Jim Kling
March 18, 2011 — There is a growing gap between the number of individuals living with HIV and the number of healthcare providers required to meet their needs, according to a new report from the Institute of Medicine entitled "HIV Screening and Access to Care: Health Care System Capacity for Increased HIV Testing and Provision of Care." The report was published online March 17 by the Institute of Medicine's Committee on HIV Screening and Access to Care.
There are believed to be 1.1 million people living with HIV in the United States, and an estimated 21% of them are not aware that they are infected. About 56,000 individuals contract new infections each year. Individuals are also living longer with HIV, further increasing demand for services. However, there are currently more providers retiring from the HIV/AIDS field than there are new providers entering the field.
In 2006, the Centers for Disease Control and Prevention recommended routine HIV testing for individuals between the ages of 13 and 64 years. After those recommendations were issued, state health departments and other organizations received additional financial support for screening, but there is some debate as to whether the support is sufficient and whether the programs will be sustainable once outside funding ceases.
Expanded screening is also resulting in the identification of more individuals with HIV, which in turn will lead to a greater demand for service providers to meet their needs.
There are few data on patterns of care for patients with HIV/AIDS, but the committee concluded that most medical care for HIV-positive individuals is provided by primary care physicians, infectious disease specialists, advanced practice registered nurses, and physician assistants. Other needed providers include registered nurses, dentists, pharmacists, and social workers.
HIV-positive patients are well served by primary care providers who can address their other health needs, but there is a lack of adequate training and experience in HIV care among this group. This is especially true in outpatient clinics, which currently provide the majority of current HIV care.
The committee recommends that medical schools and residency training incorporate exposure to outpatient HIV care, and that continuing medical education programs also be developed to address the needs for the growing population of HIV-positive individuals.
In addition to the overall number of providers, it is important to have an adequate racial, ethnic, and cultural diversity among providers because many HIV-positive individuals are racial/ethnic minorities.
Another strategy in addition to increasing providers is to maximize the capacity of the current healthcare system to absorb increased demand. One approach is to implement delivery system strategies such as task shifting, comanagement, and care coordination models.
"Pathway" strategies can expose more trainees to HIV care, and financial and other incentives can be implemented to encourage more providers to enter the field. The committee also highlighted the current Ryan White model of care, in which patients receive a variety of medical and nonmedical services, and which incorporates task shifting. The Institute of Medicine recommends that this sort of integrated delivery system serve as a model for future care systems.
No matter what approach is used, it is imperative that there be an increase in HIV/AIDS care capacity. Each new detection of an HIV infection creates the need to counsel, refer, treat, and monitor an additional patient, at an average annual cost of $19,912.
If service is interrupted, patients suffer and become less productive, and the likelihood of new transmissions rises.
The report is the third and final in a series examining policy and capacity issues related to carrying out the National HIV/AIDS Strategy for the United States, which is designed to reduce the number of new HIV infections and improve access to care. Previous reports included "HIV Screening and Access to Care: Exploring Barriers and Facilitators to Expanded HIV Testing and HIV Screening" and "Access to Care: Exploring the Impact of Policies on Access to and Provision of HIV Care."
The study was supported by the National Academy of Sciences and the White House Office of National AIDS Policy. The report topic was approved by the Governing Board of the National Research Council. The members of the committee were drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The authors have disclosed no relevant financial relationships.
Institute of Medicine. Published online March 17, 2011.
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