Beginning in January 2014, an estimated 30 million newly insured Americans will swarm into the healthcare system thanks to the Affordable Care Act (ACA). A significant percentage of them will be infected with HIV or, as they gain access to preventive and screening services, will learn they are infected.
The anticipated result for the HIV community is a serious shortage of HIV physicians trained to manage HIV, complicated by a perfect storm of increased demand from newly infected and aging patients, an older workforce moving into retirement, the increasing complexity of managing HIV-infected patients, and the declining number of medical school graduates who opt for higher-paying specialties instead of primary care or infectious disease medicine.1 In a 2008 survey of HIV clinicians, most said they were worried about such a shortage.
Yet as noted in a US Health Resources and Services Administration (HRSA) report on the topic, HIV patients "depend on providers with disease expertise and sensitivity to issues like stigma, which are qualities that boost early treatment adoption and better health outcomes.” In other words, not just anyone with a medical degree should care for these patients.
Although numerous short- and long-term adjustments are underway to address the shortage—as well as the need for more primary care clinicians to integrate HIV patients into their general practices—one of the important alternatives may be shifting more care to nurses.
“Since the beginning of the epidemic, nurses and nurse practitioners have always had a primary role among the healthcare team that makes decisions about prevention of [HIV infection] and care for HIV/AIDS patients,” said Kimberly Carbaugh, executive director of the Association of Nurses in AIDS Care. “They spend more time with individuals, so they understand the whole range of issues and barriers and life experiences that impact a person’s capacity to start treatment, adhere to treatment, and manage the very complex issues that someone with HIV experiences.”
Most states allow NPs and physician assistants [PAs] to prescribe medications, including antiretroviral therapy (ART). In some rural and inner-city areas, they may provide the majority of HIV-related care.2 “With the epidemic most significantly impacting the southeastern US, the role of the NP is even more critical,” said Carbaugh. “We know that in those rural areas of the South and West, the NP is often the ‘doctor’ for patients.”
Nurses are also in an excellent position to provide the plethora of non-HIV-related primary care services that patients need, from diagnosing and treating minor acute conditions like respiratory infections to providing screening services and helping to manage chronic diseases such as hypertension and diabetes.
But are they good enough?
Several studies find that nurses consistently deliver high-quality care in the HIV realm. In one study of HIV care by non-physician providers, researchers compared the quality of care provided in 68 Ryan White-funded HIV care sites in 30 states by NPs and PAs, infectious disease-trained physicians, generalist HIV experts, and generalist non-HIV experts. They used chart reviews to evaluate eight quality-of-care measures based on national guidelines.
The analysis showed that the physician extenders cared for about a fifth of patients. The patients tended to be slightly younger with fewer comorbid conditions than those physicians managed, and were more likely to have documented substance abuse.
The result: The physician extenders had performance rates that were at least as high, and often higher, for all quality measures. They were more likely to conduct purified protein derivative and PAP smear tests than physicians in any of the three specialties. For ART use and viral load control, influenza vaccine use, and number of visits, they had rates similar to those of infectious disease and generalist HIV specialists, and higher than those for generalists not expert at treating HIV.
There was no difference between rates of P. carinii prophylaxis and hepatitis C testing between the five groups. It did not appear that physicians in the study were caring for more complex patients.
More recently, in a talk at the 2012 International AIDS Society meeting in Washington DC, mayor Vincent Gray said that since 2009 not a single HIV-infected baby has been born in the city, which has one of the highest HIV infection rates in the nation. He credited this to the intervention of nurse-midwives who track pregnant women with HIV and link them to care.
Obstacles and opportunities
Barriers to the expanded role of nurses in HIV care include the national shortage of nurses in all areas and laws that limit the practice scope of NPs, Carbaugh said. In addition, she said, “We need to get across to the general nursing community that every nurse is an HIV nurse. We all need to have some level of understanding of where the epidemic and disease is now and be able to recognize acute symptoms of HIV and the risk of HIV in the community around us.”
Those nurses who choose to specialize in HIV care can receive advanced training through certification programs for RNS and NPs, both administered by the HIV/AIDS Nursing Certification Board.
To encourage more nurses to move into HIV/AIDS care, the Association of Nurses in AIDS Care is reaching out directly to nursing students. The group held two standing-room-only focus groups on sexual health during the National Student Nurses Convention, Carbaugh said. “This is the first time many students ever heard about these things,” she said, “because the nursing curriculum is so tightly packed that they often don’t spend time on HIV and very little, if any, talking about some of these tougher topics like sexual health.
“Overall, we just want to make sure that as the Affordable Care Act goes into effect, and the national HIV drive (for testing and treatment) continues to be implemented, that one of the discussion points continues to be workforce capacity,” she said. That doesn’t mean just talking about doctors. “Don’t forget that there are others on that team besides physicians who can practice to the full extent of their education and license and move us through this period of expanded access.”