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Who Should Be Providing HIV Care? A Roundtable Discussion

The question of who should provide HIV care has been around as long as the HIV epidemic itself. What constitutes HIV expertise? Can primary care providers acquire that expertise as readily as infectious disease (ID) specialists? Where do midlevel providers fit in, and how should future HIV experts be trained to provide the best care possible? To address these questions, AIDS Clinical Care convened a discussion with a diverse group of HIV experts, including Drs. Jonathan Appelbaum, Richard Elion, Joel Gallant, Keith Henry, Meg Newman, and Michael Saag. The discussion was moderated by ACC’s editor-in-chief, Dr. Paul Sax.

Dr. Sax:
What constitutes HIV expertise, and how is it measured?

Dr. Saag:
The primary requirement is that the individual be a good physician, regardless of whether his or her training is in internal medicine, family medicine, or ID. The second requirement is a commitment to providing HIV care on a full-time or frequent basis. Clinicians should have some minimum number of HIV-infected patients in their practice and show a commitment to continuing education.

Dr. Henry:
Along those lines, the American Academy of HIV Medicine offers credentialing to HIV specialists who, in the past two years, have cared for at least 20 HIV-infected patients, have completed at least 30 hours of HIV-related CME category 1 credits, and have completed the Academy’s credentialing exam. I would also add that having a good multidisciplinary team is important but very difficult to measure. That’s not ordinarily considered for certification or credentialing, but I think it’s important for patient care.

Dr. Saag:
Within the American Board of Internal Medicine (ABIM), there’s a heavy focus lately on the question of how to measure confidence in any area of medicine, not just in HIV. The ABIM is moving toward a two-step approach that I think is correct: (1) An assessment of knowledge, done by a test and by open-book modules reviewing focused areas of knowledge (e.g., MKSAP). My bias is that the test should be a closed-book exam that is rigorously assessed in terms of its psychometrics and performance characterizations so that it meets the same validity standards as other board exams; and (2) A measurement of practice outcomes, in which individual providers actually perform chart reviews and demonstrate performance in certain key areas. I think this two-pronged approach would help assess both how well a practice is performing and how much knowledge an individual has.

Dr. Henry:
One issue with outcome measures, though, is that you have to consider the patient population being managed. At my clinic, we often see the more difficult patients, and that makes our numbers look worse. We have a very high number of uninsured or mentally ill patients and a high prevalence of tuberculosis. We also have a very high no-show rate (23%) and a huge number of non-English–speaking people. All of this just creates chaos.

Dr. Newman:
I’m in the same situation, in a tertiary referral center for people who are failing and very complex, but I still think a set of measurements could be made about antiretroviral treatment, intervals of appropriate monitoring, drug interactions, and so on. Given the dynamic nature of HIV medicine, though, we have to have moderately high expectations for longitudinal education and assessment.

Dr. Sax:
Let’s get back to the examination question for a moment. Are there efforts to make HIV a specialty recognized by the National Board of Medical Examiners and ABIM?

Dr. Saag:
The HIV Medicine Association (HIVMA) has submitted an application to the ABIM for a "Certificate of Added Qualification" or CAQ. The ID Board has approved it enthusiastically, and the hope now is that the family medicine board will cosponsor it, so that anybody who’s board-certified in family medicine or internal medicine could apply for it. That said, it will probably be another 2 to 3 years before the CAQ is finally approved.

Dr. Sax:
The fact that we have two HIV-focused professional organizations (the Academy and the HIVMA) is notable. Most of us belong to both of them, but do we really need to have two?

Dr. Appelbaum:
At this point, the two organizations collaborate on many things, certainly the policy aspects of HIV. There are some philosophical differences, though, about what constitutes an HIV expert.

Dr. Saag:
Dr. Appelbaum is right: There’s been a remarkable amount of collaboration in the past 2 years, especially around policy issues on Capitol Hill. There are two organizations, in part, because the Infectious Disease Society of America (IDSA) did not become responsive to the HIV community until the late 1990s. Since then, the IDSA’s been pretty phenomenal in supporting HIV providers, but earlier in the epidemic, there was a huge need for an organization of people who took care of HIV patients, and the Academy filled that niche first. Now, both organizations are providing services, and as you noted, most of us belong to both.

Dr. Elion:
The main distinction between the memberships now is the midlevel practitioners, the physician assistants (PAs) and nurse practitioners (NPs). The Academy has historically focused on the broad set of clinicians who provide HIV care, including ID folks, internists, family practitioners, PAs, and NPs, while the IDSA has focused exclusively on physicians. The HIVMA initially focused only on ID-trained physicians providing HIV care, but they now also serve internists and family practitioners who practice HIV medicine.

Dr. Appelbaum:
NPs and PAs provide a lot of the front-line HIV care in this country. Where would they fit in with a CAQ?

Dr. Saag:
Both the Academy and the HIVMA encourage membership of midlevel providers. The key difference between the groups is that the HIVMA and the ABIM have come down strongly that the HIV credentialing exam should not be the same for physicians as for midlevel providers, and the Academy doesn’t seem to think that it matters as much.

Dr. Newman:
It’s tough to have one exam. If a CAQ does get approved, something else could be worked out with the licensing boards of NPs, PAs, RNs, PharmDs, LCSWs, and other members of interdisciplinary HIV teams. Midlevel practitioners play a critical role; what needs to be acknowledged is that interdisciplinary care works best when there’s a consultative model, meaning there’s plenty of physician consultative back-up.

Dr. Sax:
Should HIV clinicians be considered primary care providers who give HIV-infected patients all of their medical care? Or should they be considered specialists who see patients only for their HIV-related care? Is there a role for a hybrid model, as there is with many rheumatologic diseases and severe diabetes?

Dr. Gallant:
For most of my patients, that question is out of my hands. The decision is dictated entirely by insurance companies. I’m happy to be a primary care provider for many of my patients, but very often, the insurance companies won’t let that happen. I find that my own practice is a hodgepodge: I provide consultative care for some people, primary care for others, and distance or periodic consultation for still others.

Dr. Henry:
In Minneapolis, many of the large HMOs still act as gatekeepers, so I try to become a primary care provider within their systems. Otherwise, patients get routed to HIV providers with less experience and no interest in research. To some extent, my approach has been successful, but the more people I provide primary care to, the fewer patients I can actually take care of. We struggle with this on a daily basis.

Dr. Newman:
We tend to work in the primary care model in our clinic too, and I think we all recognize the downsides of that in terms of time. That being said, I think it’s hard for us not to be primary care providers. Managing any concurrent acute or chronic primary care problem in an HIV-infected patient requires understanding how it could affect his or her HIV disease or treatment.

Dr. Saag:
In our practice, 53% of the patients have undetectable viral loads, so that means we start treating them like any other patient in an internal or family medicine practice. In the ideal sense, we have to be their primary care providers.

Dr. Gallant:
I generally prefer that role when I’m allowed to have it, but we also have to remember that as our patients get older and develop more concomitant medical conditions, the burden of primary care in that population will increase. In fact, we’re already seeing that. Fortunately, I have some patients who are well managed by primary care providers who know something about HIV medicine but who also understand their limitations. They take good care of the patients and come to me whenever they’re at a decision point or just to get an update to make sure the patient’s regimen is still appropriate. That model works well, but it requires the availability of good primary care doctors who also have the time to communicate with the consultant.

Dr. Henry:
The number of people going into primary care is static or dropping, even in internal medicine, so you know what the pipeline looks like.

Dr. Sax:
If you’re in a primary care practice, you’re expected to have a different throughput than physicians in HIV or ID clinics. How can we ensure that this is appropriately compensated?

Dr. Newman:
I actually don’t think we’re ever going to be compensated differentially for our HIV focus.

Dr. Saag:
We have a paper in press in Clinical Infectious Diseases looking at the annual cost of care for HIV-infected patients. Without going into too much detail, we basically measured all related expenditures (including hospital and medication costs and physician fees) and discovered that the average annual cost of care for an HIV-infected patient was US$18,600. The cost was much higher for patients with low CD4-cell counts (up to $36,500) and somewhat lower for those with higher CD4-cell counts ($13,900), but no matter which group patients were in, 75% to 80% of their costs were medication costs. The punch line germane to this conversation is that if every patient had full insurance, and collection rates were 100%, the average reimbursement per provider would be $370 per patient per year. So that kind of says it all, doesn’t it?

Dr. Sax:
This issue of who should be providing HIV care has been controversial since the beginning of the epidemic. Do you think it’s changed at all since 1994 or 1995, when treatment became more successful but also more complicated?

Dr. Saag:
In the early 1980s, HIV care was sort of haphazard — mostly oncologists seeing people with lymphadenopathy — but then it merged into an ID subspecialty. In the late 1980s, it started to head toward primary care with referral to specialists as needed, which is kind of what we’re talking about now. With the advent of potent combination antiretroviral therapy in the mid-1990s, care moved back to specialists. Our discussion today indicates that HIV care might be heading back toward a primary care model, with the HIV specialist being more like a cardiologist, seeing some patients full-time but leaving more of the routine care to an internist or family practitioner.

Dr. Gallant:
I don’t know if that’s what we’re recommending; we’re just saying that it’s the reality of healthcare financing today. On the one hand, I have young, otherwise healthy patients for whom HIV is the only medical issue. They might have to see a primary care doctor every 3 months for no other reason than to get a referral to see me, which means that there are two visits for every visit that’s needed — a real waste of time and money. On the other hand, I have patients who could benefit from having a primary care doctor because of the complexity of their medical conditions, but they can’t get one because Ryan White funding won’t cover it. This is a real dilemma, and our hands are often tied.

Dr. Elion:
I worry that if we integrate HIV care into primary care, clinicians with less expertise might think that it’s okay to start the first regimen before sending patients to a specialist. The care of HIV patients is essentially a subspecialty that can be combined with primary care principles and delivered by one provider or collaboratively by two.

Dr. Henry:
Since the regimens are less intimidating than they were 4 or 5 years ago, it’s easier for a primary care provider to imagine giving them.

Dr. Gallant:
We saw that with AZT/3TC/abacavir (Trizivir), and we’ll see it again when the tenofovir/FTC/efavirenz combination pill comes out. One pill, once a day — how hard can that be? When speaking to physicians, I try to make the point that as therapy gets easier for patients, it gets harder for doctors. To do this right, they need to know about resistance, toxicity, and drug interactions, and they need to have systems in place for patient education and adherence support. That will always be true, even when we’re prescribing one pill, once a day. Unfortunately, the patients referred to me are not those who are about to start therapy or who have failed their first regimens, but patients who have failed their fifth regimen, with the first five regimens having been chosen in a way that seems almost random. We have to get the message out that nobody should start antiretroviral therapy without a visit to an HIV specialist, no matter how easy the regimen might seem.

Dr. Elion:
When I speak to internal medicine groups, I use the analogy that they wouldn’t start an oncology patient on their first treatment regimen.

Dr. Sax:
I couldn’t agree with you more, Dr. Elion. I think that oncology’s been a good analogy for us all along, which is why I’m surprised that HIV has not yet become a certification in some way.

Dr. Henry:
I would say that HIV care has evolved to be a blend resembling a TB clinic (where an early foul-up leads to resistance and very complicated therapies thereafter) and a cancer clinic. Because HIV therapy stretches over decades for many patients, HIV outpatient care is somewhat unique in that it functions as a specialty clinic, primary care clinic, and even a geriatrics clinic.

Dr. Gallant:
There are doctors who will refer a patient with zits to a dermatologist for doxycycline — but will start antiretroviral therapy in an HIV-infected patient. This inconsistency is really disturbing.

Dr. Sax:
Let’s shift gears a bit. What path do you recommend to young people interested in careers in HIV medicine?

Dr. Gallant:
At our institution, an ID fellowship is most common, but I have to say that ID training is less and less relevant to what we do in HIV medicine today. In HIV medicine, we now spend a lot less time trying to figure out the cause of a fever, and a lot more time dealing with drug toxicity, resistance, and interactions. ID training is useful because it provides some outpatient exposure to HIV medicine, but we have general medicine fellows in our outpatient clinic doing the same thing as the ID fellows, and I think their training is just as good.

Dr. Newman:
At UCSF-San Francisco General Hospital, we have an HIV Clinical Scholars Fellowship, which is a clinical educator’s fellowship that is focused entirely on HIV medicine and all of the areas it encompasses (including pharmacology, psychiatry, medical ethics, and healthcare financing). It provides a huge amount of continuity experience, but there are very few of these programs across the country and very limited slots for people outside the traditional research-based ID fellowship. The funding has been a really big problem for us.

Dr. Henry:
We have medical students who want to go overseas and do HIV care, but I don’t understand how they can dig themselves out of debt and do the right thing at the same time. They’ll obviously get paid less overseas than they’ll get paid here, which wouldn’t be a lot either. So it’s hard for me to be optimistic that the funding right now will attract people to do this long-term, even though I think they’d love the work.

Dr. Newman:
The Institute of Medicine has proposed a program called "Healers Abroad" that would reasonably compensate people doing international work and grant them loan forgiveness. Like everything else, we’re going to need ongoing lobbying to make something like this come to fruition.

Dr. Saag:
This is precisely what the HIVMA has proposed to Congress — to allow loan forgiveness programs. It hasn’t been approved yet, but it’s definitely on their radar.

Dr. Elion:
Another aspect of this, a larger issue in medicine, is that physicians need to diversify in terms of revenue. Just as academics learn a variety of ways to underwrite their salaries, doctors in private settings are starting to learn the same thing — that they can do a combination of research, teaching, lecturing, and the like.

Dr. Saag:
At the University of Alabama at Birmingham, we encourage a more traditional academic track. To date, we’ve had only one person come through absolutely confident that she did not want to pursue academics; she ended up doing a 2-year ID fellowship and now does HIV medicine in private practice. That worked out, but the availability of a 1-year track would be very attractive to other people like her.

Dr. Gallant:
All of our fellows come in wanting to do academics, and most who have an HIV interest want to do international HIV research, which is exciting, rewarding, and well funded at the moment. Very few of them come in saying, "I want to be an HIV doctor," though some of them may end up moving to that over the course of their fellowship.

Dr. Sax:
When you have ID candidates who want to do HIV medicine, how do you ensure that they’re getting state-of-the-art HIV training?

Dr. Gallant:
This is becoming a problem, in part because training requirements have changed, so that fellows now only get 1 or 2 years of longitudinal clinic experience, which is not enough. If they have 1 year in the clinic, they’re only seeing any given patient about four times at the most. That’s also very disruptive to the patient, as it’s obviously upsetting to have to change doctors every year or two. From what I understand, it’s no longer possible to get a 3-year longitudinal clinic experience, which is something I worry about.

Dr. Sax:
The training is cut even shorter for those who want to do international work. We’ve just been told that our fellows cannot leave before the 3rd year, which is good in some ways, because they’ll get at least 2 years of longitudinal training, but at the same time, they’re eager to get to Africa.

On a separate note, do you think we have an obligation to recruit HIV specialists from the groups that are hardest hit with the epidemic, specifically gay men and racial/ethnic minorities? Should there be practices with an explicit focus on care for these demographics?

Dr. Saag:
I don’t know that specific practices are necessary. Those sort of emerge based on community need and people voting with their feet, but we do desperately need more minority physicians providing HIV care. I’ve observed firsthand what a difference it makes to our patients to have a minority physician. The problem is that although there are a lot of really good minority providers, they don’t tend to gravitate toward HIV.

Dr. Newman:
We need to make remedying that a broad societal goal, both inside and outside of HIV medicine. Particularly given who we serve, we need to make that a priority in our professional organizations.

Dr. Elion:
We have the same obligation in terms of researchers. You see studies in which 70% of the population is African American, but what percentage of the investigators are African American? If we could offer minorities the same opportunities in research as in clinical care, that would level the playing field.

Dr. Appelbaum:
I think reaching out to minority populations would be a great thing for the Academy and the HIVMA to collaborate on.

Dr. Sax:
Thank you all for taking time to speak with us today.

Dr. Appelbaum is Secretary of the American Academy of HIV Medicine and Medical Director of Brigham and Women's Physician Group. Dr. Elion is Associate Professor of Clinical Medicine at George Washington University School of Medicine and Research Director of CAREID, a community-based HIV research program. Dr. Gallant is Associate Professor of Medicine and Epidemiology in the Division of Infectious Diseases at Johns Hopkins University School of Medicine. Keith Henry is Professor of Medicine at the University of Minnesota School of Medicine, Director of HIV Clinical Research at Hennepin County Medical Center in Minneapolis, and Associate Editor of ACC. Dr. Newman is Associate Professor of Clinical Medicine at the University of California, San Francisco, Attending Physician at the UCSF-Positive Health Program at San Francisco General Hospital, and Director of the HIV Clinical Scholars Fellowship. Dr. Saag is a Board Member of the HIV Medicine Association and the American Board of Internal Medicine, and Chair, ID Subspecialty Board, Professor of Medicine at University of Alabama at Birmingham, and Director of the UAB Center for AIDS Research. Dr. Sax is Clinical Director of the HIV Program and Division of Infectious Diseases at Brigham and Women's Hospital, Assistant Professor of Medicine at Harvard Medical School, and Editor-in-Chief of AIDS Clinical Care.

Published in Journal Watch HIV/AIDS Clinical Care February 15, 2006

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