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In response to concerns about
the growing shortage of HIV health
care providers, and the subsequent
impact on access to quality care,
the HRSA’s (HRSA’s) HIV/AIDS
Bureau is working to study the phenomenon
and develop a plan for action. In
pursuit of its goals, HRSA convened
a stakeholder meeting of clinicians,
workforce and other health researchers,
State Health Department officials
and health care funders to discuss
major factors contributing to the
decline in HIV clinicians, learn about
promising workforce development strategies
being implemented in local communities
and States, and suggest potential
short-, medium- and long-term solutions
to the problem.
The meeting was held September 15-16,
2008 in Rockville, Maryland. Attendees
were welcomed by Deborah Parham Hopson,
Associate Administrator of the HIV/AIDS
Bureau. Parham Hopson told those assembled
that the Bureau had initiated discussions
on the topic in 2006, as part of a
broader strategy to identify and address
emerging issues in the epidemic. It
was determined that a stakeholder
meeting would prove helpful in determining
an appropriate, effective role for
HRSA and others in addressing the
issue. Parham Hopson acknowledged
the leadership of her Deputy Chief
and Chief Medical Officer, Laura Cheever,
in helping to define a plan for moving
forward.
Dr. Cheever explained that the role
of HRSA's workforce initiative is
to "determine strategies to support
an appropriate workforce to provide
high quality, compassionate care today
and in the future in Ryan White programs."
Cheever emphasized that the Bureau's
intent is to focus not only on the
HIV/AIDS workforce, but to consider
its work in the context of broader
workforce shortages in primary care
and care to the underserved, and to
consider a variety of health professions,
including nursing, medicine, dentistry
and pharmacy.
To learn more about workforce shortages
and their impact at the local level,
HRSA has contracted with Mathematica,
a health policy research organization,
to develop case studies of local systems
of care that have innovative approaches
to addressing workforce challenges.
The stakeholder meeting, explained
Cheever, would be used to help generate
an agenda for what can be done in
the short- and long-term to improve
the capacity of the HIV workforce.
Some of the factors that HRSA has
identified as having a strong influence
on the workforce include: 1) Increases
in the demand for care and services
due to the fact that clients are living
longer; 2) Constraints in Ryan White
grantee capacity due to increases
in client caseloads without significant
increases in budgets; 3) Fiscal constraints
within Medicaid and other funding
systems that affect provider reimbursements;
4) Increasing pressure on providers
to deliver a broader spectrum of prevention
and primary care services; 5) Impact
of fiscal constraints on provider
productivity requirements, which can
lead to increased burnout; and 6)
Potential implications of routine
testing.
Cheever urged stakeholders to keep
these issues in mind as they work
together to construct a process for
addressing the workforce shortage.
Overview of Domestic Workforce
Issues
Tim Dall
Vice President
The Lewin Group
There is a growing consensus that
the supply of health care is not keeping
up with demand, said Tim Dall, Vice
President of the Lewin Group. At the
same time, there are diverse opinions
about the factors affecting supply
and demand, which have in turn led
to an array of forecasts regarding
workforce trends. Some believe more
clinicians are needed. Others believe
the current supply of clinicians is
not being used efficiently. Dall's
presentation sought to highlight data
on workforce shortages and what they
indicate.
Often it is asked, said Dall, how
a complex health care system comprised
of 800,000 nurses, 300,000 physicians,
and thousands of other clinicians
in a variety of specialties, as well
as a range of health care plans, employers,
facilities and regulations can be
modeled. Several approaches prevail.
One is known as the inventory model.
It starts with the demographics of
the current workforce, adds the number
of new entrants to the field, subtracts
the number of retirees or those exiting
the field, and produces a number used
as the starting point for the following
year's projections. In applying the
model to the current physician workforce,
Dall has found:
- A significant decrease in the
number of physicians who practice
after age 60;
- A majority of physicians nearing
retirement age are men;
- The majority of students entering
medical school are women; and
- Female physicians tend to work
13 percent less than men.
Modeling data from the Association
of the American Medical Colleges (AAMC),
said Dall, shows that many physicians
work longer and more consistently
than they expect. The data also show
that women and men tend to retire
at the same ages, but given men's
shorter lifespans overall women physicians
actually spend more time in the workforce.
Dall then presented data on pharmacists.
In applying the inventory model, he
found that a large number of pharmacists
in the United States are between the
ages of 45 and 50, there are growing
numbers of women moving into the field,
and in the next 15-20 years women
will comprise two thirds of all pharmacists,
if current trends hold. As with physicians,
labor force participation for both
men and women pharmacists starts to
decline significantly after age 60.
Dall used sample survey data collected
by HRSA to model the nursing workforce.
The results showed a substantial drop
in the number of new nurses entering
the profession, coupled with high
attrition rates. About 95 percent
of the nursing workforce is female,
although the number of male nurses
is growing. Labor force participation
by nurses decline between the late
20s and early 40s, and picks up around
age 45. It then remains fairly constant
until age 60, after which it drops
off again. Labor force participation
rates are higher now than they were
in previous years, possibly due to
higher wages. Because many nurses
tend to be second-earners in their
households, said Dall, labor force
participation rates for nurses tend
to correspond with economic cycles;
better economic conditions are often
accompanied by reductions in the nursing
workforce, while the supply of nurses
increases during economic downswings.
There is a lack of consensus regarding
what future needs will be for different
types of physicians. Dall suggests
that demand-based forecasting models
yield the most accurate data, predicting
demand and supply in the context of
existing system inefficiencies. They
use current patterns of health care
utilization and service delivery to
extrapolate into the future, taking
certain trends into account.
Another approach to forecasting is
called benchmarking, used by Jonathan
Weiner in the mid-1990s to predict
the future supply of physicians for
HRSA. Wiener's data was published
in the Journal of the American Medical
Association and was used by, among
others, the Council on Graduate Medical
Education to develop funding policy
for graduate medical education. In
addition, educational institutions
used the data to determine which specialties
would be emphasized. The problem,
explained Dall, is that Weiner's model
was predicated on the notion that
managed care would drive staffing
patterns for the long term. When that
proved not to be true, the projections
were no longer valid. Dall cautioned
on the use of models that depend on
the consistency of one trend. Researchers,
he said, "better be sure that
trend materializes, [and] if not,
they should do a sensitivity analysis
so that people realize what could
happen if the trend doesn't hold."
Many current forecasts for physicians,
nurse practitioners and physician
assistants, according to Dall, are
drawn from a trend model developed
by Richard Cooper. Cooper has correlated
the physician/population ratio with
gross domestic product as an indicator
of economic well being. Using the
model, he has predicted a physician
shortage of 200,000 by 2020, mostly
in the area of specialty practice.
Based on these results, Cooper suggests
that the major trend affecting the
demand for physician services is the
economy.
To examine the use of specialists
by those with HIV/AIDS, Dall and his
colleagues first looked at information
from the National Ambulatory Medical
Care Survey and the National Hospital
Ambulatory Care Survey. They examined
data for patient visits to inpatient
or outpatient hospitals in which HIV/AIDS
was indicated. What they found in
those settings is that non-Hispanic
Whites represented 38 percent of all office
visits, non-Hispanic Blacks represented
43 percent, Hispanics represented 15 percent and
non-Hispanic others were 4 percent.
They then looked at the types of
doctors providing care to those particular
patients. The results indicated that
the clinician was an infectious disease
doctor in 23 percent of office visits, a
family practitioner in 16 percent of office
visits, and an internist in 57 percent of
office visits. Hematologists/oncologists,
obstetricians, gynecologists and ophthalmologists
were used to a lesser extent. Dall
then took this data and forecast the
future demand for physicians within
these areas of practice.
Using this data, Dall projected that
the total demand for physician services
will increase 25 percent by 2025. At that
time, the nation will be short 35,000
- 44,000 adult care generalists practicing
in family and internal medicine.
Dall then presented data on other
clinicians. With regard to nurses,
he explained that an increased emphasis
on expanding nurse education programs
coupled with better nursing salaries
had improved the outlook regarding
future supply. However, despite these
efforts and based on current trends,
there will likely be a shortfall of
several hundred thousand nurses by
2025.
In 2000, it was estimated that the
vacancy rate for pharmacists was 8 percent
and growing rapidly. Since that time,
the supply has increased due to higher
pay scales and expansion of training
programs. If trends continue, said
Dall, there should be a modest shortfall
by 2025.
He Stated that the supply of nurse
practitioners and physician assistants
is growing pretty steadily and that
there is some question about whether
those professions will hit a saturation
point. That is clearly not the case
at the present time, said Dall.
Demand for dental services continues
to grow at a significant rate. Barriers
to care are largely related to geographic
maldistribution of services and lack
of access by certain populations,
including the medically underserved.
In concluding, Dall presented some
considerations for engaging young
clinicians in HIV care based on what
the data says about their interests
and priorities.
- An increasing proportion of physicians
are women who have different workplace
expectations than men.
- Racial and ethnic minorities are
still underrepresented in the health
care professions.
- Young clinicians have different
attitudes about work/life balance
than their predecessors.
- Young clinicians tend to embrace
new technologies and want to practice
in facilities with State-of-the-art
equipment.
What We Know About the Workforce
in HIV/AIDS
Christine Lubinski
HIV Medicine Association
The HIV Medicine Association (HIVMA)
represents more than 3600 physicians,
nurse practitioners, and physician
assistants working in HIV medicine.
The organization works to promote
an alternative pathway that supports
the training and certification of
primary care providers as HIV experts.
In pursuit of this goal, HIVMA developed
the Minority Clinical Fellowship Program
in 2006 to increase minority representation
in the HIV workforce. The program
provides Latino and African-American
medical residents with mentoring and
1 year of clinical training in a center
of excellence with a mentor.
Christine Lubinski, Executive Director
of HIVMA, said that most of the HIV
care provided in the United States, particularly
in public settings, is delivered by
multidisciplinary teams. Each member
of the team is critical, she said.
 She
referenced a 2005 study of Ryan White HIV/AIDS Program Part C clinics that showed 20 percent of
patients had the majority of their
care provided by physician assistants
or nurse practitioners. These clinicians,
said Lubinski, maintained average
patient panels of 100, and while they
tended to see younger patients with
fewer HIV complications, they scored
as well as infectious disease doctors
and HIV experts on quality measures.
In addition, they often scored better
than internists without HIV expertise
or training.
Lubinski also presented data from
the HIV Cost and Service Utilization
Survey (HCSUS), conducted from 1996-98.
The survey showed that 14 percent of persons
with HIV/AIDS in care had unmet dental
needs, and those who were uninsured
or had Medicaid were three times more
likely than those with insurance to
go without needed medical or dental
care.
"I would venture to say, given
what I know has happened to Medicaid
since the late 90s, that even fewer
people with HIV now have an adult
dental care benefit," she said.
She expressed growing concern about
the availability of dental services
to those with HIV, especially in light
of recent dental school closures due
in part to insufficient reimbursements
for care.
Lubinski said HCSUS data on the physician
workforce, collected between 1998-99
from a sample of 372 physicians, showed
that one third had annual incomes
below $100,000, the majority were
White men, and 20 percent were gay and providing
care to 18 percent of patients. In addition,
40 percent were infectious disease physicians
and 56 percent were general practitioners.
In general, Lubinski said, numerous
studies document that health outcomes
are better for HIV patients when physicians
see more HIV patients and keep up
with current treatment standards.
This is true for all clinicians providing
care to people living with HIV/AIDS.
Further, formal training in HIV care
is usually in infectious disease programs,
although other specialties offer structured
training experiences. There are a
host of informal opportunities for
non-infectious disease physicians
to receive HIV clinical experience
and mentoring. Doctors in training,
including those being trained in Ryan White HIV/AIDS Program-funded clinics, perform an important
role in providing HIV care.
As treatments have moved to outpatient
settings, said Lubinski, medical residents
have received less exposure to HIV
patients. Data she presented from
a 1998 survey of residents at academic
health centers that found 22 percent of internists
and 58 percent of family medicine residents
felt "somewhat or very unprepared"
to take care of people with HIV/AIDS.
Antiretrovirals have significantly
increased the lives of those with
HIV/AIDS, said Lubinski, and as a
consequence HIV primary care providers
are now expected to provide a broader
range of services, such as risk reduction,
diabetes screening, management of
hypertension and other conditions
associated with aging. Earlier in
the epidemic, studies indicated that
HIV patients were frequently referred
to HIV specialists by their general
practitioners. Current data suggests
a trend in the reverse direction;
infectious disease physicians are
increasing referrals to internists
for the management of general medical
conditions.
In 2004, HIVMA conducted a survey
of 729 first-year medical residents
in internal medicine programs in ten
States with the highest HIV prevalence.
The average debt level was $108,000.
The results showed that a majority
(70 percent) planned to do specialty
training upon completion of their
medical residencies. Forty percent
were interested in working in HIV
medicine or research, and 79 percent
indicated a preference for a year
of focused training rather than a
2-year fellowship. Half of respondents
(51 percent) felt their residency
had not prepared them to practice
HIV medicine.
Lubinski also presented results from
a Workforce and Capacity Survey conducted
by HIVMA and the Forum for Collaborative
HIV Research. Responses came from
252 Ryan White HIV/AIDS Program Part C programs serving
135,000 patients in 2007. Forty-one
percent were located in the south
and 61 percent were in metropolitan areas.
Ryan White provided funding for 69 percent
of all primary care staff.
Results showed that the clinics served
an average of 650 patients each. Twenty
percent had experienced more than
a 25 percent increase in their caseloads
in the previous 3 years, 51 percent
had experienced up to a 25 percent
increase in their caseloads, and the
remainder had experienced stable or
decreasing caseloads. Many clinics
in the south and rural areas reported
rapid growth in patient caseloads.
The range in panel size per physician
was substantial, from 8-1250. The
ranges for physician assistants were
equally broad (4-600) as were the
ones for nurse practitioners (5-750).
Appointment times for new patients
ranged from 15 to 240 minutes.
The majority of respondents indicated
that it was very difficult to recruit
primary care providers to HIV. Less
than 10 percent said it was easy or very
easy. Clinics in the west and south,
and to a lesser degree the Midwest,
reported the most difficulty. Recruitment
of nurse practitioners and physician
assistants was also challenging.
Top recruitment challenges identified
by respondents included the overall
lack of clinicians in their geographic
areas (and lack of HIV clinicians
in particular), as well as low reimbursement
rates. Clinics in the northeast, south
and west reported clinician shortages
as barriers to recruitment. In the
south and northeast, physician workloads
were also a factor. To a much larger
degree than in other regions, clinics
in the south reported that physician
pay scales and provider aversion to
treating patients with HIV presented
barriers to recruitment.
Wait times for first appointments
for newly diagnosed HIV patients were
significantly longer in the south
(1.7) than in the northeast and Midwest
(1.1 weeks). Wait times were also
significantly longer in hospitals
and academic centers than they were
in publicly funded health centers
or health Departments.
Lubinski concluded her comments by
urging more study on the status of
the HIV workforce and development
of viable practice incentives. She
said regional differences, as well
as challenges unique to rural versus
urban areas, must be addressed. The
Bureau, she added, could take the
lead in developing productivity standards
that address optimum panel sizes and
appointment times, and advancing practice
models that respond to needs of patients
and clinicians.
"If we are going to address
this issue," said Lubinski, "then
it has to be integrated into broader
discussions, including on national
health care reform and into the formation
of a comprehensive national AIDS strategy."
Question and Answers
Michelle Lopez of New York asked
Tim Dall if he had data on emergency-room
visits for minority populations. Dall
said there was a lack of data on racial
and ethnic characteristics of patients.
There are some surveys, he said, but
they tend to be small with modest
sample sizes. His findings did indicate
that a significant percentage of patients
with HIV/AIDS who seek care in emergency
rooms are non-Hispanic Blacks. Data
on the characteristics of physicians
providing care in those settings is
not available, in part because many
of them provide care in multiple settings
and it is hard to know what proportion
of their time is spent in emergency
rooms.
Keith Rawlings of Dallas asked if
the presenters had data showing the
percentage of licensed physicians
in the United States who were practicing medicine
versus the percentage working in other
fields. He further asked about the
criteria being used to define HIV
expertise.
Christine Lubinski cited anecdotal
evidence suggesting that physicians
are moving into the private sector,
including the pharmaceutical industry.
With regard to defining experience,
she said studies suggest HIV experts
are those who have treated at least
20 patients and have participated
in national and regional conferences
on practice standards. The emphasis
is on intensity of practice rather
than duration.
Michael Horberg from Kaiser Permanente
asked Lubinski whether she had any
data suggesting that patients seeking
care at Ryan White clinics were doing
so because their physicians were no
longer treating HIV. Lubinski said
the HIVMA survey did not request that
information, but that anecdotally
she has heard many patients go to
public clinics because their physicians
no longer provide care or have closed
their practices.
David Reznick of Atlanta asserted
that physician reluctance to provide
HIV treatment must be considered in
efforts to expand the workforce. He
then asked Dall if he had data on
the number of clinicians working in
the public versus private health care
settings, adding that his belief is
that clinicians are leaving public
health because they feel the reimbursements
are too low. Dall said he has some
data on nurses working in public versus
private settings, but it has not received
the attention it deserves.
Bureau of Health Professions (BHPr)
Diana Espinosa
Deputy Associate Administrator
Diana Espinosa, Deputy Associate
Administrator of BHPr, highlighted
several ways in which BHPr focuses
on workforce challenges, including:
- Managing the legal process for
determining shortages;
- Funding Univ. health professions
training and education programs;
- Focusing on maldistribution by
providing support to programs that
place graduates in underserved areas;
- Providing support to programs
that conduct training in underserved
areas;
- Increasing the diversity of the
health care workforce and improving
cultural competence;
- Developing health professions
curricula that ensure patient safety,
quality of care and the provision
of culturally competent care;
- Staffing advisory committees
that focus on payment issues in
the context of larger health care
issues; and
- Supporting the development of
practice models that encourage interdisciplinary
practice and training.
Espinosa highlighted several efforts
within the Bureau that hold relevance
for HIV/AIDS. The Nursing Education
and Practice program emphasizes care
to underserved and high-risk populations,
which includes those with HIV/AIDS.
State oral health grants include Puerto
Rico, which focuses on the provision
of culturally competent oral health
services to people with HIV/AIDS.
Espinosa mentioned that the primary
care component of the statute has
a special emphasis on high-risk populations.
The Area Health Education Centers
(AHECs), which support innovation
in health professions education, help
increase the number of clinicians
in underserved areas. Twenty-three
of the program's 50 grantees provide
HIV training and education to students,
faculty and practitioners. The Preventive
Medicine Residency Program has focused
on increasing linkages and improving
the quality of care.
A new program, the patient navigator,
provides funding to community-based
organizations to develop programs
that increase care coordination and
linkages.
BHPr also awards student loans and
scholarships to primary care providers
who work in underserved and minority
communities.
Bureau of Primary Health Care (BPHC)
Amanda Reyes
Public Health Analyst
Amanda Reyes of BPHC presented information
on BPHC's community health center
program, which served 16 million patients
in 2007 through a network of 1,000
health centers. Health centers are
located in high-need communities and
must provide a broad portfolio of
primary care and support services.
Many are found in the same communities
as Ryan White clinics; in 2007, 164
community health centers received
Ryan White HIV/AIDS Program Part C funding. Health
centers employ a broad range of health
professionals to ensure high quality
medical homes for those who would
otherwise go without care.
While not required by legislation,
said Reyes, nine out of ten community
health centers directly provide HIV
testing and counseling services. In
2007, more than 500,000 clients received
HIV testing and counseling services
at health centers.
The legislation prohibits health
centers from denying access to services
based on ability to pay. There is
a sliding fee scale for those at 200 percent
of poverty and below.
Reyes suggested that collaboration
with the health centers program can
be useful in addressing HIV workforce
issues, and added that BPHC-funded
primary care associations can provide
entrée to this extensive system
of care.
Bureau of Clinician Recruitment
and Service
Mike Berry
Policy Director
The Bureau of Clinician Recruitment
and Service (BCRS) was created in
2007 to consolidate all programs in
HRSA that provide funding to individual
clinicians.
The programs are as follows.
- The National Health Service Corps
(NHSC) Scholarship program provides
tuition, stipends, fees and up to
4 years of support to clinicians
who serve in underserved areas for
a minimum of 2 years. In 2007,
the program awarded 118 scholarships
averaging $117,000 a piece.
- The NHSC Loan Repayment program
provides up to $50,000 in loan repayments
to individuals who sign a 2-year
minimum contract to work in underserved
areas. Participants can stay longer
and have a higher percentage of
their loans repaid. In 2007, the
program provided 899 awards in amounts
ranging from $130,000 to $230,000.
- The Nursing Scholarship Program
covers tuition and other education-related
costs for nursing students who agree
upon graduation to serve for 2 years at a health care facility
with a critical nursing shortage.
Nursing students also receive monthly
stipends while they are in training.
The program awarded 172 scholarships
in 2007.
- The Nursing Education Loan Repayment
Program (NELRP) is a competitive
program that repays 60 percent of student
loans for nurses who agree to serve
for 2 years in a health care facility
with a critical nursing shortage.
Participants may apply for a third
year of support, which will repay
an additional 25 percent of their debt
in return for another year of service.
Participation in NELRP is limited
by lay to three years. The program
provided 315 awards in 2007.
- The Faculty Loan Repayment Program
provides up to $40,000 to faculty
from disadvantaged backgrounds who
agree to serve at eligible health
professions schools for 2 years
and mentor students from similar
backgrounds. Twenty awards were
made in 2007.
- The Native Hawaiian Scholarship
Program covers the cost of education
for Native Hawaiin students who
commit to serving in health professions
shortage areas in Hawaii. Students
agree to provide a year of service
for each year of support they receive.
The program made 10 awards in 2007.
BCRS' Mike Berry explained that BCRS
also oversees the J1 visa waiver for
clinical care, which in 2007 provided
support to 10 clinicians serving as
primary care physicians in rural clinics
or Native American areas. Five of
those who received J1 visas served
in community health centers.
Division of Training and Technical
Assistance, HIV/AIDS Bureau
Lynn Wegman
Chief
HIV Education Branch
The mission of the AIDS Education
and Training Center (AETC) program
is to improve the quality of life
for patients living with HIV/AIDS
by providing education and training
to health care professionals. AETCs
serve as the clinical training arm
of the Ryan White HIV/AIDS program.
Physicians, physician assistants,
nurses and advanced practice nurses,
oral health professionals, and pharmacists
constitute 80 percent of those who receive
training through the AETCs. The remaining
20 percent are allied health professionals.
Providers who receive training care
for the medically underserved, include
those in health centers, Ryan White
clinics, rural health clinics, and
correctional facilities.
The program maintains 11 regional
centers with more than 130 local sites.
Funding is for 5 years. There are
also four national centers: 1) the
AETC National Resource Center; 2)
the National Minority AETC; 3) the
National Clinician's Consultation
Center; and 4) the AETC National Evaluation
Center.
From 2006-2007, AETC faculty provided
more than 46,000 hours of training
to clinicians, 25 percent of whom were nurses
and 21 percent physicians.
Questions and Answers
Lucy Bradley-Springer of Denver asked
Mike Berry if he had data on the percentage
of scholarship or loan repayment recipients
that remain in their assigned communities
after meeting their service obligations.
He said current data show that 53 percent
of program participants who met their
obligation between one and 15 years
ago are still working in their assigned
communities.
Berry added that participants in
the loan repayment program tend to
stay in the communities where they
first serve more often than scholarship
recipients. The list of approved scholarship
sites is limited because the program
is legislatively mandated to send
recipients to areas of greatest need.
In the loan repayment program, there
is also a list of sites, but it is
significantly longer and applicants
are able to visit and interview with
sites before selecting them.
Pete Gordon of New York advocated
greater emphasis on the loan forgiveness
program, because it gives residents
more choice in deciding where they
want to serve. He asked if there was
any potential to reallocate resources
from scholarships to the loan repayment
program.
Berry said he agreed with Gordon,
but added that he had no control over
how the money was allocated. He acknowledged
that the consequences for defaulting
on scholarship agreements were fairly
onerous, requiring recipients to pay
back three times the amount of their
scholarships plus penalties and interest.
As an example, Berry used a dental
scholarship recipient whose schooling
had cost $340,000. Were he to default,
Berry explained, he would owe HRSA
nearly $1 million. In consideration
of these realities, the program has
tried to target third- and fourth-year
medical students, under the assumption
that they have a better sense than
first- and second-year medical students
about their professional interests.
Keith Rawlings asked why the scholarship
program was so small, given its success.
Berry said that while scholarships
help create a pipeline, they blunt
the Bureau's ability to get more clinicians
out into the field sooner. "The
problem with scholarships," said
Berry, "is that service can be
deferred for up to 7 years while
the recipient is finishing residency
training." He said the Bureau
has been focusing more on meeting
the immediate needs of underserved
communities.
Bruce Agins asked why there were
only 10 J1 visas in 2008. Berry explained
that there were two chief factors:
1) Limited resources available at
the Bureau to implement the program;
and 2) A 50 percent decline in the number
of J1 visa holders over the past ten
years. He added that the State-based
Conrad program offers a total of 1530
waivers each year, while the number
of J1 applicants seeking them is barely
1000. Berry is coordinating with States
to ensure that applicants are referred
to him when Conrad slots are filled.
Michelle Lopez of New York said her
health center implemented HIV testing
in 1990. Given that health centers
do not employ sub-specialists, she
asked Amanda Reyes whether BPHC had
information on health center referral
systems. Reyes said she is in discussions
with colleagues about developing collaborations
with sub-specialty providers, including
HIV providers.
Janet Leigh from New Orleans expressed
concern over the costs of medical
and dental education as it affects
the practice choices of clinicians.
She asked whether the Bureau considers
the cost of schools chosen by NHSC
applicants in its award decisions.
Berry said the choice of school is
not specifically examined, however,
BCRS does assess what services are
most in demand in targeted communities.
For example, if 20 percent of the vacancy
list is in the area of family practice,
then 20 percent of scholarships will go to
medical students who plan to specialize
in that area.
Another attendee asked about the
status of the White paper developed
by the National Advisory Council on
the National Health Service Corps.
The White paper will make recommendations
for changes to NHSC authorization,
which expired in September 2006. Berry
explained that the document is still
in clearance within the United States Department of Health and Human Services.
Targeting Pre-Professionals and
Minority Students and Residents
Sade Kosoko-Lasaki
Associate Vice President
Creighton Univ.
Sade Kosoko-Lasaki is an ophthalmologist
who sees clients with HIV/AIDS. She
is also a Professor of Preventive
Public Health and Associate Vice President
of Creighton Univ. in Omaha, Nebraska.
Twenty percent of Omaha's population,
she said, is comprised of Blacks,
Hispanics, Native Americans, and Asian
and Pacific Islanders. There is under-representation
of these communities in the local
physician workforce.
In response, Creighton, using a public
health approach, developed several
pipeline programs targeting students
from economically, educationally and
socially disadvantaged backgrounds.
Middle school students participate
in the Health Careers Club, where
they learn about health and wellness
issues in the context of math and
science courses. They participate
in a range of interactive educational
activities and have opportunities
to meet one-on-one with individuals
who work in the health professions.
Creighton's Saturday Academy targets
high school students, bringing them
to campus every weekend to increase
their proficiency in math, English,
science and other subjects, with the
intention of preparing them for undergraduate
study in a pre-health field. Students
receive a stipend equal to what they
might earn if they worked for the
day. They also receive assistance
in preparing for their college entrance
exams.
In the past 6 years, 1800 middle
school, high school and college students
have participated in the Univ.'s pipeline
programs, which has helped raise their
ACT and SAT scores. For the seven
students participating in the Univ.'s
post-baccalaureate program, Creighton
has committed to awarding them $10,000
a year for health professions training.
The institution also holds financial
aid workshops for parents.
Arkansas Area Health Education
Center
Patricia Vannatta
Associate Director of Education
The Arkansas Area Health Education
Centers (AHEC) system has been in
existence since the 1970s, and is
administrated through seven regional
locations throughout the State. The
program covers every county in the
State except the one that contains
the Univ. of Arkansas Medical School.
The AHEC operates a number of pathway
programs. Career awareness activities
are designed to acquaint young students
with opportunities in the health care
field. These are held at grammar and
middle schools, and include both students
and parents. "A day in the life
of a health professional" and
other similar presentations are provided
in a variety of formats.
Career fairs are also held in high
schools to generate interest in educational
opportunities leading to employment
in health care. The AHEC develops
online and print guides that outline
educational requirements and responsibilities
of different clinicians, and lists
educational institutions in State
that have certificate and degree programs
in the health professions.
A number of pipeline programs are
administered through the AHEC regional
sites. The Community Health Applied
to Medical Public Service (CHAMPS)
program engages 9th and 10th graders
in service and learning activities
that introduce them to careers in
the health professions. The Medical
Applications of Science to Health
(MASH) program enables 11th and 12th
graders to shadow health care professionals
and receive instruction in health
and medical topics. Students are tracked
over time and about 70 percent enroll in
science majors or are already involved
in health training programs.
AHEC also provides MCAT prep courses,
mock interviews and assistance in
preparing college applications.
Arkansas' Family Medicine Residency
Training program operates in six locations
around the State. Since its inception,
the program has trained 571 physicians
who are currently practicing in 67
of the State's 75 counties. AHEC-trained
physicians comprise 49 percent of the total
population of family physicians in
the State.
"We feel if we train health
professionals in a community, they
will stay in those communities,"
said Arkansas AHEC's Patricia Vannatta,
"and our experience has borne
that out."
All training sites are affiliated
with community hospitals, health centers,
health Department clinics or nursing homes.
The curriculum for each varies based
on the emphasis of the residency program.
Two programs concentrate on HIV management.
Professional isolation can be a challenge
in rural areas, says Vannatta, so
all programs are linked to the Univ.
Medical Center through telemedicine
technology, interactive video and
other means. In addition, all programs
use electronic records and other online
resources to promote quality patient
care.
Preceptorships are offered to medical
students in their first 2 years
and four-week community clerkships
are required in the third year of
medical school. Fourth-year medical
students are able to do family medicine
rotations throughout the AHEC system.
American Academy of HIV Medicine
Workforce Initiative
Jim Friedman
Executive Director
American Academy of HIV Medicine (AAHIVM)
Jim Friedman AAHIVM's Executive Director,
discussed the Academy's workforce
initiative, launched in April 2008
and designed to generate interest
in HIV medicine by "intervening
at critical points in the [provider's]
career path."
As part of the initiative, the Academy
provides free membership to students
in training, an effort that has attracted
170 new members since the program's
inception. Students are paired with
clinical mentors in their communities;
the mentors are given access to AAHIVM-developed
learning modules to help teach students
about the fundamentals of HIV medicine.
A recently launched grant program
provides $100,000 to residency programs
to design, implement and assess innovative
ways to encourage students to enter
the HIV field. At least one grant
will go to a Historically Black College
and Univ. (HBCU). Best practices from
this effort will be included in a
guide and disseminated to medical
schools and training programs around
the country.
AAHIVM provides financial support
to first-year HIV practitioners, their
employers and their clinical mentors,
as part of package aimed at increasing
their competency for practicing HIV
medicine. The package of support includes
requirements for completing a certain
number of HIV continuing medical education
(CME) credits and becoming credentialed
by the third year of practice. In
conjunction with this effort, AAHIVM
will be advocating for greater loan
repayment through the NHSC to facilitate
student entry into HIV medicine. In
the area of retention, the program
is working to secure enhanced reimbursements
for HIV specialists.
Fellowship Training in New York
State
Bruce Agins
Medical Director
New York State Dept. of Health/AIDS
Institute
The New York State Clinical Scholars
Program was established in 1990 through
a legislative earmark of $1.5 million.
The program targets nurses, physicians
and physician assistants in a variety
of health care settings. Grants for
the program are awarded on a competitive
basis every 5 years. Despite a
cut of 6 percent to the program's budget
for 2008-09, it was able to fund training
for 12 scholars working at nine hospitals
throughout the State.
The goal of the program is to expand
the network of HIV providers practicing
in the State. The program features
three components: 1) A clinical track;
2) A core curriculum; and 3) An independent
study project. Scholars start their
clinical rotation at a funded institution
and eventually build to a full panel
of patients. The State Health Dept.
provides instruction in a core curriculum.
Scholars also spend one full day per
week learning about broad policy and
public health issues and complete
an independent study by the end of
the 2-year program. Once the program
is completed, scholars must pass the
AAHIVM exam to be certified.
Data shows that the program has been
successful in keeping HIV providers
working in the State. A recent survey
of 73 graduates showed that 89 percent still
work in HIV and 78 percent still practice
in New York.
Bruce Agins of the New York State
AIDS Institute described the program
as a "Cadillac model" developed
at a time when there was ample support
for HIV services. Shifts in the economic
climate, he added, coupled with changes
in the epidemic have led the AIDS
Institute to consider modifications.
These may include condensing the program
to 1 year to train more individuals,
different/better targeting of shortage
areas, adding an international rotation,
linking to other certification or
degree programs and requiring scholars
to sign service commitments.
Among the policy implications for
the program, said Agins, is whether
it is still necessary given the growth
in HIV clinical certification programs.
Additionally, he posed these questions:
1) What role can an HIV scholar play
in a model of care that integrates
HIV into primary care?; 2) What can
be learned from the President's Emergency
Plan for AIDS Relief (PEPFAR) where
a group of providers is trained in
HIV care?; and 3) Should the program
be combined with AETC and similar
training programs?
HIVMA Minority Clinical Fellowship
Program
Loida Bonney
Assistant Professor of Medicine
Emory Univ. Center for AIDS Research
Loida Bonney, a former HIVMA Minority
Clinical Fellow, described the HIVMA
minority clinical fellowship program
as an "excellent" learning
opportunity that enables post-residency
physicians to gain HIV clinical experience
and expertise. She said the goal is
to expand the number of HIV clinicians
from underrepresented minority communities.
During her fellowship, Bonney split
her time between an academic position
at Emory Univ. and a clinical practice
at Grady Memorial Hospital, where
she personally cared for 55 patients
with HIV. The fellowship included
weekly meetings with a mentor, attending
several key medical conferences, and
publication of an article on access
to care.
"The beauty of this fellowship
lies not so much in what I did last
year," said Bonney, "but
in what I will be doing in the future."
Her plans include continuing to work
at Grady to further build her panel
of patients and build professional
relationships with staff that will
support her ongoing learning. She
also will have the opportunity to
share her enthusiasm for, and knowledge
of, HIV medicine as she teaches students
and residents in her attending role,
and as she continues her research
on HIV.
In concluding, Bonney suggested that
1 year of HIV training might not
be adequate to orient a new provider
to the field, but added that lifelong
learning in HIV is important for every
clinician.
The Role of Historically Black
Colleges and Universities (HBCUs)
and Hispanic Serving Institutions
(HSIs)
Anthony Wutoh
Professor and Center Director
Center for Minority Health Services
Research
Howard Univ. School of Pharmacy
Howard Univ.'s Anthony Wutoh explained
that HBCUs and HSIs have, as part
of their mission, a commitment to
addressing a range of health issues
that disproportionately affect communities
of color, such as HIV/AIDS. As such,
they are well positioned to help address
workforce challenges by providing
uniquely trained professionals with
expertise in gaining access to underserved
or hard-to-reach populations.
Wutoh explained that more than 80 percent
of African Americans in the United States who
hold medical or dental degrees received
their education at either Howard or
Meharry Medical College. Currently,
nearly 20 percent of the medical and dental
degrees awarded each year to African
Americans are from HBCUs.
"So how can this potential workforce
be accessed?," asked Wutoh. He
suggested several approaches for reaching
out to these students:
- Conduct or host faculty/graduate
mentoring programs;
- Identify potential students and
nurture them through mentorships,
internships, externships and fellowships;
- Engage HBCUs and HSIs in pertinent
meetings/conferences;
- Schedule meetings with relevant
campus organizations;
- Develop recruiting incentives
for faculty;
- Improve web sites as recruitment
tools; and
- Target relevant professional
programs.
Wutoh, who is a pharmacist, says
that Howard provides students in its
health professions schools with instruction
in HIV. In noting that there is a
shortage of pharmacists nationwide
and increasing opportunities for students
to enter other fields, he emphasized
the importance of reaching out to
students early to foster an interest
in HIV.
"HRSA will not be able to do
these things alone" he said,
"but it should consider targeting
some of these individuals through
its programs."
Nurse Retention in the Ryan White
HIV/AIDS
Program Outpatient Setting
George Zangaro
School of Nursing
Univ. of Maryland, Baltimore
With a workforce of 2.9 million,
nurses represent the largest health
profession in the country, said Zangaro.
Nearly 60 percent of nurses work in acute
care facilities and less than 10 percent
work in outpatient settings.
Univ. of Maryland School of Nursing's
George Zangaro pointed out several
things that currently contribute to
the severe and growing nursing shortage
in the United States The nursing population
is aging, there are insufficient faculty
and learning opportunities and there
is a growing demand for nursing services.
In 2007, nursing programs turned away
over 40,000 students due to lack of
clinical spaces, faculty, and classroom
capacity. As a result, it is projected
that the nation may be short 500,000
registered nurses (RNs) by 2025.
The practice environment is the main
driver in nurse retention, said Zangaro,
and is influenced by factors such
as job stress, inadequate staffing,
high work volume, poor collaboration
with other nurses and health professionals,
and professional isolation, particularly
in rural areas. "Nurses have
described their practice environments
as intellectually oppressive and cognitively
restrictive," said Zangaro. As
such, work settings that empower nurses
lead to better retention.
"How do we retain nurses in
the workforce?" Zangaro asked.
He suggested that magnet hospitals
provide models for promoting leadership
opportunities, supporting professional
development, supporting nurses' autonomy
and role in decision making, and creating
a "culture of retention"
within practice settings. Other approaches
could involve developing partnerships
with nursing school deans to facilitate
student introduction to HIV learning
opportunities. Additional recommendations
from Zangaro include encouraging rural
clinics to let their staff present
on HIV issues at academic centers,
developing HIV specializations within
nursing schools, and getting nursing
school faculty to work in HIV clinics.
Zangaro explained that most current
research on nurse retention is focused
on acute care facilities, so a better
understanding of how outpatient settings
can be organized to promote nurse
retention is needed.
"It's also important to figure
out what young people [coming into
the field] want in their work environment
and professional experiences,"
he said.
Foreign-born Providers
Barbara Schechtman
Director
Midwest AIDS Education and Training
Center
|
Characteristics of Recruited
IMGs or Foreign Born Clinicians
- Bilingual / Bicultural
- Member of a disproportionately
affected group
- Trained internationally
(IMG)
- Trained in United States, but meets
1 & 2
- Credentialed to practice
in United States OR
- At specific point in credentialing
process: resident | fellows
|
Barbara Schechtman of the Midwest
AETC spoke about the potential for
increasing the HIV workforce by tapping
into the pool of internationally trained
clinicians who live in the United States but
are not working in the health care
system. Because many of these clinicians
come from nations with high HIV incidence,
said Schechtman, they may be uniquely
able to connect with patients from
immigrant communities with high rates
of HIV.
Studies conducted by Johns Hopkins
researcher Lisa Cooper, M.D. indicate
that racial and ethnic matches between
providers and patients positively
influence patient ratings of care,
said Schechtman. That may mean that
engaging foreign-born and foreign-trained
providers in the HIV health care system
could help expand access to culturally
competent care for immigrant populations.
Schechtman described African medical
providers in Minnesota as motivated
to give back to their communities,
wanting to work in medicine, and interested
in leading culturally specific training
for other providers.
Schechtman outlined some opportunities
to partner with groups that target
these provider populations. The HRSA-funded
Welcome Back Program provides intensive
case management for foreign-trained
clinicians to help facilitate their
entry into the United States health care system.
Florida International Univ. (FIU)
in Miami operates a Foreign-Educated
Physician-BSN Program, an accelerated
nursing curriculum for foreign-trained
physicians. The program, the first
of its kind in the country, graduates
roughly 40 nurses a year and was developed
to address the nursing shortage in
South Florida.
MATEC has reached out to foreign-born
clinicians through HIV rotation and
infectious disease fellowships at
the Univ. of Minnesota, and through
local partnership with organizations
such as the African and American Friendship
Association for Cooperation and Development,
which focuses on licensure for foreign-trained
professionals. The program is also
using Minority AIDS Initiative (MAI)
funds to provide shadowing experiences
for clinicians in training. MATEC's
Individualized Clinician Training
Program also includes some foreign-trained
clinicians from Africa. MATEC uses
the Twin Cities Clinician's Group
meetings to introduce foreign-trained
clinicians to networking and partnership
opportunities with HIV providers.
"MATEC has really put an emphasis
on reaching out to these clinicians
before they get certified," said
Schechtman, "because we have
found that increases their interest
in entering the field of HIV."
Questions and Answers
Pete Gordon asked if the AHEC training
programs were based at community health
centers or academic health centers.
Patricia Vannatta responded that the
training programs are all located
at community hospitals, as well as
at freestanding clinics on their campuses.
She added that most of the participating
hospitals are the largest in their
regions. The programs are long-standing
and are centrally administered out
of the Univ.-based office.
A participant asked Jim Friedman
how AAHIVM intends to fund its workforce
initiative. Friedman said the Academy
is seeking funding from foundations
and private sources. "We are
making a point of not seeking funding
from Ryan White, as we do not want
to take from one program and give
to another," he said.
Michelle Lopez mentioned that HBCUs
could use high-school career days
to generate early interest in HIV.
Anthony Wutoh liked Lopez's idea and
said he suspects some HBCUs shy away
from the topic of HIV because they
feel it will negatively impact recruitment.
He echoed what others said about reaching
out to students early in their studies,
saying "I am an HIV researcher
and I gave a presentation recently
to over 30 students who have an interest
in HIV."
Sade Kosoko-Lasaki said Creighton
has had success in using peers to
educate students, because students
speak the same language, come from
the same vantage point and belong
to similar social groups. "So
for example, we have high school students
mentor kids in grade school and do
this as we encourage students to look
at the health professions," she
said.
Inge Corless said the MGH Institute
of Health Professions has an HIV specialization
for nurse practitioners, a nine-credit
certificate program funded by HRSA
that now is available online.
Attendees were divided into three
groups and asked to develop actions
items to strengthen the pathway for
individuals entering HIV clinical
practice. Each group was asked to
consider barriers to the pathway and
in response develop potential short-,
medium- and long-term solutions. Their
discussions and actions items are
reported below.
GROUP 1
General Discussion
The group talked about factors that
influence practice decisions among
medical students and residents. One
group member offered that decisions
are often driven by what students
think their quality of life will be
in one field versus another. A member
who previously taught in a health
professions school said that her students,
particularly those who came from disadvantaged
backgrounds, are trying to move up
the socioeconomic ladder and are inclined
to choose specialties in which the
remuneration is greater.
Another mentioned that recent legislation
prohibits students from deferring
loan repayment during residency, which
she thinks will drive medical students
to shorter residencies and more lucrative
fields. She felt it would be valuable
to look at more "innovative delivery
systems" in which clinicians
share responsibility for patient care.
A doctor in the group lamented the
loss of a "commitment to doing
something positive for the community"
that once characterized medical practice.
He believes a value of service should
be re-instilled in the profession.
Members of the group also discussed
the need to intervene early in the
educational process. One participant
referenced a Robert Wood Johnson pipeline
project that targets minority college
students for careers in dentistry,
but her concern was that the program
funded more "well-resourced"
schools, rather than those having
difficulty attracting minority students.
One group member offered, "I
think what we need to do is put HIV
in the primary care sphere rather
than pull people into HIV." She
added, "In primary care you get
people who are more predisposed to
the notion of serving and want to
work with the underserved." It
was suggested that HRSA could consider
working with the National Association
of Community Health Centers on a SPNS
initiative to develop a model for
delivering high quality HIV care within
a community health center. This could,
in turn, influence changes to legislation
governing Ryan White HIV/AIDS Program Part C clinics.
One group member mentioned that all
students who serve in her dental clinic
say it is one of the most interesting
rotations they perform. She wondered
about the value of collecting data
on whether this exposure makes dentists
more inclined to serve HIV patients.
Finally, the group said that the
absence of data is a big problem in
trying to get political support for
addressing the issue. They called
for data on workforce shortages specifically
as they affect HIV care were deemed
necessary.
Action Items
Short Term
- HRSA should conduct a comprehensive
study on current HIV workforce deficiencies,
as well as develop projections on
what the areas of need will be in
the future.
- HIVMA should expand its minority
fellowship program.
- The AAHIVM HIV mentoring program
should be replicated and expanded.
- Other partners should be included
in efforts to address workforce
shortage issues and develop solutions.
- HRSA and/or PEPFAR should work
with partners on a social marketing
campaign that highlights short-
and long-term opportunities for
working in HIV care, sells the value/professional
satisfaction of working in the field,
and links the domestic and global
epidemics as part of "one epidemic."
Medium Term
- Health professions schools should
strengthen primary care education
during residency periods, focusing
on HIV care and prevention.
- HRSA should formally designate
a track within the NHSC for HIV
providers who serve in underserved
communities.
- HRSA should initiate a SPNS project
to demonstrate the effectiveness
of a co-management model with high
level treaters and community health
centers, evaluate the effectiveness
of that approach, then look at disseminating
that model along with a mentoring
and coaching component.
- HRSA should consider developing
a telemedicine demonstration to
link primary care providers and
HIV specialists in settings with
low-volume patients, using the Veteran's
Administration (VA) system as a
potential source for ideas and approaches.
- HIV specific loan forgiveness
programs should be developed for
all health professionals working
as part of the treatment and care
team.
- The VA system should be explored
for ideas about recruitment and
workforce development.
- The AETC charge should be expanded
to include professional schools
and faculties.
Long Term
- HIVMA and its partners should
delineate the essential components
of a program that addresses HIV
workforce issues throughout the
clinician's career and addresses
issues along the career pathway,
and create a program to do that.
GROUP 2
General Discussion
Group 2 examined barriers at both
the pre-professional and professional
levels. They believed recruitment
efforts were hampered by a growing
number of career options for clinicians
both inside and outside of health
care, coupled with a widespread belief
that HIV was no longer a domestic
challenge. Other barriers identified
included the cost, and subsequent
debt, associated with health professions
training, concerns about work/life
balance, and a diminished sense of
HIV as a "cause" to pursue.
The group discussed a range of issues
that inhibit health professionals
from entering HIV practice: the desire
to earn more given the cost of schooling;
the minimal focus on HIV coursework
in health professions programs; the
inadequate supply of faculty who can
teach students about HIV/AIDS; the
multidisciplinary nature of treating
HIV (specialty vs. general); the high
number of patients with co-morbidities;
the stigma still associated with the
disease; and, the funding environment.
Finally, the group felt that issues
of race and class also influenced
the desire, or lack thereof, of some
professionals to work with affected
patient populations.
Stigma, the frequency of co-morbidities
among HIV patients, the diminished
sense of "call" that once
characterized the HIV workforce, concerns
about living standards given low reimbursements
for HIV care, and system pressures
to serve more patients in less time
were all cited as barriers to practice.
Also discussed was provider discomfort
with addressing patient drug use and
sexual behavior, a critical component
of assessing risk and identifying
effective treatment plans. Safety
concerns regarding occupational exposure
to the disease, patient behaviors
and location of care sites were also
seen as barriers.
Action Items
- Identify champions to do advocacy
and promote the social responsibility
aspect of treating the disease.
- Define productivity standards.
- Set norms for staffing and multidisciplinary
teams.
- Link supportive services directly
to clinical teams to avoid burnout
and enhance retention.
- Enhance reimbursement levels for
providing HIV care, and link reimbursement
levels to provider certification.
- Set the standard for all primary
care to the standards for HIV care.
- Incentivize testing to enhance
participation by all clinicians.
- Endow HIV chairs in all health
professions schools.
- Promote and enforce quality measures
that include testing and patient
retention, and offer incentives
for meeting them.
- Fund incentives for staff, enhance
salaries and support promotions.
- Develop training on how to make
HIV care economically viable.
- In terms of clinical education
programs, do population-specific
(focus on minority clinicians) and
geographic targeting, train primary
care and sub-specialists about HIV,
and expand educational offerings
at health professions schools.
- Work with professional education
groups, such as the AAMC and the
Accreditation Council for Graduate
Medical Education (ACGME), to emphasize
basic HIV care in curricula, and
create task forces to adapt curricula
and issue related grants.
- Promote mentorship programs.
- Focus on stigma reduction and
denial.
- Educate providers about addressing
sex and drug use with their patients.
- Develop educational interventions
according to area of practice and
level of care.
- Provide HIV internships.
Recommendations in the Pre-professional
Realm
- Piggyback on existing programs,
such as AHEC.
- Conduct outreach at high schools
and colleges to attract students
to primary care.
- Target medical and nursing schools
with career teachers programs.
- Collaborate with existing education
and mentorship programs, such as
those supported by the Robert Woods
Johnson Foundation.
- Conduct marketing campaigns that
feature champions and positive examples
of those working in the field, and
highlight the values of service
associated with treating HIV populations.
- Consider using the template from
the Dental Reimbursement Program
to model similar programs in the
areas of medicine and nursing.
Recommendations on Data
- Develop an HIV provider mapping
database that includes prescribing,
insurance and pharmacy data, tracks
experienced clinicians and provide
information to help identify multidisciplinary
team arrangements that maximize
outcomes at many levels.
GROUP 3
General Discussion
Group 3 touched on some of the same
barriers at the pre-professional level
identified by the other two groups,
such as low reimbursements, high levels
of educational debt, and lack of training
opportunities in outpatient settings.
They also noted lack of passion for
HIV work as a significant obstacle.
The group felt that students tend
to be quite knowledgeable about HIV,
but are unprepared to deal with co-morbidities,
such as chemical dependency and drug
use.
General apathy about HIV (e.g., lack
of public response to recent data
that infections are increasing), the
group asserted, has translated into
apathy toward involvement in HIV training.
Few faculty are prepared to teach
students about HIV and lack the requisite
enthusiasm. Further, accrediting agencies
do not require health professions
schools to provide HIV instruction.
Many clinicians are not well versed
on the public health issues surrounding
the epidemic. HIV is not a recognized
specialty and associations and societies
are not focused on it. Public health
is such a broad topic that coverage
of HIV within that context is often
insufficient.
Action Steps
Short Term
- Expand AETC resources.
- Ensure data collection that documents
workforce needs and the impact of
training and other initiatives to
address workforce gaps, and consider
data coordination activities with
others, such as HIVMA, medical colleges,
pharmacy groups and Kaiser Permanente.
(role for HRSA to provide feedback
loop on meaning of data and to pursue
opportunities for data collaboration)
- Expand resources for HIV primary
care providers to create medical
homes for clinicians.
- Recruit ambassadors for HIV training,
individuals who will champion HIV
instruction and activities at professional
schools (via HRSA letters to professional
schools to identify challenge of
gaps in HIV professions and ask
for institutional support to address
gaps).
- Generate student interest by tasking
students to develop multi-professions
coursework, enhancing their involvement
in regional conferences, and conducting
training using new media (e.g.,
Webcasts).
Mid Term
- Create clinic-based training so
that students can gain exposure
to patients.
- Create PSAs to enhance attention
to shortages, possibly modeled on
Johnson and Johnson ads on nursing
shortages.
- Have the United States Department of Health and Human Services take the lead in developing
guidelines on recruitment and education
of HIV providers.
- Expand the NHSC Program to support
loan forgiveness specifically for
work in HIV.
- Urge Health Careers Opportunity
Program/Centers of Excellence to
add emphasis on HIV.
- Promote and support health care
reform to increase role of primary
care. (HRSA, other federal payers)
- Promote and support primary care
infrastructure, especially in the
public sector. (HRSA, other federal
payers)
Long Term
- Have accrediting bodies incorporate
HIV requirements. (professional
groups)
- Enhance reimbursement for HIV.
Meeting facilitator Lori DeLorenzo
identified the following cross-cutting
themes and strategies identified by
all three groups:
- The role of the AETCs in addressing
the workforce shortage;
- The importance of data to inform
the process and strategies;
- The development of solid partnerships
with health professions schools
to address shortage issues;
- The need to identify and energize
partners/stakeholders to work on
addressing shortages;
- The employment of ambassador/mentoring/internship
programs that build on current activities;
- The need to broaden exposure to
the HIV field for students at all
levels;
- The use of marketing/public relations
campaigns to promote the successes
of HIV and highlight the value of
working in the field;
- The need for increased reimbursements
for HIV care and loan forgiveness
efforts specifically targeting HIV;
and
- The importance of professional
schools taking responsibility for
incorporating HIV instruction into
curricula.
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