The care of patients with HIV in the United States has typically been provided by physicians formally trained in infectious diseases as well as those in primary care and doctors with experience managing HIV. In the past 5 years, the CDC and U.S. Department of Health and Human Services have pushed the medical community to get more primary care physicians (PCPs) without experience managing HIV to become comfortable with providing testing for the infection as well as counseling and initiating and monitoring patients on antiretroviral therapy (ART).
Barriers to Providing HIV Care
A survey from HealthHIV of nearly 2,000 HIV specialists and PCPs suggests that the HIV workforce may not be ready to care for the growing number of people living with the infection. “There are an estimated 50,000 new HIV infections per year in the U.S,” says Michael T. Wong, MD, who is the chairman of HealthHIV. “The number of HIV-positive people in America is estimated between 1.1 million and 1.4 million. There just aren’t enough existing HIV specialists to provide services for all of these patients.”
While about 65% of HIV care providers in the survey reported an increase in their HIV caseloads, approximately 35% reported inadequate reimbursement as a barrier to expanding their practices. More than 20% of PCPs also cited reimbursement as a significant barrier to providing HIV services. “Reimbursement rates remain low, in part because of ICD-9 coding,” says Dr. Wong. “There have also been many changes in reimbursement from CMS, with many third-party payors having followed suit. Healthcare reform has a role in this, too. We can’t provide HIV services for everybody if reimbursement for services for our most vulnerable populations is not protected.”
Other barriers to HIV care identified in the survey (Figure) include a lack of routine testing, stigma, access to care, and limited proficiency in the English language. “As the Affordable Care Act is rolled out, there is hope we’ll be able to address these healthcare disparity issues,” explains Dr. Wong. “Each state has made changes to HIV testing laws, with the exception of Massachusetts, which is in the process of making changes. We anticipate that these efforts will improve access to HIV testing, but physicians are hindered by the contexts of patients’ clinical and social scenarios. Addressing stigma requires an open, social approach to discussing HIV, the behaviors that led to infection and risks for potential co-infection, and the issues that come with managing these patients. It would be helpful if the nation could embrace the concept of universal HIV testing within a cadre of screening tests based on patients’ age groups, family history, and other risk factors. The more we make testing routine, the more likely it is that the dialog about HIV will open up in the physician’s office.”
Addressing a Growing Need of Medical HIV Support
According to responses in the HealthHIV survey, PCPs who do not consider themselves HIV experts tend to feel like they are not ready to provide testing and counseling, review sexual health, and administer ART or monitor patients on ART (Table). “While we’re trying to provide excellent care for a large number of patients, the huge wave of new HIV patients requires help from PCPs,” Dr. Wong says. “If we’re creative in networking with PCPs who aren’t currently involved in HIV care, we can effectively pass on our knowledge to these providers.”
A variety of training incentives and programs can be initiated to increase physicians’ comfort levels with HIV. Dr. Wong notes that programs like SYNChronicity offered by HealthHIV, and the Extension for Community Healthcare Outcomes (ECHO) programs are successful examples. As highlighted in the June 2011 New England Journal of Medicine, the ECHO program uses a meld of video conferencing for continuing medical education and real-time telemedicine services to allow experts in a given topic located at a central hub to connect with as many as 15 external sites where providers can get help in providing services and in obtaining knowledge on key health issues. “With ECHO, similar hepatitis C treatment outcomes have been observed between rural community centers and those occurring in academic trial settings,” adds Dr. Wong. “There’s no reason to expect anything different in HIV care and management.”
It is possible that PCPs feel discouraged after reviewing data from the HealthHIV survey, according to Dr. Wong. “The data should be viewed as a wake-up call to approach healthcare and clinical support differently,” he says. “Business as usual just doesn’t work well anymore. PCPs are expected to screen for and manage a growing number of chronic health conditions. That list is only increasing, with evolving quality outcome standards to be released by CMS and other payors. It’s not reasonable to expect PCPs who have never directly treated HIV before to just ‘pick it up.’ We do have a large number of very experienced HIV experts in this country who can help. There are unique opportunities available that can inevitably strengthen services and provider networks for HIV to better serve this growing patient population.”
Readings & Resources (click to view)
HealthHIV. 2nd annual HealthHIV state of HIV Primary Care Survey. January 2012. Available at www.healthhiv.org/modules/info/2nd_annual_state_of_hiv_primary_care_survey.html.
McCollum D. Update of the past year: a review from IDSA 2011. Top Antivir Med. 2011;10:187-192.
Kerr J, Stephens T, Gibson J, Duffus W. Risk factors associated with inpatient hospital utilization in HIV-positive individuals and relationship to HIV care engagement. J Acquir Immune Defic Syndr. 2012 Jan 30. [Epub ahead of print].
Berkenblit G, Sosman J, Bass M, et al. Factors affecting clinician educator encouragement of routine HIV testing among trainees. J Gen Intern Med. 2012 Feb 1. [Epub ahead of print].
Schwandt M, Nicolle E, Dunn S. Preferences for rapid point-of-care HIV testing in primary care. J Int Assoc Physicians AIDS Care (Chic).2012 Jan 13. [Epub ahead of print].
Hunter E, Perry M, Leen C, Premchand N. HIV testing: getting the message across—a survey of knowledge, attitudes and practice among non-HIV specialist physicians. Postgrad Med J. 2012;88:59-65.