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HIV doc shortage may block access to care
A changing of the generational guard
National HIV/AIDS groups predict a shortage of HIV physicians in the coming years as the doctors who became impassioned to work in this field early in the epidemic begin to retire.
"We share the medical provider work force crisis that we've read about so much in primary care," says Christine Lubinski, vice president for global health at the Infectious Diseases Society of America (IDSA), who spoke about what President Barack Obama could do to help fight the domestic HIV/AIDS epidemic.
"We have a limited number of clinicians, many of whom have been doing this work since the beginning of the epidemic, and many of whom who will be looking for retirement in the next five to 10 years," Lubinski says. "And there's no evidence that there are providers to replace them."
Already, IDSA has received reports of areas that have lost their HIV clinicians and haven't been able to replace them, she adds.
The HIV Medicine Association (HIVMA) of Arlington, VA, conducted a survey of HIV clinics last year in collaboration with the Forum for Collaborative HIV Research at George Washington University in Washington, DC. The survey's early results indicate that close to 70% of the programs surveyed said it was very difficult to recruit physicians, says Andrea Weddle, executive director of HIVMA. "We surveyed Ryan White, Part C programs and clinics," Weddle says. "We picked them for the survey because they provide care for people with HIV, and we were interested in their challenges in recruiting," Weddle explains. They asked about nurse practitioners, physician assistants, and physicians.
Investigators are continuing to analyze data, but so far it appears that programs across the country were reporting that it is very difficult to recruit for all three disciplines, although they're having the greatest difficulty finding HIV doctors, Weddle says. "We really see our study as a first step," she adds. "We really think we need a federally funded study that takes a look at the issue nationally and also gets a handle on the differences regionally."
Having care capacity
One key issue in expanding access to health care for HIV populations is having enough providers, Lubinski says. "The Centers for Disease Control and Prevention (CDC) is calling for free HIV screening to all adults who don't know their HIV status, who need to be in care, and who need to protect their partners against transmission," Lubinski says. "We need to have care capacity and care for those individuals once they're identified."
The reasons why medical students are drawn to work in the HIV/AIDS field over the past 25 years have changed as the epidemic has evolved. Kathleen Squires, MD, a professor of medicine and director of the division of infectious diseases at Jefferson Medical College in Philadelphia, says, "When AIDS first appeared in the U.S., it was among a group of gay men who were marginalized and stigmatized in society, and then they had a fatal disease, too."
That marginalized, stigmatized, and rapidly dying population attracted doctors who wanted to help and were cause-driven, she notes. "Now HIV has become a chronic illness, and there's not the perceived urgency anymore," Squires says. "Working with HIV patients was almost a cause for people in my generation because you had this very rapidly fatal disease."
Students go overseas
Idealistic medical students continue to be drawn to work with HIV/AIDS patients, but they're attracted to work overseas in resource-poor countries, Squires says. "Part of the excitement with medical students is the global epidemic because that's what's being publicized now through PEPFAR [U.S. President's Emergency Plan for AIDS Relief] and television commentaries," she says.
At a 2008 World AIDS Day program, Squires gave a presentation at a session for medical students, and she used a tool to show how quickly HIV can spread in a population. That created some interest among the students, but it would also help if the United States started a national AIDS Agenda, just like the global AIDS agenda, Squires says. Medical students need to be shown how the domestic epidemic also needs their help since there are 40,000 to 65,000 new HIV cases each year, and the epidemic largely affects poor and minority communities, Squires suggests.
Recruiting new HIV doctors to the Adult HIV Programs at New Jersey Medical School in Newark, NJ, hasn't been a problem so far since the New York City metropolitan area trains and attracts many medical school graduates, says Sally L. Hodder, MD, professor of medicine and director of the adult HIV programs. But at a recent national meeting with AIDS clinicians, Hodder heard many other clinicians say years of flat funding for AIDS programs have dried up money available to train new investigators in HIV care. "When you look around the room, you see the same folks who've been in the field for 20 years," Hodder says.
One of the problems is that HIV care now is primary care for HIV patients, and there has been a shortage of students being attracted to primary care in recent years, Hodder notes. Fewer students are interested in that area because of lower reimbursement and less a sense of passion about the cause now that an HIV diagnosis no longer is a death sentence, she adds.
At least one young HIV physician and researcher was drawn to the field through his post-medical school work in New York City, where he quickly learned of the injection drug use community's struggles with the epidemic. Benjamin Linas, MD, MPH, an instructor in medicine at Massachusetts General Hospital and Harvard University in Boston, graduated from medical school in 2000. "I started working in HIV while living in New York City," he says. "Part of what attracted me to HIV as a social cause was the issue of underserved populations and access-of-care issues." Later, Linas moved to Argentina where he was involved in HIV prevention efforts among poor areas of the country.
HIV still rampant in places
For most people, HIV is a global health issue, but the domestic epidemic also needs attention since there are some areas of the United States where HIV is rampant and people live in Third-World conditions, Linas says.
HIVMA has tried to address the HIV physician shortage by providing minority clinical fellowship awards to young doctors, Weddle says. Started two years ago, the program targets primary care; newly trained physicians who are interested in working with HIV patients; and underserved, minority populations, she explains. "It offers them a one-year fellowship to concentrate on training in HIV," Weddle adds. So far, six fellowships have been awarded.
Challenges for HIV providers
Another possible reason young physicians are not moving into HIV treatment is because it's both a demanding and challenging field of medicine, and it's not very well reimbursed, Weddle says. "In part, there's a broader primary care physician shortage, and for conditions like HIV, it's even more challenging because it does require primary care, but you have to stay on top of a field that's constantly changing," Weddle says. "Physicians who have a lot of experience also have better outcomes for their patients, and the care is generally more cost-effective."
HIV medicine is an underreimbursed specialty, Linas acknowledges. "It's tough," he says. "Working in Boston, I'm having a hard time." Linas does inpatient HIV consults at Massachusetts General and works in HIV outpatient care, but he devotes much of his time to HIV research. "I'm finding it difficult to pay my bills through HIV medicine," he says.
The Obama administration could have an impact on increasing the pool of HIV clinicians if he were to create a targeted loan forgiveness program for physicians who practice HIV medicine in underserved areas, Weddle says. "The one idea I've heard is to designate Ryan White Part C clinics as an eligible site for physicians who go through the National Health Service Corp [NHSC] to do their work," Weddle says.
Lubinski says, "We'd be very supportive of having HIV included as a national service. For people to work in community-based organizations, there is all kinds of work to be done, and, in regard to clinicians, we'd like to see a loan forgiveness program."
Medical students graduate with an average student loan debt of $200,000, Lubinski notes. "It's very difficult to convince them to go into a medical field that's not very lucrative," she adds. "So we'd like to see incentives for them to go into this field."
A loan forgiveness program for physicians and other HIV clinicians definitely would help attract more talent to the field, Linas says. "No matter how well-intentioned people are, the finances have an impact," he adds.