HIV Workforce and Care Teams

Announcer

Welcome to the Academy Exchange, HIV Today and tomorrow. In this podcast, we discuss the latest advances in HIV prevention care and treatment, as well as examine the societal and systemic issues facing people with HIV. Thank you for joining us.

Bruce

Welcome again to the Academy Exchange, HIV today and tomorrow. I'm the American Academy of HIV Medicine executive director Bruce Packett. And on this podcast, you'll hear from HIV health care professionals about the latest in HIV science treatment prevention, policy coverage, and so on. And on this episode, I think we're going maybe a little bit meta because we're actually going to be talking about the HIV health care workforce itself.

So I just want to start by asking, what do I mean when I say workforce? I mean that we're talking about people who provide HIV care and treatment and all the facets of support that go into caring for someone with HIV. So when we talk about all these great research developments, as we have been on episodes past, all the new treatments, the new prevention modalities, things like telehealth, the new ways to engage clients in care.

In this episode, I really want to focus on those people that actually do the work of providing HIV care and preventing new transmissions from taking place. And I should also point out that we're talking about the members of my organization, right? The American Academy of HIV Medicine, those prescribers, pharmacists, dentists, really the whole care team who make sure that all the great services that we have available for people with and at risk for HIV can get to the clients who need them.

And I have one such member and health care provider here today to talk with me, and that's Angela Kapalko and she's here to talk about the HIV workforce and how we can make sure that we have the right professionals in the right places to deliver HIV services. 

Angela, welcome. And I just want to start by saying that we love our physician assistants here at the Academy, and I hope this episode helps everyone understand why those advanced practice providers are so important in HIV. So thank you.

Angela

Absolutely. Thank you so much for having me.

Bruce

Sure. So just to do sort of a brief introduction, Angela Kapalko is again a physician assistant at Philadelphia FIGHT Community Health Centers in Philadelphia, PA. She's been practicing medicine in the field of HIV health since 2007. At FIGHT, she serves as the Education Coordinator for advanced practice clinician students, specifically nurse practitioners and physician assistant students, managing their clinical rotations, preparing and giving didactic trainings, and serving as a lead preceptor. 

Outside of Philadelphia FIGHT she lectures at a number of programs on clinical topics, including HIV medicine, viral hepatitis disorders, infectious diseases, HIV therapy, pharmacology and health disparities within the HIV community. In 2018, she took over as the chair of the Physician Assistant Committee in the American Academy of HIV Medicine with a goal of furthering the growth of PAs and PA students in HIV medicine.

In 2022, with the help of the Academy, she launched the PA Preceptorship program, which we'll talk about today, a national program connecting to students with high interest in HIV prevention, treatment, sexual health, public health in underserved health care, with practicing PAs for clinical rotations, which, again, I hope we can get into in some detail. Her passion is educating the next generation of clinicians, and not just the medical aspects of health care, but in an effective and transformational communication between patient and provider.

So we'll get into why that training of the next generation part of your work is so important, Angela, because I think there's a few main takeaways I want our listeners to hear today. But one of them is certainly that we can't simply just take for granted that there will automatically be well-trained, disease specific medical professionals ready to just expertly deliver care to all comers, with no investments in the workforce.  Or those who provide care for a complicated infectious disease, like HIV, because that's just not the way our health care system is constructed.

In fact, it's quite common for that person who has expertise in managing HIV to also provide full primary or whole person care for that client. And again, I just want to remind our listeners here that we're talking to a broader audience about some of these issues, and we don't want to assume too much specialty knowledge about these complicated health care systems and how they got to be the way they are.

So I think the best sort of ground zero place for us to start this conversation is from the perspective of, let's say, someone newly diagnosed or having a new HIV positive test. So I'll ask you, Angela, where should this newly diagnosed person go for treatment?

Angela

I think this is actually a really interesting question. And before I answer that, I want to comment on the number of ways a person can get tested for HIV because it's looked very different over the years that I have been practicing medicine. It's important to know that someone does not have to have a health care provider to get an HIV test.

The one thing that the COVID pandemic taught us is that people can do a lot from their own homes, and that includes HIV Self-Testing with an FDA approved mouth swab self-test. It is out there, and many people don't actually know that it's out there. And so where to get treatment can look different based on the way a person is diagnosed.

So with that, you know, there's a range of places that people can receive HIV care. 

First, people can go to their primary care provider. That provider might do the direct care for them or they might actually connect them to a specialist or someone that just has more training in HIV. They can go to community health centers or sexual health clinics like Planned Parenthood.  

And a patient who might not know where to go might want to do their own research and the Academy actually has an online tool called the Referral Link. And this is where you can search for providers that are near them. So you can put in your zip code, you can look up who is an HIV specialist, what kind of service they provide in terms of other primary care or other specialty services like gender affirming care, or if they have any additional resources, like for folks who don't have insurance.

So if someone was proactive in doing their own HIV test, their home self-test, they might not have a primary care provider or know where to go. And what's great is the company that made the self-test has an incredible resource with a 24 hour hotline, a website, and they are also connected with local health departments. And so this can also help navigate this person through to get them treatment.

Bruce

Yeah, that's also so important. And I want to take your answer to that question, you're great answers to that question, and get a little more specific. And maybe this is kind of a naive question for us to talk about, but I think it's important for our listeners to hear, about what types of providers can provide that care to someone diagnosed with HIV.

I mean, maybe help our listeners understand a little more here. For example, is it only doctors who can provide that? Only physicians, for example?

Angela

So yeah, there's a number of clinicians that can that can provide HIV care. And I think the other thing that we now need to start talking about is that HIV care, we keep saying “specialty care” and we keep using that term, but HIV is primary care. HIV is a chronic health condition that should be looked at in that way and should not be thought of as a very specialized, individualized care. And so I just wanted to start there.

Bruce

Right. And we'll get into that more specifically later.

Angela

Absolutely. Yeah. So, obviously, there are physicians, right? There are there are MDs, there are DOs, and they provide health care. And then there's also physician assistants and nurse practitioners. And we are in all states and we all practice health care. And so it's actually really interesting because there's also some states that pharmacists can actually administer HIV tests and start folks on medication.

So, you have a lot of options as to who can provide that care. Then the question is, is how comfortable do they feel? And more so, how trained are they and how much information have they gotten within their training to do that care? Just go back just to go back for a second around the pharmacist.

Angela

What's interesting is this is a growing number of pharmacists across multiple states that are starting to allow anti-retroviral therapy to be started. And those states include California, Colorado, Idaho, Illinois, Maine, Nevada, Oregon, Utah and Virginia. And it's just going to keep growing. Now, I want to point out, though, that in those states, pharmacists have a significant amount of training in medication and management.

However, a lot of these states and the laws around it will also make the pharmacist help connect that patient into local care, to continue that therapy going forward for continued management. So a lot of options here.

Bruce

Yeah, for sure. And that's good to hear that there are so many options because I think, most of our listeners will have heard in the news really over the past decade or so that there is in fact a shortage of doctors in the U.S. just broadly and that the shortage is actually projected to get worse. I think a recent report from the Association of American Medical Colleges projects a physician shortage of up to 124,000 doctors by 2034. So in about ten years. 

So I'm hoping you can just talk a little bit broadly about why, you know, why is this doctor shortage happening in this country.

Angela

Right. And that information that you gave is specifically only doctors. So MDs and DOs. That does not actually account for nurse practitioners and PAs as well that have been in the business for quite a long time as well, that are that are also will be retiring at some point. And so there's a lot of interconnected factors that are all working together for this shortage.

And so it's a supply and demand issue really. You know, it takes many years for specifically physicians to begin practicing. And so they need to complete four years of medical school followed by residency and that can last a couple of years. They also then go on to fellowship. And that fellowship is also a couple of years, and that spell fellowship is around specialization.

So it is specializing in hematology or oncology or infectious disease. And so they kind of pick a path. And so the first stoppage in that that pipeline is residency. So the spots are incredibly limited. And there's many new graduated medical students that don't match. And it's really interesting while we're doing this right now, because this is actually matched week for those residents.

So I've been watching on Twitter and through social media, all of these medical students who are talking about matching or not matching and what they do next. And some that are trying to match for the third year or the fourth year. And now they try multiple times over because they're trying to get into the specialty and the location that that fits their need.

And so residency slots, they're funded by the federal government through the centers of Medicare and Medicaid services. And there have been no significant increases in that funding since 1997. So even though we've had increases in schooling funds, in housing costs, you know, none of that is changing for this funding. And so it shows how the supply of physicians is dwindling. It's not increasing to meet that demand. 

So some of the demand is also coming from the aging population, I think. Our population of Americans are aging and they need health care. And older people are more likely to have chronic health issues needing more services, a higher level of care that need to be managed. 

So the aging population doesn't affect just the health care, the patients we're taking care of, those doctors who've been doing this for many years, they're aging, too, and they're retiring. And so we're losing the ones that have been in it for 20, 30, 40 years. And then the ones that are coming in, we're just not getting enough.

Bruce

Yeah, that's a really sophisticated explanation and the multifactorial problems that we're facing, you know. Putting on our policy hats, I want to try to understand what can be done about this physician shortage. You're talking about, you know, what sort of changes could conceivably be made to the health system to address this problem?

Angela

First and foremost is better funding and loan repayment. The amount of money that these physicians have or loans that they have when they graduate are astronomical. And that continues to grow as college prices continue to rise. I mean, we're having less and less students go into college because the yield when they graduate just isn't there. And if it's going to take 20 or 30 years to repay loans, it's not worth it. And so things that can be done is help out with loan repayment.

Bruce

That's great. Thanks for that explanation. And then I'm hoping we can kind of put on our policy hats and expound on why physician assistants and nurse practitioners are, in fact, such a great option for offsetting that physician shortage. How can they help? First of all, just talk broadly about the overall physician shortage. How can they help address that physician shortage?

Angel

PAs and NPs are considered advanced practice providers and we have a large amount of education and knowledge to provide a range of care and services. And we both have, both NPs and PAs have the clinical knowledge and skill to diagnose and treat, prescribe medication and function as care leaders in the health within a health care team, really. And so we both have extensive training, extensive schooling, and we both have to pass boards, national board certification exams that have to help us practice in every state.

I'm a PA and I, you know, going into PA school, I actually had a great class on the history of PAs and why we were why we were developed, what was the purpose of making us. And it specifically was to serve the underserved care and the underserved communities that didn't have access to health care.

So that that was our root. And that is where I have always believed that we need to be.

NPs have a really similar educational path and each MP either has a master's degree, or now they have a doctoral degree that specifically in nursing, their graduate programs, they require 1 to 2 years of clinical experience to be accepted into the program. So if they have a nursing degree first and that master's program then lasts for about 1 to 2 years, it might add a little bit more if they're going to do a doctoral program on top of that. So there is extensive education.

Bruce

Absolutely. And I'm hoping that we can now, in the conversation, pivot specifically to HIV and the cure for HIV. So I want to ask you, the clinicians, providers, etc., do they have to specialize in HIV medicine to be able to treat people with HIV? I guess another question here that's related is do you want your HIV health care provider to necessarily be an infectious disease specialist, for example?

Angela

That's a great question. So when HIV first came around, it was only done by infectious disease providers or clinicians, nurse practitioners and PAs who worked with infectious disease providers because of how specialized it was, how intricate it was. But over the years that has changed, which is great. And so I think this is a yes/no answer here, because, while someone does not need to be special socialized in HIV care, you obviously want someone that knows what they're doing and has some training. And nurse practitioners and PA, we are trained as generalists, so we do get this knowledge. We might not get as much as a physician would get in their training in the beginning, but if we do a rotation, if we do our clinicals in this, we are going to get that training that we would need to go out and do primary care HIV treatment.

Bruce

Right. And since you mentioned that, I think it's appropriate here to kind of talk about defining what HIV specialty care might look like and how it's sort of recognized in the world and in the country. So what is an HIV specialist credential?

Angela

Yeah. So this is a, and I first want to say that sometimes people will say that this is a test. It's not a test. The credentialing is a program through the academy that credentials physicians, nurses and pharmacists who demonstrate their knowledge of HIV care. It's a similar idea to medical boards like the Board of Internal Medicine, the Board of Pediatrics, but it's specific to HIV information and knowledge.

Clinicians need to meet a set of minimum requirements and pass an exam to earn that credential, to earn that specialist title. And it's generally a voluntary process. So this is something that you decide that you want to do. There are a few health care organizations that require it after a certain number of years for their practice.

And so because it's voluntary, it can be an important signal to patients that their medical provider has that knowledge and that training. And so knowing that someone took on that time to do the additional training and take on this certification, that's an important step. And so, what that will look like for a patient who's looking for somebody that that might be specialized is there's, we all have alphabet soup after our name. So it's kind of those letters at the end. 

And so for physicians, nurse practitioners and PAs, you're going to see AAHIVS. And so for a pharmacist, you'll see AAHIVP. And so they're going to have that certificate on their wall, and they do have to get re-credentialed every three years. So if they continue in this practice and they want to keep that credentialing, it's an every three year process.

Bruce

Exactly. Because we talk about all the great new developments of research and treatment options, prevention modalities. And it's changing and it's getting better and better. And providers really need to keep up their training. So I'm hoping you can kind of situate what the credential means in the broader health care landscape. For example, you know, what have providers have to know to obtain that credential?

Angela

Yeah, you said it. It continues to change. I mean, from when I graduated in starting practice in 2007 to now, the advancements and changes in how we provide HIV care is drastic. I actually get to do a history lesson with all of my students of back in the day. And I wasn't even back in the day with, you know, my collaborating physician was even more back in the day, she started in the 90s.

So just to say that.  So earning an academy credential is a sign that your clinician has gone above and beyond to demonstrate that they just know their stuff. But not only that they know their stuff, but they continue to educate and learn and keep up with all of the information they're holding themselves accountable to be up to date on the latest practices in the field.

And those practices are driven by clinical trials. They're driven by guidelines, and HIV medicine has been changing. And so accountability is very key. To be eligible, a clinician needs to first have experience with patients with HIV. So you have to at least have some patients with you that you're already treating right. 

And we also need to complete 45 hours of trainings specifically in HIV. And so those are your continuing medical education hours or going to lectures or doing additional reading. And so all of that together and 45 hours doesn't really sound like a lot. But when a clinician is sitting down outside of their practice to do additional work and go to lectures and read up on studies, that adds time.

They obviously have to pass an exam and it covers a wide range of topics in HIV care. And it's not just HIV care because it's also around prevention and diagnosis, treatment, the ethical requirements.  And now, because HIV is a very primary care based health issue, there's a lot of intertwined primary care concepts that are that are ongoing within this test.

Bruce

Right. Absolutely. Yeah. And it sounds to me like if someone wants to ensure that highly specialized HIV care, they should probably see a provider who's been credentialed through the Academy because that's a really strong indicator that they're well equipped to care for patients with HIV as you're demonstrating, and sort of those minimal thresholds and requirements. First of all, do you think that's the case?

And for providers who maybe don't carry that credential, does that necessarily indicate anything borrowing that credential? What else can clients seeking HIV services know about, you know, who is qualified to treat HIV effectively?

Angela

Yeah. So, I think that having that credential and that specialist or pharmacy specialist within their credentials is really important. But there are some that might not have that credential. They might not have taken that step due to financial reasons or just timing. And so I don't want to say that you have to have that credentialing to be considered a specialist in HIV.

So not to say that patients won't get great care from providers who are credentials. Just a shout out to my collaborating physician who's been practicing in HIV medicine since the nineties. She is not credentialed, but she's been doing it forever. And she has taught me and it's purely just a, it's a her thing, a personal choice. She just hasn't gotten to it yet in all honesty. I just keep pushing her a little bit.

So you're looking for that HIV specialist or pharmacy credential takes some of that guesswork out of the process for a patient where it's kind of just shows them that that this person is already on their game. And the Academy has done the work of identifying those that are specialist for you and that was with that provider like or Referral Link that I kind of mentioned earlier.

Bruce

Yeah, for sure. And I kind of want to pivot. You know, we've certainly touched on some of the care team issues, but I want to talk about, that full care team approach, coordinated care, medical home models, and really just, all the professions that actually come into play when it comes to caring for the whole HIV patient.

So apart from the clinical treatment, what other services and care do those, you know, with or at risk for HIV actually need? You know what makes up that for HIV care team?

Angela

Oh, our care team is large. And, I think what's really interesting is that I wish that all patients had the care team that we have for a lot of our patients who are living with HIV because, really, it should be the standard of care for all patients. So it's kind of going through a little bit about what that looks like.

So obviously you have your clinicians, your MDs, your NPs, your PAs, so your care team right there. You have pharmacists and pharmacy techs who are very highly specialized in in HIV care. And then we start kind of moving down the line. We have medical case managers or social workers who are helping folks out with resources. So, housing resources, insurance access issues, food access issues.

So these are all things that keep a patient in care and allowing them to stay healthy. Other things that are really important for whole patient care is good mental health care. Overall wellness. And so we have folks who are therapists and, maybe, a psychologist or psychiatrist or behavioral health consultants, BHCs, and they are within the practices that we have.

So we've got that network. And then, there's just more. So there's nurses who are on the floor with us. They're helping coordinate medical visits. We also have care outreach specialists who, if we haven't seen a patient for a while or they're really struggling to get into care, they might go out and meet with them. They might meet them at their home and try and help them out.

Bruce

Yeah, kind of to that point. I mean, all of the services sound critical and important and fantastic, but it also sounds complicated and daunting. How do people find these services or, sort of get connected with them?

Angela

So many people will be connected to those services through their main clinical care provider. So the person who's taking care of them should have those resources. And specifically, if they are a credentialed specialist or a part of the American Academy of HIV Medicine, they will know where to where to get those services if it's not directly in their office.

So if they need help finding support, though, and maybe they're going to a provider who doesn't have a credential and is not involved in the Academy right now because they might be a new clinician, HIV.gov is a great place to start to look for that information and connect to the right people.

Bruce

Sure. Absolutely. And all of those great federal resources out there, you know, and we've really talked today about some of the reasons that there is this sort of growing shortage of physicians. But I want to talk about HIV specifically. Now, those providers who have been doing this work for so long, and we can only presume that 40 years into the epidemic or so, presumably going into retirement age or past that even, what would you say drove them to work in HIV? How did they come to be in the space and to have expertise in this clinical space?

Angela

So I don't want to speak for my physician colleagues, but I will say it is it was driven based on passion. It was driven on passion to care for folks with a, at the time, back in the eighties, sometimes an unknown condition or illnesses and situations that were happening to folks that just people weren't really equipped to take care of.

And so physicians were going into specialty care, specifically infectious diseases. And through that specialized training and residency and fellowship, you got more and more infectious disease physicians that were training in HIV. And so that's that large group back in the eighties and nineties who were soon to be retiring. What's happening now, unfortunately, is new medical students are not going into infectious disease. It's not the desired residency anymore. 

And I think there's a number of reasons for that. Obviously money is one of those. It's not great to say, but the money's not there. You know, if a physician has a number of loans, hundreds of thousands of dollars of loans, they might go into a specialty that will help pay those awful lot faster. And unfortunately, that's not infectious disease right now. 

And so, you know, we're not getting enough infectious disease providers, doctors, and that HIV care is now kind of shifting into more of a general medicine, internal medicine or family medicine, primary care. And those clinicians who are going into that work have a lot to take care of. So they're not just taking care of HIV, they are taking care of whole person care. And so it's just a lot that they're that's on their plate.

Bruce

Absolutely. And I wonder again, if we can put on the policy hats again. What do you think? You know, lawmakers, policymakers, legislators could do on a policy level to improve the number of health care professionals who want to go in HIV.

Angela

So I think there's a number of opportunities. If there were loan repayment programs that were out and I believe there's a couple that are that are out or are coming out. One is the BIO Preparedness bill. And so these will help if someone wants to go into this work once they graduate, if they go into this specialty HIV care or underserved to care, then and loan repayment would be a great option. And that would that would help out a lot of folks.

Bruce

Yeah, for sure. And then there's some other avenues to address this problem, too. And I'd love to sort of wrap up this conversation in that space and talk about some of your focus around training and preceptorships in your community of advanced practice providers. So what sort of training opportunities are you specifically working on? And then generally, how can new medical providers potentially interested in going into HIV get into those programs and activities?

Angela

So I'll talk generally about NPS and PAs and how we're trained. And so we are trained as generalist and we do have clinical rotations. And so those clinical rotations are in primary care field, general care, pediatric care. We do a wide range of training, but if we don't actually get training specifically with a clinician who does HIV care, we might not see it until we get out into practice.

And even when we get out into practice, we might not see it based on where we're working or get that level of training that we have. And so, nurse practitioners specifically who are students who want to go into HIV, they'll actually seek out their rotations with other nurse practitioners who are doing HIV care. They want to do that work when they graduate. And so they will hook up that way. 

And so the way that the nurse practitioner training is is that those nurse practitioners have to go and seek out their rotations. So they have connections because they have been RNs. And through those connections that they have, they will find their preceptors.

It's a little bit different for physician assistants. So within our program we have set rotations that are mandated to learn and that we have to go on. So, topics like pediatrics and behavioral health and emergency medicine. And each graduate program, each PA graduate program, has a set number of rotation sites that school has an affiliation agreement with a number of clinicians within their network and students are, what we call, placed at a site.

And so that placement, you might get HIV care. And that was myself. So when I was in training, I was fortunate enough to get training with a clinician who actually is still practicing in Philadelphia and who did primary care, adult care and also HIV care. And that's how I saw it. And so if you don't see that, though, you graduate and you don't get that extra training.

And so specifically, what I what I wanted to do for those PAs that might have a high desire and a strong passion for HIV prevention and treatment in sexual health is make sure that they have the opportunity. What that means is I wanted to connect to those students across the country. And this all started a number of years ago when I was on a social media platform for physician assistant students, and one of them posted that, that they really wanted to do a rotation in HIV medicine, but they didn't know anybody in the small rural town that they lived in and that they were going to school in. And they were in the Midwest, and I had happened to see that message and I sent them email and said, “if your school would be willing to have an affiliation agreement with me and you're willing to travel to the East Coast, let's go.”

And a year during her clinical rotations, she showed up at my office. And you know, from there it was it we launched. I launched. I wanted to do this throughout my career of making sure that I wasn't just training the PAs, the students who are in my network in Philadelphia, but I wanted to make sure that those students who are in the Midwest, who are in the South, who are in the West Coast, have those opportunities and know that that it's there. So this is where this PA Preceptorship program was birthed out of.

Bruce

It's such important work that you do and it really takes experienced health care providers like you to you know have that infrastructure and to have those sort of training programs in preceptorship that allow for that next generation of the HIV workforce. And I really like to end on solutions rather than problems. So I think we'll stop there.

It was great to get to talk to you today. It was really a treat. Thanks so much for walking us through the complicated HIV workforce landscape today. Angela, thanks again.

Angela

Great. Thanks so much.