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Abstract: The introduction of highly active antiretroviral therapy (HAART) is typically represented as a turning point in the social and medical history of HIV/AIDS, leading to a conceptual division into pre- and post-HAART eras. This paper explores how generational discourse is produced in interviews with general practitioners (GPs) and their HIV positive gay male patients in making sense of this moment and related changes in the Australian HIV epidemic. A theme of ‘HIV generations’ was identified in in-depth interviews with GPs who have HIV medication prescribing rights (based in Sydney, Adelaide and rural-coastal New South Wales) and the HIV positive gay men who attend their practices. In a closer analysis, generational discourse was identified across the interviews with GPs, characterising pre- and post-HAART HIV generations through three main features: treatment histories, socioeconomic status, and modes of survivorship. While generational discourse was less common in the accounts of HIV positive gay men, many of their examples wove together two narrative forms – ‘a different time’ and ‘difference today’ – suggesting that concepts of time and inequity are deeply embedded in these men’s understandings of the HIV experience. Our analysis indicates that generational concepts play a significant role in shaping both professional and ‘lay’ understandings of changes and patterns in the HIV epidemic. [Copyright &y& Elsevier]

Generational change is believed to be transforming the educational and employment preferences of medical trainees. In this article, we examine generational tensions in interviews with policy leaders and clinicians on workforce issues within one subset of the Australian medical profession: general practitioners who provide care to people with HIV in community settings. Integrating the accounts of policy leaders (n = 24) and clinicians representing the ‘first generation’ (n = 21) and ‘next generation’ (n = 23) of clinicians to do this work, shared and divergent perspectives on the role of generational change in shaping professional engagement were revealed. While those engaged in the early response to HIV believed younger clinicians to be less interested in the scientific and political dimensions of HIV care and more concerned about financial security and life balance, the next generation both countered and integrated these beliefs into new ways of conceptualising the value and appeal of this field of medicine. Critical appraisal of the assumptions that underpin generational discourse is essential in appreciating the changing views of providers over time, particularly in fields of medicine which have featured significant historical turning points. [ABSTRACT FROM AUTHOR]

As the management of HIV changes and demand for HIV health services in primary care settings increases, new approaches to engaging the general practice workforce with HIV medicine are required. This paper reports on qualitative research conducted with 47 clinicians who provide HIV care in general practice settings around Australia, including accredited HIV s100 prescribers as well as other GPs and general practice nurses. Balanced numbers of men and women took part; less than one-quarter were based outside of urban metropolitan settings. The most significant workforce challenges that participants said they faced in providing HIV care in general practice were keeping up with knowledge, navigating low caseload and regional issues, balancing quality care with cost factors, and addressing the persistent social stigma associated with HIV. Strategic responses developed by participants to address these challenges included thinking more creatively about business and caseload planning, pursuing opportunities to share care with specialist clinicians, and challenging prejudiced attitudes amongst patients and colleagues. Understanding and supporting the needs of the general practice workforce in both high and low HIV caseload settings will be essential in ensuring Australia has the capacity to respond to emerging priorities in HIV prevention and care. [ABSTRACT FROM AUTHOR]

Background: HIV has become a chronic manageable infection in the developed world, and early and lifelong treatment has the potential to significantly reduce transmission rates in the community. A skilled and motivated HIV medical workforce will be required to achieve these health management and prevention outcomes, but concerns have been noted in a number of settings about the challenges of recruiting a new generation of clinicians to HIV medicine. Methods: As part of a larger qualitative study of the HIV general practice workforce in Australia, in-depth interviews were conducted with 31 general practitioners accredited to prescribe HIV medications in community settings. A thematic analysis was conducted of the de-identified transcripts, and this paper describes and interprets accounts of the rewards of pursuing and sustaining an engagement with HIV medicine in general practice settings. Results: The rewards of initially becoming involved in providing care to people living with HIV were described as interest and inspiration, community calling and right place, right time. The rewards which then supported and sustained that engagement over time were described as challenge and change, making a difference and enhanced professional identity. Participants viewed the role of primary care doctor with special expertise in HIV as occupying an ideal interface between the 'coalface' and the 'cutting edge', and offering a unique opportunity for general practitioners to feel intimately connected to both community needs and scientific change. Conclusions: Approaches to recruiting and retaining the HIV medical workforce should build upon the intellectual and social rewards of this work, as well as the sense of professional belonging and connection which is imbued between both doctors and patients and across the global and national networks of HIV clinicians. Insights regarding the rewards of engaging with HIV medicine may also be useful in enhancing the prospect of general practice as a career, and strengthening retention and job satisfaction among the existing general practice workforce. [ABSTRACT FROM AUTHOR]

High rates of both illicit drug use and depression are consistently reported among gay men. However, little is known about how beliefs about drug use shape clinical encounters between gay men and health professionals, and that in turn affect clinical communication and care, particularly in relation to depression. We compared 'doctor' and 'patient' beliefs about the role of illicit drug use in gay men's depression. Semi-structured interviews were conducted during August-December 2006 with 16 general medical practitioners working in seven 'gay-friendly' practices in Sydney, Adelaide and a rural-coastal city in New South Wales, and during February-May 2008 with 40 gay men with depression recruited through four Sydney and Adelaide practices. A thematic analysis of these two sets of interviews found that doctors expressed the beliefs that: illicit drug use is related to depression in gay men; illicit drug use impedes effective diagnosis and treatment of depression in gay men; and illicit drug use increases the level of complexity involved in caring for gay men with depression. Gay men expressed the beliefs that: illicit drug use is closely related to depression; illicit drug use can be helpful in dealing with difficult experiences; and illicit drug use is just what you do as a gay man living in a big city. Both groups believed drug use and depression were related, but doctors emphasised the negative outcomes of drug use and interpreted these in relation to health. Gay men believed that drugs could have both negative and positive uses and differentiated between health and social outcomes. While the doctors articulated a pragmatic position on drug use, which is consistent with harm reduction principles, communication with gay male patients could be enhanced if both groups acknowledged their divergent views of illicit drugs and their potential role in mental health. [ABSTRACT FROM AUTHOR]

General practitioners (GPs) identify that depression can be difficult to diagnose in populations with high rates of alcohol and other drug (AOD) use. This is a particular concern with gay men who are a population known to engage in high rates of AOD use and who are vulnerable to depression. This paper uses data from 563 gay men and their GPs to describe concordance between assessments of major depression and, in particular, whether AOD use undermines concordance. Data were collected as part of a larger study of male patients and GPs at high HIV-caseload general practices in Australia. Concordance was measured by comparing patients' scores on the Patient Health Questionnaire-9 screening tool, which is based on the Diagnostic and Statistical Manual of Mental Disorders IV criteria, and GPs' ratings of the likelihood of depression for each participant. We observed high concordance between GPs' assessments of major depression and patients' scores on the PHQ-9 (79% agreement), although our analysis also suggested that concordance was better when it related to cases in which there was no depression. The high concordance observed in our study did not appear to be undermined by gay male patients' AOD use, with the exception of frequent use of crystal methamphetamine. Here, men who reported frequent use of methamphetamine were significantly less likely to have concordant assessments (adjusted odds ratio 0.3, 95% CI 0.1-0.8). Overall, GPs appear to identify depression among many of their gay male patients. While GPs should be aware of the potential complications presented by frequent crystal methamphetamine use, other AOD use may have less impact on the diagnosis of depression. [ABSTRACT FROM AUTHOR]

Objectives HIV care is provided in a range of settings in Australia, but advances in HIV treatment and demographic and geographic changes in the affected population and general practitioner (GP) workforce are testing the sustainability of the special role for GPs. This paper explores how a group of 'key informants' described the role of the GP in the Australian approach to HIV care, and conceptualised the challenges currently inspiring debate around future models of care. Methods A thematic analysis was conducted of semistructured interviews carried out in 2010 with 24 professionals holding senior roles in government, non-government and professional organisations that influence Australian HIV care policy. Results The strengths of the role of the GP were described as their community setting, collaborative partnership with other medical and health professions, and focus on patient needs. A number of associated challenges were also identified including the different needs of GPs with high and low HIV caseloads, the changing expectations of professional roles in general practice, and barriers to service accessibility for people living with HIV. Conclusions While there are many advantages to delivering HIV services in primary care, GPs need flexible models of training and accreditation, support in strengthening relationships with other health and medical professionals, and assistance in achieving service accessibility. Consideration of how to support the GP workforce so that care can be made available in the broadest range of geographical and service settings is also critical if systems of HIV care delivery are to be realistic and cost-effective and meet consumer needs. [ABSTRACT FROM AUTHOR]