The State of HIV in Primary Care: A Fractured Landscape Hujdich, B., Johnson, A., Orose, J., Salazar, J. & Welch, N. HealthHIV, Washington, D.C., USA Introduction: Workforce Shortages, Increasing Caseloads, and Time Constraints
Materials & Methods: Nationwide Survey with over 1,800 Respondents
Primary care providers (PCPs) are increasingly being called upon to treat patients living with HIV. By extension, they are seeing, treating, and managing HIV as a chronic disease more frequently. Therefore, PCPs are critical links to continuity of care and keeping patients in care. Within the U.S. there are about 2,000 HIV Specialists1 and 208,807 PCPs2. However, HRSA estimates there is a current shortage of both HIV Specialists and PCPs, along with increased caseloads and a need for task shifting to address time constraints for providers3.
HealthHIV’s 2nd Annual State of HIV in Primary Care survey was implemented to identify trends in the provision of HIV care among PCPs and HIV Specialists. The national survey was conducted online with respondents recruited through targeted invitations between July and October 2011. HealthHIV and Medscape fielded the 45question instrument in Survey Monkey™.
Table 1. Demographic Highlights of Survey Respondents (Providers = 627) Professional Designation
Top Specialties
Gender
Provider Demographic Highlights n=627 MD/DO 59% <30 yrs NP 36% 30-39 yrs PA 5% 40-49 yrs Family Practice 38% 50-59 yrs
2% 17% 26% 26%
Internal Medicine
19%
60-69 yrs
15%
Infectious Disease Female Male
19% 61% 38%
>70 yrs Urban Rural
3% 64% 19%
Transgender
<0.5% Practice Setting Suburban 70%
South
39%
African American/ Black Asian
13% 7%
West Northeast
19% 26%
Midwest
19%
Community Health Centers
31%
4%
Not Hispanic/Latino
Hispanic/Latino
Region
85%
9% Most Common Academic Health Centers Practice Types Private Practice
16%
Caucasian/White
Most Common Races Two or More Races
Ethnicity
Age
Figure 1: State of HIV in Primary Care Prescribing Clinician Survey Respondents (N = 627)
16% 15%
Results: Health Care Delivery is Fractured, Creating a Newly Defined Provider Type! ! The survey obtained 1,806 US-based respondents to the survey with 627 prescribing clinicians. Among the 627 prescribers, there were: HIV Specialists (29%), primary care providers that provide HIV care (HIV PCPs) (34%), and PCPs (26%). Respondents were asked to self-identify in one of three provider types: Credentialed HIV Specialist – Defined as a HIV clinical care provider credentialed as an “HIV Specialist.” 4
Figure 3 below quantitatively supports the qualitative responses to the participants’ views of the State of HIV in Primary Care. The figure demonstrates increasing caseloads among HIV PCPs, with an estimated 500,000-600,000 newly insured patient needing HIV care. It also shows decreasing workforce numbers in HIV and primary care, coupled with increased patient flow into community health centers in Figure 4. Figure 3: The Fractured Landscape!
HIV Primary Care Provider (HIV PCP) – Defined as a primary care provider, not identifying as a credentialed HIV specialist, who identifies as providing HIV primary care to patients and reports spending at least 1% of practice time providing HIV care.
Increasing Caseloads and Decreasing Providers Create a Fractured Delivery Landscape
Patients Accessing Care & HIV Caseloads Increasing
Primary Care Provider (PCP) – Defined as a primary care provider who does not provide HIV care to patients.
HIV Care Provider Workforce Decreasing
Figure 2. Profile of Primary Care Providers who Provide HIV Care (HIV PCP)
HIV Patients
HIV Specialists
HIV Caseloads
Primary Care Providers
500,000 - 600,000 will be newly insured in 2014*
Projected shortage of Primary Care Providers by 2020. (2)
Consistent “increase in HIV caseloads” among HIV PCPs since 2010
2012
60%
2010
62%
Roughly one-third of HIV Specialists are planning to retire in the next 10 years. (1)
HIV PCPs “able to provide care to newly diagnosed HIV positive patients”
2012
1
0%
20%
40%
1
2010 60%
65%
80%
* HealthHIV calculation based on 2009 CDC estimates of 45% of people living with HIV that are uninsured.
The survey asked participants their views on the current state of HIV in primary care. The results for each provider type below:
73%
0%
20%
40%
60%
80%
Figure 4: HIV PCPs report working mostly in Community Health Centers Other, 23%
Credentialed HIV Specialist • HIV Specialists described the current state of HIV in primary care as “excellent” or "good" overall. HIV Primary Care Provider (HIV PCP) • HIV PCPs stated that that although the state of HIV primary care is “getting better,” the current state is challenged by many factors, including level of funding, barriers to access, and fragmentation across the health care system. Primary Care Provider (PCP) • Primary care providers that do not provide HIV care were contradictory to the other groups, stating a “disjointed or fragmented” landscape, suggesting a chaotic and perplexing view of the state of HIV primary care.
HIV Clinic, 15%
Private Practice, 15%
CHC, 31%
Academic Health Centers, 16%
Conclusions: HIV PCPs Positioned as Primary Care Deliverers!
Implications: Scaling Up Primary Care Settings for Newly Insured !
Study results indicate that a new provider type has emerged: the HIV Primary Care Provider (HIV PCP). These providers’ responses to the current state of HIV in primary care differed in comparison to HIV Specialists or primary care providers. This provider type also primarily works in community health centers. Consequently, they serve as a linkage between HIV Specialists and primary care providers. These results identify the HIV PCP as one who is positioned to bridge the gaps among HIV care providers within the fractured health care landscape. This task shifting to HIV PCPs is occurring alongside increasing patient caseloads and decreasing workforce numbers within the United States.
With a projected 500,000-600,000 newly insured HIV positive patients coming into care, the health system will be most impacted in terms of its service delivery and the availability of its workforce. Consequently, there is a need to scale-up the number of HIV PCPs and resources available for care delivery in order to provide continuity of care for patients with HIV. There is also a need to provide additional education to PCPs who will end up providing care to patients with HIV. This supports the second goal of the U.S. HIV/AIDS Strategy of increasing access to care and improving health outcomes for people living with HIV.
Acknowledgments! HealthHIV, Medscape, Joe Hopper from Versta Research.
Literature Cited ! 1. Carmichael, K. et al. Averting a Crisis in HIV Care: A Joint Statement of the American Academy of HIV Medicine (AAHIVM) and the HIV Medicine Association (HIVMA) On the HIV Medical Workforce. 2009. Accessed July 2012. 2. Primary Care Workforce Facts and Stats No. 1: The Number of Practicing Primary Care Physicians in the United States. AHRQ Publication No. 12-P001-2-EF, October 2011. Agency for Health Care Policy and Research, Rockville, MD. http://www.ahrq.gov/research/pcwork1.htm 3. U.S. Department of Health and Human Services. Health Resources and Services Administration, HIV/AIDS Bureau. HRSA CAREAction Newsletter: Workforce Capacity in HIV. hab.hrsa.gov/newspublications/careactionnewsletter/april2010.pdf. Accessed April 2010. 4. The American Academy of HIV Medicine. Credentialing. http://aahivm.org/about. Accessed July 2012.
Presented at AIDS 2012 – Washington, D.C., USA