HIV Screening and Access to Care Health Care System Capacity for Increased HIV Testing and Provision of Care (2011) / Chapter Skim
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HIV Screening and Access to Care: Health Care System Capacity for Increased HIV Testing and Provision of Care
HIV Screening and Access to Care: Health Care System Capacity for Increased HIV Testing and Provision of Care
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, convened a committee on HIV screening and access to care in 2009 to plan and host a series of three workshops and data gathering activities to evaluate barriers to expanding HIV testing and treatment. The committee's first report focused on the extent to which federal and state laws and policies, private health insurance policies, and other factors inhibit or promote expanded HIV testing (IOM, 2010)
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c. What manpower or training/experience improvements are needed to absorb more newly diagnosed HIV-positives from expanded HIV testing services?
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The two primary issues raised relate to the personnel and procedures necessary to implement expanded HIV testing successfully in a variety of different venues and to the personnel and procedures needed to provide counseling and linkages to care for individuals who test positive. The report next provides information about where HIV-positive individuals currently receive care.
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At the same time, expanded HIV testing initiatives in response to 1 At least one-third of individuals who test positive for HIV in the United States are tested too late to receive full advantage from treatment (CDC, 2010b)
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SOURCE: Hall et al., 2008. CDC recommendations to promote routine HIV testing (CDC, 2006)
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A variety of approaches will be needed to respond to these challenges. The current comprehensive and integrated model of care often exhibited by Ryan White-funded clinics provides a foundation upon which future care systems could be structured.3 EXPANDED HIV TESTING Since the beginning of the HIV epidemic, HIV testing and counseling traditionally have been administered by providers who are specifically trained in these areas, and providers not trained in HIV testing and counseling would refer patients out to those who were.
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. The first report of the Committee on HIV Screening and Access to Care discussed the various barriers and facilitators to expanding access to HIV testing (IOM, 2010)
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Once these and other barriers to the implementation of expanded HIV testing are overcome, the question remains whether various components of the health care system have the capacity to provide such screening. In addition to the need for adequate space to permit privacy when interacting with patients about HIV testing, the primary concern about capacity centers on the question of a sufficient number of adequately trained personnel.
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Some providers say that all they need is funding for test kits and the testing procedure or to hire additional staff; others say that they will not implement a program unless the health department provides the staff. Incorporation of routine HIV testing into office visits with family practitioners and other primary care providers may present smaller obstacles in terms of logistics and provider capacity.
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already are so overwhelmed by patient case loads that they resist the addition of routine screening to the services they provide. Often the CHCs that are most interested in establishing routine HIV testing are in rural areas with a lower percentage of HIV positive individuals.
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Committee member Beth Scalco mentioned that this dependence on the health department support is also present in Louisiana. Andrew Young, Associate Professor, Emory University School of Medicine, also provided the committee with information on the capacity implications of expanded HIV testing, addressing both the ED and clinical laboratory settings.
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However, the very rapid result time may facilitate usage and streamline routine HIV testing in busy hospital-based settings and help to extend routine HIV-testing to novel venues. 9 See http://www.cms.gov/CLIA/ (accessed March 3, 2011)
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to manage the testing and linkages to care. There are approximately 150,000 visits to the Grady ED each year, so routine HIV testing has been extended to only a fraction of patients seen there.
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Registered nurses, along with testing counselors, can be effectively utilized in the provision of testing, prevention counseling, and care linkage for individuals who test positive. Young also raised concerns about a rise in the rate of false positive tests as routine HIV screening programs are implemented in lower prevalence areas.
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Highlevel administrative involvement is critical in large health care systems to ensure institutional endorsement of screening and to provide the necessary leadership and resources to clinical departments and laboratories, so that their roles are coordinated and HIV screening programs are affordable, sustainable, and compliant with regulations. He also discussed the merits of support for demonstration programs that would allow clinical laboratories to explore methods to expedite testing to meet the needs of EDs and other settings where routine HIV testing is taking place.
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Another long-term consideration is the need for access to ongoing care by those receiving new diagnoses. The second report of the Committee on HIV Screening and Access to Care addresses policies that may inhibit entry into clinical care by newly diagnosed HIV-positive individuals and the provision of continuous, sustained clinical care for HIV-positive individuals.
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. 13 Besides a confirmed HIV diagnosis, to be eligible for care and support services through the Ryan White program, persons must have an income too low to pay for care and have no insurance or not enough insurance to pay for care (HRSA, 2011)
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is a component of the Ryan White program that provides HIV-related prescription drugs to lowincome people with HIV who have limited or no prescription drug coverage. Approximately 183,000 HIV-infected people received medications 14 A more detailed discussion of the Ryan White Program appears in HIV Screening and Access to Care: Exploring the Impact of Policies on Access to and Provision of HIV Care (IOM, 2011b)
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Part C of the Ryan White program funds planning grants, capacity development grants, and grants to service providers to support early intervention outpatient services and ambulatory care. Figure 2 shows a map of the Part C-funded outpatient clinics in the United States with more clinics in regions where HIV is more heavily concentrated.
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Table 5 shows the extent to which case management, treatment adherence, mental health, substance abuse, oral health, and other services are provided by Ryan White funded sites. The table shows a heavy reliance on nonmedical support personnel 17 The eight-state region includes Colorado, Kansas, Nebraska, New Mexico, North Dakota, South Dakota, Utah, and Wyoming.
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. There has been a dramatic increase in the number of clients served in Ryan White clinics in the past decade.
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/NPs, and RNs) as well as improvements in training or experience that are needed to help absorb an increased number of newly diagnosed individuals as a result of expanded HIV testing services.
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; · Infectious disease specialists: physicians sub-boarded in infectious diseases (they may or may not also serve as the principal source of primary care for their patients and may or may not be experienced in HIV care) ; and · Generalists: health care providers who have neither specialized nor are certified, credentialed, or experienced in HIV/AIDS care.
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Three professional bodies that have specified standards for HIV expertise are HIVMA, created in 2000 by the Infectious Diseases Society of America; the Association of Nurses in AIDS Care (ANAC) , and its sister body the HIV/AIDS Nursing Certification Board (HANCB)
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fellows or those recently certi fied or recertified in infectious diseases should be considered qualified providers of patients with HIV/AIDS for 12 months after certification or recertification as outlined above. However, given the rapid pace of change in HIV medicine, board certification in infectious diseases and pediatric infectious diseases does not guarantee sufficient knowledge to assure that an ID specialist will remain an expert in HIV disease over time.
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and about 4,500 infectious disease specialists engaged in patient care in the United States (AAMC, 2008)
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At the University of Colorado, where he cares for HIV/AIDS patients and provides training, he noted the following shortcomings of resident training: · Most HIV care experiences are limited to inpatient settings. · HIV training is not a mandatory part of any of the residency pro grams apart from the infectious disease fellowship.
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Johnson described the difficulties of providing sufficient training in a CME environment to enable generalists to become HIV experts. At the Mountain-Plains AETC, the training offered to non-HIV providers tends to emphasize HIV testing, post-exposure prophylaxis, and the recognition of HIV/AIDS complications, rather than the ongoing treatment and care of HIV-positive individuals.
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Adele Webb, Executive Director/CEO, Association of Nurses in AIDS Care, described how, for example, nursing students may have little or no exposure to HIV content in nursing school curricula.27 If HIV is covered, it may be covered briefly in the context of other infectious diseases. Furthermore, clinical rotations during nursing school often do not expose nursing students to HIV patients.
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of the participants stated that they had very little or no HIV education during school and very little or no HIV training during employment. Thirty-seven percent stated that they do not refer patients for HIV testing, and 35 percent did not know where to refer a patient for HIV care.
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For medical students and residents, exposure to HIV care could be augmented, especially in outpatient settings, and the importance of taking a comprehensive sexual history and providing routine HIV testing emphasized. Cultural competence could be improved through experiential learning, especially regarding differences in knowledge, attitudes, and practices regarding sex, alcohol and drug dependency, and poverty and its effects on health behaviors.
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Appropriately trained RNs can fill important roles in the implementation of routine HIV testing, prevention counseling, and care for HIVinfected individuals, including patient education and care coordination. Registered nurses, licensed practical nurses, nursing assistants, and other providers in long-term care facilities increasingly will be called upon to care in subsequent years to encourage "teaching health centers" (THCs)
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To improve HIV nursing education further, Webb recommended · integration of more substantial HIV prevention, care, and treat ment education into nursing school curricula (e.g., ANAC's Core Curriculum for HIV/AIDS Nursing) ; · increased opportunities for nursing students to learn about the field of HIV through exposure to HIV care environments during clini cal rotations (e.g., Ryan White clinics, public health departments, community health centers)
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Providers need to be aware of the changing landscape of HIV/AIDS care and also of the legal/regulatory environment in which HIV testing occurs. They may not be familiar with CDC's revised recommendations for routine HIV testing in health care settings, which recommend that separate written informed consent and
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As many community-based providers are in the position to implement CDC's recommendations for routine HIV testing, these areas could be considered important areas of focus for AETCs. HIV-infected patients of providers with substantial HIV/AIDS experience/expertise have better outcomes, but there are few widely used measures of such expertise.
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. These findings are consistent with a 2008 survey of 400 providers and student members of the American Academy of HIV Medicine (AAHIVM)
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, while only 7 percent of ANAC members are 20 to 29 years old, evidence that recent nursing school graduates are not entering the HIV/AIDS field at a pace necessary to keep up with future needs. Just as the physician and nursing workforces are aging, so too is the public health workforce, which serves an essential role in the delivery of HIV prevention and care services and programs.
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Anna Buchanan, Senior Director, Immunization and Infectious Disease Association of State and Territorial Health Officials, and Julie Scofield, representing NASTAD, described the essential role of state health departments and their staffs in meeting the needs of individuals with HIV/AIDS. Scofield pointed out that state health departments are responsible for programs that administer more than half of the CDC's domestic HIV prevention budget and Ryan White program funding.
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Over the past 2 years, 41 states reported more than 200 open or unfilled positions in HIV/AIDS and viral hepatitis programs, representing roughly 20 percent of the total workforce in responding state health department HIV/AIDS, STD, and viral hepatitis programs. Positions that are 100 percent federally funded have not been exempt in most jurisdictions.
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In addition to adequate funding to support and maintain necessary staff positions, consideration of various strategies to increase the number of new providers entering the field of HIV/AIDS care is needed. DELIVERY SYSTEM STRATEGIES TO MAXIMIZE CAPACITY OF CURRENT WORKFORCE The committee was asked to examine the increases in workforce that would be needed to provide care for the greater number of newly diagnosed HIV-positive individuals expected to result from expanded HIV testing services.
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. Full realization of the potential for task shifting to maximize the ability of the current HIV care workforce to absorb a significant increase in patients will depend upon efforts to address such regulatory and policy barriers.
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In addition to providing medical care, patients' primary care providers coordinate and help to arrange for their dental, pharmacy, counseling, educational, and other support service needs. The flexible nature of some Ryan White funding has permitted some medical providers to hire the support staff needed to facilitate access to these other important nonmedical services.
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Conclusions Increased use of strategies such as task shifting, comanagement, and care coordination can help to maximize the ability of the current health care workforce to accommodate an increased number of HIV-positive individuals. In addition, these strategies may result in improved patient care and increased provider satisfaction, which, in turn, may increase the retention of HIV/AIDS care providers in the field.
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HIV medicine viewed HIV medicine viewed as one Environment/climate as new and exciting and of many low-paying career considered a cause and choices a passion Epidemic concentrated Epidemic diffuse, with a in the gay community, concentration among poor, which was politically disenfranchised populations organized and active SOURCES: Gallant, 2010; Saag, 2010. In the following sections, the impediments to new providers entering the HIV/AIDS workforce are described for different professional groups.
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He suggested that if the Ryan White program were not in place, practices specializing in HIV/AIDS care would not be sustainable. Loida Bonney, Assistant Professor of Medicine, Division of General Medicine, Emory University, stated that the median salary for an assistant professor in infectious disease is approximately $130,000 per year, compared to $148,000 for an assistant professor in general internal medicine (AAMC, 2009)
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The responding program directors reported the belief that patients prefer to be seen, and receive better care, in infectious disease or HIV clinics than in general medicine clinics, despite the evidence that many HIV/AIDS patients receive care from primary care providers without specialty training in HIV/AIDS. (The response rate to this survey was 62 percent [230 of 372 program directors responded]
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. of patient to staff is somewhat lower in general outpatient care settings than that typically seen in community health centers (958 vs.
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The tendency for providers thinking about careers in HIV medicine to consider working abroad was mentioned by Kitahata, Cheever, and committee chair Paul Cleary.39 Nursing Professionals A key factor affecting the shortage of APRNs and RNs to accommodate increases in HIV testing and care is the lack of training programs resulting, in part, from a shortage of nursing school faculty (IOM, 2011a)
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Non-specialist nurses may lack the specific knowledge, competence, and confidence to provide adequate HIV testing and care. Webb anticipates that the HIV care workforce, under an expanded testing framework and in the context of changes resulting from the ACA, cannot practically accommodate an increased demand without consideration of the training needs of all levels of nursing professionals.
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HIV/AIDS as a topic should be discussed when learning about the reproductive health system, dermatology, and infectious disease. PAs should also be exposed to HIV patients as they do their rotation in internal medicine.
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Recruitment Among the incentives that may help to attract more providers, including those from underrepresented groups, into the practice of HIV medicine are loan forgiveness/scholarships to medical residents choosing HIV/AIDS-related specialties; full-funding of the Health Professions Title VII program,41 which supports expansion of the geographic, racial, and ethnic distribution of the workforce; and designation of Ryan White-funded clinics as National Health Service Corps-eligible sites.42 Retention Incentives that might encourage HIV/AIDS providers to continue practicing in the field include the development and application of innovative 41 Title VII of the Public Health Service Act was enacted in 1963 in response to a shortage of health care providers. Title VII programs are designed to encourage providers to practice in underserved areas, increase the number of primary care providers, and increase the number of minority and disadvantaged students in health care programs and faculty in health care education and training programs.
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Third, engaged faculty mentors may stimulate sufficient interest in the practice of HIV medicine both to draw more graduates into the field and to counteract the tendency toward "reverse brain drain." Fourth, clinics partnering with hospital-based residency programs not only provide improved educational opportunities for trainees, but also increase the interest level among clinic practitioners, leading to improved retention. Similarly, some of the collaborative delivery system strategies (coordinated care models)
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Work environment · s HIV testing is expanded and more patients enter into care, A ensure that adequate resources for staffing are considered and allocated. Public policy development · Include HIV nurse leaders in national-level stakeholder meetings and policy forums to ensure that a nursing perspective is included, especially as the National HIV/AIDS Strategy is implemented.
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The growing interest of those trained in infectious diseases in the alleviation of HIV/AIDS suffering overseas comes at the expense of domestic care. The lack of exposure of entry- and graduate-level nursing students to HIV/AIDS related curricula and clinical experiences has contributed to the shortage of RNs and APRNs in HIV/AIDS care.
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The development of patient-centered models of care and the use of interdisciplinary care teams in the provision of HIV/AIDS care not only may improve patient care, but also may improve job satisfaction among the providers. IMPACT OF THE AFFORDABLE CARE ACT ON THE PUBLIC HEALTH AND CLINICAL INFRASTRUCTURE Jeffrey Levi, Executive Director, Trust for America's Health, provided the committee with an overview of the issues related to the testing and treatment of HIV-infected individuals and the potential impact of the ACA.
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As mentioned earlier, routine HIV screening (i.e., testing of those not at increased risk) is rated C by the USPSTF and therefore is not included in the aforementioned extensions of coverage (IOM, 2010)
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Levi described some of the efforts to expand health care capacity under the ACA: · To expand the safety net, $11 billion has been allocated over the next 5 years to CHCs. · In FY 2010, $30 million was made available to the CDC, of which $21.6 million is to be used for HIV testing.
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Finally, how reimbursement for HIV testing will be administered is unclear. For example, alternative testing 48 Established as part of the ACA, the Prevention and Public Health Fund is a 10-year $15 billion commitment designed to help create the necessary infrastructure to prevent disease, detect it early, and manage conditions before they become severe.
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These wraparound services, such as case management and substance abuse and mental health services, may be vulnerable under the ACA. Prescription drug coverage under ADAP is an essential Ryan White program whose future is uncertain now that the ACA has been passed.
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She observed that many HIV/AIDS patients receive all of their care, primary and specialty care, within Ryan White programs. Saag added that the shifting focus to CHCs for HIV care is a potential threat to Academic Health Centers that want to remain engaged in HIV care.
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With an expanded population of individuals with third party insurance, Ryan White programs will be in a position to seek third party reimbursement more often. If health care services are being supported through insurance payments, Ryan White funds might be redirected to other services.
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A willingness and flexibility to develop and implement procedures that best match the needs of the setting are important to the success of expanded HIV testing efforts. A big challenge to the implementation of routine HIV testing, especially in busy, high-volume settings where patient follow-up is more challenging, is the question of who will inform and address the needs of individuals who are found to be HIV-positive.
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The current and projected capacity of the health care workforce to implement routine testing for HIV throughout the nation and to provide competent HIV/AIDS care to significantly increased numbers of patients is of grave concern. Clearly, a variety of approaches will be needed to meet the needs for diagnosis and treatment of HIV-positive individuals in the United States.
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Regardless of the approach taken, the committee was impressed by the urgency of addressing these HIV/AIDS care capacity issues. With each additional HIV infection detected, the care system inherits a responsibility to counsel, refer, treat, and monitor an additional patient, at an average per-infection cost of $19,912 per year (Gebo et al., 2010)
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