudes (%)

Strongly Agree
1. Concern with my own risk of getting infected with HIV at work could eventually prevent me from adequately looking after HIV-infected patients. (I)
2. I feel uncomfortable when explicitly asking my patients about their sexual activities (e.g., vaginal, oral, anal intercourse). (R)
3. I feel capable of really helping an HIV-infected person
4. If not required, I would not treat HIV-infected persons regardless of the stage of the disease. (I)
5. I think a physician should be able to refuse to care for HIV-infected patients. (I)
6. I do not think it necessary that all society be aware of the HIV epidemic as a major health threat to the general community.
7. I think I have sufficient knowledge to adequately treat patients with HIV disease.
8. I feel uncomfortable when touching a male homosexual during a physical examination (R)
9. I think that homosexual behavior is unacceptable and harmful. (R)
10. I think a woman infected with HIV through sexual intercourse leads a dubious lifestyle. (R)
11. It is disturbing to have prostitutes coming to my practice. (R)
12. I think I would lose some of my patients if they knew I treated many HIV-infected patients.
13. It is disturbing to have drug addicts come to my practice.

Notes (I) = infection factor; (R) = reluctance factor (see text).


Twenty-four percent of the respondents indicated they had never assessed risk items for HIV infection. Yet, 59% of the physicians indicated that within the last month, between 1 and 40 of their patients (mean 2.8; median = 1 .0; mode = 0.0) spontaneously initiated questions about their risk of HIV infection. No significant correlation existed between having patients ask these questions and the physicians’ sex, age, or specialty.

When physicians were asked which of 14 possible risk items for HIV infection they routinely assess (Table 3), only three-fourths of the responders said they included such an assessment in their patient work-up. Among those who did, far less willingness was expressed to explicitly ask about sexual activities involving multiple partners, anal, vaginal, or oral intercourse than all other potential risk factors for HIV infection. Furthermore, the number of potential risk factors that were routinely assessed was positively correlated with high scores on the Infection subscale (r = .26, p < .05). When these responses were checked for correlation with the sex. age, and specialty of the respondents, the only significant correlation found was that more male than female physicians asked about oral sex as a risk factor for HIV transmission [Χ2 (1, n = 78) = 4.4, p < .05].

Our respondents estimated that about 82% of their patients would have no risk of HIV infection within the next 5 years. Those physicians who reported experiences with HIV-infected persons had significantly lower estimates of the percentage of their patients who would have no risk of HIV infection within the next 5 years than those without this experience (mean = 60.8% vs. mean = 87.8%; t(76) = 2.56, p < .05). Nevertheless, 38% of the physicians correctly estimated that there were already more than 5,000 HIV-positive individuals in Austria, and 22% estimated that there were already more than 10,000 HIV-positive individuals in Austria. Eight percent of the respondents estimated there were fewer than 1,000 HIV-positive persons in Austria.

Table 3. Assessment of HIV Risk Factors

Physicians that assessed for HIV risk factors: n = 59 (76%)
% of 59 responders who routinely assessed each risk factor
Having had sex with an HIV-positive individual or one at risk for HIV infection 85
Having had blood transfusion between 1977-85 85
Illegal drug use in general 82
Having received blood products (e.g.. for hemophilia) 78
Sharing of drug injecting equipment 69
Mate homosexuality 65
Having had sex with someone from Africa, Caribbean, Brazil, Thailand. or Philippines 65
Having had sex with a female or male prostitute 64
Exposure to blood of an HIV-positive individual 62
Having sex with multiple partners 60
Working as a prostitute 54
Anal intercourse 36
Vaginal intercourse 28
Oral intercourse 28


Sixty-two percent of the respondents reported that they had provided at least some HIV risk-reduction counseling (Table 4). The remaining 38% admitted to providing no such counseling. Survey participants were then asked which of several risk reduction recommendations they offered patients at risk. Only a minority of physicians offered a full range of risk reduction counseling.

Adequate risk reduction recommendations such as “always use condoms,” “only use new sterile needles for injecting drugs,” and “no sharing of needles” were less often offered by respondents with high scores on the Reluctance subscale (r = -.24, p < .05) (Table 4). No significant correlation was found between the readiness to provide HIV counseling and the sex, age, or specialty of respondents.

Table 4. Risk-Reduction Counseling

% Responders saying they provide the following risk reduction recommendations, n = 48 (62%)
Always use condoms 74
Only use new sterile needles for injecting drugs 64
Give up drugs 63
Don’t share needles 62
Reduce the number of sex partners 50
Recommend monogamy 41
Explain cleaning and sterilization of needles 18
Recommend sexual abstinence 6


Fifty-six percent of the respondents reported that they would refer to another physician any patient, on clinical suspicion alone, they considered to be HIV-positive. Ninety-three percent of the respondents reported they would recommend an HIV test to a person they suspected was infected with HIV. Yet, 21% indicated they would test such patients anyway without informing them!

In the case of a positive HIV antibody test, 49% of the respondents reported that they would refer the infected patient for treatment of the HIV (disease only, but another 43% of the respondents reported that in this case they would refer the HIV-positive patient for all further treatment; they themselves would stop treating this patient. Only 8% would continue all care for this patient.

Physicians who would refer HIV-positive patients away for all further treatment simultaneously displayed higher scores on the Reluctance subscale (means 18.37 vs. 15.96; t(61) = 2.16, p < 05) and higher scores on the Infection subscale (means 12.14 vs. 8.36; t(61) = 5.71, p < .001). There was, however, no correlation with their knowledge, age, or specialty. Significantly more female than male physicians would refer an HIV-positive patient for all further treatment [Χ2 (1, n = 67) = 4.26, p < .05).


Asked if they would work in a multidisciplinary team engaged in HIV patient care, 27% of our respondents indicated they were willing, 42% indicated they were not, and 31% said they were uncertain. Physicians who would be willing to work in an HIV team, in contrast with those who would be unwilling to, displayed: (a) lower scores on the Infection subscale (means 9.24 vs. 11.52; t(52) = 2.64, p < .05) and (b) lower scores on the Reluctance subscale (means 16.45 vs. 19.33; t(52) = 2.20, p < .05). There was no correlation with sex, age, or specialty.


The respondents were asked which of four different medical education programs on HIV/AIDS should be offered by the Austrian Medical Association. They could choose more than one. Seventy-four percent of the respondents expressed interest in an education program on clinical symptoms and therapy of HIV infection, and 60% of the respondents expressed interest in a seminar on counseling patients about risk behavior, HIV-antibody testing, and psychological problems of infected persons. Thirty-four percent expressed interest in a seminar on stress and risk reduction for the physician, and only 23% of the respondents would be interested in a seminar on how to take a sexual history. No correlation existed between their view toward continuing medical education and age, sex, or specialty.

Seventy-eight percent of the respondents reported that they would participate in one of the four medical education programs on HIV/AIDS if this program took 2 hours (or less), was inexpensive (cost less than about $20 U.S.), and was offered in Graz. Nine percent indicated they would not participate regardless. Respondents who reported that they would not participate in one of these four medical education programs on HIV/AIDS displayed higher scores on the Reluctance subscale than respondents who reported that they would participate (means 18.01 vs. 13.86; t(65) = 2.31, p < .05). There was no correlation with sex, age, specialty.

One correlation with age we did find was that physicians above 60 years of age were less interested in a seminar on counseling patients than were their younger colleagues, particularly those younger than 40 years of age (Χ2 (2, n = 77)  = 9.24, p < .0 1. Those physicians with more patients per month were also less likely to be interested in such a seminar on patient counseling (with the main effect between those doctors having “more than 700 patients per month” and those having “fewer than 500 patients per month” [Χ2 (2, n = 77) = 10.04, p < .01.

In an open-ended question we asked our physicians what they thought would be good measures to help their work on AIDS. Twenty-six percent of the respondents asked for more public HIV/AIDS information campaigns on TV and radio, in magazines, and in newspapers. Many also wanted more education done in the schools and directed toward high-risk groups. Also requested were special video tapes for physicians, more articles on treatment in medical journals, and the opportunity for them to attend supervised sessions for the discussion of different problems that might arise in dealing with HIV-positive individuals and persons with AIDS.


Among the most sensitive questions we asked concerned the physicians themselves or their colleagues becoming infected with HIV (Table 5). More than 20% of the respondents felt they were at moderate or high-risk of infection. Only 9% felt the’ were not at any risk, and none thought they were at absolute risk. Most, 69%, thought they were only at slight risk. No significant differences were found between the estimate of risk and gender or specialty.

Yet, physicians had significantly different estimates of their professional risk with regard to their age. Physicians below 40 years of age had the highest estimates of risk (mean = 2.36), those between the ages of 40 and 60 had the lowest estimates (mean = 1.94) and those older than 60 had a middle estimate (mean = 2.18; F(2, 75) = 4.47, p < 0.05).

Our physicians were also asked if they would be willing themselves—due to their professional risk—to be regularly tested for HIV infection. Fifty-three percent said they would be willing, 18% said they would not be, and 29% said they were uncertain.

More than half (55%) indicated that, if personally infected, they would practice as long as possible and tell neither colleagues nor patients about their situation. The majority anticipated that their colleagues would discriminate against them and not support them.

Those professionals considered most at risk of infection were dentists. surgeons, and dermatologists. Those considered least at risk were general practitioners and internists.

Table 5. Physician’s Own HIV-Infection

Self-estimate for risk of HIV infection
% (n)


If you were HIV-positive yourself, would you:
% (n)
% (n)
% (n)
Continue to practice as long as possible?
55 (43)
21 (16)
24 (19)
Maintain complete confidentiality of your condition?
55 (42)
26 (20)
19 (15)
Expect support from your colleagues?
17 (13)
70 (54)
13 (10)
Expect discrimination from your colleagues?
54 (41)
24 (18)
22 (17)


There is little reason to think that our sample of responding physicians is not representative of all physicians in Graz or Austria. They do  generally appear to reflect the gender, marital status, and specialties of physicians in Graz. Our respondents were a somewhat younger group than average, but we can not predict how that might influence their responses.

Three-quarters of our respondents had not yet recognized any contact with an HIV-positive patient. Of those who had, such contact seemed quite limited. Most of the HIV-positive individuals seen by our physicians themselves informed the practitioner of their HIV status. These patients might have learned of their positive diagnoses from testing at an anonymous testing site or a blood donation site. They also might have learned of it while applying for the army.

It is likely that many individuals, feeling themselves at risk for HIV disease, might first present themselves for anonymous testing at such sites. These are government funded and, aside from the army tests, provide anonymous testing by nongovernmental AIDS help organizations (NGOs) such as the Austrian AIDS HILFE. These NGOs do not offer medical care. The individual, if found positive, might go directly to an independent physician or a specific government-funded clinic committed to HIV/AIDS. (None of our respondents worked at such a clinic.)2

Spontaneous suspicion of HIV infection among our physicians did not seem high. Of an estimated average of 6,000 patients seen per year per physician, fewer than 600 HIV tests were ordered in total (about 1 test per 700—800 patients). Some 30% of the respondents did not order any. This low incidence of suspicion is also reflected in their low estimate of patients at potential risk for the next 5 years. Since only 53 patients were known to our respondents to be HIV-positive, with symptoms or not, their clinical appraisal is also low. Recall that only seven persons were diagnosed HIV-positive by our 78 respondents during the past year.

Considering an HIV-positive prevalence rate of about 1.0 per 1,000 (Möse, 1991), and more if we consider only adults, each physician might be expected to have come to his/her office at least one HIV-positive person per year. Since many HIV-positive individuals are asymptomatic, particularly early in the epidemic, and as we will discuss below, about one-quarter of our respondents never assessed them for HIV risk, most HIV-infected individuals pass undetected. They miss adequate and early treatment and our physicians also become at risk.

Unless vigilance is increased, a large number of HIV-positive patients will continue to pass undetected. And the number will increase, since the average timespan between HIV infection and the appearance of AIDS is now known to take, on average, some 8 to 11 years (Lifson, Rutherford, and Jaffe, 1990), while our respondents thought about 5 or 6. On the other hand, since 1988, there has been a decreasing number of newly detected cases of HIV infection per year (Möse, 1991). It is our impression that this reflects a reluctance of individuals to appear for testing rather than a real reduction in the rate of infection. Individuals are known to hesitate or refrain from seeking medical attention, since some clinics test for HIV infection without informing the patient—even though it is against Austrian law and, as found elsewhere, many do not want to know their antibody status (Higa & Diamond, In press).

This disparity in statistical risk and office practice is also seen by the fact that only a minority of physicians use protective gloves for routine blood work or even when dealing with known or suspected HIV or hepatitis B patients. The actual risk is also at variance with the vigor of the HIV risks routinely assessed for in their patients. We think this denial of reality is a reflection of overall reluctance to deal with HIV and AIDS issues, and we interpret much of the survey responses in that light. We thus see a parallel between the way many patients and many physicians react to this disease.

The level of HIV knowledge as measured by our questionnaire was less than desired. While nine of ten physicians could recognize the common symptoms associated with HIV disease, fewer than half knew there were treatments available for asymptomatic cases and only slightly more than half knew that hepatitis B was more infective than HIV. The danger of a false positive result from an ELISA test was also only recognized by a few. Despite these sorts of findings, more than half the responding physicians felt they had sufficient knowledge to adequately treat HIV disease. Kittleson and Venglarcik (1990) had similarly reported that physicians don’t always know as much about HIV/AIDS as educated lay persons, although they perceive themselves as quite aware. This was seen particularly so in regard to sexual means of transmission and treatment modalities (Schram, 1989). Others also (Richardson et al., 1987; Lewis, Freeman, & Corey, 1987; Searle, 1987) have documented that the HIV/AIDS knowledge of physicians is often limited and inaccurate.

The attitudes expressed by the respondents, particularly when grouped in the subsets of Infection and Reluctance are quite revealing. More than half of the physicians thought they would not treat HIV-infected patients, regardless of the stage of the disease, if they were not so required. More than half, however, do not think a physician should be able to refuse to care for such patients. And according to Austrian law, they are only obligated to treat in an emergency. A similar reluctance of physicians to treat HIV-infected persons has been reported for the United States (Scott, 1990) and the United Kingdom (Searle, 1987) and has been personally noted in Japan by one of us (MD). This reluctance probably occurs to at least some extent everywhere. Actually, the moral or professional obligation to treat is a matter of intense debate in Austria as elsewhere (Sheldon, 1990).

Since only about one-quarter of the respondents think concern with their own safety might be a factor hindering treatment, and about one in three feel less than capable of really helping, it might be a feeling of wanting to be able to provide the best for the patient that is also reflected in these responses. However, this assumption is not warranted, considering that more than half of the physicians feel they already possess sufficient knowledge to adequately treat patients with HIV-disease.

Three-fourths of the physicians indicated they assessed for HIV risk factors. The factors elicited during the history taking do usually contain many of the most common high-risk factors: sex with an HIV-positive person, blood transfusion, or hemophiliac product use prior to blood bank screening, illegal IV drug use, and male homosexual activity. More often omitted, however, are questions of high-risk sexual activities such as having multiple sex partners, working as a prostitute, and engaging in anal sex. Asking questions regarding sexual practices seems to arouse the most anxiety and is in keeping with the factors considered under Reluctance and the fact that fewer than one-quarter of the respondents indicated an interest in taking a seminar on how to take a sexual history. The rigor and depth of the probes for HIV risks may be less than desired, considering that many physicians indicated reluctance to deal with individuals such as IV drug users, prostitutes, male homosexuals, and others who might indeed exhibit high-risk behaviors. Of course, it is not known how many of the patients seen by our respondents actually fit in any of these categories. Ficarroto, Grade, Bliwise, and Irish (1990) showed that antihomosexual attitudes and intolerance of drug use and drug users are also significant predictors of resistance to work with AIDS patients.

Interestingly, there didn’t seem to be any correlation between the number of risk factors checked for by the physicians with the number of risk-related questions asked by patients. The most commonly recommended advice spontaneously offered by our physicians to reduce HIV risk is to use condoms. Advice is also given to give up drugs, use sterile needles, and reduce the number of sex partners. Unfortunately, more than one-third of the respondents did not provide any such preventive counseling. Since the severity of the HIV epidemic is admitted, this is probably another reflection of discomfort with the topic.

It is understood that physicians are expected to educate their patients about crucial health matters. In today’s world, this also extends to advice on preventing HIV/AIDS (Koop, 1987; Manning & Balson 1989). Nevertheless, more than one-third of the physician respondents reported that they did not provide any HIV counseling. Attitudinal barriers seem to prevent many physicians from actually dealing with the threat of the HIV epidemic to themselves or their patients.

Most discomfort in dealing with HIV is seen with the responses the physicians offer in regard to their readiness to refer individuals with real or suspected HIV disease. More than nine of ten respondents indicated they would refer to another physician any HIV-positive patient for treatment of HIV disease, and almost half would refer the patient for all further treatment of any disease. Most revealing is that one in five physicians indicated they would test patients suspected of HIV infection without informing them, despite the fact that such testing of competent individuals is illegal in Austria. It is not known why significantly more female than male physicians would refer their HIV patients.

This propensity to refer out HIV-positive individuals may actually be a realistic reflection of our physicians’ fears of infection and concern with their own safety, despite comments to the contrary. This would not be surprising. As reported by Gerbert et al. (1989), fear of AIDS among health care professionals is pervasive and hinders treatment. They review many studies that support their case. With our findings, we agree with Schwarz (1989, pp. 31-41), who reviewed surveys of physicians’ attitudes toward HIV/AIDS and warns: “It would be infinitely more valuable to recognize the presence of the fear and deal with it directly than to deny its existence.”

When confronted with the possibility of themselves being HIV-positive, more than half the physicians anticipated continuing to practice as long as possible and without informing their colleagues. They felt their colleagues would discriminate against them in some way and would not give them support. Such feelings may be realistic, since such discrimination has occurred elsewhere (e.g., Brennan, 1987; Cherskov, 1987). We did not ask them their opinion of mandatory testing for health care workers, but were not surprised to note a majority indicated they would be willing to have themselves regularly tested for HIV antibodies.

A bright part of the survey is that many of our respondents indicated a willingness to participate in continuing medical education programs concerning HIV and AIDS. Also, about one-quarter of the physicians indicated a willingness to participate as part of a multidisciplinary team engaged in HIV patient care. These activities will prove necessary as the infection continues to spread.

Our findings indicate that discomfort with sexual topics is correlated with physicians not educating themselves or their patients about HIV/AIDS. As found in other studies, homophobia (Fredman et al., 1989; Somogyi, Watson-Abady, & Mandel, 1990) and difficulties in taking sexual histories can therefore be interpreted either as reasons for or as specific expressions of this aversion.

In addition to avoidance behaviors, physicians frequently apply other coping strategies in dealing with their fear of infection. Two such strategies used by our respondents are more assessment of potential risk factors for HIV infection and discontinuing treatment of persons who tested HIV-positive. These practices are both associated with higher fear of infection.

Results from our study suggest that the attitudes of physicians are correlated with their behavior patterns regarding HIV risk assessment, HIV counseling, and management of HIV-positive persons. In fact, the attitudinal dimensions of HIV/AIDS appear to be the epidemic’s major challenge to the medical community. Those physicians more positive and confident in their own knowledge of HIV and AIDS and in their ability to deal with individuals from groups at high risk for HIV infection are more likely to actually treat HIV-positive patients and less likely to refer them to other physicians for treatment.

Physicians cannot be held responsible for what they initially feel in coming to grips with a deadly disease. They are, however, responsible for how they manage their attitudes in relation to patients, themselves, and the public (Kelly, St. Lawrence, Smith, Hood, & Cook, 1987; Koop, 1987; Lawrence & Kahn, 1989). The acknowledgement of one’s emotions and the acceptance of one’s responsibility may not only contribute to a sense of personal growth, but may also enrich the physician-patient relationship and encourage physicians to discuss HIV-related risk behaviors with their patients. HIV-positive persons who value understanding and expertise as most important in a general practitioner would certainly also profit from such a development (King, 1988; Mansfield & Singh, 1989).

Our findings indicate a ready willingness of the majority of the responding physicians to participate in continuing medical education regarding HIV/AIDS. Our results also lead us to believe that such continuing education seminars should, in addition to providing technical medical information, also address the attitudinal-emotional dimensions of clinical practice. In such seminars, physicians could be supported in exploring their attitudes and emotions about HIV-disease and in exploring different strategies of dealing with their concerns. These concerns apply both to treating patients with this disease and the physicians’ own personal safety.

In most countries, the fight against AIDS has been directed toward education of the lay public (Diamond, In press). This education has covered both scientific and attitudinal factors. Professionals too need education which covers both areas. Unfortunately such broad educational programs are typically lacking (Diamond, 1991). While the present study investigated the knowledge, attitudes, and practices of Austrian physicians in one city, we believe our findings hold as well for other cities in Austria and other countries around be world at the same relatively early stage in the growing HIV epidemic. The tendency to think “the infection involves others elsewhere” holds for physicians as for lay persons. Professional education is needed to enhance not only technical knowledge but awareness of the severity and increasing prevalence of this disease and also to increase the willingness of health care workers to face the social and sexual attitudinal challenges of dealing with HIV/AIDS.

We believe Austrian and other governments’ authorities would be prudent, not only in augmenting the medical knowledge of physicians, but in supporting their learning how to manage their HIV-related fears, increasing their sensitivity to and understanding of different sexual and drug-related life styles, and learning how to assist their patients in HIV prevention. Furthermore, the general public should be informed that appropriate medical practice directs physicians to help their patients in these issues of HIV prevention. The easy and subsidized access to health care in Austria should facilitate a positive outcome of this preventive strategy. The magnitude of the growing HIV/AIDS problem demands, for the safety of health care workers as much as for the public, that such programs be quickly developed.



Allard, R. (1989). Beliefs about AIDS as determinants of preventive practices and support for coercive measures. American Journal of Public Health, 79, 448-52.

Bortz, J. (1989). Statiztik für Sozialwissenschaftler. Berlin: Springer.

Brandt, A. M. (1968). AIDS in historical perspective: Four lessons from the history of sexually transmitted diseases. American Journal of Public Health, 78, 367-71.

Brennan, T. A. (1987). The acquired immunodeficiency syndrome (AIDS) as an occupational disease. Annals of Internal Medicine, 107, 581-583.

Cherskov, M. (1991) MD with AIDS: Scenario poses policy questions. Hospitals, 61 (April 5), 68-69.

Diamond, M. (1991). Sex Education for the Prevention of AIDS. 3rd Tokyo Conference on the Epidemiology of AIDS. Tokyo, Japan.

Diamond, M. (In press). Sexual considerations in a community’s psychosocial responses to AIDS. In M. Ng & L. S. Lam (Eds.), Sexuality in Asia.

Ficarroto, T. J., Grade, M., Bliwise, N., & Irish. T. (1990). Predictors of Medical and Nursing Students’ Levels of HIV/AIDS Knowledge and their Working with AIDS Patients. Academic Medicine, 65, 470-471.

Fredman, L., Rabin, D., Bowman, M., Bandemer, C., Sardeson, K., Taggart, V. S., & English, D. K. (1989). Primary care physicians’ assessment and prevention of HIV infection. American Journal of Preventative Medicine, 5, 188-195.

Freimuth, V., Edgar, T., & Hammond, S. (1987). College students’ awareness and interpretation of the AIDS risk. Science, Technology and Human Values, 12, 37-40.

Frierson, R., & Lippmann, S. (1987). Stresses on physicians treating AIDS. American Family Physician, 35, 153-159.

Gerbert, B., Maguire, B, Badner, V., Altman, D., & Stone, G. (1989). Fear of AIDS: Issues of health professional education. AIDS Education and Prevention, 1, 39-52.

Higa, D., & Diamond, M. (In press). Knowledge, attitudes and practices regarding HIV disease among gay men in Hawaii.

Kelly, J. A., St. Lawrence, J. S., Smith, S., Hood, H. V., & Cook, D. J. (1987). Stigmatization of AIDS patients by physicians. American Journal of Public Health, 77, 789-791.

King, M. B. (1988). AIDS and the general practitioner: Views of patients with HIV infection and AIDS. British Medical Journal, 297, 182-184.

Kittleson, M. J., and Venglarcik, J. S. (1990). Assessing primary care physicians’ knowledge about HIV transmission. The Journal of Family Practice, 31, 661-663.

Klein, D., Sullivan, G., Wolcott, D., Landsverk, J. N., & Fawsey, I. (1987). Changes in AIDS risk behaviors among homosexual male physicians and University students. American Journal of Psychiatry, 144, 742-747.

Koop, C. E. (1987). Physician leadership in preventing AIDS. Journal of the American Medical Association, 258, 2111.

Lawrence, S., & Kahn, K. (1989). Physician attitudes toward the “laying on of hands” during the AIDS epidemic. Academy of Medicine, 64, 408-409.

Lewis, C. E., Freeman, H. E., & Corey, C. R. (1987). AIDS-related competence of California’s primary care physicians. American Journal of Public Health, 77, 795-799.

Lifson, A. R., Rutherford, G. W., & Jaffe, H. W. (1990). AIDS commentary: The natural history of human immunodeficiency virus infection. Journal of Infectious Diseases, 158, 1360-1367.

Manning, D. T., & Balson, P. M. (1989). Teenagers’ beliefs about AIDS education and physicians’ perceptions about them. Journal of Family Practice, 29, 173-177.

Mansfield, S. J., & Singh, S. (1989). The general practitioner and human immunodeficiency virus infection: An insight into patients’ attitudes. Journal of the Royal College of Practitioners, 39, 104-105.

Montgomery, S. B., Joseph, J. G., Becker, M. H, Ostrow, D. G., Kessler, R. C., & Kirscht, J. P. (1989). The Health Relief Model in understanding compliance with preventive recommendations for AIDS: how useful? AIDS Education and Prevention, 1, 303-323.

Möse, J. R. (1991). AIDS-aktuell: Gefahr im Mutterleib. Österreichische Ärztezitlung, 10, 14-22.

Richardson, J. L., Lochner, T., McGuigan, K., & Levine, A. M. (1987). Physicians attitudes and experiences regarding the care of patients with Acquired Immunodeficiency Syndrome (AIDS) and related disorders (ARC). Medical Care, 25, 675-85

Schram, N. (1989, November 10). When doctors know less than patients. Los Angeles Times, p. B13.

Schwarz, M. R. (1989). Physicians’ attitudes toward AIDS. In D. E. Rogers & E. Gonzberg (Eds.). Public and professional attitudes toward AIDS patients: A national dilemma (pp. 31-41). San Francisco: Westview Press.

Scott, J. (1990, June 24). Many new doctors won’t treat AIDS, study finds. Los Angeles Times.

Searle, E. S. (1987). Knowledge, attitudes and behaviour of health professionals in relation to AIDS. The Lancet, 1, 26-28.

Sheldon, M. (1990). HIV and the obligation to treat. Theoretical Medicine, 11, 201-212.

Shultz, J. M., MacDonald, K. L., Heckert, K. A., & Osterholm, M. T. (1988). The Minnesota AIDS physician survey. Minnesota Medicine, 71, 277-283.

Sibbald, B., & Freeling, P. (1988). AIDS and the future general practitioner. Journal of the Royal College of General Practitioners, 38, 500-502.

Somogyi, A. A., Watson-Abady, J. A., & Mandel, F. S. (1990). Attitudes toward the care of patients with acquired immunodeficiency syndrome. Archives of Surgery, 125, 50-53.

World Health Organization (1990). AIDS Surveillance in Europe. Quarterly Report of the WHO Collaborating Center on AIDS, Paris. Institute de Medicine et D’Epidemiologie Africanes et Tropicales (June 26), pp. 3-5.


1 Vienna, for comparison, has a population of approximately 1.5 million individuals.

2 This clinic is for HIV testing and treatment for ambulatory patients and in-patients.

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