Concerns of GPs and general practice staff

Just as for gay men, general practitioners' concerns vary. However, a pattern of similar concerns have been identified by a number of reports[17].

Time pressures, financial constraints and equity

A common concern is that discussions of sexual health and HIV may not be the prime reason for the consultation and that introducing the subject of sexual health might initiate prolonged conversations, lengthening the working day and causing delays for other patients.

One of the purposes of this guide is to recommend ways of improving the service that are cost and time neutral, since they involve doing some routine things differently rather than doing more.

The essence of the primary care team's response here is simply to provide a safety net and refer patients on to other services, such as the local gay men's health project, who do have the time and resources to devote to detailed sexual health discussions with their clients. In districts where gay men's projects don't yet exist there may be a local gay switchboard listed in the phone book.

The primary care team's knowledge and skills

A wide variety of health care professionals say they feel unsure that they have the skills to discuss patients' risk factors for HIV infection or alternatives to penetrative sex[18]. The problem is often information overload for non-specialists rather than the unavailability of information.

General practice staff often express concern or embarrassment about discussing sex with patients[19]. A key barrier may be the fear of initiating discussions where they subsequently feel out of their depth. Members of the primary care team may also be worried about discussing unfamiliar sexual practices. In reality, gay men are not going to want to have this kind of discussion with them.

Research shows that staff find guidelines help them to raise the subject of sexual health promotion opportunistically[20]. Such protocols can be developed through practice group discussions, as well as building on knowledge of referrals and local services. This will also be a useful exercise to identify staff training needs. Thus, concerns can be allayed if there are protocols established to make clear that staff are not specialists expected to deal with all the issues that are raised. The essence of such protocols is:

• clarity about boundaries and limits to responsibility
• clarity about the health gains expected
• discussion of ways of closing interviews
• knowledge of local referral agencies.

However, it is also noteworthy that several studies have now reported that patients are less embarrassed than is generally believed and are often waiting for their doctor or nurse to raise the subject of sexual health[21]. And a pilot project has shown that appropriate training can produce substantial improvements in the confidence and quality of sexual history taking[22].

It is worth knowing that sources of timely, concise and up-to-date information about new developments in HIV/AIDS treatments are available[23].

Availability and distribution of condoms

The resourcing of free distribution schemes varies from one health authority to another. Some have established projects, and some are currently piloting them.

However, the condoms provided in general condom distribution schemes are often designed for heterosexual sex, so it is important to ensure that some of the condoms available are the stronger ones recommended for anal sex, such as Durex Ultra Strong, Mates Super Strong, and HT Specials.

Alternatively, information about where gay men can get free condoms and lubricant should be available from the local gay men's health project. They may also be able to make them available to your practice directly.

Next: likely benefits